Predictors of moral distress among intensive care nurses in Jordan
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https://www.eduzhai.net International Journal of Nursing Science 2013, 3(2): 45-50 DOI: 10.5923/j.nursing.20130302.03 Predictors of Moral Distress among Jordanian Critical Care Nurses Rabia Allari1,*, Fathie h Abu-Moghli2 1Al-Isra University, Faculty of Nursing, B.O. Box 11622, Elmatar Street, Amman, Jordan 2The University of Jordan, Faculty of Nursing, Amman, Jordan Abstract Many research studies suggested that moral d istress is associated with perceptions of ethical climate and is influenced by demographic variables. This study aimed to examine the ability of selected demographics and variables related to perception of hospital ethical climate in pred icting the level of mo ral d istress among critical care nurses in Jordan. A descriptive, correlation design was used in this study. Moral Distress Scale, Hospital Ethical Climate Scale and a demographic data form were admin istered to a random sample of 150 crit ical care nurses at 12 hospitals in Jordan. Data were analyzed using descriptive and inferential statistics. Factors constituting the hospital ethical climate and demographic characteristics revealed no ability to predict moral d istress. However, moral distress was found to be a common encounter among Jordanian nurses though they are not familiar with the term which imp lies that solutions to relieve their distress are unexplored. But still the result has a clinical merit that may help in establishing imp licat ions and recommendations of further researches. The findings of this study may assist hospitals and nurse managers in identifying factors contributing to moral distress fro m the nurses' perspective, and assist in planning and imp lementing strategies to reduce moral distress among nurses in crit ical ca re units and consequently improving the quality of care . Keywords Moral Distress, Critical Care Nurses, Hospital Ethical Environ ment 1. Introduction Today's acute care environment presents nurses with difficult situations and ethical dile mmas that may lead them to experience moral d istress. The changes in health care delivery models, new technological advances and the emotionally charged environ ment of the critical care units add to the complexity of the situation[1, 2]. The co mp lexity and frequency of ethical d ilemmas are the major determinants of the intensity of moral d istress. Ethical dile mmas encountered by the nurses working in critica l ca re units greatly exceed those encountered by nurses working in other acute care settings leading to more ethical distress. Moral distress is a phenomenon of increasing concern in nursing practice, education and research. It constitutes a significant cause of emot ional suffering among nurses that may result in un favorab le outco mes fo r both nu rses and patients. Feelings labeled as stress, emotional exhaustion, and job dissatisfaction may actually be indicative of mo ral distress. The experience of moral distress leads to frustration, depression and absenteeism that jeopardize nursing care. These sympto ms may be the reason g iven by nurses for leaving a specific work environ ment or even for departure * Corresponding author: email@example.com (Rabia Allari) Published online at https://www.eduzhai.net Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved fro m the nursing profession. Research to date suggests that the ethical c limatecontribu tes to moral distress, nurses’ decreasing job satisfaction, attrition and unsafe patient care[2, 5]. Perception of the ethical climate of one’s workplace is based on the relationships with peers, patients, managers, physicians, and hospital administration when encountering ethical problems . These relat ionships, according to Olson, are influenced by many conditions such as varying levels of power, t rust, inclusion, role flexib ility, and inquiry that is necessary for ethical problem-solving. Pau ly reported that peers, physician, and hospital management In addition to patients and nursing mangers were pred ictors for moral d istress among nurses. In addition to the hospital ethical climate, demographic variables of gender, education, ethics education, and work experience were listed as potentially having significant correlation and prediction of the experience of moral distress[6, 9, 10]. Conversely, many other studies found no correlation between demographic characteristics such as gender, education, age and years of experience[4, 9, 11-13]. Elpern reported that, except for the years of nursing experience in nursing, all individual characteristics, were positively correlated with the level of mo ral distress. According to Meltzer and Huckabay nurses' age was found to be a significant predictor of emot ional stress as younger nurses appeared to have somewhat more feelings of depersonalizat ion than did o lder nurses. Furthermore, 46 Rabia Allari et al.: Predictors of M oral Distress among Jordanian Critical Care Nurses Meltzer and Huckabay reported a significant negative relationship between educational level and mora l distress. In another study done by Allari & Abu-Moghli in Jordan (2011) to describe nurses’ level of mo ral d istress, their perception of the hospital ethical climate, and the relationship between their level of mo ral distress, the results showed that total moral distress and the two subscales Intensity and Frequency had moderate mean.When mo re specifically looking at the intensity subscale of the MDS in the same study, the situations that were considered the highest in intensity in causing moral distress were those related to the “suffering often seen in patients with comp lex, life threatening illnesses”. Also the top five items with the highest total distress scores were related to the “end of life issues”. The item regarding "Continue to participate in care for a hopelessly injured person who is being sustained on a ventilator, when no one will make a decision to turn off the life support machine." had the first place for the Total Subscale scores. This study aims at examining the ab ility of selected demographic (age, gender, education, years of professional experience, and employ ment years in the same hospital) and variables related to the nurses perception of hospital ethica l c limate (peers, patients, managers, hospitals administration, and physicians) in predicting the level of moral distress among critical care nurses in Jordan. The findings of this study may assist hospitals and nurse managers in identifying factors contributing to moral d istress fro m the nurses' perspective and in planning and implementing strategies to reduce moral distress among nurses in general and crit ical care nurses in particular. 2. Methods 2.1. Study Design A quantitative descriptive design was used to examine the predictors of moral d istress among critical care nurses in Jordan. 2.2. Sample & Setting This study was conducted in critical care units in public and private hospitals in Jordan. On ly hospitals with bed capacity of 150 beds or more (N=12) were selected to ensure the availability of nurses in critical care units. The stratified disproportional random sampling of (150) participants were selected. Inclusion Criteria were being a Jordanian registered nurse with a minimu m a BSC degree; working in a critical care unit; and working in the current institution for at least six months. 2.3. Ethical Considerati ons Approval for conducting the study was obtained fro m the ethical co mmittee at the University of Jordan, the Min istry of Health (M OH), and the selected hospitals. The selected nurses were in formed that part icipation is voluntary, that they can withdraw fro m this study at any time without penalty, not to write the names to ensure anonymity, and that the completion of the questionnaire is considered as a written consent for participation. 2.4. Study Instrument & Data Collection The study instrument includes two self-administered Likert-type scale questionnaires; The DDS was developed by the researcher based on a rev iew of the literature. Demographic data included gender, age, education, and experience as registered nurses, and length of current emp loyment. The Moral Distress Scale (MDS) was developed by Corley (1995) to assess the nurses' level of moral d istress. The MDS is a 38-item scale measuring moral distress intensity and frequency. Two 6-point Likert scales are included in front of each statement to assess the level of moral d istress in terms of intensity (ranging fro m ‘none’ to ‘great extent’) and frequency (ranging fro m ‘none’ to ‘very frequently’). The Hospital Ethical Climate Scale (HECS) was developed by Olson (1998) to assess nurses' perception of hospital ethical climate (HEC). The HECS is a 26-item self-ad min istered survey that asks participants to rate their responses using a 5-point Likert scale ranging fro m 1 to 5 (1 = almost never true to 5 = almost always true). The items of the HECS are included under five subheadings including relationships with peers, patients, managers, hospital administrators, and physicians. The questionnaires were pilot tested to determine their cultural appropriateness, clarity and the time needed to be completed. Meetings with the nursing managers in all 12 selected hospitals were conducted to inform them about the study and to gain their cooperation. Each selected nurse was met in person, received an exp lanation of the purpose of the study and a copy of the questionnaires, accompanied with an envelope and a cover letter attached to each envelope, these envelopes were recollected by the researcher after one to two weeks period or upon nurses' requests. Data were collection was completed over a 10 week t ime period. Coded information fro m the instrument was entered into data files using Statistical Package for the Social Sciences Version 17.0 (2007). All statistical procedures were performed at α=0.05 (2-tailed statistics). Descriptive statistics including means, standard deviations, and actual ranges were reported for the following study variables including: age, years of professional experience, variables related to HECS (peers, patients, physicians, managers, and hospital admin istrators). Inferential analyses including regression analysis procedure was used to answer the study question. Since the regression analysis is used to model the value of a dependent scale variables based on its relationship to one or more p redictors, mult iple regression analysis was used to estimate the probability of recorded variables including sample demographics namely: age, gender, education, years of experience, employ ment years in the same hospital and the total hospital ethical climate score, and the factors related to hospital ethical c limate (peers, patients, physicians, managers, and hospital administrators) to predict International Journal of Nursing Science 2013, 3(2): 45-50 47 moral d istress level, mo ral distress intensity, and moral distress frequency. Enter method was used to introduce predictors in regression model, and stepping method criteria was set using probability of F entry 0.05 and removal 0.1. Gender and educational level were du mmy coded (0.1) for the purpose of running mu ltip le regression as they are at nominal level. In addition, d ifferent entry methods of regression, different values of entry and removal of predictors, and examination of colinearity, skewness, and ext reme variables were conducted to elucidate valid reliable results. For the same purpose, assumptions in regard to correlat ion and regression were also checked again including recorded variables. Mu lticollinearity was also examined and reported through the final regression analysis model. 3. Results 3.1. Characteristics of the Sample Table (1) shows that of the sample (N=150), male and female part icipants were co mparable with a mean age of 27 years old (SD=4.5, R=21-45). The majority of part icipants hold a Bachelor degree (n=143, 95%). Furthermore, participant of this study had an average of 4 years experience as registered nurses, and average of 3.3 years of employ ment in the same hospital. 3.2. Predictors of Moral Distress Tables (2), (3), and (4) show mu ltip le regression analysis of predictors of total mo ral distress, moral distress intensity, and moral distress frequency. The results in table (2) indicate that none of the variables has prediction performance of total moral d istress among critical care nurses and the prediction performance was (F=.95, P<0.001, R2 = 0.07, adjusted R2=-.003). Similar results were shown in tables (3, and 4), poor prediction performance of moral distress intensity and moral d istress frequency (F=.65, P<0.001, R2 = .05, adjusted R2=-.026, and F=1.00, P<0.001, R2=.08, ad justed R2=-.014). These results indicate that these variables including: demographic (age, gender, education, years of experience, & emp loyment years in same hospital) and variables related to hospital ethical climate(peers, patients, physicians, managers, & hospital ad ministrators) were having no statistically significant predict ion performance in relation to mo ral distress, however, they may retain a clinically significant performance on nurses' perception of moral distress at critical care settings as proposed in the current study framework. And it is worthy to mention that there were no differences in the results between hospitals fro m all three s ecto rs . Table 1. Description of demographic characteristic Variables Gender Female Male Educational Level BSC MSN Sect or Go v ernment al Private Teaching Age in years Years of P rofessional Experience Employment years in same hospital Range - - 21-45 6 months-20 years 6 months-20 years Mean - Standard deviation - - - - - 27 4.2 4 years 3.9 3.3 years 3.4 % (n) 43% (65) 57% (85) 95% (143) 5% ( 7) 33% (49) 33% (50) 34% (51) - Table 2. Mult iple Regression analysis of predict ors of tot al moral dist ress Variables B SE β P value Collinearity statistics Tolerance VIF Gender 20.7 29.0 .063 .478 .857 1.16 Age -5.78 9.32 -.148 .536 .119 8.43 Educational Level -28.6 64.4 -.037 .657 .964 1.03 Years of P rofessional experience 8.04 10.1 .190 .429 .117 8.51 Employment years in hospital 5.44 7.75 .112 .483 .264 3.78 P eers -8.65 7.16 -.150 .229 .433 2.30 P at ient s -.806 7.92 -.012 .919 .490 2.04 Hospital administrators 4.32 7.02 .112 .539 .204 4.89 Physicians .271 5.13 .007 .958 .360 2.77 Managers -9.40 5.09 -.259 .067 .342 2.92 Hospital Ethical Climate 3.91 3.35 .362 .245 .070 14.2 * Predictors of total moral distress final model produced at α=0.05, F=.95, P<0.001, R2 = 0.07, adjusted R2=-.003 48 Rabia Allari et al.: Predictors of M oral Distress among Jordanian Critical Care Nurses Table 3. Linear Regression analysis of predictors with moral dist ress intensity Variables B SE β P value Collinearity st at ist ics Tolerance VIF Gender 6.74 5.85 .103 .251 .857 1.16 Age .816 1.87 .105 .664 .119 8.43 Educational Level 2.78 12.9 .018 .830 .964 1.03 Years of P rofessional experience -.639 2.04 -.076 .755 .117 8.51 Employment years in h o sp it al 1.03 1.55 .107 .508 .264 3.78 P eers -.595 1.44 -.052 .681 .433 2.30 P at ient s .524 1.59 .039 .743 .490 2.04 Hospital administrators .387 1.41 .050 .784 .204 4.89 Physicians 1.13 1.03 .152 .273 .360 2.77 Managers -.685 1.02 -.095 .505 .342 2.92 Hospital Ethical Climate .061 .675 .028 .928 .070 14.2 * Predictors of moral distress intensity final model produced at α=0.05, F=.65, P<0.001, R2 = .05, adjusted R2=-.026 Table 4. Linear Regression analysis of predictors with moral dist ress frequency Variables Gender Age Educational Level Years of P rofessional experience Employment years in h o sp it al P eers P at ient s Hospital administrators Physicians Managers Hospital Ethical Climate B 3.65 -1.08 -4.02 1.34 .876 -2.02 .207 1.16 1.31 -1.38 .197 SE β 5.06 .063 1.62 -.158 11.2 -.030 1.76 .181 1.34 .103 1.24 -.200 1.37 .017 1.22 .171 .894 .199 .886 -.217 .584 .104 P value .472 .504 .720 .446 .517 .107 .881 .342 .145 .121 .736 Collinearity st at ist ics Tolerance VIF .857 1.16 .119 8.43 .964 1.03 .117 8.51 .264 3.78 .433 2.30 .490 2.04 .204 4.89 .360 2.77 .342 2.92 .070 14.2 * Predict ors of moral dist ress frequency final model produced at α=0.05, F=1.00, P <0.001, R2 = .08, adjust ed R2=-.014 4. Discussion None of the demographic variab les includ ing (age, gender, years of p rofessional experience, educat ion, and emp loyme nt years in the same hospital) were able to predict mo ral distress, moral d istress intensity, and frequency. While several studies reported that Moral distress was influenced by nurses’ educational levels, Meltzer and Huckabay reported that, in their study, nurses with a bachelor’s degree reflected significantly higher feelings of moral d istress when witnessing futile care fe lt unable to provide adequate care. Similarly, lacks of knowledge of other treat ment options or inexperience were found to be influential on nurses’ perception and response to otherwise unethical decisions or p lan s  . In spite the fact that many studies indicated moderate ability of the hospital ethical c limate to predict the presence of mo ral distress[4, 8, 16], the results of the current study indicated that the participants' perception of hospital ethical climate and its' five co mponents s including: peers, patients, physicians, mangers, and hospital administrators were unable to predict the moral d istress, intensity, and frequency at Jordanian crit ical care settings. Although the predictors including (de mographics, total HECS, & variables re lated to HECS) were controlled in two stages: 1) the prediction performance within the moral d istress in general and 2) the prediction performance when demographic variables are covariates; there was no prediction performance reported for all recorded variables and mora l distress, moral intensity and frequency. Thus, there should be other factors beyond the researcher’s vision of the current study as represented and proposed through the framework, which may lay behind retaining the predict ion performance of moral d istress among critical care nurses. Despite the fact that the current study didn't show statistically significant prediction results, it has a clin ical merit that may help in establishing imp lications and recommendations of further research venue. 5. Study Limitations Generalization should be cautionly considered. Despite International Journal of Nursing Science 2013, 3(2): 45-50 49 the assurance of anonymity of all part icipants, potential socially desirable responses may have affected the results because of the nature of this study. A limitation of this study, as in prev ious research that has attempted to measure mo ral distress, is that the MDS draws on Jameton’s defin ition of moral distress with an emphasis on the inability of nurses to act due to institutional constraints rather than as a function of an inability to balance between individual and contextual constraints on mora l act ion. On the other hand, as the first study that investigated issues related to moral d istress and hospital ethical climate in Jordan, the findings provide a foundation for the development of evidence-based interventions, designed to improve the nursing profession. Data in the current study point to the importance of moral distress and the ethical climate in ICUs as variables worthy of further investigation. The nature and extent to which organizational factors contribute to moral distress require further attention in research. Given that some researchers have shown that nurses leave their positions because of moral d istress, there is a particular need to focus on the relationships among moral distress, intension to stay, recruit ment, and retention. In addition, focusing on the role of hospital ethical c limate as a med iating factor between moral distress and decisions to leave nursing is exceptionally needed by both quantitative and qualitative research for better understanding of these phenomena. Fru itful areas for future research include exploring also the situations giving rise to moral distress which pertained to the nurses' work environment are acknowledged. 6. Conclusions This study has revealed that moral distress is a common encounter among nurses, regardless of age, gender, work experience, years of experience, o r own perception of hospital ethical environ ment, though they are not familiar with the term which implies that solutions to relieve their distress are unexplo red. It is suggested, therefore, that ethics and ethical decision ma king be included as an integral part of all nursing curricula. A foru m also needs to be founded to facilitate sharing of nurses' moral concerns and experiences of moral distress, as well as encouraging nurses to voice these concerns to physicians, patients, and families. This would serve to aug ment nurses' coping abilit ies and support them in their role as moral agent. Education may be included in this setting, if necessary, to allow for a co mmon language for nurses to discuss moral issues with clarity and understanding. Based on the results and conclusions of the present study, it is reco mmended that: Further studies should be conducted addressing other variables than hospital ethical climate as a predictor of moral distress, different study designs, considering larger samp le size, and other areas of specialization. Furthermo re, Co mmunicat ion between professionals in health care organizations should be studied using both quantitative and qualitative approaches. Emphasis needs to be on partnership in ethical decision making that related to patients in critica l ca re units. An analysis of moral agency in relation to organizational structures is required in order to enhance our understanding of moral distress in nursing practice and the possibilities for improving care. Examining the nature of moral distress in relation to the ethical c limate has potential benefits for both nurses and patients. So the exp loring the extent to which organizational factors contribute to moral d istress requires further attention in research. Given the current and future shortages of registered nurses, attention to moral d istress and the development of positive ethical c limates is of para mount importance to the evolution of quality work environ ments and quality patient outcomes. ACKNOWLEDGEMENTS The authors gratefully acknowledge funding from Deanship of Scientific research in the University of Jordan. Thanks also to Dr. Linda L. Olson & Dr. Mary Corley, for sharing their instruments. Also special thanks to Dr. Mohammad Nassar who provided assistance with statistical analysis of this study. REFERENCES  M eltzer LS, Huckabay LM . (2004). Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care, 13: 202–208.  Elpern, E., Covert, B., & Kleinpell, R. (2005). M oral distress of staff nurses in a medical intensive care unit. AJCC, 14, 523-530.  Berger, M . C., Seversen, A., & Chvatal, R. (1991). Ethical issues in nursing. Western Journal of Nursing Research, 13, 514-521.  Corley, M ., M inick, P., Elswick, R., & Jacobs, M . (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12, 381-390.  Hart, S. (2005). Hospital ethical climates and registered nurses’ turnover intentions. 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