Moral sensitivity and moral distress correlation in nurses caring of patients with spinal cord injury

Abstract

Background and aim

Ethical sensitivity of nurses often plays an important role in their occupational commitment and moral decision-making. In some working conditions, nurses are affected by ethical distress and fail to pursue correct ethical actions despite having knowledge and a tendency for moral practice. Therefore, the present study aimed to investigate the correlation between sensitivity and ethical distress in the nurses of patients with spinal cord injuries.

Materials and methods

This descriptive-analytical study was performed on 160 of the nurses of patients with spinal cord injuries. The participants were selected through the purposive sampling method out of the nurses in Khatamolanbia and Sasan hospitals, Tehran, Iran. Data collection tools included the Moral Sensitivity Questionnaire by Han and Corley’s Moral Distress Scale. Data were analyzed by the independent t-test and Pearson correlation coefficient using the SPSS software version 19.

Results

The mean values of ethical sensitivity was 80.48 ± 14.45 and ethical distress among the subjects was 62.39 ± 3.54. Moreover, a significant negative correlation was observed between moral sensitivityand moral distress (P<0.05, r = −0.37).

Conclusion

According to the results of this study, increased ethical sensitivity is associated with diminished moral distress among the nurses of patients with spinal cord injuries. On the other hand, moral sensitivity is of considerable importance in nurses, especially in taking care of patients with special conditions. Consequently, it is recommended to provide some conditions for maintaining and enhancing ethical sensitivity in nurses taking care of patients with spinal cord injuries.

Keywords

Moral sensitivity moral distress ethics nurse spinal cord injuries

Introduction

Spinal cord injuries are among the most disastrous damages a person might experience. This disease is considered as a disability accompanied by high costs, as well as numerous physical, psychological, social and vocational pressures imposing a great need for a change in the lifestyle of the patient and their families.¹ The prevalence of spinal cord injuries in iran is more than 318 per million.² Different aspects, including the performance, lifestyle, roles, occupation, family relations, and social relationships of the patients with spinal cord injuries may alter.³ These patients require care along with special support and consideration due to the sequels, problems, and negative impacts of this disease on all features of life and body systems.^4,5

Nursing is one of the most important jobs that provide health and treatment services.⁶ The main aim of this profession is to improve the value of humans and dignity of all people who need care.⁷ The work environment of nurses and confrontation with death and decision-making leads to ethical distress.^8,9 According to Goethals et al., the lack of ability for encountering ethical problems results in job quit or professional change by some nurses.¹⁰ Ethical distress is the situation in which a nurse fails to pursue the correct moral course of action despite having knowledge and ability regarding ethical performance.¹¹ Moral distress is a common phenomenon, which has the potency for affecting the working life of nurses.^9,12 Literature indicates the negative impacts of moral distress on the self-efficacy, professional commitment, self-confidence, and hope of nurses.^13–16

Shafeei conveys from Corley that moral distress causes conflict for a nurse concerning diagnostic-therapeutic practices leading to the reduced quality of care. These points might result in the problematic recovery of patients and increased hospitalization duration.¹⁷ In addition to headache, gastrointestinal disorders, anger, feelings of sin, depression, fatigue, and decreased self-confidence, nurses affected by ethical distress experience job dissatisfaction and occupational fatigue and quit their job.¹² Several studies noted the influence of individual, environmental, and background factors on the rate of moral distress in nurses.^12,14 Some of the major factors contributing to ethical distress in the personnel of health system include working in the special units with higher responsibility, limited nursing force, high workload, conflicts between treatment teams and colleagues, incorrect policies of institutions, invasive treatments, patients near to death, unnecessary tests, cheating in tests, insufficient and incomplete treatments by the coworkers.^15,18,19 Ethical sensitivity is one of the leading factors regarded as the predictors of moral distress.²⁰

Ethical sensitivity, as the principle of ethics in nursing, provides a background for nurses to take care of their patients effectively and morally. Ethical sensitivity makes nurses sensitive to moral subjects in their working environment, in addition to enabling them to make moral decisions.²¹ Therefore, the patient receives nursing cares with more certainty and trust. In this regard, any deficit in following nursing ethics can affect the most scientific and best nursing care.^22–24

Escolar-Chua in a study on the undergraduate students of nursing found a positive significant relationship between moral sensitivity and ethical distress.²⁰ Nejadsarvari et al. in an investigation on doctors reported ethical sensitivity to have negative and positive significant relationships with the frequency and intensity of ethical distress, respectively.²⁵ However, Borhani et al. did not reveal a significant correlation between ethical sensitivity and moral distress among Iranian nurses working in special units.²⁶

The development of ethical sensitivity creates a basic reaction and attitude for nurses making them capable of influential and ethical care.²⁷ Moreover, this sensitivity highlights the necessity of knowledge and the interpretation of behaviors, as well as the verbal and non-verbal signs of the patients for identifying their needs.^11,28

On the other hand, difference and contradiction between the results of studies denote the importance of further investigations. Consequently, the present study aimed to evaluate the relationship between ethical distress and moral sensitivity in nurses taking care of patients with spinal cord injuries.

Materials and methods

This descriptive-analytical study was performed on the study population of all the nurses taking care of patients with spinal cord injuries in the 440-bed Khatamolanbia Hospital and 210-bed Sasan Hospital, Tehran, Iran. Both of hospitals provide services for patients with spinal cord injuries and entail special wards along with trained personnel for taking care of and treating these patients and they are similar in this terms.

The sample size was obtained as 157 people and finally, 160 subjects were invited to participate in the study. The sample size was calculated based on the study completed by Abbaszadeh et al.¹⁸ using the equation of sample size for correlation study²⁷ and considering α, d, and σ as 0.05, 0.05, and 0.32, respectively. Samples were selected through the purposive sampling method.

Data collection tools entailed a demographic questionnaire, Moral Sensitivity Questionnaire (MSQ) by Han,^29,30 and a researcher-made survey of ethical distress based on Corley’s Moral Distress Scale (MDS).¹¹ The demographic questionnaire included age, gender, marital status, education, work experience, employment status, work shift, experience in taking care of patients with spinal cord injuries, and participation in congresses and workshops.

The MSQ by Han is, in fact, the MSQ by Lutzen validated in Korea. This questionnaire measures the moral sensitivity of nurses with 25 items arranged under the three features of respect to the patient (8 questions), occupational commitment (8 questions), and ethical behavior (9 questions). Each item is scored based on a 5-point Likert scale ranging from 0–4 for completely agree to completely disagree. Ranges of scores for respect to the patient, occupational commitment, ethical behavior, and total score were 0–32, 0–32, 0–36, and 0–100, respectively. The mean scores of each aspect and total score were considered as the score of moral sensitivity.⁷ The total scores of 0–50, 50–75, and 75–100 for each participant were regarded as low, intermediate, and high ethical sensitivity, respectively.³¹ Numerous researchers have utilized this questionnaire to assess moral sensitivity in Iran.^31,32 Abbaszadeh et al. confirmed the reliability of the questionnaire previously³³ and the same instrument was used in the current study with their permission. The validity of this questionnaire was evaluated through a pilot study on 20 people of the study population. In addition, the internal consistency of the questions was confirmed by the Cronbach’s alpha of 0.81.

The MDS was designed based on the literature review and the survey by Corley considering the existing conditions in the wards of study hospitals. The MDS applied in the present study was adjusted to the intended units of study hospitals because the MDS by Corley is ageneral questionnaire. This questionnaire with 25 items scored based ona 5-point Likert scale (i.e., 0–4 for not at all to very much) addresses the level of ethical distress experienced by a nurse in each situation. The moral distress score for each person was obtained according to the answers to all questions ranging from zero to 100. The validity of the survey was assessed and confirmed by ten of the scientific members of Shahid Beheshti University of Medical Sciences, Tehran, Iran.In order to recheck the validity, the study was performed on 20 people from the study population and internal consistency was confirmed by the Cronbach’s alpha of 0.83.

The present study was approved by the Ethics Committee of Shahid Beheshti University and the management of the two hospitals. In addition, the researchers were introduced to the participants and informed consent was taken following explaining the objectives of the study. It was noted that first names and family names were not needed and the subjects were assured regarding optional participation without affecting their evaluation procedures. The data were analyzed by descriptive statistics (i.e., mean and standard deviation), as well as analytical tests, namely independent t-test and Pearson correlation coefficient using the SPSS software version 19.

Results

A total of 80 nurses from Khatamolanbia and 80 from Sasan hospitals participated in the study. The mean age of the subjects was found as 34.96 ± 7.83 years. The means of working experience and experience in taking care of patients with spinal cord injury were 8.52 ± 6 and 4.13 ± 3.5 years, respectively.

Moreover, 61.9%, 72.5%, and 70.6% of the nurses were female, married, contract employment, respectively. Our findings demonstrated that 69.4% of the participants had a Bachelor's degree,52.5% worked on fixed shifts, and69.4% of the subjects had not participated in any Ethics Seminar (Table 1).

Table 1.

Demographic characteristics of participants.

Variables	Category	Total
Variables	Category	N	%
Hospital	Khatam-al Anbiya	80	50
Hospital	Sasan	80	50
Gender	man	61	38.1
Gender	woman	99	61.9
Marital status	single	44	27.5
Marital status	married	116	72.5
Employment Status	Official	47	29.4
Employment Status	Contractual	113	70.6
Attending a moral seminar	Yes	49	30.6
Attending a moral seminar	No	111	69.4
Level of education	Associate degree*	20	12.5
	Bachelor of Science	111	69.4
	Master of Science	29	18.1
Shift work	Fixed (day, afternoon, night)	84	52.5
Shift work	Shift in circulation	76	47.5

*Two years university course after diploma.

Furthermore, the mean scores of ethical sensitivity and moral distress were reported as 81.71 ± 18.19 and 62.39 ± 3.54, respectively (Table 2). A negative significant relationship was observed between ethical sensitivity and moral distress (P = 0.01, r=−0.37) (Table 3).

Table 2.

Statistical indices of nurses’ sensitivity and moral distress.

Variables	Minimum	Maximum	Mean	SD
Moral distress	52	74	62.39	3.54
Patient respect	14	40	29.11	6
Professional responsibility	12	39	25.8	5.12
Ethical behavior	14	43	26.7	10.27
Total moral sensitivity	47	116	81.71	18.19

Table 3.

Correlation between moral distress, moral sensitivity, and subscales in nurses.

Variables	Moral distress
Variables	Coefficient	p-Value
Patient respect	-0.14	p = 0.077
Professional responsibility	-0.192	*p = 0.032
Ethical behavior	0.166	*p = 0.036
Total moral sensitivity	-0.375	*p = 0.017

*Statistically significant.

Discussion

According to the results of the present study, ethical sensitivity was of high level among the nurses of patients with spinal cord injuries in Khatamolanbia and Sasan hospitals. Kim et al. reported the moral sensitivity of Korean nurses working in hospitals as high.³²

Ethical sensitivity causes the nurses to consider diverse issues from the moral point of view. Therefore, favorable ethical sensitivity in nurses who take care of spinal cord injuries patients could be regarded as a positive point for the health system, patients, and their families. On the other hand, moral sensitivity is correlated with the quality of nursing services, as well as the confidence and trust of patients.³⁴ As a result, any disturbance in pursuing nursing ethics may affect the most scientific and best nursing care.

Moreover, the moral distress of nurses in the current study was found as moderate to high. The latter result is consistent with the findings of Abbaszadeh et al., Mohammadi et al., Shafipour et al., and Whitehead et al.^12,35,36 Nursing occupation is complicated by numerous distressing factors that impose unfavorable influences on nurses. One of the most important distresses is ethical distresswhich is correlated with different aspects of moral issues.

Ethical distress has a negative impact on the work quality of nurses, including taking care of patients.³⁷ Persistence of moral issues for nurses leads to distinct problems, such as reduced self-esteem, disturbed interpersonal relationships, psychological disorders, physical symptoms, behavior change, instability, confusion, and distress. Consequently, continuous confrontation with ethical distresses might be accompanied by occupational fatigue and dissatisfaction and endanger the professional status of nurses.³⁸

The findings of the present study indicated a significant inverse correlation between moral sensitivity and distress in the nurses of patients with spinal cord injuries. In other words, elevated ethical sensitivity among nurses is accompanied by diminished moral distress. Investigations in this regard have reported different results. Escolar-Chua performed a study on the undergraduate students of nursing and revealed a positive significant relationship between ethical sensitivity and moral distress.²⁰ The work environment and experience of nurses are among the factors affecting ethical distress.^11,18,39 The latter variables might account for the controversy between the present study and the investigation completed by Escolar-Chua. Nejadsarvari et al. in an investigation on 321 specialists reported that moral sensitivity influenced the reduction in the frequency of ethical distress. These authors proposed the participation of doctors in the periodic workshops of ethics to be necessary for decreasing their moral distress. However, they observed a positive significant relationship between ethical sensitivity and the intensity of moral distress.²⁵ This difference between the findings of the mentioned investigation and our study might be due to diverse work environments and distinct study populations.

Borhani et al. in their study on the Iranian nurses of special units found no significant relationship between ethical sensitivity and distress. In addition, they emphasized that in order to enhance care quality, the ethical sensitivity of nurses should get improved.²⁶ In addition to the work environment as a contributing factor to the different results of their study and the current investigation, the tools for measuring moral sensitivity and distress were different. Silen et al. noted the ethical work environment as one of the remarkable factors affecting the moral distress of nurses, which should be taken into consideration in the nursing profession.⁴⁰ Furthermore, Corley introduces an ethical work environment as one of the important variables that can predict ethical distress.⁴¹

Moral distress is common among nurses and as a considerable factor that influences the physical health, mental health, and well-being of nurses causes them to not support the patients. Therefore, regarding the impacts of ethical distress on nurses, it should be taken into consideration and the identification of effective and predictive factors is of great importance.

One of the limitations of this investigation was the high workload of nurses which might have resulted in a low concentration on questions. However, we attempted to provide them with sufficient time for filling the questionnaires and the importance of their answers was explained to them. Another limitation was the self-assessment type of tools for measuring ethical sensitivity, which is consistent with the nature of ethical concepts. However, readers should take this point into consideration for generalizing the findings.

Conclusion

According to the results of the present study, ethical sensitivity plays a role in predicting moral distress in nurses of patients with spinal cord injuries. As a result, periodic ethics workshops and the identification of influential factors could be of value in familiarizing nurses with ethics regarding special conditions leading to diminished distress and enhanced quality of services in the nursing profession.

Footnotes

Acknowledgements

The authors of this study would like to appreciate theMedical Ethics and Law Research Center of Shahid Beheshti University of Medical Sciences. Moreover, we extend our gratitude to the management, nursing supervisor, and nurses of the hospitals.

Declaration of conflicting interests

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.

ORCID iDs

Naser Sedghi Goyaghaj

Amir Zoka

Mohaddeseh Mohsenpour

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