Volume 30, Issue 3 (6-2020)                   JHNM 2020, 30(3): 166-173 | Back to browse issues page


XML Print


Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:

Habibzadeh S M, Reza Masouleh S, Mitra Chehrzad M, Kazemnejad Leili E. Moral Distress and Related Factors in Nurses Working in Intensive Care Units. JHNM 2020; 30 (3) :166-173
URL: http://hnmj.gums.ac.ir/article-1-1408-en.html
1- Nursing (MSN), School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
2- Instructor, Department of Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran , srezamasouleh@gmail.com
3- Assistant Professor, Department of Nursing (Pediatrics), School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
4- Associate Professor, Social Determinants of Health Research Center (SDHRC), Biostatistics, Guilan University of Medical Sciences, Rasht, Iran.
Full-Text [PDF 565 kb]   (717 Downloads)     |   Abstract (HTML)  (1885 Views)
Full-Text:   (1230 Views)
Introduction
Considering the physical, mental, and psychological dimensions of human beings, caring for patients and their families has always been among the moral issues. In the meantime, the nursing profession is essentially a moral profession due to the principle of the need to care for others. Nurses spend most of their time on patients’ bedsides, so they are constantly dealing with ethical issues and decisions [1]. However, doing so and adhering to ethical issues and responsibilities can sometimes lead to obstacles that ultimately result in moral distress [2, 3].
Nurses working in various sections of health care centers may inadvertently experience occupational stress. Nurses sometimes have to make ethical decisions in caring for the patient and are expected to adhere to ethical principles in their performance [4, 5]. Approximately one out of three nurses experiences moral distress, which in some cases may even lead to job leaving [6].
Moral distress is a feeling of uneasiness that results from not doing the right moral action. This can be caused by factors such as time constraints, medical restrictions, care institute policies, and moral, personal, or religious considerations [7-9], which can have a negative impact on the nurses, patients and their families, as well as on the health care systems [10]. As a result, moral distress can cause dissatisfaction, stress and burnout in nurses, forcing them to quit their job. On the other hand, the quality of nursing care may decrease and the length of hospital stay may increase. Also, health care providers may be affected and incure heavy costs for staff loss, reduced service quality, and patient’s dissatisfaction [10-12].
Various factors such as heavy workloads, imbalance between the number of nurses and the number of patients, direct therapeutic and care communication with patients and their families, lack of participation and cooperation of members of the care and treatment team, decision making for patients in the late stages of their lives, all can cause moral distress [13]. Studies in this regard showed different results. For example, the results of a study in northwestern Iran showed that the majority of nurses working in different units had moderate to high moral distress [14]. Abbaszadeh et al. showed in their study that the level of moral distress of nurses was moderate [15]. However, in some studies, the moral distress of nurses working in the emergency and psychiatric wards has been reported at a low level [5, 16]. As nursing duties become more specialized and their responsibilities in caring for critically-ill patients increase, the intensity of moral distress increases too [17, 18]. Therefore, moral distress as a negative experience seems to be one of the serious problems of nurses working in the intensive care unit [19, 20]. The long-term consequences of moral distress on nurses in intensive care units can include avoidance, emotional exhaustion, and even indifference to patients [21]. In addition, it can have several negative consequences on nurses’ health [23] and can be expressed as anxiety, depression, nightmares, insomnia, palpitations and neck pain [24].
Considering what was said about the challenging environment of the intensive care units and the fact that moral distress overshadows the functional quality of nurses, we decided to conduct a study to determine the moral distress and related factors in nurses working in intensive care units of educational and medical centers throughout Guilan Province, Iran.
Materials and Methods
This was an analytical cross-sectional study and the research population included all nurses working in intensive care units of 20 hospitals affiliated to Guilan University of Medical Sciences, including 414 people (172 nurses in coronary care units and 242 nurses in intensive care units) in 2018. The inclusion criteria were having at least a bachelor’s degree in nursing and one year of experience in the intensive care unit (to ensure that the subject is fully acquainted with the conditions of the ward and equipment). Nurses with more than one month’s sick leave, and those who did not agree to participate in the research, were not included in the study. In order to collect data, a complete enumeration method was used and 341 out of 414 nurses in the intensive care units of Guilan Province were included in the research. A total of 51 nurses refused to cooperate or did not complete the questionnaires, and 22 were on long leave.
The data collection instrument was a 9-item questionnaire of individual-social factors, including age, gender, marital status, level of education, type of employment, work experience, duration of work in the intensive care unit, monthly working hours, and monthly income.
To examine the moral distress in nurses, the 21-item standard Corley’s moral distress scale questionnaire was used based on two components: intensity and frequency. The moral distress questionnaire items on “intensity” was scored from 0 to 4 (from “not at all” to “very high”), and on “frequency” from 0 to 4 (from “never” to “frequent”). The actual score of moral distress was calculated by first combining the score of the two components “intensity” and “frequency” to get the score of each item. The score of each item was between 0-16 and the final score of 21 items of the standard instrument was between 0 and 336. A higher score indicated higher moral distress and a lower score indicated lower moral distress [25]. The instrument validity was confirmed by CVR and CVI content validation methods by more than 90% by nursing faculty members. The reliability of the instrument was also determined using Cronbach alpha coefficient of 92%.
After obtaining the necessary permits to collect information and explaining the objectives of the research and the questionnaire items, as well as explaining the confidentiality of the information, the questionnaires were distributed among qualified nurses at the beginning of a shift and then collected at the end of the same shift. Data analysis was performed under SPSS version 21 using descriptive statistics indicators and the Kolmogorov-Smirnov tests to determine the normal distribution, and Mann-Whitney, Kruskal-Wallis, and logistic regression analysis by backward LR were performed. The significance level of the tests was set at less than 0.05.
Results
Results showed that the majority of the surveyed units were female (90.6%), married (67.4%), official employees (44.6%), 31 to 40 years old (50.4%) with an Mean±SD age of 34.19±11.7 years, 4 to 96 months work experience (46.9%) with an average of 112.61±75.98 months, 1 to 96 months work experience in the intensive care unit (68.6%) with an Mean±SD of 75.69±59.93 months, with monthly working hours more than 170 hours per month (39.6%), with a bachelor’s degree (90.3%), and with a monthly income of 300 to $800 (76.5%). Their mean score of moral distress was 91.30±65.03 (range 0-332).
The results also showed that the nurses’ moral distress score in terms of “gender” (P=0.012) (based on Mann-Whitney U test), and in terms of “work experience in intensive care unit” (P=0.027), “monthly working hours” (P=0.023) and “income” (P=0.029) (based on the Kruskal Wallise statistical test) had a significant difference (Table 1).
Logistic regression model was used in multiple analysis of determining individual, social, and organizational factors related to moral distress. In this model, the score below the average moral distress was 0 and the score above the average was 1. Then, in the first step, the individual-social variables that had a P<0.25 in the single-variable analysis were included in the model (gender, monthly working hours, monthly income, work experience, work experience in the intensive care unit).
In the final model, “gender” (OR=2.410, 95%CI; 1.19-5.6, P=0.016) and “work experience in intensive care unit” (OR=0.64, 95%CI; 0.94 0.43, P=0.23) were identified as two factors associated with moral distress. That is, the high average score related to moral distress in men was 2.4 times higher than in women. Also, with increasing work experience in the intensive care unit, the chances of having a high average score in the studied samples were reduced by 0.642 times (Table 2).

Discussion 
The results of this study showed that the nurses in intensive care units participating in this study had a low average score of moral distress. In line with the present study, Fumis in Brazil [26], Allen in the United States [27] and Karagozoglu in Turkey [28] all showed some degree of moral distress in nurses in intensive care units. In Iran, studies of Mohammadi in Tabriz [29], Etebari in Ardabil [30], Sadeghi in Shahroud [31], and Ashktorab in Tehran [32] showed the moral distress in nurses. While Wenwen et al. in China [33] confirmed less moral distress in nurses in intensive care units. The results of other studies also showed less range of moral distress in nurses in intensive care units [34-36].
This difference in the results may be due to differences in research communities and in the instruments used. Due to the specific work environment of intensive care units, the moral distress faced by nurses in these sections are different from those in other parts. Intensive care units are places where patients benefit from advanced medical care technologies. Because dying patients are cared for in these units and vital decisions are made about the final stages of these patients’ lives, nurses working in these units are exposed to a lot of stress and moral issues. This condition not only affects the quality of care and clinical decisions of the nurses, but also overshadows their personal lives. It seems that the equipment, manpower and even the type of disease of patients admitted to these units can affect the level of moral distress experienced by nurses.
Among the individual-social factors related to moral distress, “gender”, “work experience in intensive care unit”, “monthly working hours”, and “income” are the items that have a statistically significant relationship with moral distress. In multiple analysis of determining the individual-social factors associated with moral distress, the results of logistic regression showed that “gender” and “work experience in the intensive care unit” were considered to be the only factors related to moral distress.
The results of Ebrahimi’s study in Iran showed no significant statistical relationship between gender and moral distress, but similar to the present study, the average score of men’s overall moral distress was higher than women’s [14]. This result was similar to the results of another study conducted in Iran by Sadeghi [37]. O’Connell’s study, meanwhile, found that women had a higher moral distress than men [38]. However, the results of some studies have not shown a relationship between gender and experienced moral distress [9, 28, 30, 39].
Different cultures, the type of intensive care unit under study, and the number of male nurses in these studies can be the reasons for different results in different studies. It may seem that women due to their sensitive spirit are more exposed to moral distress arising from work environment, but due to women’s ability to openly express their feelings and emotions in sensitive situations, they may be less likely to be exposed to moral distress than male nurses.
Regarding the relationship between work experience in the intensive care unit and the results of the present study, Ashktorab’s study showed a relationship between work experience and moral distress [32]. In his study of nurses in intensive care unit, Sauerland found a significant relationship between moral distress and nurses’ work experience [40]. While Karagozoglu’s study did not show this relationship [28]. Regarding these different results and considering the fact that nurses in intensive care units are constantly exposed to critically ill patients with life-threatening diseases and with a high rate of mortality, then it is likely that more work experience in these units may lead to more moral distress.
In terms of income, the results of Wenwen’s study in China showed a significant relationship between moral distress and monthly income; as income increased, so did moral tensions [33]. Instead of examining the monthly income level of nurses, some research has examined employment status [32, 37], which in itself can be a sign of job stability and better income of permanent employees than others. To explain the relationship between monthly income and moral distress, it can be said that high income in the face of high stress in the work environment may, to some extent, can make better the condition of nurses.
The results of the present study can help managers and officials of health care services to hold classes and retraining courses for health care staff in order to familiarize them with the concept of moral distress and the factors affecting it and how to reduce it.
Also, recognizing the problems related to moral distress and its impact on job performance and the quality of patient care, and the impact of organizational issues on moral distress, it can drawn the attention of health management to hospitals. It is recommended that steps be taken to establish and strengthen supporting institutions, and to acquaint nurses working in stressful units with the culture of adaptability to a variety of psychological and moral problems. According to the results of this study, it is suggested that more extensive studies be conducted on the moral distress of nurses in different wards in terms of different clinical conditions.
One of the limitations of this research was that the moral distress questionnaire was self-reporting. Also, the conditions prevailing in the hospital unit at the time of completing the questionnaires could affect the mental state and psychological condition of the participants.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Guilan University of Medical Sciences (Code: IR.GUMS.REC.1397.024).
Funding
This study was extracted from a Master’s thesis of Seyedeh Mohadeseh Habibzadeh in nursing approved by Guilan University of Medical Sciences. 
Authors contributions
Conceptualization: Seyedeh Mohadeseh Habibzadeh, Shadman Reza Masouleh, Minoo Mitra Chehrzad and Ehsan Kazemnezhad Leili; Drafting and data analysis : Seyedeh Mohadeseh Habibzadeh, Shadman RezaMasouleh; Investigation and data analysis: Seyedeh Mohadeseh Habibzadeh and Ehsan Kazemnezhad Leili; and Editing and review: All authors.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgements
The authors would like to thank the Deputy for Research and Technology and all nurses for their cooperation and support.


Reference
Beikmoradi A, Rabiee S, Khatiban M, Cheraghi MA. [Nurses distress in intensive care unit: A survey in teaching hospitals (Persian)]. Medical Ethics and History of Medicine. 2012; 5(2):58-69. http://ijme.tums.ac.ir/article-1-5044-en.html
Wasylenko E. Jugglers, tightrope walkers, and ringmasters: Priority setting, allocation, and reducing moral burden. Healthcare Management Forum. 2013; 26(2):77-81. [DOI:10.1016/j.hcmf.2013.04.006]
Ameri M, Mirhashemi B, Hosseini SS. Moral distress and the contributing factors among nurses in different work environments. Journal of Nursing and Midwifery Sciences. 2015; 2(3):44-9. http://www.jnmsjournal.org/article.asp?issn=2345-5756;year=2015;volume=2;issue=3;spage=44;epage=49;aulast=Ameri;type=0
Ulrich C, O’Donnell P, Taylor C, Farrar A, Danis M, Grady C. Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Social Science & Medicine. 2007; 65(8):1708-19. [DOI:10.1016/j.socscimed.2007.05.050] [PMID] [PMCID]
Fernandez-Parsons R, Rodriguez L, Goyal D. Moral distress in emergency nurses. Journal of Emergency Nursing. 2013; 39(6):547-52. [DOI:10.1016/j.jen.2012.12.009] [PMID]
Afshar L, Joolaee S, Vaskouei Kh, Bagheri AR. [Nursing ethics priorities from nurses aspects: A national study (Persian)]. Medical Ethics and History of Medicine. 2013; 6(3):54-63. http://ijme.tums.ac.ir/article-1-5120-en.html
Abbaszadeh A, Borhani F, Kalantary S. [The moral distress of nurses in health centers in the city of Bam in 2011 (Persian)]. Medical Ethics Journal. 2011; 5(17):119-40. http://journals.sbmu.ac.ir/en-me/article/view/12773
Allari R, Abu-Moghli F. Moral distress among Jordanian critical care nurse and their perception of hospital ethical climate. Journal of Natural Sciences Research. 2013; 3(5):144-53. https://www.iiste.org/Journals/index.php/JNSR/article/view/5313
De Villers MJ, DeVon HA. Moral distress and avoidance behavior in nurses working in critical care and noncritical care units. Nursing Ethics. 2013; 20(5):589-603. [DOI:10.1177/0969733012452882] [PMID]
Borhani F, Esmaeli-Abdar M, Razban F, Roushanzadeh M. [Moral distress in the nursing and relationship with job burnout (Persian)]. Medical Ethics Journal. 2013; 7(25):123-44. http://journals.sbmu.ac.ir/en-me/article/view/10201
Atashzadeh Shoorideh F, Ashktorab T, Yaghmaei F, Alavi Majd H. Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nursing Ethics. 2015; 22(1):64-76. [DOI:10.1177/0969733014534874] [PMID]
Pauly B, Varcoe C, Storch J, Newton L. Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics. 2009; 16(5):561-73. [DOI:10.1177/0969733009106649] [PMID]
McCarthy J, Deady R. Moral distress reconsidered. Nursing Ethics. 2008; 15(2):254-62. [DOI:10.1177/0969733007086023] [PMID]
Ebrahimi H, Kazemi A, Asghari Jafarabadi M, Azarm A. [Moral distress in nurses working in educational hospitals of Northwest Medical Universities of Iran (Persian)]. Medical Ethics and History of Medicine. 2013; 6(4):80-8. http://ijme.tums.ac.ir/article-1-5188-en.html
Abbaszadeh A, Nakhaee N, Borhani F, Roshanzadeh M. [Moral distress in the nurse’s practical action: A descriptive - cross sectional study (Persian)]. Medical Ethics Journal. 2012; 6(21):113-30. http://journals.sbmu.ac.ir/en-me/article/view/12727
Ohnishi K, Ohgushi Y, Nakano M, Fujii H, Tanaka H, Kitaoka K, et al. Moral distress experienced by psychiatric nurses in Japan. Nursing Ethics. 2010; 17(6):726-40. [DOI:10.1177/0969733010379178] [PMID]
Choe K, Kang Y, Park Y. Moral distress in critical care nurses: A phenomenological study. Journal of Advanced Nursing. 2015; 71(7):1684-93. [DOI:10.1111/jan.12638] [PMID]
Shafipour V, Esmaeili R, Heidari MR, Aghaei N, Saadatmehr SR, Sanagoo A. [Investigating the level of moral distress and its related factors among nurses in Mazandaran burn center (Persian)]. Journal of Mazandaran University of Medical Sciences. 2015; 25(126):58-67. http://jmums.mazums.ac.ir/article-1-5933-en.html
Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care. 2005; 14(6):523-30. [DOI:10.4037/ajcc2005.14.6.523] [PMID]
Mealer M, Moss M. Moral distress in ICU nurses. Intensive Care Medicine. 2016; 42(10):1615-7. [DOI:10.1007/s00134-016-4441-1] [PMID] [PMCID]
Rushton CH, Caldwell M, Kurtz M. CE: Moral distress a catalyst in building moral resilience. AJN, American Journal of Nursing. 2016; 116(7):40-9. [DOI:10.1097/01.NAJ.0000484933.40476.5b] [PMID]
Hamric AB, Davis WS, Childress MD. Moral distress in health care professionals. The Pharos of Alpha Omega Alpha-Honor Medical Society. 2006; 69(1):16-23. [PMID]
McClendon H, Buckner EB. Distressing situations in the intensive care unit: A descriptive study of nurses’ responses. Dimensions of Critical Care Nursing. 2007; 26(5):199-206. [DOI:10.1097/01.DCC.0000286824.11861.74] [PMID]
Mohammadi Nafchi S, Borhani F, Roshanzadeh M. [Relationship between moral distress and environmental empowerment for nurses in education hospitals in Kerman (Persian)]. Medical Ethics Journal. 2014; 8(26):91-113. http://journals.sbmu.ac.ir/en-me/article/view/10191
Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. Journal of Advanced Nursing. 2001; 33(2):250-6. [DOI:10.1046/j.1365-2648.2001.01658.x] [PMID]
Fumis RRL, Amarante GAJ, de Fátima Nascimento A, Junior JMV. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Annals of Intensive Care. 2017; 7(1):71. [DOI:10.1186/s13613-017-0293-2] [PMID] [PMCID]
Allen R, Butler E. Addressing moral distress in critical care nurses: A pilot study. International Journal of Critical Care and Emergency Medicine. 2016; 2(1):015. [DOI:10.23937/2474-3674/1510015]
Karagozoglu S, Yildirim G, Ozden D, Çınar Z. Moral distress in Turkish intensive care nurses. Nursing Ethics. 2017; 24(2):209-24. [DOI:10.1177/0969733015593408] [PMID]
Mohamadi J, Ghazanfari F, Azizi A. [The effectiveness of ethics training on nurse’s ethical distress (Persian)]. Journal of Medical Education Development. 2016; 8(20):98-105. http://zums.ac.ir/edujournal/article-1-479-en.html
Etebari-Asl Z, Etebari-Asl F, Nemati Kh. [A survey on the level of moral distress among nurses of special wards affiliated to educational-therapeutic centers in Ardabil University of Medical Sciences in 2016: A short report (Persian)]. Journal of Rafsanjan University of Medical Sciences. 2017; 16(2):169-78. http://journal.rums.ac.ir/article-1-3643-en.html
Sadeghi M, Ebrahimi H, Abbasi M. [The relationship between moral distress and burnout in clinical nurses in the Shahroud city (Persian)]. Iranian Journal of Nursing Research. 2016; 11(2):78-87. http://ijnr.ir/article-1-1719-en.html
Ameri M, Safavi Bayat Z, Ashktorab T, Kavoosi A, Vaezi A. [Moral distress: Evaluating nurses’ experiences (Persian)]. Medical Ethics and History of Medicine. 2013; 6(1):64-73. http://ijme.tums.ac.ir/article-1-5065-en.html
Wenwen Z, Xiaoyan W, Yufang Z, Lifeng C, Congcong S. Moral distress and its influencing factors: A cross-sectional study in China. Nursing Ethics. 2018; 25(4):470-80. [DOI:10.1177/0969733016658792] [PMID]
Tavakol N, Molazem Z. [Exploring moral distress in the intensive care unit nurses of Shiraz Heart Center in 2013 (Persian)]. Education & Ethics in Nursing. 2015; 4(2):49-56. http://ethic.jums.ac.ir/article-1-330-en.html
Naboureh A, Imanipour M, Salehi T, Tabesh H. [The relationship between moral distress and self-efficacy among nurses in critical care and emergency units in hospitals affiliated to Ahvaz Jundishapur University of Medical Sciences in 2015 (Persian)]. Journal of Rafsanjan University of Medical Sciences. 2015; 14(6):443-54. http://journal.rums.ac.ir/article-1-2565-en.html
McAndrew NS, Leske J, Schroeter K. Moral distress in critical care nursing: The state of the science. Nursing Ethics. 2018; 25(5):552-70. [DOI:10.1177/0969733016664975] [PMID]
Sadeghi M, Ebrahimi H, Aghayan Sh. [Evaluation of the Moral Distress and Related Factors in Clinical Nurses of Shahroud city (Persian)]. Iranian Journal of Psychiatric Nursing. 2015; 3(3):20-8. http://ijpn.ir/article-1-613-en.html
O’Connell CB. Gender and the experience of moral distress in critical care nurses. Nursing Ethics. 2015; 22(1):32-42. [DOI:10.1177/0969733013513216] [PMID]
Hatamizadeh M, Hosseini MA, Bernstein C, Ranjbar H. Health care reform in Iran: Implications for nurses’ moral distress, patient rights, satisfaction and turnover intention. Journal of Nursing Management. 2019; 27(2):396-403. [DOI:10.1111/jonm.12699] [PMID]
Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part 1. Dimensions of Critical Care Nursing. 2014; 33(4):234-45. [DOI:10.1097/DCC.0000000000000050] [PMID]
Article Type : Research | Subject: Special
Received: 2020/07/4 | Accepted: 2020/07/4 | Published: 2020/07/4

Add your comments about this article : Your username or Email:
CAPTCHA

Send email to the article author


Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.