The Association between Moral Distress and Moral Courage in Nurses: A Cross-Sectional Study in Iran.

BACKGROUND: Moral distress and moral courage among healthcare professionals have received considerable attention in recent years. However, there is a paucity of studies investigating these topics among nurses. Thus, the present study aimed to evaluate the association between moral distress and moral courage among nurses in an Iranian sample population.
MATERIALS AND METHODS: The present cross-sectional study was conducted during February-December 2018. Corley's Moral Distress (MDS-R) and Sekerka's moral courage scales were used to collect the data. MDS-R is a 21-items scale which includes frequency and intensity ranges from 0 (never) to 4 (very frequently) and 0 (none) to 4 (great extent), respectively. In addition, the moral courage scale contains 15 items ranging from "never true" (1 point) to "always true" (7 points). In total, 225 eligible nurses were entered into this study. Finally, SPSS-16 was used for statistical analysis at the α = 0.05 level.
RESULTS: The mean scores of the frequency and intensity of moral distress and moral courage were 45.41 (95% CI = 43.37-47.45), 44.24 (95% CI = 42.98-45.42), and 59.63 (95% CI = 58.50-60.87), respectively. Eventually, a significant relationship was found between the moral courage and frequency of moral distress (r = 0.46, p < 0.001) and the intensity of moral distress (r = 0.73, p < 0.001).
CONCLUSIONS: In general, encouraging healthcare managers and administrators is considered as crucial for developing supportive structures and highly sensitive management which promotes moral courage while reducing moral distress in nurses' work setting. Copyright:

Introduction

Nurses constitute a large group of caregivers who are constantly facing ethical issues and problems importantly associated with the quality of care.[1] In addition, they face with a contradiction believing that although their performance is correct, they cannot always act according to their beliefs. Therefore, they probably suffer from moral distress as well.[2],[3] In such situations, most of these nurses become frustrated in their efforts to uphold their professional commitment to their patients in acceptable ways, thus leading to their moral distress.[4] This kind of distress is defined as painful feelings and psychological disequilibrium which results from recognizing an ethically appropriate action.[5] In addition, it has been defined as “an emotion which is provoked within individuals when they are constrained from fulfilling obligations or responsibilities that they believe to be morally correct”.[6] Further, moral distress as an ethical problem is linked to the quality, quantity, and cost of care and treatment[7] and may have internal or external consequences such as eliminating self-esteem or reducing contact with other members of the health team, respectively.[8] Furthermore, moral distress has serious ramifications to nurses since it can lead to professional burnout, physical and emotional distress, moral apathy, and even job abandonment among nurses.[9] Nurses may be indifferent to the conditions and provide no appropriate services or even leave their profession when encountering these conditions relying on their degree of sensitivity and commitment.[10],[11] Accordingly, nurses act contrary to their personal and professional values when having moral distress.[12] Thus, addressing moral distress is imperative since it can reduce the negative consequences of this ethical problem, promote moral courage, which can ultimately promote safe and quality patient care. Additionally, the ability to be sensitive and responsive to difficult ethical situations can lead them to have courage to act on their convictions.[4]

Moral courage is considered as one of the fundamental values in the nursing profession[13] and is described as standing for what is right.[1],[14] In addition, it is a valuable virtue which helps nurses make desirable decisions and function properly in moral dilemmas.[2],[15] Further, moral courage is a great virtue in the nursing profession that helps nurses' personal and professional progress.[4] Kidder and McLeod argued that people who have moral courage in performing tasks are committed to moral principles.[16] Furthermore, Gallagher concluded that moral courage is one of the essential factors in preventing moral distress in clinical settings and people experience less moral distress if they have the necessary courage for taking actions based on moral principles.[1] Although previous studies have focused on moral distress and moral courage among registered nurses in other countries,[17],[18] a limited body of research is available on these topics in Iran. Different stressful conditions in various working environments can lead to different results. In addition, the incidence of the evaluated variables in the present study may be due to cultural differences in the study area due to the nature of ethical issues that take different dimensions in various sociocultural contexts. Therefore, the present study aimed to evaluate the relationship between moral distress and moral courage among nurses in the teaching hospitals of Bam University of Medical Sciences.

Materials and Methods

The present descriptive cross-sectional study was conducted during February–December 2018. The census sampling method was used based on the aim of the study, and 280 nurses working at Pasteur Hospital were included in the research. The inclusion criteria were having at least a bachelor's degree, having one year of work record in clinical units of the hospital, and representing informed consent to participate in the study. On the other hand, the exclusion criteria encompassed participants' non-cooperation until data collection. Based on the inclusion criteria, 225 nurses who had given verbal informed consent were included in the study. Participants were ensured of data confidentiality and allowed to freely discontinue the study. Finally, the questionnaire was handed to all 225 nurses out of which, 8 cases were excluded due to incomplete responses to questionnaires. Eventually, 217 nurses completed and delivered the questionnaires and were included in the analysis.

A three-part questionnaire was used to collect data throughout a demographics form, Corley's “Moral Distress” Scale (MDS-R),[19] and Sekerka's “Moral Courage” Scale,[20] respectively. The demographics forms contained information about age, sex, marital status, education level, work experience, and the type of employment. Additionally, the MDS-R, which was developed by Corley and Hamrick,[21] was utilized to assess moral distress. It is a 21-item scale which measures moral distress levels in healthcare providers. The moral distress Likert-type scale includes a frequency range from 0 (never) to 4 (very frequently) and an intensity range from 0 (none) to 4 (great extent). In addition, the Likert-type scale data can then be computed into a composite score or actual moral distress using a two-part procedure. First, the frequency multiplied by the intensity (fxi) score is obtained, which can range from 0 to 16, where less distressing items have low fxi scores versus more distressing items have higher fxi scores. Reporting fxi scores allows identifying individual items or situations which are distressing. Then, the composite or actual moral distress score is obtained by summing the fxi score of each item, leading to a range of 0 to 336, where less and more actual distress are considered as lower and higher composite scores, respectively.[22] According to the reliability and validity results of the MDS-R scale, the Cronbach's alpha coefficient and the test-retest correlation coefficient were 0.88 and 0.58, respectively.[21] It was further validated by Merghati Khoiee et al. in Iran.[23] Furthermore, Borhani et al. reported the reliability and validity of the moral distress scale as 0.93 and 88% by Cronbach's alpha and the Content Validity Index (CVI), respectively.[3]

Additionally, the Moral Courage Scale, which was designed by Sekerka et al.,[20],[24] encompasses 15 items regarding five themes of moral agency, multiple values, threat endurance, beyond compliance, and moral goals. Moral agency is considered as a predisposition toward moral behavior and possessing a persistence of will to engage as a moral agent. In addition, multiple values refer to the ability to draw on multiple value sets in moral decision-making, effectively sort out and determine what needs to be exercised and hold firm to beliefs despite external concerns or demands. Further, threat endurance indicates facing an ethical or moral difficulty, both perceived and real danger or threat, with endurance. Finally, moral goals are regarded as a drive for task accomplishment which includes using virtues throughout the decision-making process in order to achieve a virtuous outcome. Based on the Likert-type scale, it is arranged from “never true” (one point) to “always true” (seven points).[24] This scale was translated and validated by Mohammadi et al. in Iran and its reliability and validity were 0.85 and 81% by Cronbach's alpha and the CVI method, respectively.[8]

The data collection lasted for one month from July to August 2018 and then data were analyzed using SPSS software (version 16, SPSS Inc, Chicago, IL, USA). Descriptive statistics including mean, percentage, and Standard Deviation (SD) were used to determine moral distress and moral courage levels. To analyze the data, the Kolmogorov-Smirnov test for normality, ANOVA, and two independent t-tests were used at the significance level of p < 0.05.

Ethical considerations

The present research was approved by the Ethics Committee of Bam University of Medical Sciences with the code of ethics (IR.MUBAM.REC.1397.018). Written informed consent was obtained from the participants before participating in the study. Additionally, research aims and procedures were thoroughly explicated to the participants while they were allowed to withdraw from the study at any possible stage. Next, all nurses filled and signed the informed consent. Finally, permission was granted from the hospital for conducting the present study.

Results

The mean (SD) age of participants was 31.80 (4.25). In addition, most participants were females (90.78%) and married (88.94%). Further, 96.31% of nurses had a bachelor's degree in nursing and 44.39% were provisional contract employees [Table 1].

Table 1

Frequency distribution of demographic variables of the participants

Variables		Frequency (%)
Age (year)	20-30	106 (48.80)
	31-40	103 (47.50)
	41-50	8 (3.70)
Gender	Male	20 (9.22)
	Female	197 (90.78)
Marital status	Single	24 (11.06)
	Married	193 (88.94)
Level of education	Bachelor degree	209 (96.31)
	Master degree	8 (3.69)
Employment status	Permanent	49 (22.58)
	Provisional contract	105 (48.39)
	Task plan	15 (6.91)
	Contractual	48 (22.12)
Work experience (year)	1-5	55 (25.35)
	6-10	93 (42.86)
	11-15	61 (28.11)
	16-20	4 (1.80)
	>20	4 (1.80)

Based on the results, the mean of moral distress was 45.41 (95% CI = 43.37-47.45), 44.24 (95% CI = 42.98-45.42), and 59.63 (95% CI = 58.50-60.87) in terms of frequency and intensity, and moral courage. In the present study, a statistically significant relationship was found between moral courage and the frequency of moral distress (r = 0.46, p < 0.001) and intensity of moral distress (r = 0.73, p < 0.001). Furthermore, the results [Table 2] demonstrated a significant correlation between the intensity and frequency of moral distress (r = 0.77, p < 0.001).

Table 2

The total mean and 95% CI for moral distress (frequency and intensity) and moral courage

Variable	n	Mean (SD)	95% CI
Moral distress (Frequency)	217	45.27 (15.35)	43.37-47.45
Moral distress (Intensity)	217	44.55 (9.59)	42.98-45.42
Moral courage	217	59.47 (8.96)	58.50-60.87

Based on the results, a significant correlation was observed between age (χ2 = 18.82, df = 2, p < 0.001) and intensity of moral distress (χ2 = 4.49, df = 2, p < 0.001). Additionally, the total mean of moral distress frequency had a significant relationship with gender (t215= 2.17, p < 0.001), marital status (t215= 2.17, p = 0.03), employment status (χ2 = 22.39, df = 3, p = 0.01), and working experience (χ2 = 11.84, df = 4, p = 0.03).

In addition, the results revealed a significant correlation between the intensity of moral distress with gender (t215= 1.62, p < 0.003) although the mean of moral distress intensity represented no significant difference with other demographic variables. Eventually, no significant correlation was found between moral courage and any of the demographic variables [Table 3].

Table 3

The total mean (SD)of moral distress (frequency and intensity) and moral courage on the basis of demographic variables

Variables		Moral distress		Moral courage
		Frequency	Intensity
Age	p	<0.001	<0.001	0.887
Gender	Male	34.50 (4.70)	38.30 (5.75)	61.15 (14.50)
	Female	46.52 (15.62)	44.84 (9.70)	59.47 (8.24)
	p	0.001	0.003	0.428
Marital status	Single	39 (12.04)	42.12 (7.93)	60.45 (13.06)
	Married	46.21 (15.55)	44.50 (9.76)	59.52 (8.36)
	p	0.030	0.252	0.633
Education level	Bachelor degree	45.16 (15.11)	44.17 (9.49)	59.57 (9.08)
	Master degree	52.12 (20.71)	46.12 (12.54)	61 (5.26)
	p	0.209	0.573	0.661
Employment type	Permanent	51.66 (16.45)	45.22 (8.06)	58.84 (8.25)
	Provisional contract	44.86 (15.83)	44.96 (11.18)	59.40 (7.17)
	Task plan	37.86 (5.26)	43.80 (8.06)	63.93 (16.34)
	Contractual	42.42 (13.13)	41.74 (7.16)	59.59 (10.02)
	p	0.003	0.229	0.273
Work experience (year)	1-5	43.07 (14.29)	43.42 (8.30)	59.90 (9.65)
	6-10	44.37 (14.96)	43.46 (9.62)	60 (10.02)
	11-15	48.55 (16.45)	45.67 (10.45)	58.83 (6.73)
	16-20	62 (14.67)	50 (12.70)	61 (7.74)
	>20	37.25 (1.25)	46 (8.04)	58 (6.16)
	p	0.038	0.418	0.924

Discussion

In the present study, a significant correlation was found between moral distress and moral courage in nurses. In addition, the results indicated that there was a significant relationship between the frequency and intensity of moral distress. In other words, higher moral courage in nurses leads to lower moral distress, which is in line with the results of previous studies.[1],[8],[25] Further, Gallagher reported that moral courage is an important factor in reducing moral distress when facing ethical challenges.[1] Furthermore, nurses' courageous decision-making can maintain ethical frameworks and prevent ethical distress.[1] Thus, strengthening moral courage can play a significant role in controlling the undesirable consequences of moral distress in the clinical setting.[25] Therefore, being brave in pursuing morality despite the existing obstacles, mentally and organizationally reduces the negative effects of moral conflicts in nurses and enables them to achieve ethical goals.[8] In the present study, nurses had a moderate to high level of moral distress, which is consistent with the findings of previous studies[9],[10],[26],[27] demonstrating concerns about the growing trend of this phenomenon in medical settings. Health care settings are inherently challenging and can create destructive impacts including distress on nurses.

Based on the results of the present study, a significant correlation was observed between age and the frequency and intensity of moral distress. More precisely, moral distress demonstrated an increase by increasing age, which corroborates with the findings of some studies.[28],[29] For instance, the results of a previous study represented that age was significantly related to the intensity of moral distress and increased by increasing age.[29] However, these results contradict those of some other studies.[9],[11],[30] Based on these contradictory results, nurses acquire greater clinical experience by aging and are in different moral standings, which may lead to their increased moral distress. Thus, younger nurses with insufficient clinical experience are expected to undergo low levels of moral distress.[31]

In the present study, a significant correlation was found between gender and moral distress. Women had more moral distress than men, which is in line with the results of previous studies[32],[33],[34] while contradicting those of some other studies.[27],[35] Some studies indicated that gender differences affect the level of people's awareness of ethical principles. Therefore, cultural norms and social patterns play a significant role in the decisive behavior of men toward women.[1],[15]

The results of the present study revealed a significant correlation between the frequency of moral distress and work experiences. In other words, nurses with 16–20 years of work experience had more moral distress and more experienced nurses had higher moral distress. Some nurses may adapt themselves to moral distress situations and others may suffer from the frequency of moral distress.[5],[30],[36] In their study, Rice et al. concluded that more experienced nurses had higher moral distress. They further found that increasing the level of nursing work experience and the years of residence in the current situation increases moral distress.[37]

On the other hand, less experienced nurses may feel that they should not be at the front line of the process of ethical decision-making at the start of their life work and thus they have less stress.[7],[38] However, they may experience more moral distress in the process of ethical decision-making in front of nurses with more work experience and responsibility.[7],[32],[39] Some other studies reported that moral distress decrease by increasing experience.[8],[26] More precisely, nurses with more work experience may have learned to adapt to ethical distress more effectively.[40] It seems nurses are more exposed to moral distress by increasing work experience. Additionally, experienced nurses may even experience severe moral distress due to unfamiliarity with strategies for coping with and controlling moral distress. In addition, adherence to the codes of ethics could lead to higher moral distress in nurses with more clinical experience.[31]

Based on the results of the present study, a significant correlation was found between moral distress frequency and employment status, and nurses with permanent employment obtained a higher score in terms of moral distress, which is in line with the findings of other studies.[36],[41],[42] In the present study, more experienced nurses had a higher moral distress, and this may be due to an increase in the moral sensitivity of the individual. Further, a significant correlation was reported between the frequency of moral distress and marital status so that the average score of moral distress was higher in married nurses compared to the single ones, which is consistent with the results of Abbaszadeh et al.[26] However, Fazljoo et al. found that the mean score of moral distress was higher in singles compared to married nurses.[34]

The mean score of nurses' moral courage was moderate, which is in line with the results of some studies conducted in Iran and Canada.[8],[10] In another study performed in Iran, the moral courage of nurses was reported to be high[26] while other studies demonstrated a low level of moral courage,[9],[27] which is inconsistent with the results of the present study. Therefore, the unequal level of moral courage in studies can be due to differences in organizational culture, workplace, moral climate, support of managers, support of the organization, fear of social isolation, and organizational disapproval.[1],[5],[43]

One of the limitations of the present study was the few sample size which led to the use of the census sampling method for conducting the study. Furthermore, the current study was undertaken with a sample of nursing professionals from a region in the city in the south-east of Iran. Thus, the results may not be generalizable to other multiple health contexts.

Conclusion

In general, the findings of the present study demonstrated a significant relationship between moral distress and moral courage, indicating that moral distress decreases in nurses by an increase in moral courage. Given that all nurses experience moral distress in clinical settings, greater improvement in moral courage is important in providing complete care. Eventually, identifying and eliminating moral distress situations are essential since they may affect nurses.

Financial support and sponsorship

Bam University of Medical Sciences

Conflicts of interest

Nothing to declare.