Investigation of Moral Distress in Nurses of Jahrom Hospitals in 2018

Hasan Zabetian¹, Mohamad Javad Zarei², Fatemeh Honarmand Jahromy³, Saman Siasi⁴, Mohammad Radmehr¹ and Samaneh Abiri^5*

^*Correspondence: Samaneh Abiri, Department of Emergency Medicine, Jahrom University of Medical Sciences, Jahrom, Iran, Email:

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Introduction

Nurses are the largest part of health professional staff who have several roles and responsibilities in delivering health care services [1]. Their duties include promoting health, preventing illnesses, maintaining health and well-being, relieving pain and helping patients to adapt to existing conditions [2]. Since nurses spend more time with the patients, they are often the first to be aware of changes in patients' conditions. They can rescue patients from incidents leading to failure by implementing quick and life-saving interventions in order to reduce death rates. Nurses should be aware of physiological warning signs and be able to respond to rapid changes in patients' condition. In addition, they have strong confidence in clinical skills and functions [3] to evaluate patients’ information and promote the interventions needed for care [4]. In the discussion of factors affecting nursing employees, clinical work environment cannot be ignored because nursing performance can lead to proper outcome and safety of work according to its working environment [5]. Inappropriate working environment is one of the effective factors in leaving nursing career or retiring [6]. Working in hospital environment is physically challenging. A large number of nurses tend to change their work environment or leave their jobs, and some also apply for early retirement [7]. Clinical environments play a valuable role in facilitating the connection between theory and practice. Given the fact that professional nursing is continuously based on performance, the existence of supportive clinical environments is much important [8]. Clinical work environment is a set of information, resource allocation, support and learning opportunity, and a place for expanding and reinforcing personnel skills enabling nurses to work with a sense of cooperation and satisfaction [9]. Today's worldview approach can be considered a return to rationality and ethics. After going through various eras, humanity is going to provide a rational and ethical approach in the provision of its material and spiritual needs. For this reason, ethics can be considered the center of the developments in the world today. This approach affects many disciplines that are prerequisites for serving humans. The nursing profession is a science that has many moral and ethical implications both in the past and in the future [10]. Due to the fact that ethics is a matter of good decision-making and diagnosis of good from bad, professional ethics and decision-making based on professional morality can be considered equal to professional merit. It means that if a nurse obtained this merit and virtue based on professional ethics, and can distinguish good deed from bad deed and can make himself responsible to do good things and avoid bad things when confronted with working conditions, his actions will lead to the development of virtues at work [11]. Moral distress is described as an emotional discomfort or a state of mental imbalance which is developed as a result of lack of appropriate ethical action despite proper recognition due to obstacles such as lack of adequate time, opposition of superior authority, medical constraints, institutional policies and ethical considerations [12]. There are many stressors in the nursing profession that have an adverse effect on these employees. One of these tensions is the moral distress which is associated with various aspects of ethical issues [13]. Moral distress in nursing has been widely considered since 1980. Jameton first defined this concept in 1984 [14], and Wilkinson introduced a model of moral stress [15]. Jameton believed that ethical tensions arise due to organizational factors such as lack of time, lack of manager support, physicians' power, institutional rules, and legal constraints. He believed that moral tension caused unpleasant feelings that could cause anger, disappointment, anxiety, headache, digestive changes, sadness, and feelings of frustration, depression and moral mistakes. He also believed that the conflict between nurse's willingness to do good and ethical work and organizational rules on permissible actions were the source of moral stress for nurses in health environments [14]. Wilkinson explains moral stress as a psychological imbalance and a negative feeling that happen when a person is in a position unable to make a proper decision to solve a problem [15]. Therefore, moral distress puts nurses in a state of mental imbalance and prevents them from proper practices and decisions. They may inevitably do something that they believe to be wrong [16-18]. There was no significant difference in the frequency and severity of moral stress among nurses working in different parts according to Joolaee et al. [19]. In a study by Mohammadi et al. intended to investigate the relationship between moral distress and job control and demand in nurses of Tabriz hospitals, the results showed that moral distress had a positive significant relationship with job demand, and a negative significant relationship with job control. Therefore, the severity of moral distress is associated with an increase in job demand and a decrease in job control. Therefore, nursing ethics can be improved among nurses through the training of nursing ethics in order to reduce job demand and increase the quality of work [20]. Considering the potential significant impact of nurses' clinical performance on the quality of care and the necessity of measuring their performance, and the recognition and utilization of effective models and considering the results of various studies on the inconsistency in the level of moral distress, and the existence of evidence on its relationship with personal and occupational effective factors, further research in this field seems necessary. Therefore, the present study aims to investigate the moral distress of clinical nurses in Jahrom hospitals in 2018.

Materials and Methods

This descriptive cross-sectional study was conducted after obtaining permission (IR.JUMS.REC.1397.073) from the Ethics Committee of Jahrom University of Medical Sciences. This study started from the beginning of October 2018 and continued until November 2018. The population of this study included all nurses who were working at the time of the data collection in the intended wards of hospitals. Nurses were randomly selected if they had the criteria for entry into the study, i.e., employment in the hospital and consent with participation in the study. Criteria for elimination of participants from the data were the lack of consent to participate and incomplete questionnaires. The instrument of the study included a demographic questionnaire and Corley's Moral Distress Scale (MDS) [21]. Demographic data included age, gender, marital status, and work experience. The first Moral Distress Scale was developed by Corley et al. [22] with 38 items. Then, Moral Distress Scale, Revised (MDS-R) was designed and developed by Hamric et al. for nurses with 21 items [23]. In Iran, this instrument was translated to Farsi and validated by eliminating three items and thus it includes 18 items.

Scoring

The scoring was done based on a five-point Likert Scale. Score 1 indicates the lowest agreement with the item, and score 5 indicates the highest agreement with the item (very high=5, high=4, moderate= 3, low=2 and very low=1). A minimum score of 18 and a maximum score of 90. The mean of scores given by each nurse was considered as the moral distress score of that nurse. The score for each person's moral distress ranged from 1 to 5, and higher scores represent higher moral distress. Score 3 was considered as a moderate level of distress. Scores less than 3 means less moral distress and a more desirable condition, scores higher than 3 means higher moral distress and more unfavorable conditions [24,25].

Reliability and validity of the questionnaire

Corley et al. [22] assessed the content validity of the 38- item version of MDS. In addition, Hamric et al. assessed the content validity of the 21-item version of MDS-R and calculated the correlation of this instrument with multiyear experience of nurses (R=0.22) and ethical atmosphere of organization (R=-0.40) [23]. To obtain its reliability, Cronbach's alpha was used and the reliability of the whole questionnaire was 0.89. Simms et al. and Abbaszadeh et al. confirmed the content validity of the questionnaire through experts in the field and then used Cronbach’s Alpha to obtain its reliability. The reliability of the questionnaire was 0.75 indicating a proper reliability for this questionnaire [24,25].

Results

A total number of 145 nurses of Jahrom hospitals participated in this study among which 37.1 percent was male, 64.8 percent was married and 93 percent had BA degree and the rest had MA degree. The mean of their age was 30 with a standard deviation of around 7. Minimum age was 21 and maximum age was 57 among the nurses. After categorizing the age of participants, it was found out that 33.1% was 25 years old or younger, 48.6% was 26-35 years, 14.8% was 36-45 years and 3.5% was 45 years old or older. In terms of work experience, the mean and standard deviation of work experience was seven. The minimum working experience was 1 year and the maximum working experience was 29 years. After the classification, it was found out that the work experience of the participants is as follows: 55.7% had 5 years or less, 22.9% had 6-10 years, 9.2% had 11-15 years and 12.2% had over 15 years of work experience. The results are presented in Table 1.

Table 1: Frequency and percentage of participants according to demographic indicators

Investigation of the level of moral distress among clinical nurses

Table 2 shows the descriptive statistics of moral distress of nurses. According to the results, the mean score of moral distress of nurses is 2.77 with a standard deviation of 0.68. This mean is less than moderate score of 3 and is relatively desirable.

Table 2: Quantitative description of moral distress among clinical nurses

The minimum score for moral distress was 1.29 and the maximum score was 5. In addition, the median and mode of this variable are 2.72 and 2.67 respectively, which indicates that the state of moral distress is relatively desirable.

In order for a better description, moral distress scores were divided into 5 categories, i.e., very low, low, moderate, high and very high. The results are presented in Table 3. It can be observed that 8.3% of nurses had very low moral distress, 31% had low distress, 44.8% had moderate distress, 13.1% had high distress and 2.8% had very high moral distress. Therefore, it can be seen that in general, a small percentage (a total of 15.9%) of nurses are in high and very high levels of moral distress and the majority (39.3% low or very low and 44.8% moderate) of nurses have a favorable or moderate status.

Table 3: Qualitative description of moral distress among clinical nurses

Investigation of the level of moral distress among clinical nurses based on demographic variables

Independent t-test (for two-level demographic variables) and one-way analysis of variance (for demographic variables with more than two levels) were used to compare the mean scores of moral distress in terms of demographic variables. The results are presented in Table 4.

Table 4: Comparison of the mean score of moral distress of clinical nurses by demographic variables

According to the results, there is a significant difference between the mean score of moral distress of male and female nurses (t=2.361, D.F=141, p=0.020, p<0.05). It is noticeable that men with a mean score of 2.95 had a significantly higher moral distress compared to women with a mean score of 2.67.

In terms of demographic variable “work experience”, there was a significant difference between nurses with different working experience (F=3.010, p=0.033, p<0.05). According to the mean scores of moral distress, it is clear that the distress score of nurses with a work experience of 15 years or less is approximately the same, i.e., below the moderate level 3. While the score for nurses with a work experience of more than 15 years is 3.2, i.e., above the moderate level 3. Therefore, nurses with a work experience of more than 15 years have significantly more moral distress than nurses with a work experience of 15 years or less.

There was no significant difference between the mean score of moral distress in terms of demographic variables such as marital status, education level and age (p>0.05).

Discussion

The purpose of this study was to investigate moral distress among nurses. The results of this study showed that the minimum score of moral distress is 1.29 and the maximum score is 5. The mean score of moral distress of nurses is 2.77 with a standard deviation of 0.68 which is less than moderate score 3 and relatively favorable. The results of the study by Shakeriniya and Fry et al. showed that at least one third of nurses had experienced moral distress [26,27]. A study done by Joolaee et al. on 210 nurses showed that the population under study had a moderate intensity of stress [28]. In a study by Solomon et al., it was concluded that approximately 50 percent of nurses caring for dying patients experience moral distress [29]. The shortage of trained nursing staff, heavy load of clinical work and lack of facilities are among the factors that contribute to increased moral distress in which case, nurses cannot provide comprehensive and effective care and, if faced with situations in which they cannot meet the demands of patients, they will experience moral challenges and consequently disruptions in the work and occupational burnout. On the other hand, increased moral distress among nurses decreases their job satisfaction and leads to occupational burnout and, as a result, they will be unable to care for patients, and the process of patient recovery will be in trouble. According to the results, there is a significant difference between the mean score of moral distress of male and female nurses (t=2.361, D.F=141, p=0.020, p<0.05). It is noticeable that male nurses with a mean score of 2.95 have a significantly higher moral distress than women with a mean score of 2.67. Men are more likely to encounter moral distress because of more exposure to patients and more working shifts and offensive work [22]. In terms of the demographic variable “work experience”, there was a significant difference between nurses with different working experiences (F=3.010, p=0.033, p<0.05). According to the mean scores of moral distress, it is clear that the distress score of nurses with a work experience of 15 years or less is approximately the same which is below the moderate level 3. While the score for nurses with a work experience of more than 15 years is 3.2 which is above the moderate level 3. Therefore, nurses with a work experience of over 15 years have significantly more moral distress compared to nurses with a work experience of 15 years and less. Increased work experience of personnel increases the frequency and severity of exposure to futile medical care leading to a manifestation of moral distress and the incidence of fatigue and occupational burnout [30]. In addition, increased work experience and increased exposure to prolonged stress and contact with novice colleagues make nurses suffer from excessive fatigue and moral distress. This finding is consistent with the results of the study done by Shakerinia [31]. There was no significant difference between the mean score of moral distress in terms of demographic variables, i.e., marital status, education level and age (p>0.05). In a study done by Corley, a negative relationship was found between age and moral distress. Younger nurses do not have the experience, skills and knowledge required to overcome the limitations and do not have the necessary moral competence and feel incapable against difficulties. In contrast, nurses with more work experience can easily manage ethical clinical dilemmas through their experience of encountering different ethical situations [21].

Conclusion

The results of this study showed that the mean of moral distress of nurses was reported at a relatively desirable level. However, the lower the level of moral distress in nurses, the higher their work efficiency will be. Therefore, more accurate planning and training workshops can reduce the moral distress of nurses.

Acknowledgments

We would like to thank the Clinical Research Development Unit of Peymanieh Educational and Research and Therapeutic Center of Jahrom University of Medical Sciences for providing facilities to this work

Ethical Considerations

Ethical issues were completely observed by the authors.

Conflict of Interest

The authors declare that there is no conflict of interest regarding the publication of this manuscript.

References

1. Azemian A. The standards of professionalism in nursing: The nursing instructors’ experiences. Evid Based Care 2014; 4:27-40.
2. Dehghani K, Nasiriani K, Mousavi T. Investigating intensive care unit nurses' performance and its adjusting with standard. SSUJ 2014; 21:808-15.
3. Harvey EM, Echols SR, Clark R, et al. Comparison of two Team STEPPS® training methods on nurse failure-to-rescue performance. Clin Simul Nurs 2014; 10:e57-64.
4. Negarandeh R, Pedram RS, Khosravinezhad M. Effect of clinically competent nurses services on safety and patients' satisfaction in an emergency department. Hayat 2013; 19.
5. Ellis JR. Quality of care, nurses’ work schedules, and fatigue: A white paper. Seattle: Washington State Nurses Association 2008.
6. www.icn.ch/
7. Manion J, Conseil international des infirmières, Fondation Internationale Florence Nightingale, et al. Managing the multi-generational nursing workforce: Managerial and policy implications. International Council of Nurses 2009.
8. Lambert V, Glacken M. Clinical education facilitators: A literature review. JCN 2005; 14:664-73.
9. Kanter RM. Men and women of the corporation: New edition. Basic Books 2008.
10. Horton K, Tschudin V, Forget A. The value of nursing: A literature review. Nurs Ethics 2007; 14:716-40.
11. Fitzgerald L, Van Hooft S. A Socratic dialogue on the question ‘What is love in nursing?. Nurs Ethics 2000; 7:481-91.
12. Mobley MJ, Rady MY, Verheijde JL, et al. The relationship between moral distress and perception of futile care in the critical care unit. Intensive Crit Care Nurs 2007; 23:256-63.
13. Hardingham LB. Integrity and moral residue: Nurses as participants in a moral community. Nurs Philosophy 2004; 5:127-34.
14. Jameton A. Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall 1984; 331.
15. Wilkinson JM. Moral distress in nursing practice: Experience and effect. In Nursing forum. Oxford, UK: Blackwell Publishing Ltd 1987; 23:16-29.
16. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care 2005; 14:523-30.
17. Ganske KM. Moral distress in academia. OJIN 2010; 15:6.
18. Schluter J, Winch S, Holzhauser K, et al. Nurses' moral sensitivity and hospital ethical climate: A literature review. Nurs Ethics 2008; 15:304-21.
19. Joolaee S, Jalili H, Rafiee F, et al. The relationship between nurses’ perception of moral distress and ethical environment in Tehran University of Medical Sciences. Iran J Med Ethics Hist Med 2011; 4:56-66.
20. Mohammadi J, Ghadampour A, Azizi A. Assessment the relationship between moral turmoil with job demand-control in Tabriz hospitals nurses. J Educ Ethics Nurs 2014; 3:23-30.
21. Corley MC. Nurse moral distress: A proposed theory and research agenda. Nurs Ethics 2002; 9:636-50.
22. Corley MC, Minick P, Elswick RK, et al. Nurse moral distress and ethical work environment. Nurs Ethics 2005; 12:381-90.
23. Hamric AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research 2012; 3:1-9.
24. Simms L, Starr A. The person in a leadership role. The professional practice of nursing administration. Albany, NY: Delmar Thomson 2000; 80-2.
25. Abbaszadeh A, Nakhaei N, Borhani F, et al. Moral distress in clinical function of nurses: A descriptive-periodic Study. J Morl Hist Med 2012; 6:113-30.
26. Shakeriniya I. Moral distress: The latent stress in nursing. Iran J Med Ethics Hist Med 2011; 4:26-35.
27. Fry ST, Harvey RM, Hurley AC, et al. Development of a model of moral distress in military nursing. Nurs Ethics 2002; 9:373-87.
28. Joolaee S, Jalili HR, Rafii F, et al. Relationship between moral distress and job satisfaction among nurses of Tehran University of Medical Sciences Hospitals. J Hayat 2012; 18:42-51.
29. Solomon MZ, O'Donnell L, Jennings B, et al. Decisions near the end of life: Professional views on life-sustaining treatments. Am J Public Health 1993; 83:14-23.
30. Manzano GG, Ayala CJC. Emotional exhaustion of nursing staff: Influence of emotional annoyance and resilience. Int Nurs Rev 2012; 59:101-7.
31. Shakerinia I. Relationship between moral distress, psychological hardiness and occupational burnout in the nursing. Iran J Med Ethics Hist Med 2010; 4:56-69.