Date of Award

January 2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Nursing

First Advisor

Rhoda A. Owens

Second Advisor

Dawn L. Denny

Abstract

Background: Moral distress is an occupational hazard for nurses that can negatively impact nurses, patients, and the healthcare system. Moral distress has been well documented in high-risk care environments. Each nursing care environment has its own unique triggers for moral distress, but these triggers are unknown in rural clinic nurses. Design and Purpose: This convergent mixed methods study sought to gain a broader understanding of moral distress in nurses working in rural clinic settings.

Methods: Convergent mixed methodology was used to gain a broader understanding of moral distress in nurses working in rural clinic settings. Following ethical approvals, informed by Rural Nursing Theory, this study consecutively sampled nurses employed in rural clinics (RUCA 4.0-10.0) across 4 states in the midwestern United States. Moral distress was assessed with the Measure of Moral Distress for Healthcare Professionals (MMD-HP) and written narrative questions from a sample of 52 nurses. Data were analyzed through thematic and correlation analyses, respectively, then merged.

Results: Mean moral distress was 74.7 (SD = 76.8), range was 0 to 246, and no significant relationships were found between moral distress, demographic characteristics or work experience variables. Four main themes were identified: 1) Lack [of something] leads to Moral Distress 2) Barriers to Patient Care and Adherence 3) Inappropriate Healthcare Utilization 4) Care and Practice Factors that Lead to Moral Distress.

Discussion and Implications: Rural clinic nurses experience moral distress for reasons unique to rural practice, while other triggers are shared with urban nurses. Convergent data that triggered moral distress for rural clinic nurses overlapped existing literature and supported items in the MMD-HP. Divergent data that triggered moral distress supported Rural Nursing Theory. Further research is warranted on sources of moral distress for rural clinic nurses, especially inappropriate healthcare utilization. Results may inform interventions specific to mitigating moral distress in rural clinic nurses.

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