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© 2019 Medical Ethics and History of Medicine Research Center,
Tehran University of Medical Sciences. All rights reserved.
Original Article
Volume 12 Number 8 August 2019
The relationship between moral distress in nurses and ethical climate
in selected hospitals of the Iranian social security organization
*Corresponding Author
Mohsen Shahriari
Nursing & Midwifery Care Research
Center, School of Nursing and Midwifery,
Isfahan University of Medical Sciences,
Hezar jerib Ave., Isfahan, Iran.
Postal Code: 8174673461
Tel: (+98) 31 37927500
Email: shahriari@nm.mui.ac.ir
Received: 19 May 2018
Accepted: 6 July 2019
Published: 4 Aug 2019
Citation to this article:
Bayat M, Shahriari M, Keshvari M. The
relationship between moral distress in
nurses and ethical climate in selected
hospitals of the Iranian social security
organization. J Med Ethics Hist Med.
2019; 12: 8.
Mina Bayat1, Mohsen Shahriari2*, Mahrokh Keshvari3
1.MSc Student, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
2.Associate Professor, Nursing & Midwifery Care Research Centre, School of Nursing and Midwifery, Isfahan
University of Medical Sciences, Isfahan, Iran.
3.Assistant Professor, Nursing & Midwifery Care Research Centre, School of Nursing and Midwifery, Isfahan
University of Medical Sciences, Isfahan, Iran.
Abstract
The present study was conducted to determine the relation
between nurses’ moral distress and the ethical climate in
selected hospitals of the Iranian Social Security Organization
(ISSO). This descriptive-analytical correlational study was
conducted in 6 hospitals under the coverage of the Iranian
Social Security Organization in 2016. Three hundred nurses
were selected by convenience sampling method. Data were
gathered using Corley’s Standard Moral Distress and Olson’s
Hospital Ethical Climate Scales. Data were analyzed using
SPSS software version 19.
The mean score of the nurses’ moral distress was 1.94 ± 0.66,
which is considered moderate. The mean score of ethical
climate was 88.97, indicating desirable ethical climate in
these hospitals. The frequency score of moral distress had a
unilateral reverse correlation with the total score of ethical
climate as well as its dimensions, including colleagues,
patients, hospitals and physicians. The score of the intensity
of nurses’ moral distress also had a unilateral reverse
correlation with the total score of ethical climate and the
scores of the hospital and physicians dimensions.
These results emphasized the importance of creating a
positive ethical climate to decrease moral distress as well as
the need for professional interventions to increase support in
moral issues.
Keywords: Moral distress; Nurses; Ethical climate; Hospital
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Volume 12 Number 8 August 2019
Introduction
Generally, providers of health-related
services encounter various moral issues and
problems on a regular basis (1). Changes in
the healthcare system lead to an increased
need for ethics laws, policies and therapeutic
instructions, and highlight the accountability
of the healthcare personnel. Also,
occupational pressures and raised levels of
social expectations increase health-care
providers’ level of moral distress (2). On the
other hand, developments in technology and
medicinal interventions in patient care,
especially when the results are uncertain,
would escalate moral conflicts (3). These
moral problems could lead to stress in
caregivers and consequently cause physical,
emotional, mental and social moral distress
(1).
As important members of the health team,
nurses play an essential role in providing
competent, responsive and moral care.
However, nursing care is mostly provided in
a context filled with moral conflicts and
challenges (4). Moral distress is frequently
discussed in relation to occupational
satisfaction, occupational burnout and
interactions in nursing relationships (5). In
addition, various personal and structural
factors could be effective in causing moral
distress (6).
Moral distress is a disturbing mental
imbalance caused by recognition of a
morally correct action that cannot be
performed due to organizational barriers
such as lack of time, supervisors’
unwillingness, physicians’ inhibiting power
structure, organizational policies and legal
considerations (7).
Moral distress is a common phenomenon in
nursing practice that can cause conflicts
when encountering patients and providing
quality care. On the one hand, moral distress
may disrupt the process of achieving care
system objectives and consequently have an
adverse effect on the health pattern of the
society (8); on the other, it can create mental
and physical problems for nurses, which
may influence their occupational satisfaction
and their willingness to remain in the
profession, and eventually the quality of care
(9). Nurses have reported moral distress as a
result of changes in human resources and the
health system as well as increased social
demands (2).
Moral distress affects not only nurses’
professional life by disturbing their focus
and creating feelings of inefficiency, but
also their personal life by causing mood
disorders and irritability (5). Study results
have shown that increased levels of moral
distress could cause medical errors, harm,
burnout, excessive fatigue and reluctance to
help patients (10). Furthermore, extreme
disappointment and occupational
dissatisfaction might lead to collateral
violence and in general, an insecure work
environment (11).
In most studies, the emphasis has been on
determining the relation between nurses’
personal characteristics and moral distress,
and less attention has been paid to the
organizational environment and inter-
organizational relationships (12). Ethical
climate indicates a common understanding
of the organizational activities associated
with moral decisions and inter-
organizational issues such as power, trust
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Volume 12 Number 8 August 2019
and human relationships (13). Fry et al.
showed that the lower the level of the
hospital ethical climate is, the higher the
severity of perceived moral distress and its
complications will be (14). Also, Borhani et
al. revealed a reverse relationship between
perceived moral distress in nurses and their
perception of the ethical climate (8). Hart
showed that a negative ethical climate is
related to nurses’ decision to leave their job
or the nursing profession (15). Corley et al.
reported that 25% of the studied nurses had
left their positions due to moral distress.
Aiken et al. also found that 40% of the
nurses were not satisfied with their work
environment and 1 out of 3 nurses aged
under 30 planned on leaving their jobs
within the next year (16). Also about half of
the nurses (44%) reported a decline in the
quality of the care they provided. It seems
that in order to determine the causes of
moral distress, occupational satisfaction and
nurses’ willingness to change their place of
duty, the ethical climate needs to be
improved (17).
There is evidence about the higher
occurrence of moral distress in certain
occupational situations (1). Rice et al.
reported that nurses working in oncology
and organ transplant wards experience moral
distress more than other nurses (18).
Another study reported that health
community nurses and nurses working in
mental hospitals experience lower levels of
moral distress (19). Anke et al. showed that
in providing end-of-life care, due to lack of
internal independence, sometimes nurses are
not able to work based on their values,
which might lead to moral distress (5). Also,
there is evidence about the effect of
colleagues’ support (4), supervision (20) and
ethical climate on moral distress, all of
which are influenced by the perceptions of
the nursing staff, organizational viewpoints
and management of moral issues (6).
Most of the studies in this field have been
conducted on the quiddity, prevalence and
personal determinants of moral distress. Few
studies have been conducted on occupational
factors involved in occurrence or non-
occurrence of moral distress (21) and the
effect of the workplace on the occurrence of
moral distress (22). Therefore, it is necessary
to evaluate these factors comprehensively
and provide effective solutions to prevent
moral distress among nurses (23). According
to surveys, all related research in Iran has
been conducted in hospitals affiliated with
medical universities and the issue has not
been investigated in hospitals under the
coverage of the Iranian Social Security
Organization (ISSO).
The Iranian Social Security Organization
(ISSO) is a public insurance institution
whose main mission is to cover wage and
salary workers (compulsory) and self-
employed individuals (optional). The
population covered by this organization is
about 12 million insured people and more
than 2 million pensioners, and reaches 37
million including family members who
receive health care.
By law, the ISSO is a public
nongovernmental establishment that is not
reliant on government resources, and the
major part of its funding comes from the
premium provided through participation of
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Volume 12 Number 8 August 2019
the insured and the employer. For this
reason, its assets pertain to segments
covered in successive generations and
cannot be merged with any governmental or
nongovernmental organization or institution.
The core of this organization is the tripartite
participation of employers, insured persons
and the government in various fields of
policy- and decision-making as well as
financing.
Hospitals covered by the ISSO do not
operate under the supervision of medical
universities and therefore do not have a
strong academic and educational
background. Since a large portion of health
services in Iran is provided by this
organization and many nurses are hired there
after graduation, research in this field, which
has so far been outdated, seems to be
necessary. Moreover, the results of such
studies can contribute to a better
understanding of this huge part of the
community health system. Additionally,
since the researcher is employed as a nurse
in one of the ISSO hospitals, she is familiar
with the study environment and relevant
authorities, which has facilitated the research
process and helped to better reflect the
actual experiences of the participants. For
these reasons, the present study was
conducted to determine the relationship
between moral distress in nurses and the
ethical climate in selected hospitals of the
ISSO in two cities.
Method
The present study was a descriptive-
analytical correlational study conducted in 6
hospitals under the coverage of the ISSO (4
in Tehran and 2 in Isfahan) during 2016. The
sample size for this study was calculated to
be 255 participants, and after considering a
20% sample loss, the number was increased
to 300. The share of each hospital was
determined based on the number of the
nurses working there. At first the sampling
method was quota, and then samples were
selected using convenience sampling from
the wards of the selected hospitals. The
inclusion criteria were having at least a
bachelor’s degree in nursing and having a
minimum one-year work experience at the
hospital.
We had to obtain permission from the ethics
committee of the Isfahan University of
Medical Sciences (No. 395230) and make
arrangements with the treatment
management of the ISSO in the study
environment. After explaining the goals of
the study and presenting the proposal, we
received approval to enter the selected
hospitals. To attract the participation of
nurses, a meeting was held with the presence
of hospital management and nursing
managers to explain the process and
methods of the study, and participants were
assured that the results of the study would be
presented to hospital authorities, optionally.
After preparing a list of the nurses in each
ward, the number of participants from each
ward was determined based on the quota to
each hospital, and the questionnaires were
distributed among the nurses through
convenience sampling.
To provide ethical considerations, the
participants’ written consent was obtained at
the beginning of the queries to make certain
of their agreement to participate in the
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Volume 12 Number 8 August 2019
research. As the next step, the goals and
nature of the study were explained to the
participants and they were assured of
confidentiality of their information and the
voluntary nature of participation.
Subsequently, questionnaires were
distributed among the nurses in three
working shifts based on the allocated quota
for each ward. To answer the questions of
the participants, the researcher remained at
each ward during an entire working shift.
The questionnaires were distributed among
the participants at the beginning of each
working shift when there was enough time
to talk, and the manner of answering the
questions was explained to them. The
participants were asked to complete the
questionnaire before their next working shift
at the latest, and then place it in the envelope
that was given to them and hand it to their
head nurse. Due to the sensitivity of the
issue and in order to ensure data collection
precision, the researcher personally did the
entire work for all the 300 participants, and
was present in the research environment
both in Tehran and Isfahan.
A three-part questionnaire was used for
gathering the data. The first part was about
demographic characteristics including age,
gender, marital status, educational level and
profession-related information such as type
of employment, working ward and hospital,
work experience and the number of overtime
hours. The second part included Olson’s
Ethical Climate Scale, designed and
psychometrically evaluated by Olson in
1995 to measure hospital ethical climate.
Olson determined the validity of the
questionnaire using content validity index
(CVI) at 87% and its reliability at 91% using
Cronbach’s alpha (Olson 1995). This scale
was translated and used in a study by Hariri
et al. in 2011 (24), and its content validity
index and reliability were measured using
internal consistency and test-retest methods
(content validity was 0.89). In the present
study, the translated tool from Hariri’s study
was used. This scale has 26 items scored
from almost never (1) to almost always (5)
using a 5-point scale. Thus the score of each
questionnaire ranges between 26 and 130,
with higher scores indicating more positive
ethical climates. This questionnaire contains
5 factors that evaluate nurses’ perceptions
about their colleagues (questions 1, 10, 18
and 23), patients (questions 2, 6, 11 and 19),
managers (questions 3, 7, 12, 15, 20 and 24),
hospital (questions 4, 8, 13, 16, 21 and 25),
and physicians (questions 5, 9, 14, 17, 22
and 26).
The third part aimed to measure moral
distress and was first designed by Corley in
1995. This scale has 24 items, each
presenting a stressful situation and asking
the respondents to score the moral distress
they would experience in each case.
Corley’s scale shows the frequency and
severity of moral distress in nurses based on
a 5-point Likert scale from 0 to 4. To
determine the severity of distress, options
varying from “it causes no distress for me”
(score of 0) to “it causes great distress for
me” (score of 4) were used. To determine
the frequency of perceived distress, options
varying from “I have never experienced
moral distress” (score of 0) to “I have
experienced a lot of moral distress” (score of
4) were used. The lowest score (0) indicated
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Volume 12 Number 8 August 2019
the minimum perceived distress at the
intended situation and the highest score (96)
indicated the maximum perceived distress at
the intended situation. The total score of the
questionnaire would be categorized as low
(0 to 24), moderate (24.1 to 48), high (48.1
to 72) and very high (72.1 to 96). Also, at
the end of the questionnaire, there was a
three-choice question to evaluate nurses’
intention to leave the nursing practice. In
this study, the translated tool from Borhani’s
study was used. The validity of this scale
was measured to be 100% by Borhani et al.
(2014) (8), using content validity index
(CVI). The reliability of the tool was
approved using test-retest and Cronbach’s
alpha. Data were analyzed using SPSS
software version 19 and descriptive statistics
including mean, percentage, standard
deviation, tolerance and inferential statistics
to determine the relation and correlation
between qualitative and quantitative
variables including Pearson’s correlation
coefficient, Spearman’s correlation
coefficient, and one-way variance analysis.
Results
Three hundred questionnaires were
completed by the nurses and then analyzed.
According to the results, the mean age of the
participants was 37 years, 73.3% were
female, 78.7% were married, and 84% had a
bachelor’s degree. In terms of employment,
58% had ordinary organizational positions,
76% were officially employed, and 88.3%
did not work in other hospitals. Also, 86%
had a work experience of 15 to 19 years and
the mean of their overtime hours per month
was 77.4, while 76% had to work extra
obligatory hours. Most of the participants
(56%) were working rotational shifts, 7.51%
had passed ethics courses, and 61 percent
were chosen based on their interest in
nursing (Table 1).
According to the results, the mean score of
perceived moral distress in nurses was 1.94
± 0.66, which indicated moderate moral
distress. Among the items related to the
frequency of occurrence of moral distress,
the item of “Giving nursing care to a patient
under ventilation with no hope for living”
had the highest (2.1 ± 9.34), and the item of
“When patient’s death is inevitable, I speak
to the family about organ donation” had the
lowest frequency of moral distress (1 ±
1.16).
Among the items related to the severity of
moral distress, the item of “Due to the large
number of patients, I cannot provide high
quality care to all of them” had the highest
(with a mean of 2.1 ± 84.26), and the item of
“I accept the physician’s request not to talk
to a near-death patient about death” had the
lowest (with a mean of 1.1 ± 82.37) severity
of moral distress among nurses.
The mean score of ethical climate was
88.97, which indicated good ethical climate
in the selected hospitals. Among the items
related to the ethical climate questionnaire,
the item of “I have an appropriate working
relationship with my colleagues” had the
highest score (with a mean of 4), and the
item of “In this hospital, nurses are
supported and respected” had the lowest
score (with a mean of 2.65).
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Table 1- Mean score of moral distress of nurses and their perception of ethical climate in terms of
individual characteristics
Statistical Test
Severity of Moral
Distress
Frequency of Moral
Distress
Frequency
Individual
Characteristics
P-Value Mean P-Value Mean
Independent
T-Test
0.92
Sex
50.3
0.002
41.1 220 Woman
50.1 47.8 80 Man
Independent
T-Test
0.33
Marital Status
50.6
0.07
43.6 236 Married
47.8 39.3 64 Single
One-Way
Analysis-
Variance
0.34
Employment Status
51.1
0.72
43.3 228 Official
46.7 41.6 55 Pseudo-Official
50.8 41.3 17 Contractual
ANOVA
0.027
Ward
2.14
0.001
1.81 167 Intensive
2.04 1.75 68 Surgical
2.44 2.27 20 Internal
1.67 1.31 23 Pediatric
1.99 1.74 22 Other
Independent
T-Test
0.95
Passing Ethics Courses
2.09
0.004
1.89 155 Yes
2.09 1.66 145 No
Independent
T-Test
0.46
City
50.8
0.63
42.6 205 Tehran
49 43.6 95 Isfahan
The results of the present study showed no
significant difference between nurses in
Isfahan and Tehran regarding the frequency
and severity of moral distress. Also, the total
mean score of the frequency of moral
distress was 1.0 ± 78.68, and the total mean
score of the severity of moral distress was
2.09 ± 0.81. While the mean score of the
frequency of moral distress was significantly
higher among male nurses, the mean score
of the severity of moral distress was not
significantly different between male and
female nurses. Also, no significant
difference was observed between single and
married nurses regarding the mean scores of
frequency and severity of moral distress
(Table 1).
There was no significant relationship
between the means of frequency and severity
of moral distress in nurses and their hospital
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Volume 12 Number 8 August 2019
of duty (P = 0.07), organizational position
(P = 0.89), employment status (P = 0.44)
and the type of overtime hours (P = 0.46).
Also, nurses who had passed ethics courses
had encountered morally distressful
situations more often, but regarding the
severity of moral distress, no significant
difference was observed between nurses
who had passed ethics courses and those
who had not.
The results of the present study showed that
the mean scores of frequency and severity of
moral distress in nurses had a significant
relation with their working department. In
this regard, nurses working in the internal
wards reported higher frequency and
severity of moral distress (mean = 2.27)
compared to nurses working in other wards.
Also, pediatric nurses reported the lowest
moral distress (mean = 1.31).
The results showed no significant
relationship between the mean scores of
frequency and severity of moral distress in
nurses and their age, overtime hours, or
work experience. Likewise, no relationship
was found between the mean of the severity
of moral distress and the nurses’ educational
level and work experience. However, there
was a direct relationship between the mean
score of the frequency of moral distress and
the nurses’ educational level, that is, with
their educational level rising from bachelor’s
to master’s degree and Ph.D., their
perception of moral distress was improved
(table 2).
Table 2- Pearson’s correlation coefficients between the severity and frequency of moral distress in
nurses, and age, overtime, education level and work experience
Severity of Moral Distress Frequency of Moral Distress
Score
P R P R
0.75 0.018 0.99 - 0.001 Age
0.90 - 0.007 0.63 0.027 Overtime
0.87 0.009 < 0.001 0.218 Level of Education
0.75 0.018 0.78 0.016 Work Experience
According to the results, the mean score of
ethical climate in the ISSO hospitals of
Isfahan and Tehran was 88.97, which is at a
good level based on the applied rating scale.
As for the total mean score of ethical climate
and its domains, there was no significant
difference between the nurses of Isfahan and
Tehran (P > 0.05). Also, in both cities,
nurses had the most desirable viewpoint in
the managers’ domain and the least desirable
viewpoint in the patients’ domain (Table 3).
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Table 3- Mean of total score of ethical climate and its domains by city of service
Score
Isfahan Tehran Independent T-Test
Mean
Standard
Deviation
Mean
Standard
Deviation
T P
Total Score of Ethical
Climate
88.7 14.9 89.1 16.3 0.19 0.85
Ethical
Climate/Colleagues 15.4 2.6 15.3 2.6 0.30 0.77
Ethical
Climate/Patients
13.7 2.7 13.9 2.4 0.68 0.50
Ethical
Climate/Managers
21.3 5.2 22.2 5.5 1.24 0.21
Ethical
Climate/Hospital
19.7 3.8 19.1 4.2 1.08 0.28
Ethical
Climate/Physicians 18.6 4.3 18.6 5.2 0.03 0.98
The score of the frequency of moral distress
in nurses had a reverse relationship with the
total score of ethical climate, and the
domains of colleagues, patients, hospital and
physicians. However, no significant
relationship was observed between the score
of the frequency of moral distress and the
score of ethical climate in the domain of
managers. Also, the score of the severity of
moral distress had a reverse relationship
with the total score of ethical climate, and
the domains of physicians and hospital
(Table 4).
Table 4 - Pearson’s correlation coefficients between severity and frequency of moral distress in
nurses, and the total score of ethical climate
Score
Frequency of Moral Distress Severity of Moral Distress
r P value r P value
Total Score of Ethical Climate - 0.194 0.001 - 0.170 0.003
Ethical Climate/Colleagues - 0.187 0.001 - 0.069 0.23
Ethical Climate/Patients - 0.181 0.002 - 0.053 0.36
Ethical Climate/Managers - 0.090 0.12 - 0.092 0.11
Ethical Climate/Hospital - 0.139 0.02 - 0.153 0.008
Ethical Climate/Physicians - 0.224 < 0.001 - 0.259 < 0.001
Discussion
According to the results of the present study,
the mean scores of frequency and severity of
moral distress in nurses indicated moderate
moral distress among participants from the
selected ISSO hospitals. Also, the scores of
moral distress in the nurses of Isfahan and
Tehran were both at a moderate level, and
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Volume 12 Number 8 August 2019
no significant difference was observed
between the nurses of these two cities.
The results showed that the severity and
frequency of moral distress in nurses had a
significant unilateral reverse relationship
with the hospital ethical climate. This means
that the more positive and favorable the
ethical climate of a hospital is, the lower the
severity and frequency of moral distress will
be. Overall, the mean score of ethical
climate in the selected hospitals of the ISSO
in Isfahan and Tehran was at a good level.
Different studies have reported different
results regarding moral distress among
nurses. Fernandez-Parsons et al. reported
low moral distress among emergency nurses
(25), while de Veer et al. found that nurses
experience high levels of moral distress (5).
A study by Abbaszadeh et al. reported a
moderate level of moral distress and showed
a significant relationship between the
severity of moral distress and its recurrence
(23).
Sile´n et al. demonstrated that although the
severity of moral distress increased in
situations where secure and appropriate care
was not provided for the patient, the
frequency and severity of nurses’ moral
distress were still at a low level. In general,
they reported that the frequency of moral
distress was less than its severity. They also
showed that a more positive perception of
the ethical climate would decrease the
frequency of morally distressful situations
(12).
These differences in the results might be due
to the different scales that were used in
various studies on moral distress. Also, the
items of the moral distress questionnaire
may not sufficiently cover the moral
concerns of the participating nurses, and
even for those who have recognized their
own distress, the items might cause too
much discomfort, distress and disruption to
answer realistically (6).
In studies that have reported higher levels of
moral distress compared to the present
study, there could be other personal and
organizational factors causing moral distress
to escalate among nurses; these factors may
include the disproportion between the
number of nursing personnel and the number
of empty beds at the hospital, or the
presence of unskilled physicians and
managers.
Also in studies that reported lower perceived
moral distress, these factors might have a
certain quality that could consequently
decrease the level of perceived moral
distress among nurses (6).
In a study by Pinhero and De Souse in 2016
on operating room nurses with at least one
year of work experience at the central
hospital of Portugal, it was revealed that
work environment and occupational
satisfaction were at a desirable level and to
improve and enhance this environment, the
cooperation of the managerial team was
necessary (26). Another study by Humphries
and Woods in New Zealand showed that
participants’ perceptions of the hospital
ethical climate had been formed under the
influence of interrelated factors (27). These
factors included staffing levels, patient
throughput (turnover) and the dynamics
between the nursing staff and others within
the workplace (27). Also in a 2007 study by
Ulrich et al. conducted on 300 nurses across
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four different states of the United States,
most of the participants evaluated the ethical
climate of their workplace positive and
higher than neutral with a mean score of 93
(2).
A 2016 study by Bartholdson et al. showed
the nurses to have a weak perception of the
ethical climate (28). This was due to inter-
professional interactions, for instance the
physicians’ attention to the opinions of
nurses and assistant nurses, treatment-related
decisions and respect for others’ opinions,
especially at times of disagreement between
different specialists on the best approach for
the patient. After reviewing 32 articles,
Schluter et al. revealed that weak ethical
climate would escalate issues such as moral
distress, insufficient or futile care, and
unsuccessful or insufficient support for
others, and might create false hope for the
patients and their families (4).
According to the results, a significant
relationship exists between the nursing
service hospital and the ethical climate
scores in the managers and hospital
domains, but not the other domains. This
indicates the effectiveness of the impact of
management in the creation and
development of a suitable and safe
environment for the activities of the staff,
which ultimately contributes to preventing
or reducing moral distress among nurses and
the adverse effects of these disturbances in
the health care system.
The nurses who participated in this study
expressed the most favorable opinion in the
domain of managers, and the most
unfavorable viewpoints in that of patients. In
a study by Fazljoo et al. in 2014, the most
favorable opinion pertained to managers and
the most unfavorable viewpoint was related
to physicians (29). Since nursing directors
are chosen from among members of the
nursing community and most of them have
long-term clinical backgrounds, it seems
reasonable that they should have a good
understanding of the ethical atmosphere in
this field. On the other hand, the hospitals
affiliated with the ISSO are very crowded
clinical centers in Iran, and providing health
care for a large number of insured persons in
this organization is very difficult and time
consuming. Nurses are the most accessible
responders to patients and are therefore
required to address their needs and health
expectations, which leads to inconveniences
and problems in providing proper service
and ultimately creates an undesirable view in
this domain.
Of course, Health care organizations seem to
be able to control the distresses by providing
the nursing staff with ethical support and
empowering them to offer quality care. It
should also be noted that, managers and
peers must also be willing to advocate for
each other, should ethically difficult
situations arise (4).
In the moral distress questionnaire, the
highest frequency pertained to item 5
(Continue to participate in care for a
hopelessly ill person who is being sustained
on a ventilator, when no one will make a
decision to withdraw support) with an
average of 2.90. Conversely, item 2 (When
the patient’s death is inevitable, I talk to the
family about organ donation) had the lowest
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frequency with an average of 1.01. These
findings are fully consistent with the results
of other studies (10, 23, 30).
In general, review of the literature did not
greatly change the results. The findings of
different studies on nurses working in
various clinical environments indicated that
desirable ethical climate would decrease
moral distress. A study by Pauly et al. in
Columbia also showed that there was a
significant relationship between nurses’
perceived moral distress and the hospital
ethical climate, that is, improved ethical
climate would decrease the perceived moral
distress by nurses (6). Fry et al. also found
that the more undesirable the hospital ethical
climate was, the higher would the intensity
of the perceived ethical distress and its
complications in nurses be (14). Similarly,
Fazljoo et al. showed a direct negative
relationship between severity of perceived
moral distress in nurses and ethical climate
(29).
Based on the results of the present study, the
mean scores of frequency and severity of
moral distress was significantly lower
among nurses who had selected nursing
practice based on their own interest
compared to those who had done so without
interest. Borhani et al. also showed that the
frequency and severity of moral distress
were higher among nurses who had selected
nursing practice without passion (8).
According to their results, the mean scores
of frequency and severity of moral distress
were significantly lower among nurses who
had never considered quitting their position
or their profession compared to other nurses.
These findings were in line with the results
of other studies (2, 25, 31). A review study
by Schluter et al. in 2008 demonstrated that
moral distress and unfavorable ethical
climate were causing a growing shortage of
nursing personnel and an increase in nurses’
intention to transfer (4), and there is
evidence indicating the effect of weak
ethical climate on quitting the nursing
practice. It seems that selecting nursing
practice with passion could decrease nurses’
encounters with morally distressful
situations due to better adjustment to the
existing conditions (7). Although many
researchers have stated that weak ethical
climate and moral distress would cause
nurses to leave the profession, the
phenomenon has unfortunately not been
accurately measured and reported. In fact,
nurses’ decision to quit their profession due
to moral distress and their perception of their
workplace is still undetermined (4). If
nursing practice is recognized as an ethical
profession and nurses believe that they are
performing an ethical act, the need for
determining the effect of organizational
barriers to performing the right action will
be felt (32).
In the present study, all of the dimensions of
ethical climate (colleagues, patients, hospital
and physicians) had a significant
relationship with moral distress, except for
the dimension of managers. Also, the score
of severity of moral distress had a significant
reverse relationship with the total score of
ethical climate and the dimensions of
hospital and physicians. These results
indicate that a series of factors are effective
in nurses’ perception of ethical climate, and
that a complex relationship exists between
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experiencing moral distress and the
dimensions of ethical climate (6).
In the present study, the frequency and
severity of moral distress varied in different
wards. Thus, nurses working in the internal
ward reported the highest level of moral
distress compared to other nurses. The
reason for this difference might be the fact
that nurses of the internal ward would spend
more time with their patients in comparison
to nurses of other wards. Patients may be
hospitalized in the internal ward for a long
period of time, which can cause challenges
to providing care. Also, the highest mean of
severity of moral distress belonged to the
item of “Due to the large number of patients,
I cannot provide high quality care”. This
indicates the occurrence of moral distress in
situations where nurses are forced to provide
care for a large number of patients in a short
amount of time. A study by de Veer et al. in
2013 showed that nurses who face a
shortage of time in providing care for their
patients experience more moral distress, and
the perceived pressure resulting from lack of
time probably causes further concerns about
the quality of the care they provide (5).
Participants in the present study had the
most desirable viewpoint in the managers’
dimension and the least desirable viewpoint
in the patients’ dimension. Since nursing
managers are part of the nursing community
and mostly have a lot of experience working
in clinics, it seems only natural that they
should have a more desirable perception of
the ethical climate in this dimension. On the
other hand, the ISSO hospitals are some of
the most crowded medical centers and
providing service and care for such a large
number of patients is exhausting if not
intolerable. Nurses are required to fulfill all
of the patients’ medical needs and
expectations, and since they are the most
available staff members, they are bound to
encounter problems and experience
dissatisfaction, and eventually develop
undesirable viewpoints in this dimension.
Organizations providing health services
could control the dissatisfaction by
providing guaranteed moral support for the
nursing staff and empowering them to have
control over the provision of quality care.
Managers and other colleagues should also
try to support each other in morally difficult
situations (4).
The present study was conducted in the
ISSO hospitals of Isfahan and Tehran. In
Iran, the variables affecting the relationship
between nurses’ moral distress and ethical
climate have been examined by only one
study conducted in hospitals covered by
medical universities of Yazd. In the large
cities of Iran, especially in Tehran, no
similar study has been performed on the
subject. The current study was done in the
ISSO hospitals, which are rather different
from university hospitals for reasons
explained in the introduction section above.
Therefore, to improve the generalizability of
the results, it is recommended that future
studies be conducted with larger sample size
and participation in other large city
hospitals.
Conclusion
This study was an effort in the field of moral
distress and ethical climate in the nursing
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community of the ISSO hospitals, and
indicated that moral distress is closely
related to hospital ethical climate. It is clear
that determining strategies for decreasing the
intensity and frequency of moral distress is
an importance issue in these settings.
Current study results showed the importance
of creating a positive ethical climate to
decrease moral distress in nurses and their
tendency to leave their position or even the
profession. This would lead to presentation
of professional interventions for managing
moral stress, increasing support for moral
problems, creating appropriate
communication within the organization and
eventually decreasing moral distress in
nurses.
Acknowledgements
The authors would like to thank the School
of Nursing & Midwifery of Isfahan
University of Medical Sciences for
supporting this study financially. We would
also like to thank all the persons who made
this study possible.
Conflict of Interests
The authors have no conflict of interests to
declare.
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