Relationship between perceived organizational justice and moral distress in intensive care unit nurses

Abstract

Background:

The nature of the nursing profession pays more attention to ethics of healthcare than its therapeutic dimension. One of the prevalent moral issues in this profession is moral distress. Moral distress appears more in intensive care units due to the widespread need for moral decision-making regarding treatment and care in emergency situations. In this connection, organizational justice is of high importance and, as a significant motivational tool, leaves important impacts upon attitude and behavior of personnel.

Aim/objective:

This study aimed at investigation of the relationship between perceived organizational justice and moral distress in intensive care unit nurses.

Research design:

This is a descriptive-correlational research which examined the relationship between perceived organizational justice and moral distress in intensive care unit nurses.

Participants and research context:

A total of 284 intensive care unit nurses were selected via census sampling. The data were collected through questionnaires and then were analyzed via SPSS-20 using Pearson and Spearman correlation tests.

Ethical considerations:

This study was approved by the Committee of Ethics in Medical Research. Completion of informed consent form, guarantee of the confidentiality of information, explanation on purposes of the research, and voluntary participation in the study were moral considerations observed in this study.

Findings:

There was a statistically significant negative correlation between the total perceived organizational justice and the total moral distress (p = 0.024, r = −0.137) and also between “procedural and interactional justice and errors” and “not respecting the ethics principles.” Meanwhile, no relationship was found by the findings between distributive justice and dimensions of moral distress.

Conclusion:

According to the results of the study, there was a reverse significant relationship between moral distress and perceived organizational justice; therefore, the head nurses are expected to contribute to reduce moral distress and to increase perceived organizational justice in nurses.

Keywords

Distributive justice intensive care unit nurses interactional justice moral distress perceived organizational justice procedural justice

Introduction

Nursing comprises the largest area of activity and personnel in healthcare organizations so that nurses make up 40%–60% of the total human resources who have longest and closest contact with patients.¹ Therefore, the quality of nursing care affects considerably the overall representation of a hospital and affects indirectly even the performance of the hospital.¹ Nursing usually is in shortage of financial resources, time,^2,3 number and composition of sufficient manpower,^4,5 trained manpower,⁶ and suitable care and organizational structures.^5,7 These factors affect a qualified nursing care service⁸ and may result in a moral distress.⁵

Moral distress is an emotional and mental discomfort when one, in spite of enjoying adequate awareness and ability to judge, commits a moral error due to actual or mental constraints.⁹ Moral distress may lead to a number of behavioral and psychological consequences such as sense of sadness, shame, deprivation, burnout, stress, and turnover.¹⁰

Moral distress is seen more in intensive care unit (ICU) nurses. There are some stressful factors in ICU including adverse environmental conditions and insufficient equipment, bad conditions of patients despite the intensive care by staff, and responsibility against life or death of patients. In addition, close relationship between patients and the concerned companies and healthcare staff, unreasonable expectations of families, shortage of intensive care beds, hospital’s poor support of personnel, mortality of patients, and ethical problems are the other stressful factors in ICU.¹¹

Intensity of the experienced moral distress in ICU nurses in different communities has been found within average to high.^12
–14 A study by Joolaee et al.¹⁵ in Iran revealed that nurses experience an average moral distress, while another research by Atashzadeh-Shoorideh et al.¹⁶ demonstrated a high moral distress among nurses. Moral distress needs to be taken into account seriously since it affects the care service provided to patient¹⁷ and reduces the job motivation of personnel.¹⁸

Organizational justice is considered as an important incentive for organizational behavior and refers to the personnel’s perception of organization’s fair procedures and effects.¹⁹ Personnel perceive mentally fair or unfair procedures and results via observing resource allocation, decision-making, and interpersonal interaction within the organization.¹ Understanding of justice or injustice in an organization affects the attitude, performance, and reaction of staff to it²⁰ and is of high importance among health and treatment personnel on account of being in a direct touch with well-being, attitude, performance, and ability of adaptation in crisis and stressful conditions.²¹ Injustice in an organization could be a stressful factor that may affect the adaptation ability of personnel to their organization’s expectations.²⁰

There are three types of justice including distributive, procedural, and interactional. Distributive justice refers to application of fair principles in distribution of salary, reward, advantages, and equipment, while procedural justice points out the fair decision makings together with a fair notice and implementation of the decisions for all (fair official policies of organizations and used procedures in determining the outcomes). Interactional justice has two aspects, interpersonal and informational justice. Interpersonal justice implies observing the politeness, respect, dignity, and conditions of personnel by supervisors and managers, and informational justice refers to explanations provided to employees that convey information about decisions.²²

The former studies show that there is a relationship between organizational justice and stress, mental disorders, sick leave,²³ nurse turnover,²⁴ emotional exhaustion, reduced care quality,²⁵ and satisfaction.^26,27 The previous researches have also demonstrated that injustice is a cause of adverse emotional response and may put people exposed to physical and mental diseases including depression, hyperlipidemia, and coronary heart disease.²⁸ Increased justice at work environment has been introduced as a solution to stress management in treatment settings.²⁸

Iran is a developing country with particular moral values and is located in Southwest Asia with a population of about 80 million people. A 150,000 nursing workforce is estimated in the country at different levels. Like every developing country, the Iranian healthcare system suffers from shortcomings in financial and human resources to meet the current healthcare needs. Nurses in Iran, like many other countries, face challenges such as shortage of personnel, heavy workload, indefinite duties, insufficient equipment, and low payment which have brought about dissatisfaction with work and feelings of hopelessness (pessimism) and frustration.²⁹

Given the issues said above, conducting a study on the relationship between organizational justice and moral distress sounds essential. Owing to differences between different ICU wards and other treatment wards, the researchers aimed at carrying out a research examining the relationship between perceived organizational justice and moral distress in ICU nurses.

Methods

Research design

This was a descriptive-correlational research, which examined the relationship between perceived organizational justice and moral distress in ICU nurses. The research environment comprised ICU units of the hospitals of Ayatollah Taleghani Hospital, Shohadaye Tajrish Educational Hospital, Masih Daneshvari Medical Center, Imam Hussein Hospital, Loghman-e-Hakim Hospital, and Shahid Modarres Educational Hospital. The ICU nurses of the above-said hospitals made up the population of this research. A census sampling was accomplished on those nurses who met the inclusion criteria including being employed in ICU ward, holding at least a nursing BS, and 1 year of work experience in ICU. A total of 319 nurses were identified as qualified and included in the study. They were given the research tools in three work shifts (morning, evening, and night) and were supposed to complete the questionnaires in peace and free time within 3 days. The researcher received the completed questionnaires 3 days later of which 284 ones (response rate = 89%) were seen fully completed and were then analyzed.

Data gathering tools

Data gathering tools included three instruments as the following:

1. Demographic information questionnaire

Demographic information included age, sex, marital status, education, work experience, overtime work, type of employment, work shift, type of job splitting, monthly income, and participation in ethics courses.

2. Organizational justice questionnaire

This questionnaire was developed in 1993 by Niehoff and Moorman and includes 20 items covering three dimensions of distributive justice (5 items), procedural justice (6 items), and interactional justice (9 items) which collectively form the total organizational justice. The questionnaire has been developed based on the 5-point Likert scale (from 1 = completely disagree to 5 = completely agree), and the score of organizational justice is obtained from the total score of its dimensions. The scores in this questionnaire range from 20 to 100 which are divided to the number of questions (i.e. 20), resulting in a score 1–5. The higher the score of the participant, the more perceived organizational justice is represented. Also, further to the total organizational justice score which is obtained through the total score of the dimensions, the score of each dimension is reported separately as well.³⁰

In order to determine the validity of the Niehoff and Moorman’s Organizational Justice Questionnaire, two methods of face and content validity were used. In order to identify the face validity via a qualitative technique, the questionnaire was given to 15 qualified nurses similar to the samples. Following collecting the opinions, the needed changes were made. In order to identify the content validity via a qualitative technique, the questionnaire was given to 10 experts of bioethics and nursing ethics in Shahid Beheshti University of Medical Sciences, Baqiyatallah University of Medical Sciences, Tehran University of Medical Sciences, and Iran University of Medical Sciences. The required changes were made after obtaining the opinions of the aforesaid experts.

This study used Cronbach’s alpha and test–retest methods to obtain the reliability of the employed tools. To do so, the Niehoff and Moorman’s Organizational Justice Questionnaire was given to 20 qualified individuals (who were excluded from the main research) in two occasions at an interval of 15 days, and the results obtained from the two conducted tests via intraclass correlations (ICC) represented r = 0.87 for the above-said questionnaire. In this study, Cronbach’s alpha coefficient for organizational justice questionnaire, distributive justice, procedural justice, and interactional justice was 0.87, 0.88, 0.94, and 0.89, respectively.

3. ICU Nurses’ Moral Distress Scale

This questionnaire developed and validated in 2012 by Atashzadeh-Shoorideh examines the moral distress intensity in ICU nurses. The tool contains 30 items in three dimensions including 10 for inappropriate competencies and responsibilities, 11 for errors, and 9 items for not respecting the ethics principles. The scoring in this tool for all items ranges between 0 and 4 on Likert scale (none to very much). Each item received 0–4 points and the whole instrument had a score between 0 and 120. The moral distress score is obtained from the average total points of the items. Similarly, the score of each dimension is obtained from the average total points of the items of the same dimension. The moral distress score obtained from the whole scale was grouped into four categories (0–1 = low, 1.01–2 = average, 2.01–3 = high, 3.01–4 = very high). Thus, the obtained score ranged from low to very high of which the higher score represented more moral distress.

The validity of ICU Nurses’ Moral Distress Scale (IMDS) has been already fully reported by Atashzadeh-Shoorideh et al.¹⁶ Cronbach’s alpha coefficient for moral distress scale (total), dimension of inappropriate competencies and responsibilities, for errors, and for dimension of not respecting the ethics principles was 0.93, 0.93, 0.96, and 0.89, respectively.¹⁶

Ethical considerations

This study was approved by the Committee of Ethics in Medical Research (IR.SBMU.PHNM.1394.254). In order to observe the research ethical principles, following approval of the university and the above-said hospitals, the informed consent form was completed by all the participants. In addition, the confidentiality of the information of the participants was stressed and all the participants expressed their consent for inclusion into the study. All the participants were informed of the purposes of the research and voluntary nature of their participation. They were told they could leave the study at any stage.

Data analysis

The collected data were analyzed via SPSS software package (Ed. 20) using the descriptive statistics of data as absolute and relative frequency report, and inferential statistics as a determination of correlation between the variables under study via Pearson correlation coefficient for quantitative and normal variables, and Spearman correlation coefficient for rating variables.

Findings

The research participants were mostly 30–39 years old with the average age of 33.05 ± 6.05 years. Most of the participants were females (81.3%) and married (53.5%). Also, 91.9% held a bachelor’s degrees, 62% worked in general ICU (hospitalized high risk surgical patients except neurosurgery), 44% were official staff, 55.6% had work experience of less than 5 years, and 58.1% had passed ethics courses. Most of the participants were engaged in rotating shift schedule (61.6%) and case method was dominant manner of dividing tasks.

According to the findings, the mean total perceived organizational justice and all its dimensions were lower than average. The highest (2.99 ± 1.08) and lowest (2.25 ± 0.82) mean scores of perceived organizational justice were witnessed in dimensions of interactional justice and distributive justice, respectively. Also, the mean of total moral distress was obtained 1.51 ± 0.99 which is considered within the average range. Meanwhile, the scores of all dimensions of moral distress were found average as well. The maximum (1.71 ± 0.72) and minimum (1.33 ± 0.69) mean scores of moral distress were identified in the dimensions of errors and inappropriate competencies and responsibilities, respectively. Table 1 shows the mean and standard deviation of the obtained scores of organizational justice, moral distress, and the associated dimensions.

Table 1.

Mean and standard deviation (SD) of the obtained scores of organizational justice, moral distress, and the associated dimensions.

Variable	Mean	SD
Perceived organizational justice	2.79	±0.86
Distributive justice	2.25	±0.82
Procedural justice	2.94	±0.99
Interactional justice	2.99	±1.08
Total moral distress	1.51	±0.99
Inappropriate competencies and responsibilities	1.33	±0.69
Errors	1.71	±0.72
Not respecting the ethics principles	1.49	±0.91

it is necessary to mention that in order to investigate the normal distribution of data, Kolmogorov–Smirnov test was used showing that all indicated data were normal (Table 2).

Table 2.

Kolmogorov–Smirnov test for investigation of normal distribution of variables of organizational justice, moral distress, and the associated dimensions.

p value	Statistic	Variable
0.09	1.21	Perceived organizational justice
0.071	0.543	Distributive justice
0.126	1.175	Procedural justice
0.440	0.867	Interactional justice
0.672	0.723	Total moral distress
0.385	0.906	Inappropriate competencies and responsibilities
0.083	1.26	Errors
0.134	1.12	Not respecting the ethics principles

Pearson’s correlation reflected a significant inverse correlation between perceived organizational justice and total moral distress (p = 0.024, r = −0.137). Also, a statistically negative significant correlation was observed between “procedural justice and interactional justice,” and “errors and not respecting the ethics principles.” However, no relationship was found between distributive justice and moral distress and its dimensions. The highest correlation was identified between procedural justice and errors (p = 0.00, r = −0.210) (Table 3).

Table 3.

Correlation between perceived organizational justice and its dimensions and moral distress and its dimensions in research participants.

	Inappropriate allocation		Errors		Not respecting the ethics principles		Total moral distress
	p	r	p	r	p	r	p	r
Distributive justice	0.595	0.032	0.366	−0.054	0.626	−0.029	0.714	−0.022
Procedural justice	0.230	−0.072	0.00**	−0.210	0.013*	−0.148	0.004**	−0.169
Interactional justice	0.626	0.029	0.004**	−0.171	0.007**	−0.160	0.035*	−0.125
Perceived organizational justice	0.990	−0.001	0.002**	−0.182	0.012*	−0.148	0.024*	−0.137

r: correlation coefficient.

*p < 0.05; **p < 0.01.

Discussion

This study examined the correlation between perceived organizational justice and moral distress in ICU nurses in teaching hospitals of Shahid Beheshti University of Medical Sciences, Tehran University of Medical Sciences, and Iran University of Medical Sciences in 2016.

According to the results of the research, the perceived organizational justice in the nurses under study and its all dimensions was lower than average. A study by Fathabad et al.³¹ estimated the mean of the perceived organizational justice higher than average. Also, Ito et al.³² in another study reported a 68.2 perceived organizational justice in Japanese nurses which was believed to be higher than average. This was reported 3.17 ± 0.89 in a research by Hatam et al.³³ Altogether, it could be said that the perceived organizational justice was identified average approximately. It seems that this attitude in nurses springs from comparison of their workload, serious responsibility and income, and those of others in other professions, particularly doctors. Given the impact of perceived organizational justice upon the care quality, it sounds necessary for managers to take steps to increase the perceived organizational justice.

In this study, the average score of distributive justice was found to be the weakest perceived dimension, and this is consistent with the findings of other formerly carried out studies.^31

–34 However, another research conducted on the Canadian nurses demonstrated procedural justice as the weakest dimension and reported the distributive justice mean of 3.09 ± 1.03 which was higher than that of this study.³⁵ In a research in Korea, Park and Kim³⁶ investigated procedural justice and distributive justice and showed that the average score of procedural justice was lower than that of distributive justice. This inconsistency may be due to the nurses’ increased awareness of their payments and advantages, no fair salary rise, widened gap between payments to nurses and doctors, and increased workload to given payment over time. Moon et al.³⁷ believed that organizational justice in its distributive and procedural dimensions has a positive relationship with payments in the organization. Therefore, since distributive justice is more in touch with work-resulted rewards, the received rewards by the nurses should be fair in order to achieve an increased justice in this dimension.

Interactional justice in this research secured the highest mean within the nurses. These findings were consistent with those of other previously accomplished studies.^31,33
–35 These, however, were inconsistent with the results obtained by Ito et al. who introduced procedural justice as the highest mean in the Japanese nurses.³² It seems the cause of higher mean of interactional justice in Iranian nurses is associated with the ruling climate in the organization, environmental conditions, and personal traits of the nurses’ asocial and humanitarian people.

The results of this research indicated also that the scores of moral distress and all its dimensions were identified average. A study by Vaziri et al.³⁸ found the score of moral distress at a range of average to high where the maximum degree of moral distress was observed in emergency, neonatal intensive care unit (NICU) and ICU nurses, while the minimum degree was found within nurses of internal ward. The results of a research which investigated the moral distress among the healthcare professionals showed that the moral distress in nurses is lower than average, but higher than that in other professions.³⁹ In a research by Atashzadeh-Shoorideh et al.,¹⁶ the moral distress score of nurses was obtained 2.08 ± 0.98 which was higher than the average. On the other side, a number of studies formerly carried out in the United States reported relatively low scores of moral distress in nurses.^13,40 In another research on nurses by Silén et al.⁴¹ in Sweden, the moral distress score in nurses was reported low. This is inconsistent with findings of this study, which may be associated with a high level of knowledge and awareness of treatment staff, enjoying the needed standards by the hospital and the related department, high participatory relationship among the treatment staff, and personal traits of the participants. The above-said issue may come from differences in cultural, belief, organizational, geographical, educational, and individual factors. Also, the difference in the reported moral distress intensities of this study and other ones may arise from difference in the used tools (i.e. the used Iranian and specific tools in this study for moral distress in ICU nurses) as well as the population under study. The moral distress scale in the present research has three different dimensions while it has been investigated in other studies with a single dimension of which some items do not come true in Iran.

This study revealed the highest moral distress intensity in errors which was consistent with the findings of a study by Atashzadeh-Shoorideh et al.,¹⁶ although it went against the results of a research by Pooladi et al.⁴² An attempt by Vaziri et al.³⁸ revealed that the highest moral distress occurs during working with unqualified personnel and inexperienced doctors conducting unnecessary tests, imaging, and inappropriate treatments. Also, in the study by Atashzadeh-Shoorideh et al.,¹⁶ clinical situations with futile care services and also working with unqualified nurses were included in the most frequent situations leading to moral distress. Accordingly, high moral distress in errors, compared to other dimensions, sounds natural in ICU nurses on account of using a wide variety of equipment and technologies and facing with vulnerable patients in the ICU as well.

This study found the least moral distress in inappropriate competencies and responsibilities (2.07 ± 1.19) which was in line with the findings of the study by Atashzadeh-Shoorideh et al.¹⁶ and inconsistent with the research by Pooladi et al.⁴² The difference between this attempt and the latter, Pooladi’s, may come from different research populations. The statistical population of this research consisted of ICU nurses, while the population of Pooladi’s study was made up of nurses from other wards and departments. Delegating tasks to competent people would reduce certainly the injuries and losses. Silén et al. believed in this connection that nursing performance and competencies are considered moral virtues. It is understood that a novice doctor or nurse is different from an experienced doctor or nurse. Therefore, leaving qualification distribution conditions unnoticed would affect the quality of work. It may be considered unethical and may lead to moral distress.⁴¹ Given the differences in the work nature and expertise of ICU nurses, this department employs experienced and specialist nurses and hence sees less inappropriate competencies and responsibilities.

The findings of this study unveiled a statistically significant negative correlation between perceived organizational justice and dimensions of procedural and interactional justice, with moral distress and dimensions of errors and not respecting the ethics principles. According to the above-said findings, the highest correlation, although weak, was found between procedural justice and errors. Despite many searches, no research was found on investigation of the relationship between the aforesaid two variables in nursing society to be compared with the results of the present attempt. The level of organizational justice within an organization is able to predict psychological responses of people to stress.⁴³ A study by Elovainio et al.⁴⁴ demonstrated that there is a relationship between the low organizational justice and high prevalence of sickness and mental disorders in nurses. A research by Ito et al.³² indicated a strong relationship between mental distress and all dimensions of organizational justice and also a statistically significant relationship between organizational justice and stress in nurses. Kovner et al.⁴⁵ also found a strong relationship between job satisfaction and distributive justice. Therefore, more organizational support and improved job and work environment conditions would cause nurses to feel more satisfied with their job and work environment and this would bring about optimized patient care quality and increased satisfaction of patients.⁴⁶

Conclusion

Given the approved negative significant correlation between moral distress and perceived organizational justice, it can be inferred that development of perceived organizational justice help to decrease the moral distress of nurses.

In this connection, if procedures of allocation, promotion, and other advantages given to nurses are made free from personal interests and based on accurate information in a way that the nurses see the procedures fair, moral distress and errors are reduced making their perception of organizational justice rise. Managers, also, are able to decrease moral distress in nurses via appropriate policies in line with increasing the organizational justice.

In order to achieve the distributive justice, managers need to use an appropriate performance evaluation system holding a suitable job description. For this, after identification of discrimination perception factors, appropriate planning and measurements should be carried out to meet the material and spiritual needs of people. To realize and hold procedural justice, the organizational guidelines and procedures should be clear and transparent.

In order to establish the interactional justice, the decision made within the organization must be available to personnel in a good manner and with a constructive interaction. Mandatory overtime was identified as a shared and effective variable on organizational justice and moral distress. The resolving of this problem and finding an appropriate solution are recommended. In those situations where distressful factors are related to organizational context (such as budget restriction, heavy workload, and shortage of nurses), certain managerial strategies need to be adopted. Coping strategies against moral distress, such as education and promotion of psychological knowledge of people, optimization of effective communication skills, use of spiritual teachings in communication with others, changing of doctors’ attitude toward other members of treatment team, and paying more attention to their advisory opinions are suggestions of this study to reduce the moral distress in nurses.

Taking something such as providing nurses with education via holding ethical workshops, presenting periodical advisory for nurses, changing the department, increasing the reward, revision of procedures and guidelines, reducing work hours, and making nurses informed of moral distress and its aftermaths would ease moral distress and could be useful in the long run for health of the profession.

Footnotes

Acknowledgements

All collaborating persons especially participants and colleagues are acknowledged here to with profound gratitude for all their contributions made to the development of this study.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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