Investigation of Moral Distress in Nurses of Jahrom Hospitals in 2018
Introduction: There are many stressors in the nursing profession that have an adverse effect on nursing employees. One of these tensions is the moral distress associated with various aspects of ethical issues. Therefore, the purpose of this study was to Investigation of Moral Distress in Nurses of Jahrom Hospitals in 2018.
Methodology: This descriptive cross-sectional study was conducted on 145 nurses from educational and therapeutic hospitals in Jahrom in 2018. The instrument of the study included a demographic questionnaire and Corley's Moral Distress Scale (MDS). The data analysis was performed using SPSS version 21 through descriptive statistics (mean, percentage, and standard deviation, Frequency) and analytical tests (Independent t-test & one-way analysis of variance). Significant levels for all tests were considered as p<0.05).
Findings: The mean score of moral distress of nurses was 2.77 ± 0.68. Accordingly, the moral distress of 8.3% of nurses present in the research was very low, the moral distress of 31% of them was low, the moral distress of 44.8% of them was moderate, the moral distress of 13.1% was high and the moral distress of 2.8% was very high. There was a significant relationship between gender, work experience and moral distress of nurses (p<0.05).
Conclusion: The results of this study showed that the mean of moral distress of nurses was reported at a relatively desirable level. Therefore, more accurate planning and training workshops can Increase the moral distress of nurses.
Moral distress, Nurses, Jahrom City Hospitals
Nurses are the largest part of health professional staff who have several roles and responsibilities in delivering health care services . Their duties include promoting health, preventing illnesses, maintaining health and well-being, relieving pain and helping patients to adapt to existing conditions . 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  to evaluate patients’ information and promote the interventions needed for care . 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 . Inappropriate working environment is one of the effective factors in leaving nursing career or retiring . 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 . 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 . 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 . 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 . 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 . 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 . 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 . Moral distress in nursing has been widely considered since 1980. Jameton first defined this concept in 1984 , and Wilkinson introduced a model of moral stress . 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 . 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 . 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. . 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 . 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) . Demographic data included age, gender, marital status, and work experience. The first Moral Distress Scale was developed by Corley et al.  with 38 items. Then, Moral Distress Scale, Revised (MDS-R) was designed and developed by Hamric et al. for nurses with 21 items . In Iran, this instrument was translated to Farsi and validated by eliminating three items and thus it includes 18 items.
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.  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) . 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].
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.
|Age (years old)||25 and younger||47||33.1|
|46 and older||5||3.5|
|Work experience (years)||5 and less||73||55.7|
|15 and more||16||12.2|
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.
|Characteristics||Category||Mean||Standard deviation||Test statistic||p-value|
|Age(years old)**||25 and younger||2.69||0.58||1.074||0.362|
|46 and older||2.64||0.94|
|Work experience (years)**||5 and less||2.75||0.66||3.01||0.033***|
|15 and more||3.2||0.69|
|*independent t-test was used for the comparison.|
|**one-way analysis of variance was used for the comparison.|
|***difference at 0.05 significance level (p<0.05)|
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).
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 . In a study by Solomon et al., it was concluded that approximately 50 percent of nurses caring for dying patients experience moral distress . 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 . 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 . 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 . 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 .
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.
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 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.
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2Department of Emergency Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
3Department of Nursing, Jahrom University of Medical Sciences, Jahrom, Iran
4Student Research Committee, Jahrom University of Medical Sciences, Jahrom, Iran
5Department of Emergency Medicine, Jahrom University of Medical Sciences, Jahrom, Iran
Citation: Hasan Zabetian, Mohamad Javad Zarei, Fatemeh Honarmand Jahromy, Saman Siasi, Mohammad Radmehr, Samaneh Abiri, Investigation of moral distress in nurses of Jahrom hospitals in 2018, J Res Med Dent Sci, 2019, 7(1): 195-200.
Received Date: Jan 24, 2019 / Accepted Date: Feb 20, 2019 /