Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.



Degree Program

Nursing, PhD

Committee Chair

Christian, Becky

Committee Co-Chair (if applicable)

Shawler, Celeste

Committee Member

Shawler, Celeste

Committee Member

Clark, Paul

Committee Member

Kolers, Avery

Author's Keywords

moral distress; moral residue; crescendo effect; nursing; coping; intensive care unit nurses


Introduction: Approximately one in five Americans will die in the intensive care unit (ICU). Nurses spend more time with chronically ill and end-of-life patients than any other healthcare professional, and may perceive some actions in the ICU as immoral. Moral distress is defined as knowing the right course of action to take but being hindered by institutional constraints. Development of the Moral Distress Scale-Revised revealed that 31% of ICU nurses left a prior position or considered leaving their current nursing job because of moral distress. The purpose of this descriptive qualitative study is to explore surgical ICU (SICU) nurses’ perceptions and experiences of moral distress and moral residue, coping, and perceived quality of care. Methods: A descriptive qualitative approach used in-depth, semi-structured individual interviews with SICU nurses. Purposive sampling methods of maximum likelihood variation and snowball sampling recruited a heterogeneous sample of 21 SICU nurses from two SICUs in a university hospital until theoretical saturation occurred. Essential themes were identified through reflective writing, rewriting, memoing, and content and thematic analysis. Verbatim transcription of interviews and an audit trail ensured rigor and trustworthiness of the data in order to highlight descriptions, patterns, uniqueness, and interpretations of firsthand accounts. Conclusion: Moral issues were highlighted to explore root causes of moral distress at the individual-level for SICU nurses with a deeper understanding of moral distress and moral residue, particularly how nurses cope with the stress involved and their perceptions of the influence of moral distress on quality patient care. Understanding nurses’ experiences is essential to addressing ethical issues of moral distress and moral residue before they negatively impact patient outcomes.