Moral Distress and Intention to Leave the Profession: Lithuanian Nurses

Moral Distress and Intention to Leave the Profession: Lithuanian Nurses in Municipal Hospitals Lina Laurs, RN, MS1, Aurelija Blaževičienė, RN, MPH, PhD2 , Elizabeth Capezuti, RN, PhD, FAAN3, & Daimantas Milonas, MD, PhD4

1 PhD Candidate, Nursing and Care Department, Lithuanian University of Health Sciences, Kaunas, Lithuania 2 Phi Gama, Professor, Head Nursing and Care Department, Lithuanian University of Health Sciences, Kaunas, Lithuania 3 William Randolph Hearst Foundation Chair in Gerontology, Professor, Associate Dean for Research, Director, Center for Nursing Research, Hunter- Bellevue School of Nursing, Hunter College of CUNY, New York, NY USA 4 Professor, Lithuanian University of Health Sciences, Kaunas, Lithuania

Key words Abstract Intention to leave profession, Lithuania, moral distress, Moral Distress Scale, registered Purpose: The purpose of this study was to describe the level of moral nurses, sources of moral distress distress experienced by nurses, situations that most often caused moral distress, and the intentions of the nurses to leave the profession. Correspondence Methods: A descriptive, cross-sectional, correlational design was applied in Lina Laurs, Nursing and Care Department, this study. Registered nurses were recruited from five large, urban Lithuanian Lithuanian University of Health Sciences, municipal hospitals representing the five administrative regions in Lithuania. Eiveni str. 4, LT-50161 Kaunas, Lithuania. ų Among the 2,560 registered nurses, from all unit types and specialities (sur- E-mail: [email protected] gical, therapeutic, and intensive care), working in the five participating hos- Accepted November 7, 2019 pitals, 900 were randomly selected to be recruited for the study. Of the 900 surveys distributed, 612 questionnaires were completed, for a response rate doi:10.1111/jnu.12536 of 68%. Depending on the hospital, the response rate ranged from 61% to 81%. Moral distress was measured using the Moral Distress Scale–Revised (MDS-R). The MDS-R is designed to measure nurses’ experiences of moral distress in 21 clinical situations. Each of the 21 items is scored using a Likert scale (0–4) in two dimensions: how often the situation arises (frequency) and how disturbing the situation is when it occurs (intensity). On the Likert scale, 0 correlates to situations that have never been experienced, and 4 correlates to situations that have occurred very often. Results: Among the 612 participants, 206 (32.3%) nurses reported a low level of moral distress (mean score 1.09); 208 (33.9%) a moderate level of distress (mean score 2.53), and 207 (33.8%) a high level of distress (mean score 3.0). The most commonly experienced situations that resulted in moral distress were as follows: “Carrying out physician’s orders for what I consider to be unnecessary tests and treatments” (mean score 1.66); “Follow the family’s wishes to continue life support even though I believe it is not in the best interest of the patient” (mean score 1.31); and “Fol- low the physician’s request not to discuss the patient’s prognosis with the patient or family” (mean score 1.26). Nurses who had a high moral distress level were three times more likely to consider leaving their position compared with respondents who had a medium or low moral distress level (8.7% and 2.9%, respectively; p < .05). Conclusions: Our findings provide evidence on the association between moral distress and intention to leave the profession. Situations that may lead health professionals to be in moral distress seem to be mainly related to the unethical work environment. Clinical Relevance: The findings of this study reported that moral distress plays a role in both personal and organizational consequences, including negative emotional impacts upon employees.

Nursing as a profession is grounded in moral obliga- Papathanassoglou, & Karanikola, 2017; Papathanassoglou tion (Corley, Minick, Elswick, & Jacobs, 2005; Kirilmaz, et al., 2012). Symptoms of anxiety and depression among Akbolat, & Kahraman, 2015). Nursing practice is nurses experiencing moral distress include increased irri- grounded in ethical standards: to do no harm, to pro- tability, cynical attitudes toward the patients, and increases mote justice, to be accountable, and to provide safe in the likelihood of making medication errors (Lamiani, and competent care (Kirilmaz et al., 2015; Rushton Dordoni, & Argentero, 2018). & Stutzer, 2015). The nature of the nurse–patient Finally, the moral distress of nurses can not only therapeutic relationship requires acting on the patient’s reduce patient safety and lower productivity, but can behalf (Kief, de Brouwer, Francke, & Delnoij, 2014). also increase burdens on the healthcare system in terms Moral distress was first described in the 1980s and of financial and human resources (Austin et al., 2016; was expressed as suffering that arises from incoherence Lamiani et al., 2018). between one’s actions and convictions (Jameton, 1984). Moral distress consists of negative stress symptoms that Aims occur in situations that involve ethical situations that nurses perceive as discordant with their professional The purpose of this study was to describe the level values (Mealer & Moss, 2016). Limitation of resources, of moral distress experienced by nurses, situations that changes in the role of a nurse, staff shortages, lack most often caused moral distress, and the intentions of competence of some healthcare professionals, and of the nurses to leave the profession. certain organizational constraints can all contribute to The research questions were: (a) What is the level the nurse’s moral distress (Corley et al., 2005). This of moral distress in a selected sample of registered is especially problematic in situations where the number nurses practicing in municipal hospitals in Lithuania? of staff members is so low that it is not possible to (b) Which clinical situations most often trigger moral deliver acceptable nursing care, which leads to sub- distress? And (c) Is moral distress correlated with the standard patient outcomes (De Veer, Francke, Struijs, intention to leave the profession? & Willems, 2013). Nurses experience conflict not only when organizational constraints do not allow them to Methods operate according to their moral values, but also when they act in accordance with their own conscience but Research Design in conflict with laws and regulations (De Veer et al., 2013). Nurses feel emotionally distressed when they A descriptive, cross-sectional, correlational design was must act in a way that contradicts their personal beliefs applied in this study. and values and when they know which is the correct moral decision, but they are unable to implement this Sample decision. In their daily practice, nurses encounter dif- ficult ethical decisions due to both individual and Registered nurses were recruited from five large, organizational factors (Ameri, Safavibayatneed, & urban Lithuanian municipal hospitals representing the Kavousi, 2015). Nurses working in intensive care units five administrative regions in Lithuania (Kaunas, (Wiegand & Funk, 2012), oncology (Ameri et al., 2015; Klaipėda, Panevėžys, Alytus, and Marijampolė). Wahlberg, Nirenberg, & Capezuti, 2016), and palliative Municipal hospitals are multiprofile hospitals provid- care (Edwards, McClement, & Read, 2013) have reported ing both general and specialized healthcare services. moral distress that significantly affects their quality of The five hospitals have a combined total of 2,672 life as well as their intention to remain working at beds. Among the 2,560 registered nurses, from all their place of employment or in the profession (Austin, unit types and specialities (surgical, therapeutic, and Saylor, & Finley, 2016). The most common symptoms intensive care), working in the five participating hos- of moral distress are anger, anxiety, depression, sleep pitals, 900 were randomly selected to be recruited for disturbances, abusiveness, guilt, sadness, and tension the study. The study sample of 2,560 was based on (Weigand & Funk, 2012). a 95% confidence interval and 5% error probability Moral distress in nurses has been associated with (Tepping, 1967). According to the sample calculation psychological discomfort and low patient safety standards, formula, we had to interview 378 nurses (22,500 nurses such as dysfunctional communication among clinicians, in Lithuania, 95% probability, and 0.05 error percent- medication errors, and negative work attitudes, including age). Since we expected not all would voluntarily burnout, intention to quit work, and low job satisfac- consent to participate, we chose a higher sample size tion (Austin et al., 2016; Christodoulou-Fella, Middleton, to be adequately powered.

Measures of possible individual item scores was 0 to 16. A moral distress score was calculated for each respond- Moral distress was measured using the Moral Distress ent by summing the respondent’s item scores. The Scale–Revised (MDS-R; Hamric, Borchers, & Epstein, level of significance selected for testing data points 2012). A translated and validated Lithuanian version was established at p ≤ .05, meaning the difference utilizing inverse translation was used in this study. was statistically significant. Descriptive statistics were The developer of the MDS-R granted permission to used to calculate the average values of the variables the researcher to use the instrument. The MDS-R is within a 95% confidence interval. Statistical analysis designed to measure nurses’ experiences of moral dis- of qualitative ordinal variables was carried out by tress in 21 clinical situations. Respondents were asked means of the chi-square (χ2) test and Z test. to indicate on a 4-point Likert scale (from 0 = none to 4 = a great extent) the level of moral distress they experienced in each clinical situation and how fre- Ethical Considerations quently (0 = never to 4 = very often) they encountered The study was approved by the Bioethics Committee the situation. The MDS-R allows for separate analysis at the Lithuanian University of Health Sciences (BEC-KS of intensity and frequency, and creates a composite [M]-566). Hospital administrations were informed of the score for each individual item (frequency multiplied research goals, and their permission was obtained prior by intensity). The composite score ranges from 0 to to starting the study. In addition, verbal informed consent 16 for each item and the total possible score ranges was obtained from each participant of the study follow- from 0 to 336 for the 21-item scale. Tertiles of the ing an explanation of the research study goals during moral distress summing score divide the variation line the face-to-face recruitment process. Nurses had the right into three approximately equal parts, designated as to refuse participation in the study or withdraw at any Q1 (low moral distress), Q2 (moderate moral distress), point without penalty. Confidentiality of respondents was and Q3 (high moral distress). assured, and anonymity was maintained since respondents Psychometric testing of the MDS-R yielded Cronbach were never asked for any personal identifiers such as α reliabilities of 0.89 for nurses and 0.67 for physi- their names, surnames, or addresses. Data were sum- cians (Hamric et al., 2012). The last MDS-R scale marized and reported only in the aggregate. contains four questions about the intentions to leave the profession due to moral distress. Demographics collected included age, gender, employment, current Results work place, and length of current employment. Sample Characteristics

Data Collection Table 1 describes the sample characteristics in total and by hospital. Nurse participants’ ages ranged from One of the authors (L.L.) distributed the question- 18 to 73, with an average age of 45.8 (SD = 9.852) naires face-to-face to nurses at the hospitals during work years, and the average length of service was 25.00 hours from September to November in 2017. Of the (SD = 10.75) years. 10.9% of nurses had higher uni- 900 surveys distributed, 612 questionnaires were com- versity education and 68.9% of nurses worked in a pleted, for a response rate of 68%. Depending on the mixed shift (see Table 1). Tallies showed that 32.6% hospital, the response rate ranged from 61% to 81%. of nurses worked in a surgery department, 18.5% in an intensive care department, and 48.9% in an internal medicine department (Table 2). Data Analysis Survey data were analyzed using the statistical Registered Nurses’ Perceptions of Moral Distress software package SPSS Statistics for Windows version 19.0 (IBM Corp., Armonk, NY, USA). The mean val- In this study, MDS-R reliability was supported, with ues of moral distress were calculated. Means were a Cronbach’s αof 0.86 for nurses. Among the 612 computed from intensity and frequency ratings for participants, 206 nurses (32.3%) reported a low level each item on the MDS-R. An item score was com- of moral distress (mean score of 1.09); 208 (33.9%) puted for each of the 21 items. Each item score a moderate level of distress (mean score 2.53), and was calculated by multiplying the mean of the moral 207 (33.8%) a high level of (mean score 3.0). The distress intensity ratings by the mean of the moral mean moral distress frequency was 0.85 (SD = 1.09), distress frequency ratings for that item. The range with a range of 0 to 4. As indicated in Table 3, the

Table 1. Sample Characteristics

Hospitals by region

Characteristic n % Kaunas Klaipeda Panevėžys Alytus Marijampolė

Age, years (N = 612) 18–44 187 30.1 31 (30.7%) 28 (29.5%) 95 (34.3%) 15 (18.5%) 18 (26.9%) 44–50 208 33.5 36 (35.6%) 27 (28.4%) 89 (31.1%) 27 (33.3%) 29 (43.3%) ≥51 226 36.4 34 (33.7%) 40 (42.1%) 93 (33.6%) 39 (48.1%) 20 (29.9%) Educational preparation (N = 612) Higher university education 69 11.1 15 (14.9%) 21 (22.1%) 24 (8.7%) 3 (3.7%) 6 (9.0%) College 552 88.9 86 (85.1%) 74 (77.9%) 253 (91.3%) 78 (96.3%) 61 (91.0%) Shift (N = 612) Morning 113 18.2 21 (20.9%) 12 (12.6%) 61 (22%) 10 (12.3%) 9 (13.4%) Night/afternoon 78 12.6 20 (19.8%) 0 (0%) 36 (13%) 4 (4.9%) 18 (26.9%) Mixed (morning, afternoon, and 430 69.2 60 (59.4%) 83 (87.4%) 180 (65.0%) 67 (82.7%) 40 (59.7%) night shift) Years of experience in nursing (N = 612) 0–5 56 9.0 16 (15.8%) 13 (13.7%) 25 (9%) 0 (0%) 2 (3.0%) 6–15 59 9.5 12 (11.9%) 7 (7.4%) 33 (11.9%) 3 (3.7%) 4 (6.0%) 16–25 151 24.3 24 (23.8%) 15 (15.8%) 75 (27.1%) 18 (22.2%) 19 (28.4%) 26–31 177 28.5 22 (21.8%) 24 (25.3%) 75 (27.1) 30 (37.0%) 26 (38.8%) >31 178 28.7 27 (26.7%) 36 (37.9%) 69 (24.9%) 30 (37.0%) 16 (23.9)

Note. Total number of respondents = 612. most commonly experienced situations that resulted not reported as resulting in moral distress. Among the in moral distress were: “Carrying out physician’s orders six situations with a moral distress frequency of greater for what I consider to be unnecessary tests and treat- than 1, those that were more likely to lead to moral ments” (mean score 1.66); “Follow the family’s wishes distress were: “Initiating extensive life-saving actions to continue life support even though I believe it is when I think they only prolong death” (mean score not in the best interest of the patient” (mean score 1.56); “Following the family’s request not to discuss 1.31); and “Follow the physician’s request not to dis- death with a dying patient who asks about dying” cuss the patient’s prognosis with the patient or family” (mean score 1.52); and “Carrying out the physician’s (mean score 1.26). orders for what I consider to be unnecessary tests A score of 0 means that nurses do not experience and treatments” (mean score 1.48). The lowest distress a situation; in this sample, most clinical situations were was noted when “Increasing the dose of sedatives or

Table 2. Moral Distress Level Associated With Registered Nurse Age and Clinical Settings

Moral distress level associated with age (%)

Up to 44 years 44–50 years ≥51 years χ2 df p 21.025 4 <.0001 Low level 27.2 32.4 39.2* Moderate level 30.9 35.0 34.6 High level 41.8 32.6* 26.2*

Moral distress level associated with clinical settings (%)

Internal medicine Surgery Intensive care department department department χ2 df p 7.845 4 .097 Low level 32.6 35.5 28.7 Moderate level 36.6 29.4 32.8 High level 30.8 35.2 38.5

Note. Z test. *p < .05 compared to age <44 group.

204 Journal of Nursing Scholarship, 2020; 52:2, 201–209. © 2019 Sigma Theta Tau International Laurs et al. Nurses Moral Distress and Intention to Leave the Profession opiates for an unconscious patient that I believe could unit (38.5%), but no statistically significant differences hasten the patient’s death” (mean score 0.93). The were found (χ2 = 7.845; df = 4; p = .097; see Table 2). correlation between moral distress frequency and moral distress intensity was significant r( = 0.375–0.553; p Registered Nurses’ Perceptions of Sources of Moral < .05). Distress Low levels of moral distress were more common among the older age group of nurses (39.2%), and As shown in Table 4, seven situations were associ- a high level of moral distress dominated among the ated with high levels of distress for nurses. The three youngest nurses (41.8%). These differences are statisti- highest were: “Carry out the physician’s orders for cally significant χ( 2 = 21.025; df = 4; p < .05; see what I consider to be unnecessary tests and treat- Table 2). ments”; “Follow the family’s wishes to continue life Analyzing the level of moral distress expression by support even though I believe it is not in the best departments, we can see that a high level of distress interest of the patient”; and “Follow the family’s request prevailed among nurses working in an intensive care not to discuss death with a dying patient who asks

Table 3. Moral Distress Scale Items Associated With Highest Levels of Moral Distress

Moral distress rating

Item Frequency Intensity Item score

1 Provide less than optimal care due to pressures from administrators or insurers 0.57 1.02 0.59 to reduce costs. 2 Witness healthcare providers giving “false hope” to a patient or family. 0.79 1.15 0.91 3 Follow the family’s wishes to continue life support even though I believe it is not 1.31 1.47 1.94 in the best interest of the patient. 4 Initiate extensive life-saving actions when I think they only prolong death. 1.12 1.56 1.75 5 Follow the family’s request not to discuss death with a dying patient who asks 1.24 1.52 1.89 about dying. 6 Carry out the physician’s orders for what I consider to be unnecessary tests and 1.66 1.48 2.45 treatments. 7 Continue to participate in care for a hopelessly ill person who is being sustained 1.16 1.42 1.64 on a ventilator, when no one will make a decision to withdraw support. 8 Avoid taking action when I learn that a physician or nurse colleague has made a 0.67 1.34 0.90 medical error and does not report it. 9 Assist a physician who, in my opinion, is providing incompetent care. 0.74 1.21 0.90 10 Be required to care for patients I don’t feel qualified to care for. 0.62 1.25 0.77 11 Witness medical students perform painful procedures on patients solely to 0.69 1.17 0.81 increase their skill. 12 Provide care that does not relieve the patient’s suffering because the physician 1.03 1.37 1.41 fears that increasing the dose of pain medication will cause death. 13 Follow the physician’s request not to discuss the patient’s prognosis with the 1.26 1.18 1.49 patient or family. 14 Increase the dose of sedatives/opiates for an unconscious patient that I believe 0.53 0.93 0.49 could hasten the patient’s death. 15 Take no action about an observed ethical issue because the involved staff 0.46 1.07 0.49 member or someone in a position of authority requested that I do nothing. 16 Follow the family’s wishes for the patient’s care when I do not agree with them, 0.75 1.33 1.00 but do so because of fears of a lawsuit. 17 Work with nurses or other healthcare providers who are not as competent as 0.63 1.29 0.80 the patient care requires. 18 Witness diminished patient care quality due to poor team communication. 0.64 1.24 0.79 19 Ignore situations in which patients have not been given adequate information to 0.58 1.02 0.59 insure informed consent. 20 Watch patient care suffer because of a lack of provider continuity. 0.63 1.17 0.74 21 Work with levels of nurse or other care provider staffing that I consider unsafe. 0.72 1.32 0.95

Note. Total number of respondents = 612.

Table 4. Most Common Sources of Moral Distress Identified by Nurses

Item score Item (mean) SD

1 Carry out the physician’s orders for what I consider to be unnecessary tests and treatments. 2.45 1.47 2 Follow the family’s wishes to continue life support even though I believe it is not in the best interest of the 1.94 1.31 patient. 3 Follow the family’s request not to discuss death with a dying patient who asks about dying. 1.89 1.25 4 Initiate extensive life-saving actions when I think they only prolong death. 1.75 1.41 5 Continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one 1.64 0.98 will make a decision to withdraw support. 6 Follow the physician’s request not to discuss the patient’s prognosis with the patient or family. 1.49 1.38 7 Provide care that does not relieve the patient’s suffering because the physician fears that increasing the 1.41 1.31 dose of pain medication will cause death.

Note. Total number of respondents = 612. about dying” (their average scores were 2.45, 1.94, often based on the nurses’ concern for their patients. and 1.89, respectively). In general, nurse participants Nurses who do not agree with the treatment deci- struggled with the discrepancy between the doctor’s sions prescribed by the physician may experience and family’s desires for care that best suited the patient’s moral distress if they think that these decisions are interests and clinical condition. not consistent with the patient’s wishes. (Dillworth et al, 2016; Dudzinski, 2016). This was one of the most commonly encountered situations that was caus- Registered Nurses’ Intention to Leave the ing moral distress for these study participants. Studies Profession carried out in Saudi Arabia, Canada, and the United As indicated in Table 5, nurses with a high moral States reported results similar to ours (Abumayyaleh, distress level are more likely to consider leaving their Khraisat, Hamaideh, Ahmed, & Thultheen, 2016; position compared with respondents with a moderate Dodek et al., 2016; Lusignani, Gian, Giuseppe, & or low moral distress level (8.7% vs. 2.4% and 2.9%, Buffon, 2016). respectively; p < .05). The other two most commonly encountered situations in our study were related to the physicians’ and relatives’ decisions about the health status of the patient. Discussion For example, the most intense and frequent moral This study is the first in Lithuania to report the distress experienced by the participants were all related moral distress of nurses that includes the work situ- to providing high-intensity treatments (Borhani, ations associated with distress. Moral distress is most Mohammadi, & Roshanzadeh, 2015) to patients with advanced serious illnesses without the likelihood of recovery. Treatments such as ventilators, other life sup- Intentions to Leave the Profession With Moral Distress Level Table 5. port (e.g., transfusions, cardiopulmonay resuscitation) Scores were viewed as futile treatments by the nurses since Moral distress level they only prolonged suffering and did not cure the patient’s underlying illness; thus, the nurses experienced Low level Moderate level High level moral distress (Hamric & Blackhall, 2007; Lusignani n (%) n (%) n (%) et al., 2016; Oh & Gastmans, 2015). These concerns are closely linked to honest communication regarding Not considered leaving in 164 (79.6) 160 (76.9) 115 (55.6)* the past prognosis to patients in the terminal phase of their Considered leaving in the 25 (12.1) 32 (15.4) 56 (27.1)* illness. Although this may be a problem between past but did not leave patients and their physicians, honest communication Considering leaving now 11 (2.9) 5 (2.4) 18 (8.7)* may be requested by the family. This is often the Yes, I will leave a position 11 (5.3) 11 (5.3) 18 (8.7) most frustrating for nurses, especially when they feel for moral distress they do not have the professional or institutional power Total 206 (100) 208 (100) 207 (100) to change clinical decisions. Note. Total number of respondents = 612. The results of this study closely correlate with the *p < .05 when comparing low and moderate moral distress level. results of similar studies conducted on nurses in Iran

206 Journal of Nursing Scholarship, 2020; 52:2, 201–209. © 2019 Sigma Theta Tau International Laurs et al. Nurses Moral Distress and Intention to Leave the Profession and Australia (Robaee, Atashzadeh-Shoorideh, shaping national health policies, improving nursing Ashktorab, Baghestani, & Sharifabad, 2018; Rushton, careers in the labor market, and improving both their Caldwell, & Kurtz, 2016). These situations that prompt professional life and quality of life. moral distress are directly related to the welfare of Since this was the first study among Lithuanian nurses the patient (Hamric & Blackhall, 2007; Dudzinski; 2016). working in municipal hospitals that assessed moral distress, Another study undertaken in United States by Dillworth factors contributing to moral distress, and the intention and colleagues (2016) also confirms our results. The of nurses to leave the profession, certain limitations of nurses involved in the study identified that one of research were inevitable. One of them was not assessed: the major issues regarding end-of-life decision making the impact of the leadership role and the organizational was disagreement over prolonging life vs. quality of culture of moral distress. Therefore, these factors should life, ineffective communication between the patient be evaluated in the following tests. In particular, the and the patients’ relatives, and lack of time and unre- reorganization of the healthcare system in Lithuania is alistic expectations (Dillworth et al., 2016). currently underway, which also could be increasing ten- At times, ongoing aggressive life-prolonging interven- sion and moral distress. tions for a terminally ill patient can create ethical Despite these limitations, this study showed that conflicts and moral distress for nurses. Nurses experi- nursing care and in-patient care in Lithuania, with a ence a clash between the institution’s and the patient’s limited legal framework for care at the end of life, definition of adequacy of care. Turnover is a critical correlated with data from other countries and revealed issue for the nursing workforce, negatively affecting that despite the different socio-economic and cultural the health system and quality of the nursing services factors among other countries, nurses have a holistic (Roche, Duffield, Homer, Buchan, & Dimitrelis, 2015). approach to patient care and give priority to patient In a study by U.S. researchers conducted on health- autonomy, preferences, and interests. care professionals, the intention of the nurse to leave Nursing education and nursing science in Lithuania the profession was found to be closely related to moral are relatively young. A significant proportion of nurses distress. Conflict between professional and personal are leaving the profession, so it is very important to values in professional activities was found to lead to identify their reasons for leaving and to analyze whether the development of moral distress (Whitehead, the data correlate with those of countries where nurs- Herbertson, Hamric, Epstein, & Fisher, 2015). A study ing has a much longer history. conducted in 10 European countries reported that 9% of 23,159 participants intended to leave the nursing Conclusions profession. The percentage varied between the countries and ranged from 5% to 17%. Two of the seven fac- The outcomes of this study support the position tors related to intent to leave were nurse–physician that moral distress is experienced by registered nurses relationships and burnout. Both are strongly correlated in Lithuania practicing in multiprofile hospitals. Our with situations that cause moral distress (Heinen et findings provide evidence on the association between al., 2013). Although Lithuania was not represented in moral distress and age, clinical settings, and intention the European study, it would seem the data reported to leave the profession. Situations that may lead health from this study uncovered some of the major issues professionals to be in moral distress seem to be mainly associated with intention to leave the profession. related to the unethical work environment, including The findings of this study reported that moral dis- lack of resources; lack of communication between tress plays a role in both personal and organizational nurses, physician, and families; and implementing consequences, including negative emotional impacts unnecessary treatments. Moral distress is associated upon employees. with intention to leave a position. By understanding Although many nursing study programs are devoted its root causes, interventions can be tailored to mini- to topics related to maintaining the patient’s autonomy mize moral distress, with the ultimate goal of enhanc- and enabling the patient to make independent deci- ing patient care, staff satisfaction, and retention. sions, in the healthcare system, taking the position Supporting nurses with moral distress is essential for that “the doctor knows best” is still dominant. keeping them in the profession. Additionally, although the prestige of nurses is chang- ing, professional autonomy is increasing, and compe- tencies are expanding, teamwork and cross-sectoral Acknowledgments cooperation are still lacking (Jaruseviciene et al., 2013). The research team gratefully acknowledges all the The data from this study will be very useful in registered nurses who participated in the survey. Also

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