Health, Spirituality and Medical Ethics

Introduction
The concept of moral distress was first introduced by Jameton in 1983 (1). This concept states that nurses make decisions based on four principles: a) Competence is the duty of nurses; B) Nurses should not use their position to exploit patients; C) Patient recovery is a primary concern of nurses; and D) Nurses should be loyal to one another (1). However, the profitability approach dominant in health-care settings is increasingly putting great pressure on nurses in order to reduce hospital costs, hence causing problems such as moral distress among nurses (2). In fact, moral distress is defined as discomfort or disturbance of one’s mental peace, occurring as a result of failure to take appropriate moral actions despite their recognition (2-4). Health promotion, disease prevention, and respect for client rights are important goals in the nursing profession.
Lack of fulfillment of these objectives can lead to moral distress, which is in fact a common phenomenon in the nursing profession (3). As a huge group of caregivers, nurses are constantly faced with ethical issues that can play a significant role in their quality of care (5). Therefore, moral distress can have different effects on nurses, patients, and the health system and can result in significant consequences (6). It has been shown in various studies that moral distress in a nurse can lead to job withdrawal, stress, burnout, job dissatisfaction, poor quality of work, incidence of physical symptoms such as headache and nightmare, reduced nursing confidence, and even prolonged patient hospitalization (5-8).
Several contributors to moral distress have been enumerated in studies conducted in different countries, including labor pressure, workforce shortage, working atmosphere, futile care, unnecessary tests on the patient, and incompetency of physicians and treatment team in fulfilling demands of patients and their families and making decisions for end-stage patients (7, 9-11). Iranian nurses, similar to their counterparts from other countries, face many challenges when performing their duties. These challenges are mostly due to job dissatisfaction, weak social status of nurses, the gap between theory and practice, limited community-based nursing care, and problems with the nursing curriculum. Moral distress requires considerable attention, since as mentioned, it affects care provision. On the other hand, awareness of it and its management can help nurses to solve and manage moral issues in order to be able to continue working in this profession. Therefore, further studies in this regard are essential (7).
 Moral distress as one of the most important issues in the nursing profession can affect the healthcare system (7). It is a recognized phenomenon among Western countries, while Iranian nurses may experience moral distress in a different way from what is described in previous studies, especially because of cultural values and the type of nursing education they receive (7). Moreover, the causes of moral distress in Iran may differ from the rest of the world. Hence, given the lack of a similar study in Iran and to achieve locally-based knowledge, we sought to investigate the contributors to moral distress among nurses in the context of Iran.
 
 
Methods
In this narrative review, data were collected by searching the keywords “moral distress”, “nurse”, “moral stress”, and “nursing”, and their Persian equivalents, both isolated and combined, in the databases of SID, IranMedex, Magiran, PubMed, Elsevier, Medlin, Google Scholar, and Scopus Ovid. Narrative reviews stand as beneficial educational articles because they put pieces of information together into an understandable whole. They prove fruitful in providing an in-depth perspective on different issues and can often present the development of an issue or ways to manage it (12). The search for related articles was conducted concurrently by two researchers from March 2017 to May 2017. Of the 1,573 articles retrieved in the initial search, only articles with accessible full-texts published in Persian and English with a primary focus on the context of Iran were included. The inclusion criteria were full-text access, locally-conducted articles in the context of Iran, and articles related to distress in nursing. The exclusion criteria were articles that were unrelated to moral distress in nursing and non-native articles. The collected papers were reviewed and the data were extracted.
 
 
Results
Of the 31 articles reviewed in the field of moral distress among Iranian nurses, 4 were qualitative, 24 were descriptive-analytic, and 2 were interventional. All the articles were analyzed and categorized, whereby the following results were yielded. The factors that underlie moral distress in nurses can be grouped into the following categories:
Organizational and institutional barriers
In almost all qualitative studies, organizational factors were among the most important causes of moral distress in nurses. They include organizational and legal circumstances, physician-dominance climate, injustice towards and neglect of nurses, lack of specific policies in organizations for moral distress among nurses, and lack of support from hospital authorities (7, 13-15).
Communication problems
Communication problems concern nurse-patient communication, nurse's relationship with the patient's family, nurse’s relationship with colleagues in the workplace, and society’s reactions to the nurse (14, 16).
Medical malpractice
This is associated with disregard for the choice of patients and their families in treatment and care (14, 15).
 
 
Staff neglect and irresponsibility in treatment
This category is related to inappropriate care, healthcare errors, concealing errors, care for end-stage patients, and poor clinical skills of physicians and nurses (14).
Organizational barriers
This category includes organizational and legal subcategories, the educational nature of physicians’ recurrent visits, responsiveness and reprimand, injustice against nurses, imposing considerable financial burdens on patients, and obligation to declare recovery code. Almost all nurses proposed organizational barriers as the main obstacle in adhering to the nursing and ethical principles. Frequent visits by physicians, such as interns, and lower and higher grade residents, and attendants lead to frequent changes in patient care guidelines and sometimes to the detriment of the patients (14).
The compulsion to declare a revival code is also one of the subdivisions of organizational barriers because, according to Islamic rules, no one can end another person's life, and the laws of Iran are based on Islam. Nurses should restore patients for whom recovery is futile, which can lead to moral distress in the nurse (14, 17).
Insufficient authority
Accountability and reprimand by superiors are also among organizational limitations because responsibility and accountability are the most important principles in this profession. If nurses work against the rules and policies of the organization, even if it is in the best interest of the patient, they must be accountable and liable for their actions, and may be reprimanded for what is done.
The imposition of heavy financial burdens on patients is also among organizational barriers applied by the system to save itself and make further income (14). In addition, the lack of professional authority in nurses leads to their distress (18).
Communication problems
Inappropriate behavioral encounters of companions and patients induce disappointment and stress in nurses. The inappropriate and unreasonable nurse-physician relationship is also an effective factor in nursing distress.
The death and critical conditions of patients, especially death of young patients or unexpected deaths, as well as notification of the death to the deceased person’s family can also lead to moral distress in nurses (14). On the other hand, the presence of moral distress in the nurse can have negative outcomes such as reduced relations with other treatment team members, the consequences of which will affect patients (18).
 
Futile interventions and ethical implications
This includes neglecting ethical codes by healthcare providers, covering and justifying errors, neglecting the independence of patients and their families, lack of ethical commitment of physicians regarding research on patients, malpractice and irresponsibility of the treatment team, incorrect care, healthcare errors, and futile interventions for end-stage patients (14, 19, 20).
Inappropriate allocation of responsibilities and resources
These barriers are related to the shortage of nurses, restricted time, high nursing workload, and shortage or inappropriate functioning of medical equipment (14). This category includes the lack of knowledge and skills on the part of physicians and nurses, ambiguity in job descriptions, nurses’ being overlooked, shortage of workforce and time, low job motivation, and insufficient equipment. As nursing is performed on the basis of ethical principles and its non-observance can cause internal conflicts in nurses, the lack of scientific competence and skills of the healthcare team, especially physicians and nurses, are among the important contributors to moral distress in nurses (14).
Sadeghi et al. 2016 highlighted that disregarding nurses and lack of attention to nurses' point of views and skills by physicians also induce distress in nurses. Since nursing care is based on ethical principles, many participants in this study believed that nursing stresses are not different from ethical tensions, and they found the underlying causes of distress to be occupational problems such as job insecurity, inappropriate payment, and shortage of workforce (21).
Some of the reviewed studies had examined moral distress in different wards, such as the emergency department, special care unit, and oncology ward, while some others had covered all wards. Nonetheless, there were some minor differences between the subcategories as concerns the ward under study. These are expressed as follows:
In the emergency department, the factors with the highest impact on moral distress of nurses comprised of assisting a physician who believes that the nurse lacks competence to provide treatment, conducting recovery operations to postpone the patient's death, performing unnecessary treatments and tests, working with non-qualified health care providers, and ignoring and failing to report errors made by colleagues (15).
In the burns department, the following factors had the greatest impact on the occurrence of moral distress: the infeasibility of patient treatment and complete pain relief, taking medications without cardiac massage and intubation, non-standard care and treatment due to shortage of therapists and caregivers, oral prescription of drugs, and collaboration with physicians and nurses lacking qualification (20). Contributors to moral distress in the oncology ward were non-provision of informed consent from patients and unnecessary tests (19).
In the pediatrics department, studies have shown that due to limited professional authority on the part of nurses, moral distress leads to impairment in safe patient care. The most important contributor to moral distress in the pediatric ward is to observe medical students performing painful procedures on children to acquire skills (18, 22). Table 1 presents an overview of the included articles.
 
Table1. Characteristics of articles

	Authors	Type of research design	Aim
1	Abbaszadeh et al. 2013 (1)	Descriptive, cross-sectional	To determine moral distress in nurses’ clinical performance
2	Borhani et al. 2013 (2)	Descriptive, cross-sectional	To determine moral distress in nurses
3	Abbaszadeh et al. 2012 (23)	Descriptive, correctional	The relationship between moral distress and retention
4	Soleimani et al. 2015 (4)	Descriptive, cross-sectional	To determine the relationship between moral distressand Spiritual Well-being in nurses
5	Mohammadi et al. 2017 (5)	Descriptive, analytic	Relationship between sensitivity and moral distress in nurses
6	Borhani et al. 2013 (6)	Correlational	Relationship between moral distress and burnout
7	AtashzadehShourideh et al. 2012 (7)	Qualitative	Moral distress in nurses working in the intensive care unit (ICU)
8	AtashzadehShourideh et al. 2015 (11)	Descriptive, correlational	Relationship between psychological burnout and moral distress
9	Borhani et al. 2017 (10)	Descriptive, correlational	The relationship between sensitivity and moral distress
10	Azizi et al. 2015 (9)	Descriptive, cross-sectional	Relationship between moral distress and nursing mental health
11	AtashzadehShourideh et al. 2011 (14)	Qualitative	Experience of ICU nurses with moral distress
12	MahdaviFashtami et al. 2016 (15)	Cross-sectional	Analyzing the dimensions of moral distress and its related factors
13	Shafiei et al. 2016 (16)	Descriptive, analytic	The relationship of moral distress with burnout
14	Borhani et al. 2015 (17)	Descriptive, analytic	Determining the severity of moral distress and perceptions of futile care in nurses
15	Shafipour et al. 2015 (20)	Descriptive, analytic	Determining the severity of moral distress and its related factors in the burns ward nurses
16	Ameri et al. 2014 (19)	Descriptive, analytic	Identifying clinical situations leading to moral distress in oncology ward nurses
17	Sadeghi et al. 2017 (24)	Descriptive, correlational	Determine the role of moral distress and burnout in predicting the desire to withdraw from job
18	Sadeghi et al. 2016 (21)	Analytic, cross-sectional	Relationship between ethical stress and burnout among nurses
19	Mohammadi et al. 2013 (25)	Descriptive, analytic	The relationship between moral distress and attitude towards euthanasia
20	Naboureh et al. 2015 (26)	Descriptive, cross-sectional	Relationship between ethical stress and self-efficacy of emergency department nurses
21	Borhani et al. 2014 (27)	Descriptive, cross-sectional	The relationship between moral distress, professional stress and sustenance  in the nursing profession
22	Mohammadi et al. 2015 (28)	Interventional	The effect of teaching ethical principles on nurses’ moral distress
23	Atashzadeh Shourideh et al. 2012 (29)	Qualitative	Tries to elicit responses of ICU nurses to moral distress.
24	Khodayari-zarnagh et al. 2013 (30)	Descriptive, cross-sectional	The status of moral values; a survey in Tehran teaching- therapeutic hospitals
25	Baluchi Bidokhti, 2013 (31)	Analytic, cross-sectional	Relationship between religious orientation and ethical sensitivity in nurse's decision-making
26	Mirzadeh et al. 2015 (32)	Interventional	The impact of retelling of stressful events on nurses’ moral distress
27	Hojjati and Azma, 2014 (33)	Descriptive, analytic	Relationship between ethical climate and desire to remain in the nursing profession
28	Sadeghi et al. 2015 (34)	Descriptive, analytic	Determining the prevalence of moral distress in nurses and related factors in the city of Shahroud
29	Mohammadi et al. 2017 (8)	Correlational, analytic	Moral sensitivity and moral distress in critical care unit nurses
30	Ghasemi et al. 2017 (22)	Descriptive	Moral distress in nurses working in pediatric departments in Iran
31	Sarkouhi-Jabalbarezi et al. 2017 (18)	Descriptive, comparative, cross-sectional	Relationship between professional authority and moral distress in nurses working in pediatrics and pediatric intensive care departments

Discussion
Organizational barriers and limitations play a major role in moral distress because the patient's needs on the one hand and the organization's limitations on the other put nurses in morally distressing circumstances. In some Iranian hospitals, there is no clear policy for controlling conflict that makes decision-making difficult for nurses, ultimately leading to their moral distress. Excessive workload and shortage of workforce and resources also contribute to distress. Patients’ critical conditions and death of under-aged patients who have no time to farewell their relatives and acquaintances cause stress in nurses. Nonetheless, concerning this issue, hospital accreditation is performed in Iran. It is by definition “a systematic external evaluation of a hospital’s structures, processes, and results (outputs/outcome) by an independent professional accreditation body using pre-established optimum standards”. The hospital accreditation system aims both to assess the quality and safety of patient care and to ensure quality improvement via optimum and accessible standards. The system, as decided by the Iranian Ministry of Health and Medical Education, intends to contribute to improved public trust in healthcare services that are provided by hospitals (35)
Medical errors, unnecessary tests, unnecessary and costly drug prescriptions in the ending stages of the patient’s life, unnecessary counseling, and increased financial burden for patient families are among other factors that result in moral distress in nurses, especially those working in intensive care units (14).
Nurses experience moral distress because of ambiguity in job descriptions, nurses’ being overlooked, lack of proper attitudes and communication of the treatment team, shortage of workforce, and lack of job motivation. This means that moral distress in nurses is a serious issue that should be addressed by organizations and managers because in the long run, this problem not only results in complications such as depression, anger, lack of self-confidence, digestive diseases, anger, sadness, job dissatisfaction, withdrawal, and resignation in nurses, but it can also affect the quality of patient care and result in problems for the organization (6, 10, 21, 24-31).
One of the limitations of this study was the limited number of studies carried out on moral distress and the contributors to increased severity of moral distress in nurses although the authors had listed the causes underlying the emergence of distress in nurses among their priorities. One of the characteristics of this study was that the studies conducted in Iran in the field of moral distress among nursing staff were mostly carried out in specific wards such as intensive care units, emergency departments, as well as oncology and burns wards, and only one study had investigated this phenomenon in all hospital wards, whose results differed from findings of other papers.
Therefore, it seems that the incidence or severity of moral distress in nurses of one ward and hospital cannot be completely generalized to all wards or other hospitals and this should be examined more fully and extensively. On the other hand, since most studies have found a significant association between age, tenure, and distress among nurses, it is recommended to consider and compare moral distress and its effective factors among experienced, novice, and student nurses. This can help adopt more educational strategies to overcome moral distress in nurses. Importantly, it seems that in addition to conducting qualitative studies and reviews, it is required to investigate the effect of educational programs, clinical experiences of faculty and senior nurses, and scientific organization and promotion of skills to overcome moral distress, and to empower nursing students and nurses to deal with moral issues, so that they would not be victims of moral distress.
On the other hand, according to the authors' suggestions considering the fact that Iran is an Islamic country with specific religious and cultural characteristics and adherence to religious beliefs influences the way nurses work and make decisions, religious considerations should be specifically taken into account in educational planning. Experts in religious issues can be helpful in this regard; it is highly probable that the solutions made in this area could be effective for health care clinics.
Conclusion
Given the importance of moral distress in nurses and the effects it can have on the organization and quality of service provision in the organization (30, 32), it seems that managers' attention to this issue can be of great significance. Managers can control and improve the situation by making modifications or improvements in the organization's policies. Such policies may concern issues such as nursing support, training courses, stress management, ethical training, development of applicable policies for cases of moral distress in nurses, periodic examination of nurses' distress, periodic substitution of nurses working in stressful wards, and holding sessions to recount stressful events (14, 33). Also, the use of religious background can be considered for practical applications.
Acknowledgments
 Hereby, we gratefully appreciate all who helped us in conducting this study.
Conflicts of interest
 The authors declare no conflicts of interest.
 
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