Ethical stress and its effects on burnout rates among registered nurses

Ethical stress and its effects on burnout rates

among registered nurses
Trina Schulz
Wayne State University

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Abstract
Nurses everywhere are afflicted with stressful ethical situations within the workplace.
This ethical stress is defined as any situation that presents a strain on ones personal beliefs and
morals. It then necessary, if burnout rates are so high among registered nurses (RNs), to assess
the causes of these ethically stressing factors and discuss proposals for future research to
decrease these situations. Here it is proposed that case studies be conducted and data be
quantified to determine burnout rates among nurses. This will in turn promote awareness of
ethical stress in the nursing community so more research may be conducted to absolve this issue
and keep nurses working in the nursing community longer.
Introduction
This is a purposed research project on the effect of ethical stress on registered nurses and
its correlation with burnout rates. This research is being proposed to further the nursing
communities understanding of how ethical situations affects practicing nurses. It is the hope of
this study to reveal the increasing amount of burnout among nurses in order to bring awareness
to this significant problem and encourage more research to be done to come up with viable
solutions to decreasing burnout rates among RNs.
The medical field is experiencing a growing amount of nurse shortages (Corley., et al.,
2005). With these shortages a heavier workload is placed on those remaining. This results in an
increase in stress. Stressful ethical situations for RNs also arise according to Poncet et al., (2006)
when communication between medical professionals and their patients is subpar and when
aggressive treatment plans for the critically ill are continually implemented(Panino, Gianni, Re,
& Lusignani, 2015). Preliminary research has concluded that these three factors are the most
ethically stressful for nurses to encounter. It is therefore necessary to discuss the effects this

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stress has on nurses and ultimately of these reasons are why nurses choose to leave the field in a
time where nurses are so desperately needed.
The various causes of ethical stress have been thoroughly researched but the long terms
effects such as burnout rates have not. That is why this proposal is necessary. To prevent nurses
from leaving the community when they are stressed there must be concrete evidence to prove
how the ethical situations specified above divert nurses from their task of providing health and
wellness for their patients. But ultimately these issues can contribute to a loss of nursing
professionals. It is necessary then to continue research.
Information on previous research concerning the cause of ethical stress is abundantly
available. This allows for a starting point in examinging the current work environment for a
nurse. Ethical stress is rampant in the medical community, but is seen at alarming rates within the
nursing field. This type of stress occurs when a decision is made to the best of ones ability but
is unable to be carried out due to a variety of issues. It is important to note that this stress is
different than everyday stress. Ethical stress incorporates the values and personal beliefs of
someone in conflict with the patient or establishment one is working for. Research has been
conducted on this topic under the term moral distress, by Jameton (1993), but it is only now that
the research being conducted is conducive to finding a solution to the ethical climate that plagues
the nursing field.
As ethical stress increases it has been found that the rate of professionals leaving the
nursing community has increased as well (Poncet et al., 2006). The term for this is burnout.
Burnout can occur for many reasons. These include, according to Corley (2002), insufficient
nursing staff, inadequate education of staff personnel, unintentional objectification of patients,
and inability to act on the behalf of those suffering. In a study conducted by Ulrich et al., (2010)

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the most stressful situations nurses reported were inadequate staffing and advocacy for patients
rights. This is in agreement with Corley (2002) and partially with done by Poncet et al., (2006).
This study showed emotional exhaustion as the primary cause of burnout. In addition Poncet et
al., (2006) found that one of the largest problems within the community pertained to
communication errors between medical professionals and families.
To understand the correlation of ethical stress and burnout it is important to note the
various studies that have been conducted to measure the distress nurses experience. This ensures
that ethical stress is in fact present and provides a serious health risk to all nurses and patients
involved. There were three studies conducted that used an instrument called a moral distress
scale. This was used in a study by Corley (2002), Hamric & Blackhall (2007) and Corley,
Minick, Elswick, & Jacobs (2005). This tool functions as a quantitative way to measure the
frequency and intensity of moral distress. All three studies found the amount of stress to be too
high for a healthy work environment based upon statistical analysis.
In addition to using this scale, Corley, Minick, Elswick, & Jacobs (2005) used a questionnaire
entitled The Ethical Environment questionnaire. This was used to determine the positivity or
negativity of the work environment. A same test was used in Hamric & Blackhall (2007) in
addition to the moral distress scale. Both studies found that end of life care was seen as one of
the most stressful ethical issues. Corley (2002) concluded that most stress that results in burnout
is due to the cumulative effects of moral stress. Age was also found to be a contributing factor in
this study, claiming that nurses who were older or had more experience experienced less moral
distress than those new to the field.
Unlike the initial study by Corley (2002), the Corley, Minick, Elswick, & Jacobs (2005)
study showed sincere stress in RNs concerning end-of-life communication, the satisfaction and

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quality of care of patients, and collaboration with other medical personnel. Both studies
statistically agreed that according to the ethical environment questionnaire there is much still to
be done to improve the ethical environment of hospitals and in turn reduce burnout rates.
Almost every research study conducted pertaining to moral stress used the same type of survey
or questionnaire. In a study by Bartholdson, Sandeberg, Lutzen, Blomgren, & Pergert (2015) a
hospital ethical climate survey was distributed among 6 pediatric centers in Sweden. It was
found, according to the research, that lack of nurses and lack of influence were the most
challenging ethical struggles. This coincides with Corley (2002) and Ulrich et al., (2012) as
well.
Falco-Pegueroles, Lluch-Canut, Roldan-Merino, Goberna-Tricas, & Guardia-Olmos,
(2014) used a tool called the Index of Exposure to Ethical Conflict alongside a questionnaire to
conclude that the level of ethical stress and well-being of an RN was directly correlated to the
frequency of stressful ethical situations. It was also noted that analgesic treatment and secondary
post-traumatic stress were the most ethically stressful. Corley (2002) also found analgesic
treatment to be one of the more significant stress inducing situations, but was not found to be one
of the top ethically stress inducing factors.
Sannino, Giann, Re, & Lusignani, (2014) scientific research article used a crosssectional questionnaire survey. Also like Corley (2002), Ulrich et al., (2012), and Hamric &
Blackhall (2007) a moral distress scale was used except this one was adapted to pediatric care.
Not surprisingly the results of the Sannino, Giann, Re, & Lusignani, (2014) were fairly similar
to Corley (2002). The most significant reason for moral distress in both studies were related to
aggressive treatment plans towards those who werent likely to get better. It was under these
circumstances that nurses experienced the highest amount of ethical stress.

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It seems as though, according to the research done by many within the nursing discourse
community that ethical distress and moral stress are brought on most significantly by the
shortage of nursing staff , lack of communication between medical personnel and their patients.
It is obvious in the articles by Bartholdson, Sandeberg, Lutzen, Blomgren, & Pergert, (2015) and
Ulrich et al., (2012) and Falco-Pegueroles, Lluch-Canut, Roldan-Merino, Goberna-Tricas, &
Guardia-Olmos (2014) that the ethical climate is not at a safe value for practicing nurses mental
health. It is then hypothesized by Corley (2002) that burnout rates will continue to increase if no
action is taken. This is why it is now critical to examine how ethical stress affects burnout rates
of registered nurses and what can be done to solve this problem.
Many of the scientific studies conducted have used the same criteria and testing methods.
Some actually use the exact same surveys. This may be why data considering ethical stress rates
is so similar from study to study. A new tool to measure stress or specific case studies may help
in assisting research conducted to determine specific reasons for the burnout of registered nurses
and ultimately finding a solution.
There has been plenty of research conducted on the most strenuous ethical and moral
situations that plague nurses. There is an apparent discrepancy though when one tries to find any
research that implements a solution to accommodate the flawed nursing construct at hand. It is
known what causes ethical stress and according to many of the resources referenced above there
is a problem with the current ethical work environment. Research has been conducted and
quantified, questionnaires and surveys have been filled out, but the issue still remains. Therefore
research must continue.
From the existing data, it is seen that the ethical climate is not at practical levels for
ethical stress to not be an issue. It is therefore important to consider solutions to this rising

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problem. To do this research must first be able to establish the correlation of ethical stress and
increased burnout rates. Not much research has been done on this though. This is why it is worth
further research and analyzation to improve the ethical work environment, decrease burnout rates
and assist nurses in their tireless pursuit to promote health among their patients.
Methods
The initial research that is being proposed to be conducted will be quantitative. This will
be done by looking at 50 specific case studies of RNs, in various fields and ages, over a period
of ten years. Data will be gathered by an interviewer who will ask questions pertaining to levels
of stress experienced in accordance with specific situations found to be most ethically distressing
in previous studies. These ethical situation will be insufficient nursing staff (Corley, 2002),
(Corley, et al., 2005) communication errors between medical professionals and families (Poncet
et al., 2006) and aggressive treatment plans for the critically ill (Panino, Gianni, Re, &
Lusignani, 2015). These results will then be rated on a scale ranging from not ethically stressful,
moderately stressful, and to extremely ethically stressful. Interviewees will also be asked to rate
from 1 to 10, their inclination to leave the nursing work force or remain in the position they held.
These results will then be compared and organized by age, specialization, and whether or not the
subject left the nursing community entirely during the ten year study period. The results will then
be used to determine the relationship of these specific situations and how burnout rates are
affected by them. Those who verbally express high levels of emotional will receive more points
on the scale as will those who leave the nursing profession.
Anticipated Results
It is anticipated that nurses who are older, more established in their field, or have been
working longer in the medical community will experience less ethical stress and therefore a

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decreased rate in burnout. Those in the participants who are have been practicing for around
twenty-five years will be the most likely to experience symptoms of burnout or leave the nursing
community entirely. Nurses who are older or more experienced are less likely to experience
ethical distress due to their level of desensitization to stress factors that may have more bearing
on a nurse with less experience or age.
Discussion
The data from this research, if comes out as anticipated, will provide empirical evidence
that not only is burnout related to understaffing, aggressive treatment plans for the critically ill,
and poor communication between medical professionals and patients, but that these issues are
ongoing, problematic, and take a serious toll on the mental health of RNs. For the sake of the
medical field and patients health, it is essential to come up with viable solutions to these
problems. By conducting this study hopefully this issues will gain more recognition. With more
recognition there comes more funding for research to address these issues specifically.
This research may also inform medical professionals of the effects ethical stress can have on
those in the medical discourse community. By understanding the implications of the 3 situations
above RNs may be more aware of their susceptibility and thus create and maintain precautionary
measures. This is the intended result of this study; to establish an awareness of how ethical stress
often results in burnout, in hopes that more research will be conducted to stop this too frequent
occurrence.
If the research doesnt come out as expected there is then an opportunity for more
research. Possible issues could be the amount of case studies used, too broad of a pool of nurses,
or too small of a time frame of study for each case. Research to investigate these errors or others
may be done to discern other reasons for nurses leaving their jobs other than ethical stress. This

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would then generate a new research question pertaining to the cause of burnout and its relations
with various issues within the discourse community or factors that draw RNs from nursing to
other professions.
It is best to find a direct solution to what seems to be a failing nursing construct, but
preliminary research must first be conducted to solidify this statement and scientifically prove its
detriment to the medical community. It is only then that strides can be made in improving the
ethical climate of the workplace in hopes that nurses will be less likely to withdraw from their
work and patient safety and health will be further emphasized and more adequately executed.

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