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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 study explores how companies’ operations and supply networks can induce social impacts such as enhancing diversity, equity and inclusion (DEI). The study focuses on social enterprises’ supply networks and examines the effects of supply network characteristics on the creation and resolution of social–commercial objectives tension.

A supply network that is divided into five embedded cases, where each case is the supply network of a social enterprise, was studied. Forty-eight interviews at social enterprises, corporate customers, distributors, suppliers, non-governmental organizations and charities were conducted.

The study highlights how social enterprises use their supply networks to help disadvantaged people gain employment, truly balance DEI and efficiency objectives and manage paradoxical tensions. The results reveal three types of social purpose supply networks, dichotomized, paired and blended, that hybrid and for-profit organizations can adopt to jointly pursue multiple, potentially competing, objectives and resolve the paradoxical tensions in their supply networks. The creation and resolution of tension are also clarified by considering dyadic, triadic and tetradic tie structures.

The study contributes to the literature by extending the analysis of paradoxical tension between commercial and social welfare objectives such as DEI to the supply network level and revealing three social purpose supply network structures that depict social enterprises’ different ways to resolve paradoxical tensions. The study contributes to social network theory by describing the dynamic interaction between strong and weak ties in multi-tie structures.