Health, Spirituality and Medical Ethics

Introduction
Morality is an inseparable part of human life, which explains the right from the wrong or the good behaviors from bad ones [1]. Ethics is necessary for occupations in addition to personal life, which is even more necessary in the nursing profession due to the spiritual behaviors associated with nurses’ responsibility to save patients’ lives [2]. The importance of doing moral work becomes even more pronounced as nurses operate within a system, which is constantly changing and evolving. Further, society demands the high-quality services of nurses based on the existing conditions [3].
Moral behavior is an important feature of nurses, which has a significant effect on the treatment process [4]. Caring for patients in various physical, mental, psychological, and spiritual aspects is always associated with moral considerations. Nursing is inherently considered a moral profession since it emphasizes the care of others [5]. Nowadays, paying attention to legal and ethical issues in nursing is more important due to the advancement of technology, as well as medical and pharmaceutical equipment [6]. Nurses are forced to face different aspects of ethics since they usually present at the patients’ beds and communicate closely with them, leading to moral decisions and judgments [7]. Therefore, they face an unpleasant experience called moral distress [8].
Initially described by Andrew Jameton in 1984, moral distress is defined as knowing what to do in an ethical situation, but not being allowed to do it. He reported that moral distress causes anger, frustration, anxiety, headache, sadness, grief, and depression, as well as conflict between doing the right thing and organizational rules [9]. Corley considered moral distress as a major problem in nursing [10]. Moral distress is an emotional and mental disorder in which a person makes a mistake while being aware of the correct decision and possessing the necessary ability to judge and make decisions, yet is hindered by real and organizational moral limitations [11, 12]. Nurses are exposed to moral distress due to factors, such as shortage of time and lack of specific organizational rules, which disrupt their decision-making process and psychological balance [13]. Various studies have addressed the level of moral distress in nurses. Abbaszadeh et al. indicated that nurses in different wards experience moderate moral distress [14]. However, Altaker et al. demonstrated that high levels of moral distress were observed among nurses working in the intensive care units [15]. Moreover, Jalali et al. reported high moral distress among nurses in the emergency department [16].
Based on the studies, the type of work environment is effective in the occurrence of nurses’ moral distress [17]. The emergency department due to the direct contact with the patients and staff, high workload, and lack of the necessary facilities [13, 18], as well as the intensive care unit, which exposes nurses to high levels of patient mortality, is considered a stressful situation [19]. During the coronavirus disease 2019 (COVID-19) pandemic, issues such as increased stress, the need for faster care, the use of personal protective equipment, restrictions on patient family visits due to infection risk, and many other factors exacerbated the situation in addition to previous stressors [20]. Moreover, working in unfamiliar environments, participating in unknown processes, workforce shortages, a higher number of patients in need of urgent care at the same time, fear of infection, new waves of the disease, its deadly nature, and the potential for disability posed challenges for nurses in their decision-making between doing what is morally right and doing what is cost-effective [20, 21].
The occurrence of moral distress is predictable in nurses following the spread of the disease, which causes the placement of nurses at the forefront of the struggle and endangers their lives [22, 23]. Serious moral and emotional stress is caused by the unprecedented experience of the COVID-19 pandemic [24], as well as the ongoing and difficult work of nurses during epidemics [25] and the need to respect patient rights while attempting to balance all conditions [26]. Moreover, nurses caring for patients with COVID-19 face problems, such as unknown work environment, exposure to the disease, lack of experience in dealing with new diseases, and increased public and media attention, all of which can expose nurses to moral dilemmas [27], adversely affect the quality of care and interfere with the patient treatment. Therefore, it seems necessary to be aware of the level of moral distress in nurses in these wards. In this regard, this study aimed to determine the level of moral distress and its related factors in the nurses working in the COVID-19 wards of Ardabil, Iran.
Methods
In this cross-sectional study, all the nurses working in the COVID-19 wards of Imam Khomeini Hospital in Ardabil, including those in the emergency department, inpatient units, dialysis, intensive care units, and the nursing office in 2021, who met the inclusion criteria were included in the study based on a census method (n=159). The inclusion criteria included having at least a bachelor’s degree in nursing, having worked in the COVID-19 wards for at least one month, and the absence of life crises, such as divorce or the death of loved ones during the past six months.
Data collection tools included a form for personal-occupational characteristics, including age, gender, marital status, level of education, duration of nursing work, type of ward, job position, shift work and type of employment, as well as the Corley’s moral distress scale (MDS). This questionnaire has 21 items, which measure the frequency and intensity of moral distress on a five-point Likert, with options scored from 0 to 5 in each section. The scores range from 0 (not at all) to 5 (very high) in the intensity section, and from 0 (never) to 5 (frequent) in the frequency section. Scores 0-70, 70-140 and 140-210 indicate mild, moderate, and severe moral distress, respectively. Numerous studies used this questionnaire. Borhani et al. calculated the validity and reliability of this tool in Iran. Ten experienced people in the field of ethics examined its validity, and its content validity index was determined to be 88%. Moreover, its reliability was calculated at 93% using Cronbach’s α coefficient [28], which indicated its appropriate reliability.
The study was approved by the Ethics Committee of Biomedical Research at Ardabil University of Medical Sciences (ARUMS). The researchers obtained written informed consent from each participant, which was one of the criteria for their inclusion in the study. The consent form outlined that participation is voluntary, that participant anonymity will be protected, and that participants may withdraw from the study at any time without repercussions. All methods were carried out according to relevant guidelines and regulations. The participants were provided with the questionnaires after explaining the objectives of the study. Data collection was conducted through self-reporting. In this study, the questionnaires were distributed among the nurses working in the COVID-19 wards (223 people), of whom 71.3% (159 people) completed the forms.
The collected data were analyzed by descriptive (frequency, Mean±SD) and inferential (Pearson correlation coefficient, independent t-test, and one-way analysis of variance) statistics using SPSS version 22. A two-sided P<0.05 was considered statistically significant.
Results
The mean age of the respondents was 31±5.7 years; 83.6% were women and more than half (56%) were married, with a mean work experience of 8.35±5.6 years (Table 1).
Based on the results, 157 out of 159 nurses had moderate moral distress in terms of frequency, and all the nurses reported moderate levels of moral distress in terms of intensity. The mean frequency and intensity scores of moral distress in the studied nurses were 52.28±5.24 and 51.54±4.86, respectively, which indicated a moderate level in both dimensions of moral distress (Table 2).
As shown in Table 3, among the 21 items related to the MDS of nurses working in COVID-19 wards, the item “I hesitate to tell the patient or the patient’s family about his condition and treatment” had the highest mean (4.74±0.75), while the item “I care about patients’ feelings and emotions” had the lowest mean (1.32±1.11) indicating severe moral distress among the nurses. Moreover, the items “Too much work reduces the quality of my work” and “I have experienced conflict with my colleagues” had Mean±SD of 4.81±0.55 and 1.35±1.06, respectively, reflecting the highest and lowest frequency among the items of moral distress.
Based on the results, a significant relationship was observed between the type of employment and the intensity and frequency of moral distress (P<0.05). Further, there was a significant relationship between the job position and the frequency of moral distress (P=0.04). Nurses who worked under the temporary employment status experienced more moral distress than other nurses (Table 4).
The relationship between the intensity and frequency of moral distress and the age and work experience of the nurses was evaluated. The results of the Pearson’s correlation coefficient showed a statistically significant relationship between the nurses’ work experience and the intensity of moral distress (r=-0.17, P=0.02) (Table 5).
Discussion
The results of this study, conducted to determine the level of moral distress and its related factors among nurses in the COVID-19 wards of Ardabil, indicated a moderate level of moral distress. Various studies performed in this field have reported different results. Bayat et al., Ahmadi et al. and Hthelee et al. showed a moderate level of moral distress among nurses [29-31], which is in line with the present study. However, some other studies have reported low or high levels of moral distress among nurses. Mosalanezhad et al. indicated a low level of moral distress among the participants [32]. Arafat et al.’s study reported a low level of moral distress among nurses working in COVID-19 wards [33]. Moreover, the studies by Svantesson et al. and Maunder et al. in Sweden and Toronto reported a high level of moral distress among nurses working in COVID-19 wards [34, 35]. Factors, including cultural differences, a lack of personnel and hospital facilities, the workplace environment, economic situations, organizational rules and regulations, and nurses’ lack of knowledge on how to deal with the issue of moral distress could be considered reasons for the differences in the results.
Evaluating the relationship between the demographic characteristics and the level of moral distress of the nurses showed that there was a significant relationship between the type of employment and moral distress. Based on the results, moral distress was higher among temporary employees compared to other nurses. This may be due to the temporary nature of their work during the COVID-19 pandemic and their uncertain future. Furthermore, the results showed a statistically significant difference between the level of moral distress based on the position of nurses working in the COVID-19 wards. Nurses experienced more moral distress compared to the head nurses and supervisors, which is consistent with the results of the study by Wenwen et al. [36]. Increased direct exposure of nurses to patients with COVID-19 and the fear of contracting the disease through contact with them may justify this issue.
In the present study, a negative correlation was observed between the nursing work experience and the intensity of nurses’ moral distress, indicating that the severity of moral distress decreased with an increase in the years of nursing duty, which is in line with the results of Sadeghi et al. [13]. It seems that as nurses gain more work experience, they can find solutions for adapting to stressful conditions. Based on the results, no significant difference was observed between the mean scores of the intensity and frequency of moral distress and the marital status of the nurses, which is consistent with the findings of Sadeghi et al. and Mosalanezhad et al. [13, 32]. Moreover, no significant relationship was found between shift work and the intensity and frequency of moral distress, which is in line with the results of Altaker et al. [15].
Conclusion
All evaluated nurses had some degree of moral distress. The frequency and intensity of moral distress were found to be higher among temporary nurses compared to nursing managers and nurses in other employment situations. Special attention should be paid to the mental state of the nurses involved with COVID-19 patients, as moral distress in nurses can affect the quality and safety of patient care. Using the experiences of the nurses, who are mostly present at the patients’ bedsides and involved in the direct care of patients with various diseases, can be useful in reducing the moral distress of nurses in COVID-19 wards. Additionally, employing non-contract nurses in COVID-19 wards can be effective in reducing moral distress.
Limitations
One limitation of this study was the use of the self-report method for completing the questionnaire, as individual characteristics such as job status and psychological well-being can affect responses to the questions. Therefore, it is recommended that another qualitative study should be performed on nurses involved in the care of patients with COVID-19 to obtain more accurate results.
Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee in Biomedical Research at Ardabil University of Medical Sciences (ARUMS) (Code: IR.ARUMS.REC.1399.462). The researchers obtained written informed consent from each participant, which was one of the criteria for their inclusion in the study.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.


Authors' contributions
Study design: Masoumeh Aghamohammadi; Data collection and analysis: Mina Pooresmail; Writing and final approval: All authors.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgments
The authors thank all the nurses who participated in this study and answered the questions during a critical situation.