Date of Degree


Document Type


Degree Name





Elizabeth Capezuti

Committee Members

Laura M. Wagner

Lynda Olender

Ramona Backhaus

Rong Zhao

Steven L. Baumann

William Ellery Samuels

Subject Categories

Nursing Administration


Intent to stay, moral distress, nurse practice environment, long-term care, structural equation modeling


Background: Many long-term care facilities in the United States face significant problems with nurse retention and turnover. These challenges are attributed at least in part to moral distress and a negative nurse practice environment. Licensed nurses working in long-term care facilities experience ethical challenges such as lack of resources, use of restraints, end-of-life issues, and caring for residents with dementia that, if not resolved, can lead to moral distress- especially if left unresolved. Long-term care administrators and nurse managers increasingly strive to improve leadership support for long-term care staff that will positively affect the nurse practice environment.

Aim/Purpose: The purpose of the study was to investigate the relationships between nurse practice environment, moral distress, and intent to stay, including the potential mediating effect of the nurse practice environment on the intent to stay among those with high levels of moral distress. Secondarily, the reliability and validity of the Intent to Stay Questionnaire, Direct Care Staff Survey, and Moral Distress Questionnaire were evaluated in long-term care nurses.

Methods: This descriptive cross-sectional design study included an online, national survey of long-term care nurses’ perceptions of their intent to stay, moral distress level (Moral Distress Questionnaire), and nurse practice environment (Direct Care Staff Survey). Descriptive, correlational, regression, reliability, confirmatory factor analysis, and structural equation modeling (SEM) analysis were used to explore intent to stay, moral distress, and the nurse practice environment among long-term care nurses.

Results: A total of 215 participants completed the surveys. Participants were nationally representative of long-term care nurses by age, years of experience, employment status, and type of health setting. Predominantly the sample was white and female licensed practical nurses. The computed SEM suggested a partially mediated model. The mean moral distress score was low while the mean nurse practice environment and intent to stay were high. Moral distress was found to have a moderate negative association with nurse practice environment (β = -0.41) while nurse practice environment had a significant, moderately positive association with intent to stay (β = 0.46). The moral distress had a significant, moderately negative association with intent to stay (β = -0.20). The computed SEM suggested a partially mediated model (Indirect effect= -0.19, p=0.001). The ITS, DCSS, and MDQ demonstrated to be reliable and valid measures of intent to stay, nurse practice environment, and moral distress, respectively, among licensed nurses working in institutional long-term care.

Conclusion: Since the relationship between moral distress and intent to stay is partially mediated by the nurse practice environment, interventions aimed at improving the nurse practice environment are crucial to alleviating moral distress and enhance nurses’ intention to stay in their job, organization, and the nursing profession. Moral distress is understudied in long-term care and should be explored in further research.