Iranian Journal of Medical Ethics and History of Medicine

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Moral distress is a psychological phenomenon whose effects on people’s functions can be considered as a subject of study. Although moral distress exists in numerous professions, research dedicated to this phenomenon has proved that due to the nature of the nursing profession, it is a familiar source of stress for most nurses. Nurses are more often than not faced with moral dilemmas in the workplace, and suffer moral distress as a result. The present paper aimed to study the history of moral distress, its definitions, consequences and coping strategies through library and online research, and although it attempted to investigate the phenomenon of moral distress in general, its focus has mainly been on moral distress in the nursing profession. A thorough understanding of moral distress and its negative and positive aspects is believed to raise awareness and lead to improvements in nurses, and educate them on appropriate coping strategies to help reduce their emotional suffering.

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Nurses have to cope with various forms of tension in the workplace on a daily basis. One of the factors affecting the moral distress experienced by nurses is the ethical climate prevalent in clinical environments. The present study aimed to establish the relationship between moral distress and nurses’ ethical work environment. This was a cross-sectional, correlational study on 210 nurses in select departments of medical/educational centers of the Tehran University of Medical Sciences in 2009. Data collection tools included a demographic questionnaire, Corley’s Moral Distress Scale, and Olson's Ethical Climate Questionnaire. Data analysis was performed using SPSS version 14. Findings confirmed that the nurses under study were tolerating an average amount of moral distress, although they did not perceive the frequency of morally stressful situations to be particularly high. There was no significant relationship between the moral distress of the nurses under study and their evaluation of the ethical climate of their workplace. Of the five factors affecting the ethical climate, there was a meaningful indirect relationship between managers and frequency of moral distress (P ≤ 0.04), and patients and frequency and intensity of moral distress (P = 0.001). The results obtained through this research indicated a need for authorities to pay more attention to medical/educational centers and devise various strategies in order to make work environments more ethical, so that nurses can continue to offer health care services in more relaxed environments and with less stress.

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Moral distress is one of ICU nurses' major problems that can happen due to various reasons and may have several consequences. Considering that certain variables can be related to moral distress and turnover intention in nurses, this study was done to determine the correlation between ICU nurses' demographic characteristics and their moral distress and turnover. In this correlational study, 159 ICU nurses were selected from medical universities of Iran. Data collection instruments included a demographic questionnaire, ICU nurses' moral distress scale, and Hinshaw and Atwood's turnover scale. Data analysis was done by using SPSS 17_. The findings showed high level of moral distress and turnover in ICU nurses. The results revealed a positive statistical correlation among ICU nurses' age, their work experience, the ratio of nurses to ICU beds and their moral distress. However, there was no correlation among sex, marital status, educational degree, work shift and moral distress. Similarly, moral distress and intent to turnover did not have a statistical correlation.The results showed that increasing recruitment of young nurses and nursing staff, and diminishing ICU nurses' moral distress and turnover intention are essential.

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Moral distress is considered as an important issue in nursing. Nurses participation in ethical decision making and taking deliberate action are facing them with many ethical challenges in their work environment. Confronting those challenges can lead to moral distress. This descriptive study was conducted to determine moral distress and its contributing factors from the perspective of oncology nurses in Tehran teaching hospitals in 2011. Data collection was done through a demographic questionnaire, the Moral Distress Scale – revised (MDS-R) and a questionnaire on moral distress related factors administered to all oncology nurses with inclusion criteria. Findings showed that nurses reported a high level of moral distress overall. The highest level of moral distress was associated with giving inadequate information to patients about informed consent and carrying out a physicians’ order for unnecessary tests and treatments. A significant correlation was found between oncology nurses’ age, their work experience and employment status with moral distress. Institutional factors such as managers’ support, nurses’ autonomy and having determined duties had the greatest effect on moral distress from oncology nurses’ view. Oncology nurses commonly encounter situations that are associated with high levels of moral distress, and therefore strategies need to be developed in order to mitigate moral distress.

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Moral distress is one of the common issues in nursing that has been receiving a lot of attention in research related to this profession. Moral distress is a phenomenon that can impact nurses, patients and health systems greatly. One significant impact of moral distress on nurses is its role on their desire to continue to work in their profession, and the present cross-sectional, descriptive and analytical study was conducted in order to determine this impact. Study samples were nurses in Birjand teaching hospitals who were selected through polls and according to entrance criteria. A 22-item questionnaire was developed by combining demographic information, Corley’s moral distress scale and the nurses’ desire to stay in the profession. The questionnaire was translated from English by the researcher and its validity and reliability were assessed. The results indicated that there is no significant relationship between moral distress and the desire to stay in the nursing profession (P>0/05). Moreover, levels of moral distress in the nurses in this study were moderate 2.25±0.6 (mean±SD) Given the level of moral distress in nurses and its possible consequences, strategies and solutions should be devised to familiarize nurses with moral distress and its underlying factors in order to reduce the undesirable outcomes of this phenomenon more effectively.

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One of the most important issues in nursing ethics is moral distress, which is a severe psychological problem among nurses. The purpose of this study was to determine the nurses’ moral distress in the hospitals of the northwest of Iran.This was a cross-sectional study in which 418 nurses were selected by randomized multistep sampling method in the northwest of Iran in 2012. Data collection was done using the moral distress standard scale with high reliability and validity. In order to analyze data, descriptive (mean, standard deviation, frequency and percent) and inferential statistics (independent t-test and one way ANOVA) were used.The mean score of nurses’ moral distress was 148.49 ± 32.93, and 222 nurses (53%) suffered from severe moral distress. Of the three provinces under study, Zanjan (152.46 ± 35.88) and intensive care units (152.72 ± 33.36) had the highest moral distress scores. Among the respondents’ demographic characteristics, province (P < 0.01), education (P < 0.05), type of shift (P < 0.05) and job status (P < 0.05) were significantly related to the level of moral distress experienced by the nurses.Due to the high level of moral distress in the nursing profession, dealing with it requires a lot of attention. Studies on casual and predictive factors in different wards and teaching coping strategies to nurses appear to be necessary in order to address this issue.

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Moral distress is an important issue in the field of medical ethics that can have serious effects on nurses, patients and health organizations. One of the most common effects of this phenomenon is professional stress in nurses. Stressful situations in nurses’ job environment lead to burnout and dissatisfaction, and adversely affect the quality of care.This was a cross-sectional study aimed to determine the relationship between moral distress and professional stress in 220 nurses of educational hospitals in the city of Birjand. Data were collected using a 51-item questionnaire based on Corley’s Moral Distress Scale and Wolfgang’s Health Professions Stress Inventory. Reliability and validity of the questionnaire were assessed by the researchers, and its reliability was calculated using Cronbach’s alpha (93%).The results indicated a positive relationship between moral distress and professional stress (P<0/05, r = 0/8). Intensity and frequency of moral distress and professional stress were reported average.Moral distress and professional stress were reported at a frequency and severity of moderate size. Findings of this study can provide guidelines for educating nurses on this phenomenon and the conditions leading to it. They may also be used to develop management strategies and establish organizations to prevent and minimize the consequences of these phenomena in nurses.

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Moral distress is one of the ethical challenges that nurses face due to the nature of their career. Nurses' frequent confrontation with this phenomenon can have different outcomes such as frustration and boredom in providing patient care. This will lead directly to a decline in care quality and can hamper the accomplishment of health goals. Therefore, the present study examined the relationship between moral distress and compassion fatigue in nurses.This cross-sectional study was conducted on 260 nurses of intensive care units in Kerman who were selected through convenience sampling method. In this study, Corley’s moral distress scale and Figley’s Compassion Fatigue Scale were used for data collection. The collected data were analyzed using the SPSS software and descriptive and analytical statistics.The results of this study indicate that there is a significantly positive relationship between moral distress and compassion fatigue (P<0.05). From a total range of 0 to 5, the average score of moral distress was 3.5±0.8 in terms of intensity, and 3.9±0.55 in terms of frequency. The mean of compassion fatigue score was 3.5±0.68 from a range of 0 to 5.Moral distress and its association with compassion fatigue suggest that conditions contributing to moral distress can have an important role in the quality of care. It is clear that strategies should be adopted to prevent the occurrence of these conditions. Informing nurses about moral distress and its consequences as well as periodic consultations will play an important part in the identification and management of moral distress and its consequences.

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Considering the advances in today's world, the increased complexity of diseases and longer life expectancy, nurses experience a great deal of moral distress. One factor that is likely to contribute to the development of moral distress is the ethical climate prevailing in hospitals. This study aimed to assess the relationship between nurses' perceptions of moral distress and the ethical climate in Shahid Sadoughi University of Medical Sciences in Yazd. This correlational descriptive study used the Moral Distress Scale (MDS) and Hospital Ethical Climate Survey (HECS) to examine 370 nurses working in a number of hospitals including Shahid Sadooghi, Shahid Rahnemun, Shahid Afshar and Savaneh Sukhteghi. Data analysis was performed using SPSS18 and descriptive and analytical statistics. Findings showed that the intensity of perceived moral distress among nurses was 3.41±1.28, and their perceptions of the ethical climate were 3.22±0.78. There was a significant negative relationship between nurses’ perception of moral distress and the ethical climate (P=0.00). The findings of this study suggest that development of plans to improve the ethical climate prevailing in hospitals might decreases nurses’ perceived moral distress.

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In the nursing profession, moral distress is a challenge thatc an have different consequences. The nurses’ moral courage to make the right decision can play an important role in the prevention of moral distress, and thus promote moral comfort. The present study examined the relationship between moral distress and moral courage in nurses. In this study, 313 nurses from hospitals in southern Khorasan Province were selected through quota sampling, and Corley’s Moral Distress Scale and the Professional Moral Courage Scale by Sekerka, et al. were used for data collection. The collected data were analyzed by descriptive and analytical statistics. The findings showed a significant relationship between the intensity of moral distress and moral courage (P = 0.03, r = - 0.44). From a range of 0 - 5, the mean of moral distress was 3.7 ± 0.5 in terms of intensity, and 3.55 ± 0.86 in terms of frequency. The mean score of moral courage was calculated at 3.33 ± 0.46 from a range of 1 - 5.The significant correlation between moral distress and moral courage strongly suggests that high levels of moral courage in nurses can play an important role in controlling moral distress. Determining the factors that create moral courage and developing strategies and circumstances such as promoting an appropriate moral climate could play a major role in encouraging moral behavior and controlling moral distress.

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The nursing profession is based on ethics. Clinical decisions that most nurses have to deal with include cases that involve moral conflicts. Moral distress is a phenomenon that causes pain, suffering, anxiety, depression and psychological damage. Emotional exhaustion can cause moral distress and is a consequence of job stress that has even been investigated as a reason for the high turnover in nursing. Therefore, the present study investigated the relationship between moral distress and emotional exhaustion among nurses.In this cross-sectional study, 265 nurses who employed in teaching hospitals of Sabzevar University of Medical Sciences were selected through convenience sampling. Data collection tools included a questionnaire on personal information a moral distress scale whose validity and reliability had been measured in previous studies (Cronbach's alpha 0.86) and a scale for emotional exhaustion that had also been tested for validity and reliability through content validity and test-retest (r = 0.84). Data analysis was performed using SPSS version 18.In this study, mean and standard deviation of moral distress and emotional exhaustion of nurses were 4.99 (0.91) and 4.17 (1.58) respectively. A statistically significant correlation was found between moral distress and the nurses’ field of work (rho = 0.338, P = 0.000). There was also a significant correlation between emotional exhaustion and rotating working shifts (rho = 0.385, P = 0.000) and ward (rho = 0.173, P = 0.03).The moral distress and emotional exhaustion of the nurses in this study were found to be higher than average. Education, counseling and raising nurses’ awareness of these concepts seem to be necessary in order to empower them to better deal with ethical issues.

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Moral distress is a phenomenon that can result in feelings of disappointment, guilt, depression, insecurity, fear, discouragement, and depression in nurses, and can affect their personality and professional performance. Burnout in nurses could cause various complications in their families, personal and social lives, and organizations. The aim of the present study was to determinate the correlation between moral distress and burnout in nurses.

This was a correlative descriptive study conducted on 224 nurses selected by stratified randomized sampling. Data were collected through a demographic characteristics questionnaire Corley’s Moral Distress Scale and the Copenhagen Burnout Inventory. Data analysis was performed by SPSS 20 software and Spearman correlation tests.

In this study, mean of moral distress score, mean of personal burnout score, score of work-related burnout, and mean of client-related burnout were 1.31, 55.97, 54.35 and 51.28 respectively. The findings showed a positive significant correlation (P<0.001) between moral distress and all of its dimensions, and personal burnout, work-related burnout, and client-related burnout, although the correlation was low.

According to these findings, it is recommended to reduce the conditions and situations causing moral distress and burnout in order to promote job satisfaction and quality of nursing care.

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Moral distress has been identified in nursing literature as a major dilemma affecting nurses in all healthcare systems. It is viewed as an important factor threatening the integrity of nurses and ultimately the quality of patient care. The present study attempted to determine levels of moral distress among the nursing staff employed in hospitals across the city of Malayer. This was a descriptive and cross-sectional study conducted on 195 nurses of Malayer hospitals during 2015. Data were collected using a demographic questionnaire and the standard moral distress scale (MDS). Data analysis was performed by descriptive and analytical statistics using SPSS software version 18.

In this study, 88 nurses (45.1%) were found to be suffering from severe moral distress. The most important factors causing moral distress pertained to substandard care and treatment due to a shortage of health professionals and care providers (6.6±0.21), physician orders for unnecessary tests, treatments and care (6±0.12), and measures taken by staff who lacked clinical competency (5.9±0.22). Among the nurses’ demographic data, gender (P=0.001), job experience (P=0.001) and nursing ward (P=0.01) were significantly related to the level of moral distress experienced by the nursing staff. The results imply that in nursing, moral distress is a highly important and pertinent issue that requires greater consideration by health service managers, policymakers and nurse educators.

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Stressful ethical situations are considered as one of the problems of nursing profession, which disrupts the competence of simultaneous application of knowledge, skills, attitudes, and values in patient care. Since clinical nurses are more exposed to ethical distress due to their nature of job, especially in in critical care and psychiatric wards, this study was conducted to analyze the relationship between three dimensions of moral distress. In this descriptive-correlational study 545 nurses from Tabriz educational centers were selected by census method in 2013-2014. The moral distress scale (MDS) questionnaire was distributed among partcipants and data was collected during nine months. Data were analyzed by SPSS V13, descriptive statistics, Chi-square test, and Kendall's tau-b correlation coefficient. According to the findings, the mean of moral distress was 141.89 ± 29.6 (in the intermediate range). Chi-square test showed the relationship between the dimensions of moral distress (the relation between patient's ignorance, decision-making power, and professional competence) (P <0.05). According to the Kendall's tau-b correlation coefficient test, there was a direct and significant correlation between the dimensions of moral distress (P <0.05). There was a meaningful correlation between the moral distress and the demographic characteristic of the educational level (P <0.05). Considering the direct and meaningful relationship between three dimensions of moral distress (patient's ignorance, decision-making power, and professional competence), each dimension of moral distress affects another as aggravating or modifying factor. Therefore, it is recommended that planners and health care administrators at the macro level provide appropriate programs to increase the nurse's attention and support to patients and reinforce decision-making power and professional competence by increasing the number of nurses and other controlling programs.

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Nurses in the intensive care unit face a variety of ethical issues that can lead to moral distress. Nurses need moral courage for correct moral performance in a state of moral distress. The aim of this study was to investigate the relationship between moral courage and moral distress in nurses. The descriptive-analytic study of correlation type which aimed to investigate the relationship between moral courage and moral distress in nurses. A total of 310 nurses from special units of educational hospitals in Kerman were selected by census method. The tools Sekerka's moral courage and Corley's moral distress were used to collect data. Data were analyzed by descriptive and analytical tests of SPSS version 24.  Mean score of moral courage of nurses was 42.71 ± 9.67. Moral courage was the highest in moral agent. The mean of moral distress was 56.03 ± 18.21 and the most moral distress was in the dimension of errors. There was a significant and negative relationship between moral courage and moral distress (R = -0.166; p = 0.003). Moral courage was different in position, type of department, and marital status. Moral distress differed only from type of department. The results of study indicated a significant and negative relationship between moral courage and moral distress. Strengthening the moral courage of nurses plays an important role in controlling and reducing moral distress. Therefore, nurses can reduce their moral distress by reinforcing moral courage and, instead, increasing the quality of care for patients.

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