Coping strategies of intensive care unit nurses reducing moral distress: A content analysis study

Introduction

Intensive care unit is a stressful environment ¹ due to high mortality ² and morbidity, ³ and also daily exposure to moral crises. ⁴ Nurses working in intensive care units have a difficult and complex work environment. They are frequently exposed to work-related stresses such as end-of-life issues, prolongation of life with artificial support devices, and delivery of inadequate or futile care. ² These nurses, despite recognizing their professional-ethical commitments, cannot comply with these obligations, ³ as a result they face moral distresses. Moral distress standards in intensive care units are significantly higher than in other clinical settings. ⁴ Healthcare workers working in adult intensive care units experience higher levels of moral distress compared to non-intensive care unit nurses. ⁵ Studies have shown that more than 80% of intensive care unit nurses experience moral distress, ⁶ because they often feel involved in the experienced conflict. ⁷ Moral distress can lead to feeling of hopelessness, anxiety and anger, emotional stress, ⁷ loss of independence, inability to perform delegated task, invisibility of the self,^1,8 fear, failure and demoralization, extreme fatigue, loss of empathy and compassion in providing patient care, and guilt. It also has impact on family dynamism and personal life ⁹ and leads to loss of identity, insecurity and loss of meaning, and job leave.^8,10 As a result, moral distress can have negative effects on nurses, patients and their families, and also can reduce the quality of patient care. ¹¹ In order to have a healthy and sustainable workforce in the future, recognizing moral distresses and providing environments that facilitate the use of coping strategies by employees are important. ⁹

Over the past three decades, there has been a growing body of literature that describes moral distress as an important and prominent issue, which negatively affects intensive care nurses. These studies believe it is critical to pay attention to how intensive care nurses deal with moral distress.^12–14 There have been several studies on ways that intensive care unit nurses deal with moral distress in recent years. In Forozeiya et al.’s ³ study, nurses’ method for coping with moral distress ranged from avoiding the situation by using techniques such as distraction and leaving the ICU, to addressing the problem by using problem solving skill, seeking social support, and performing positive reassessment. Nurses in the study of Henrich et al. ¹⁵ to deal with moral distress, used methods such as talking to trusted colleagues, not taking work problems to home, staying away from the causes of moral distress, suppressing emotions and feelings, leaving the ICU, drinking alcohol, exercising, and spending time with children. It should be noted that the majority of these studies have been conducted in developed countries.^3,9,16–18 However, it is clear that ethics are influenced by many factors such as culture, religion, upbringing, and individual values and beliefs. These factors shape our ethical perspectives and influence ethical decisions that affect nurses and their patients. ¹⁹ This study was conducted to investigate the coping strategies of intensive care nurses reducing moral distress in Iran. The results of this study can be used to design interventions to increase coping ability and positive adjustment of nurses in the face of moral distress, and to promote their moral resilience.

Method

Findings

This study was conducted to explore the coping strategies of intensive care nurses reducing moral distress in Iran. Findings of this study are the result of 17 interviews with 17 nurses working in intensive care units. The mean age of participants in this study was 32 years and their mean work experience was 8.55 years. Also, 70.58% of the participants were female and 29.41% were male. Other demographic characteristics of the participants are given in Table 1.

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Table 1.

Demographic characteristics of the participants.

Demographic characteristics		Frequency	Percentage
Gender	Male	5	29.41
	Female	12	70.58
Marital status	Single	9	52.94
	Married	8	47.05
Employment status	Supernumerary	4	23.52
	Contractual	3	17.64
	Agency	5	29.41
	Permanent	5	29.41
Education	Bachelors’ degree	10	58.82
	Masters’ degree and above	7	41.17
Organizational position	Nurse	15	88.23
	Head nurse	2	11.77
Current place of work	ICU	11	64.7
	CCU	6	35.29

	Min	Max	Mean
Age (year)	24	44	32
Work experience (year)	2 years	20	8.55

Sources of moral distress

In response to the first question of the interview, the nurses referred to some moral situations that had created moral distress in them, including: futile care (including unnecessary tests and surgeries, prescribing expensive drugs for end stage patients, and lack of resource allocation; non-observance of the principle of usefulness), not obtaining informed consent and not being honest with patients in providing information about the disease and treatment (non-observance of the principle of patient autonomy and honesty), discrimination in providing care (non-observance of the principle of justice), negligence and unprincipled care by colleagues (non-observance of the principle of nonmaleficence), and incorrect orders of doctors and confusion in execution (non-observance of the principle of nonmaleficence). Dealing with these ethical issues had disrupted the physical, mental, psychological, and social health of nurses.

Experiencing negative physical and emotional reactions allowed the participants to do what they thought was right and not let patients to be harmed. They did this by discussing and persuading other team members and patients’ families. But when they failed, they used a variety of the desirable and the less desirable coping strategies. Therefore, the results of this study can be summarized in two main categories of the desirable coping strategies (with two subcategories of compensation and rejuvenation) and the less desirable coping strategies (with three subcategories of indifference over time, escape, and concealment) (Table 2).

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Table 2.

Categories and subcategories resulted from data analysis.

Categories	Subcategories	Meaning unit
Positive coping strategies	Compensation	“In a way, you want to work more for the patient, spend more time for him. Maybe you used to spend less time with patient. For example, maybe you spent less time by his bedside and now, you want to spend more time with him, change his positi.on, do more NG tube flash, and wash his face. Somehow you want to calm yourself down, although you can’t calm down, but it still has some effect” (int10p10).
	Rejuvenation	“In order to reduce my stress, I spend time with my spouse and two daughters. I try to have some free time with them away from the work environment. For example, watching a movie together, going to a restaurant or a park together” (int9p9).
Negative coping strategies	Indifference over time	“It is an experience for you. This experience shows that you said this, you got angry, screamed and yelled, but you didn’t get any results, so you prefer to be patient and keep silent. You have to not see sometimes because you have no choice. Until it is fixed from above, you can do nothing”(int12p12).
	Escape	“I swore right there and said that I will not come to shift tomorrow. Swear to God. Why didn’t I stay? Because of mistakes. I couldn’t cope. I couldn’t deal with this issue. The next day, I went to the hospital with my husband, took my things and uniform, said goodbye to all the staff, and came out” (int7p7).
	Concealment	“I am a little too lazy to think that I am doing something right. For example, the doctor prescribes the infusion of a certain IV drug, I may not say anything and record it, but I will not do it” (int2p2, Pos. 18).

Discussion

Most nurses in this study believed that they do not have independence and decision-making power. In their opinion, some situations were beyond their power and they could not stand against the organization and doctors, and only carried out doctors’ orders. A strong sense of coping or dominance reduces the risk of moral distress and protects against stress, but a lack of dominance may evoke the sense of helplessness, and possibly affect the way nursing staff experience moral and ethical problems, which increases the stress related to guilty conscience. ²² In this study, when nurses saw the situation as uncontrollable, they used a variety of coping strategies to deal with the situation, so that each nurse had a set of strategies, but sometimes their method changed over time. For example, at first, they tried to solve the moral problem, but when they saw that it was ineffective or their values were ignored, they withdrew from their decision to take moral action. Lievrouw et al. ⁷ stated that individuals change their methods of managing moral distress depending on personal experiences or perceived work and team culture. Forozeiya et al. ³ instead of the desirable and the less desirable coping strategies, talk about concepts such as Turning away and Turning toward moral distress. She believes that nurses’ coping with moral distress is a dynamic situation between avoiding, communicating, and moving along with it.

One of the desirable coping methods used by the intensive care unit nurses in this study was compensation by eliminating shortcomings, making efforts in other aspects of care, asking for forgiveness from the patient, seeking help from the law and superiors, learning from the past moral situation, and increasing their scientific knowledge. Nurses felt remorse and guilt when they failed in moral situations, so they tried to spend more time in other patient care or seek forgiveness from patient. This coping strategy is not seen in other studies. Asking for forgiveness is one of the tools of compensating for non-pecuniary damages that play an important role in relieving mental pain, improving relationship with the one who caused mental pain, ²³ and freeing the wrongdoer from feelings of regret and guilt. ²⁴ Asking for forgiveness is a reflection of society’s culture. ²⁵ Factors such as fear of legal consequences and patient’s negative response to the request of forgiveness make the treatment team cautious about asking for forgiveness. But culture, education, and personality traits are factors that make it easier to ask for forgiveness or receive it. ²⁶ It is therefore essential to create an honest, fear-free, blame-free, and non-judgmental work environment in hospitals that allows expression of mistakes and promotion of forgiveness seeking.

Another way of compensating for moral mistake was to describe the incident to a higher authority to deal with a moral issue. In this study, nurses who thought they do not have power, were mostly younger and less experienced nurses, so they tried to resolve the moral issue through law and superior’s power. They believed that even if they commit negligence and harm the patient, they should inform their superiors in order to help create solutions and prevent these errors from happening again. This is consistent with the findings of Lievrouw et al.’s ⁷ study, which reported that nurses and young physicians do not always have enough self-confidence to express their moral beliefs, so they delegate independence to the supervisor. In the study of Jansen et al., ²² nurses by delegating their responsibility to supervisors and other healthcare professions, protected themselves from moral conflicts. However, they may later prefer different ways of coping method in their careers or in a different environment.

In this study, most nurses stated that they try to learn from past moral situations and increase their knowledge to prevent the recurrence of moral distress. Increasing their knowledge also helped to alleviate their fears and gave them more courage to express their views and opinions in the face of future moral issues. In addition, increasing knowledge helped them to avoid having a sense of guilt in certain moral dilemmas and reduce moral distress, so they tried to achieve this goal in various ways. In Forozeiya et al.’s ³ study, positive reassessment (i.e., focusing on personal growth to find meaning in situations) was used by more experienced nurses. These nurses re-evaluated the situations and thought about how they could learn, grow, and move forward from moral situation. Most nurses in this study learned from their more experienced colleagues and referred to ward rounds, workshops, and in-hospital conferences as important sources of learning. Nurses in the Helmers et al.’s ²⁷ study also talked about communication with senior team members, and recommended peer support programs for personal learning to novice nurses. The ability to re-describe the event in a group with a structured and guided explanatory framework ensures that each nurse compares his/her feelings and coping strategies with others. This experience can be useful when dealing with moral distress. ¹⁷ It seems that providing an atmosphere in which, novice nurses could talk to more experienced nurses and physicians about their moral experiences without being humiliated or blamed can help to prevent or successfully resolve moral distresses.

Another desirable coping strategy used by nurses in this study was to separate work issues from family issues and rejuvenate by using adequate rest and spending time with loved ones having fun activities. Although participants in the present study tried not to think about ethical issues at home, these thoughts were constantly and involuntarily recalled in their minds, even during rest. According to nurses, rejuvenation helped them to temporarily distance themselves from the moral issue and return to work with a more open mind and power. However, due to the current shortage of nursing staff in Iran, ²⁸ they not only are deprived of annual leave, but also they are forced to work overtime, which gives them no time to rejuvenate. In this regard, nursing managers said they were working to restore nurses' lost strength by moving nurses to other wards. Temporary absence from ICU gives nurses time to recover and rejuvenate. Creating a process by which nurses and other healthcare professionals can perform non-clinical tasks in the ICU or work outside the ICU for a short period of time can reduce burnout and stress, improve job satisfaction, and increase mental health. ²⁹ Consistent with our findings, nurses in the study of Boulton et al. ³⁰ to cope with moral distress used methods such as walking in open spaces, breathing fresh air, exercising, and drinking alcohol. Self-care methods such as healthy diet, sleep and rest, spending time in nature, physical activity, meditation, mindfulness, yoga, massage, music, art, and therapy with pets reduce stress and moral tension and promote ethical resilience of health care professionals. ³¹ Another coping method used by nurses in this study was to turn to prayer, which was in the category of rejuvenation. A close relationship with God can help people cope with stressful situations, including moral distress. ³² People with stronger belief have more access to spiritual and religious coping strategies when faced with stressful situations. These coping strategies can reduce their stress and increase their mental and physical health. ³³ In the study of Shamsaei et al., ³⁴ a negative and significant correlation was observed between spiritual health and severity of moral distress in nurses. This means that the higher the nurses' spiritual health is, the lower their moral distress will be. Spiritual health is an effective parameter in reducing nurses' moral distress. Therefore, it is suggested to pay more attention to the spirituality of nurses in promoting nurses’ health and reducing their moral distress.

In this study, nurses expressed differing opinions about talking to co-workers and family members about morally tense situations. They chose someone to talk to who was trustworthy and understanding. Nursing co-workers are often chosen as sources of support, because they can identify and understand the moral distress non-judgmentally. Peer support makes nurses perceive moral distress as a shared experience; an experience that mostly stems from nursing practice in ICU than personal deficiencies or performance. ³⁵ This would be much more beneficial if this support is also provided by nursing managers. ³ Talking to each other, using each other’s experiences and reaching an agreement on certain issues can relieve stress and prevent burnout. This finding is supported by other studies.^30,36 In the study of Boulton et al., ³⁰ the most common and valuable of coping strategy in response to moral distress was talking informally with co-workers, such as chatting in the coffee room. The authors of this study mentioned individualized informal support as the most valid, accessible, fastest, and most efficient intervention to reduce moral distress. Fantus et al. (2024) stated that communicating with trusted colleagues and peer support helped enhance novice clinicians’ self-confidence and professional development, and is an effective coping strategy for reducing moral distress. ³⁶

In this study, some nurses, especially less experienced nurses, used the less desirable coping strategies to deal with moral distress. One of these methods was to become indifferent to moral issues that had occurred over time and learn from previous unsuccessful experiences. Hancock et al. ¹⁸ also showed that one of the most destructive ways for nurses and physicians to deal with moral distress was to isolate themselves from the patient and stay away from colleagues. In the study of Boulton et al., ⁹ nurses withdrew from interacting with patients/families to protect themselves. In the study of Henrich et al., ¹⁵ nurses also said that in order to cope with moral distress, they invest less in their work and try to distance themselves from the causes of moral distress and hide or suppress their emotions so that they do not look weak. In the present study, nurses concealed their ethics due to lack of support, futility of their efforts to stand up for their values, concern about being condemned, and fear of negative reaction from the other party. They said that in ethical decisions, the final decision is made by doctors, their moral values are often ignored, and whenever they insist upon something they are condemned by the managers, most of them were accustomed to this issue and had come to terms with it. Similar to this result, a study by De Brasi et al. ¹⁷ revealed that newly hired nurses avoid engaging with medical staff due to the lack of courage and fear of negative reactions.

Leaving the profession or leaving the intensive care unit was another less desirable coping strategy used by nurses to deal with moral distress. According to literature, negative experience of moral distress affects nurses’ career decisions and causes some nurses to question their future in intensive care unit.^27,37,38 In one study, even young staff looking for jobs in intensive care unit changed their carrier after experiencing and trying to cope with moral distress. ⁹ In this study, nurses stated that, they thought about leaving ICU or their job in order to avoid being in such situations again. In the study of Forozeiya et al., ³ some inexperienced participants stated that they thought about leaving nursing profession or their specialty due to the lack of support from managers. It seems that inability of nursing managers to support their employees is one of the reasons for moral distress in nurses. ⁹

Some of the less experienced nurses in this study, due to their perceived inability to make ethical decisions, tried to find odd reasons to justify their immoral behavior, and by doing so, tried to calm, convince, and satisfy themselves. Others used a concealment strategy to do what they thought was right without recording it in patient’s file. They stated that they avoid documenting their moral actions due to the fear of legal issues, but keep their conscience clean by doing the right thing. This coping strategy is not found in other texts either, so no comparison could be made in this regard, which highlights the need for more in-depth studies on this topic in the future.

Limitations

Participants in this study were nurses from public hospitals and may not represent the experiences of nurses who work in other settings, such as non-governmental or non-educational hospitals. The findings of this study cannot be generalized to other societies due to its qualitative nature.

Implications and recommendations for practice

The results of this study showed when the desirable coping strategies are not effective, nurses turn to the less desirable coping strategies to deal with moral distress. To prevent moral distress in nurses, it is necessary for managers to provide a supportive atmosphere for discussion about moral experiences without fear of blame and punishment, and also support nurses during inter-professional moral discussions. Strengthening the relationship between physicians and nurses, teaching desirable coping strategies, providing training courses tailored to existing ethical issues, and providing rest times and a place away from the stresses of intensive care unit to recover and rejuvenate can help nurses to effectively deal with moral distress.

Conclusion

The data obtained from this study showed that nurses working in intensive care units in Iran first try to solve moral problems through discussion in the face of moral situation, but when they fail to solve it peacefully, use the desirable and less desirable coping strategies. In this study, nurses’ preferential strategies sometimes changed over time with increasing experience. For example, the unsuccessful experience of solving a moral problem over time led to the indifference of some nurses toward solving such issues. Several coping strategies such as trying the best in other aspects of cares, apologizing to the patient, justifying immorality, and concealing non-ordered but morally right actions are specific to this study and cannot be found in other studies. The less desirable coping strategies often resulted from nurses’ lack of power in the doctor-dominated medical system, the need to adhere to hierarchy, fear, lack of support from officials, and a lack of proper communication between the treatment team. Managers need to first identify nurses’ preferred coping strategies by encouraging nurses to discuss their ethical experiences in a blame and punishment-free atmosphere, and then by teaching desirable and active coping strategies and supporting nurses in ethical discussions, reduce their moral distresses and related harms. In addition, by providing time and space for rejuvenation, managers can help nurses to regain their lost strength. Providing a work environment in which nurses can express their views without fear, offering training courses tailored to existing ethical issues, holding meetings with cordial conversations with colleagues, especially experienced colleagues, and ultimately supporting nurses in ethical issues are among the duties of nursing managers.