Moral distress and ethical climate in a Swedish nursing context: perceptions and instrument usability

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Aims and objectives.

The aim was fivefold: to describe Swedish nurses’ perceptions of moral distress and determine whether there were differences in perceptions depending on demographic characteristics and to describe the usability of the Moral Distress Scale in a Swedish context. Further, the aim was to describe Swedish nurses’ perceptions of ethical climate and the relationship between moral distress and ethical climate.


Moral distress has been studied for more than two decades and the Moral Distress Scale is the most widely used instrument for measuring it. Moral distress has mainly been studied in relation to nurses’ characteristics, but increasing attention has been paid to contextual aspects, such as ethical climate, that could be associated with moral distress.


Descriptive, with a quantitative approach.


The study used two questionnaires: the Moral Distress Scale and the Hospital Ethical Climate Survey. The study was carried out at two hospitals in Sweden and included 249 nurses.


Both level and frequency of moral distress were low, however level of moral distress was high in situations when the patient was not given safe and proper care. Generally, the frequency of moral distress was lower than the level. Of the situations on the Moral Distress Scale, 13 of the 32 were considered irrelevant by 10–50% of the participants. The more positive the ethical climate was perceived to be, the less frequently morally distressing situations were reported.


Since a positive ethical climate was associated with less frequent occurrences of moral distress, it should be investigated what contributes to a positive ethical climate. To be used in a Swedish context, the Moral Distress Scale needs further revision.

Relevance to clinical practice.

Open dialogues at wards are encouraged regarding what practices contribute to a positive ethical climate.

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