Purpose: To examine relationships between moral distress, moral distress residue, and moral courage and to determine which nurse characteristics are predictive of moral distress and moral courage. Methods: The study used a mixed methods cross-sectional correlation design and qualitative content analysis to investigate oncology nurses' characteristics and relationships between moral distress, moral distress residue, and moral courage. A convenience sample of 187 oncology nurses working in inpatient and outpatient settings was recruited through the national Oncology Nursing Society in the Southeastern United States. Hamric's 21-item Moral Distress Scale-Revised (MDS-R) and Sekerka et al. 15-item Professional Moral Courage Scale (PMCS) supplemented with written examples of moral courage were used for data collection. Descriptive statistics, independent-samples t test, Pearson correlation, ANOVA, and multiple regressions analyses were used to evaluate data. Findings: MDS-R scores were not predictive of PMCS scores. No statistically significant differences were found between nurses' characteristics (age, education level, certification, ELNEC training) and MDS-R. Though nurses with BSN had higher Moral Distress scores compared with other levels of education, none were predictors of MDS-R. ANOVA results indicate a marginal but not significant difference of the MDS-R score among the nurses with different basic ethics education (p = .067). Nurses working in adult inpatient settings had significantly higher MDS-R than those in outpatient settings. Nurses who had moral distress residue by virtue of leaving a previous job (26%) and those who considered leaving (28%) reported statistically significantly higher mean Moral Distress levels than those who had not considered leaving. Nurses (17%) currently considering leaving their jobs due to the way patient care was handled at their institutions had the highest Moral Distress mean scores and the lowest Professional Moral Courage scores. Work setting and having left a previous job were weak predictors of MDS-R, accounting for 11.6% of the moral distress score variance (p = .013) compared with 4.4% when work setting was a single predictor (p = .014). Total years' oncology experience was a weak predictor of PMCS, accounting for 2.5% or an inconsequential amount of the variance (p = .043). Moral courage was displayed in major areas of supporting the patient, risk taking, advocacy, enlarging the circle for decision-making, putting aside personal beliefs, respecting patient autonomy, empowering the patient, fighting for the patient in face of consequences in a complex system, sharing information, getting to the meaning, handling tricky situations, protecting the patient and truth-telling. Discussion/Implication: Despite experiencing levels of moral distress, oncology nurses demonstrate support and respect for patients' decision-making and autonomy. Ethics education derived from clinical practice can provide an opportunity for open discussion for nurses to create and maintain morally acceptable work environments that enable them to be morally courageous. This research underscores the presence of moral distress and moral distress residue among oncology nurses and the importance of finding ways to lessen moral distress and strengthen moral courage in nurses.


If this is your thesis or dissertation, and want to learn how to access it or for more information about readership statistics, contact us at STARS@ucf.edu

Graduation Date





Chase, Susan


Doctor of Philosophy (Ph.D.)


College of Nursing



Degree Program










Release Date


Length of Campus-only Access

3 years

Access Status

Doctoral Dissertation (Open Access)

Included in

Nursing Commons