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Nurse leaders are challenged by ethical issues in today’s complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries.

This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries.

The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries.

Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.

This ethnographic revisit of a general hospital aims to critically explore and describe the mechanisms of corporate culture change and how institutional excellence is facilitated and constrained by everyday management practices between 1996/1997 and 2014/2015.

A five-month field study of day-to-day life in the hospital's nursing division was conducted by means of an ethnographic revisit, using participant-observation, semi-structured interviews, free conversations and documentary material.

Using labour process analysis with ethnographic data from a general hospital, the corporate culture is represented as faceted, complex and sophisticated, lending little support to the managerial claims that if corporate objectives are realised, they are achieved through some combination of shared values, beliefs and managerial practices. The findings tend to support the critical view in labour process writing that modern managerial initiatives lead to tightened corporate control, advanced employee subjection and extensive effort intensification. The findings demonstrate the way in which the nursing employees enthusiastically embrace many aspects of the managerial message and yet, at the same time, still remain suspicious and distance themselves from it through misbehaviour and adaptation, and, in some cases, use the rhetoric against management for their own ends.

What are the implications for clinical and managerial practitioners? The recommendations are to (1) develop managerial practitioners who are capable of managing change combined with the professional autonomy of clinical practitioners, (2) take care to practise what you preach in clinical and managerial reality, as commitment, consent, compliance and difference of opinion are signs of a healthy corporate culture and (3) consider the implications between social structures and human actions with different work behaviours on different levels involved.

This ethnographic revisit considers data from a labour process analysis of corporate culture change in a general hospital and revisits the ways in which contradictory expectations and pressures are experienced by nursing employees and management practitioners spread 17 years apart.