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SUPPORT: An Evidence-Based Model for Leaders Addressing Moral Distress

Pavlish, Carol PhD, RN, FAAN; Brown-Saltzman, Katherine MA, RN; So, Loretta MSN, RN, CGRN; Wong, Julia BS

JONA: The Journal of Nursing Administration: June 2016 - Volume 46 - Issue 6 - p 313–320
doi: 10.1097/NNA.0000000000000351

OBJECTIVE: The aim of this study is to explore nurse leaders’ experiences working in ethically difficult situations and helping nurses cope with moral distress.

BACKGROUND: Moral distress is associated with ethically complex situations where nurses feel voiceless and powerless. Moral distress can lead to disengagement, burnout, and decreased quality of care.

METHODS: The critical incident technique was used to collect descriptions of ethically complex situations from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and subsequently counted.

RESULTS: Participants noted affective, behavioral, cognitive, physical, and relational signs of moral distress. System-level factors along with team conflict and different perspectives were perceived to increase the probability of ethical conflicts. Key actions to address moral distress included acknowledging its presence, creating a culture of care, and increasing nurses’ resilience to difficult circumstances through education, support, and collaboration.

CONCLUSIONS: On the basis of study findings, we created the SUPPORT model as an action guide for addressing moral distress.

Author Affiliation: Associate Professor (Dr Pavlish), Student Research Assistant (Mss So and Wong), School of Nursing, University of California, Los Angeles; Codirector of Ethics Center (Ms Brown-Saltzman), Quality and Safety Specialist (Ms So), University of California, Los Angeles, Health System.

The authors declare no conflicts of interest.

Correspondence: Dr Pavlish, School of Nursing, University of California, Los Angeles, Factor 4-238, 700 Tiverton Ave, Los Angeles, CA 90095 (

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.