Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)



Committee Chair

Jennifer R. Bail

Committee Member

Elizabeth G. Epstein

Committee Member

Todd B. Smith

Committee Member

Teresa D. Welch

Committee Member

Miranda M. Smith


Ethical problems--Nursing, Nursing ethics, Leadership--Nursing


Moral distress (MD) occurs when an individual knows the ethically correct action to take in a situation but institutional constraints prevent the individual from acting. MD is a well-documented phenomenon among nurses and occurs at a high frequency in the critical care setting. When MD is not adequately addressed and actions are not taken to mitigate precipitating factors within an organization, moral injury, moral residue, and burnout may consequentially result in nurses leaving their role or the profession. Nurse leaders are positioned to exemplify ethical leadership and provide support for their staff when MD is experienced; however, nurse leaders experience MD to a more global degree and much less is understood regarding the experience of MD among nurse leaders, as few studies have examined MD within this population. The aim of this dissertation was to explore the experience of MD among nurse leaders through qualitative methods. An initial qualitative study among unit-based critical care nurses in a single hospital in Alabama examining how unit-based critical care nurse leaders navigate MD among their staff revealed nurse leaders are likely to experience MD as a result of similar sources to staff nurses with the additional source of role-specific challenges. A qualitative systematic review revealed the known experiences, consequences, and strategies to address MD existing within the literature. A second, qualitative descriptive study conducted state-wide in Alabama among unit-based critical care nurse leaders converged with the findings of the qualitative systematic review and further added context to existing literature by revealing the experience of MD among nurse leaders may not be impacted by geographic contexts. Findings of these studies may inform the development or adaptation of MD measurement tools and interventions, conceptual and theoretical frameworks, and/or further exploration of the experience of MD among the nurse leader population.


Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Joint Nursing Science Ph.D. Program ...

Available for download on Thursday, December 11, 2025