Volume 22, Issue 5 (8-2024)
Nursing and Midwifery Journal 2024, 22(5): 352-364 |
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Research code: 162833806
Ethics code: IR.IAU.BABOL.REC.1402.115
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Rahmani N, Seyed Nematollah Roshan F, Nabavian M, Firouzbakht M. EXPLORING THE EXPERIENCES OF NURSES WORKING IN PEDIATRIC UNITS REGARDING MORAL DISTRESS: A PHENOMENOLOGICAL STUDY. Nursing and Midwifery Journal 2024; 22 (5) :352-364
URL: http://unmf.umsu.ac.ir/article-1-5178-en.html
URL: http://unmf.umsu.ac.ir/article-1-5178-en.html
1- Department of Nursing and Midwifery, Comprehensive Health Research Center, Babol Branch, Islamic Azad University of Iran (Corresponding Author) , na57ra@yahoo.com
2- Assistant Professor, Department of Nursing, Tehran Azad Islamic University of Medical Sciences, Tehran, Iran
3- Department of Nursing and Midwifery, Comprehensive Health Research Center, Babol Branch, Islamic Azad University, Iran
2- Assistant Professor, Department of Nursing, Tehran Azad Islamic University of Medical Sciences, Tehran, Iran
3- Department of Nursing and Midwifery, Comprehensive Health Research Center, Babol Branch, Islamic Azad University, Iran
Abstract: (1787 Views)
Background & Aim: Nurses, as direct providers of patient care, face higher levels of psychological stress in the workplace compared to other healthcare professionals. Nurses working in pediatric wards, where they interact with children and their families, experience increased levels of moral distress. This study was designed to explore the experiences of nurses working in pediatric units regarding moral distress.
Materials & Methods: This qualitative study was conducted using interpretive phenomenological analysis between 2023 and 2024. Twelve nurses with moral distress experiences were selected through purposive sampling from hospitals of Babol and Tehran Universities of Medical Sciences. Data were collected through semi-structured and individual interviews and analyzed simultaneously using Van Manen's approach.
Results: The findings include three main themes and seven subthemes including moral distress related to colleagues (lack of competence, physician-centered), hospital policies (lack of personnel, high workload, and lack of proper equipment), psychological stress following moral distress (negative effects following the sudden death of a child, feeling of insufficiency, and helplessness).
Conclusion: According to the study's findings, reducing moral distress by enhancing clinical knowledge and experience, fostering self-confidence, providing organizational support, managing nurses' workloads, and paying attention to nurses' emotions can be beneficial. Also, designing and organizing educational programs and workshops to help reduce nurses' distress by identifying stressful conditions and minimizing exposure to moral dilemmas.
Materials & Methods: This qualitative study was conducted using interpretive phenomenological analysis between 2023 and 2024. Twelve nurses with moral distress experiences were selected through purposive sampling from hospitals of Babol and Tehran Universities of Medical Sciences. Data were collected through semi-structured and individual interviews and analyzed simultaneously using Van Manen's approach.
Results: The findings include three main themes and seven subthemes including moral distress related to colleagues (lack of competence, physician-centered), hospital policies (lack of personnel, high workload, and lack of proper equipment), psychological stress following moral distress (negative effects following the sudden death of a child, feeling of insufficiency, and helplessness).
Conclusion: According to the study's findings, reducing moral distress by enhancing clinical knowledge and experience, fostering self-confidence, providing organizational support, managing nurses' workloads, and paying attention to nurses' emotions can be beneficial. Also, designing and organizing educational programs and workshops to help reduce nurses' distress by identifying stressful conditions and minimizing exposure to moral dilemmas.
References
1. Giannetta N, Villa G, Bonetti L, Dionisi S, Pozza A, Rolandi S, et al. Moral distress scores of nurses working in intensive care units for adults using Corley's scale: A systematic review. Int J Environ Res Public Health 2022;19(17):10640. [PMID: 36078353] [DOI:10.3390/ijerph191710640] [PMCID: PMC9517876]
2. Fourie C. Moral distress and moral conflict in clinical ethics. Bioeth 2015;29(2):91-7. [PMID: 24602097] [DOI:10.1111/bioe.12064]
3. Giannetta N, Sergi R, Villa G, Pennestrì F, Sala R, Mordacci R, et al., editors. Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study. Healthcare (Basel) 2021;9(12): 1673. [PMID: 34946401] [DOI:10.3390/healthcare9121673]
4. Prompahakul C, Epstein EG. Moral distress experienced by non-Western nurses: An integrative review. Nurs Ethics 2020;27(3):778-95. [PMID: 31750780] [DOI:10.1177/0969733019880241]
5. Villa G, Pennestrì F, Rosa D, Giannetta N, Sala R, Mordacci R, et al., editors. Moral distress in community and hospital settings for the care of elderly people. A grounded theory qualitative study. Healthcare (Basel) 2021;9(10):1307. [PMID: 34682986] [DOI:10.3390/healthcare9101307]
6. Giannetta N, Villa G, Pennestrì F, Sala R, Mordacci R, Manara DF. Instruments to assess moral distress among healthcare workers: A systematic review of measurement properties. Int J Nurs Stud 2020;111: 103767. [PMID: 32956930] [DOI:10.1016/j.ijnurstu.2020.103767]
7. Lamiani G, Ciconali M, Argentero P, Vegni E. Clinicians' moral distress and family satisfaction in the intensive care unit. J Health Psychol 2020;25(12): 1894-904. [PMID: 29921136] [DOI:10.1177/1359105318781935]
8. Lazzari T, Terzoni S, Destrebecq A, Meani L, Bonetti L, Ferrara P. Moral distress in correctional nurses: A national survey. Nurs Ethics 2020;27(1):40-52. [PMID: 30966867] [DOI:10.1177/0969733019834976]
9. Delfrate F, Ferrara P, Spotti D, Terzoni S, Lamiani G, Canciani E, et al. Moral Distress (MD) and burnout in mental health nurses: a multicenter survey. Med Lav 2018;109(2): 97-109. [PMID: 29701626] [DOI: 10.23749/mdl.v109i2.6876] [PMCID: PMC7682177]
10. Dodek PM, Wong H, Norena M, Ayas N, Reynolds SC, Keenan SP, et al. Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. J Crit Care 2016;31(1):178-82. [PMID: 26596697] [DOI:10.1016/j.jcrc.2015.10.011]
11. Russell AC. Moral distress in neuroscience nursing: An evolutionary concept analysis. J Neurosci Nurs 2012;44(1):15-24. [PMID: 22210300] [DOI:10.1097/JNN.0b013e31823ae4cb]
12. Khalili A, Molavi EA, Familmotaghi A. Design and Psychometric of Pediatric Ethical Care Questionnaire. Sci J Nurs Midwifery Paramed Fac 2023;8(3):90-100. [URL:]
13. Bartholdson C, Sandeberg Ma, Lützén K, Blomgren K, Pergert P. Healthcare professionals' perceptions of the ethical climate in paediatric cancer care. Nurs Ethics 2016;23(8): 877-88. [PMID: 26116632] [DOI:10.1177/0969733015587778]
14. Koskenvuori J, Numminen O, Suhonen R. Ethical climate in nursing environment: a scoping review. Nurs Ethics 2019;26(2):327-45. [PMID: 28659068] [DOI:10.1177/0969733017712081]
15. Ventovaara P, Sandeberg Ma, Räsänen J, Pergert P. Ethical climate and moral distress in paediatric oncology nursing. Nurs Ethics 2021;28(6):1061-72. [PMID: 33706607] [DOI:10.1177/0969733021994169] [PMCID: PMC8408826]
16. Behbodi M, Shafipour V, Amiri M. Comparison of moral distress severity between pediatric ward and pediatric intensive care unit nurses. J Religion Health 2018;6(1):19-28. [URL:]
17. Hendrick J. Law and Ethics in Children's Nursing: John Wiley & Sons; 2011. [DOI:10.1002/9781444320428]
18. Rabiee S, Khatiban M, Cheraghi MA. Nurses distress in intensive care unit: a survey in teaching hospitals. J Med Ethics Hist Med 2012;5(2): 58-69. [URL:]
19. Bartholdson C, Lützén K, Blomgren K, Pergert P. Experiences of ethical issues when caring for children with cancer. Cancer Nurs 2015;38(2):125-32. [PMID: 24945260] [DOI:10.1097/NCC.0000000000000130]
20. Tahmasebi S, Sabeti F, Hagani H, Mohammadi R. Investigating the relationship between clinical decision making and moral distress of pediatric intensive care unit nurses. Nurs Midwifery J 2022;20(2):137-46. [URL:] [DOI:10.52547/unmf.20.2.137]
21. Molazem Z, Tavakol N, Sharif F, Keshavarzi S, Ghadakpour S. Effect of education based on the "4A Model" on the Iranian nurses' moral distress in CCU wards. J Med Ethics Hist Med 2013;6. [PMID: 23967371] [PMCID: PMC3740193]
22. Trotochaud K, Coleman JR, Krawiecki N, McCracken C. Moral distress in pediatric healthcare providers. J Pediatr Nurs 2015;30(6): 908-14. [PMID: 25869472] [DOI:10.1016/j.pedn.2015.03.001]
23. Naboureh A, Imanipour M, Salehi T, Tabesh H. The relationship between moral distress and self-efficacy among nurses in critical care and emergency units in hospitals affiliated to Ahvaz Jundishapur University of Medical Sciences in 2015. J Rafsanjan Univ Med Sci 2015;14(6): 443-54. [URL:] [DORL:]
24. Jameton A. A reflection on moral distress in nursing together with a current application of the concept. J Bioeth Inq 2013;10: 297-308. [PMID: 24048753] [DOI:10.1007/s11673-013-9466-3]
25. Oh Y, Gastmans C. Moral distress experienced by nurses: a quantitative literature review. Nurs Ethics 2015;22(1): 15-31. [PMID: 24091351] [DOI:10.1177/0969733013502803]
26. Karakachian A, Colbert A. Nurses' moral distress, burnout, and intentions to leave: an integrative review. J Forensic Nurs 2019;15(3): 133-42. [PMID: 31436681] [DOI:10.1097/JFN.0000000000000249]
27. Sannino P, Giannì ML, Carini M, Madeo M, Lusignani M, Bezze E, et al. Moral distress in the pediatric intensive care unit: an Italian study. Front pediatr 2019;7: 338. [PMID: 31456996] [DOI:10.3389/fped.2019.00338] [PMCID: PMC6700377]
28. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part 1. Dimensions Crit Care Nurs 2014;33(4): 234-45. [PMID: 24895954] [DOI:10.1097/DCC.0000000000000050]
29. Grove SK, Gray JR. Understanding nursing research e-book: Building an evidence-based practice: Elsevier Health Sciences; 2018. [Google Books:]
30. Rahmani N, Nabavian M, Seyed Nematollah Roshan F, Firouzbakht M. Explaining nurses'experiences of social stigma caused by the covid-19 pandemic: A phenomenological study. Nurs Midwifery J 2022;20(7): 538-48. [URL:] [DOI:10.52547/unmf.20.7.538]
31. Polit DF. Essentials of nursing research: Printed in China; 2010. [Google Books:]
32. Dowling M. From Husserl to van Manen. A review of different phenomenological approaches. Int J Nurs Stud 2007;44(1): 131-42. [PMID: 16412442] [DOI:10.1016/j.ijnurstu.2005.11.026]
33. Van Manen M. Researching lived experience: Human science for an action sensitive pedagogy: Routledge; 2016. [DOI:10.4324/9781315421056]
34. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24(2): 105-12. [PMID: 14769454] [DOI:10.1016/j.nedt.2003.10.001]
35. Corbin J, Strauss A. Basics of qualitative research: Techniques and procedures for developing grounded theory: Sage publications; 2014. [Google Books:]
36. Karagozoglu S, Yildirim G, Ozden D, Çınar Z. Moral distress in Turkish intensive care nurses. Nurs Ethics 2017;24(2): 209-24. [PMID: 26208720] [DOI:10.1177/0969733015593408]
37. Hamric AB, Epstein EG, editors. A health system-wide moral distress consultation service: development and evaluation. Hec Forum; 2017: Springer. [PMID: 28070806] [DOI:10.1007/s10730-016-9315-y]
38. Corley MC, Minick P, Elswick R, Jacobs M. Nurse moral distress and ethical work environment. Nurs Ethics 2005;12(4): 381-90. [PMID: 16045246] [DOI:10.1191/0969733005ne809oa]
39. Lewis SL. Emotional intelligence in neonatal intensive care unit nurses: decreasing moral distress in end-of-life care and laying a foundation for improved outcomes: an integrative review. J Hosp Palliat Nurs 2019;21(4):250-6. [PMID: 31268970] [DOI:10.1097/NJH.0000000000000561]
40. Papathanassoglou ED, Karanikola MN, Kalafati M, Giannakopoulou M, Lemonidou C, Albarran JW. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. Am J Crit Care 2012;21(2): e41-e52. [PMID: 22381995] [DOI:10.4037/ajcc2012205]
41. Bagheri F, Aghebati N, Heydari A. The concept of moral distress in the neonatal intensive care unit: a concept analysis using Rogers' evolutionary method. J Educ Ethics Nurs 2022;11(3&4): 50-60. [URL:]
42. Yeganeh MR, Pouralizadeh M, Ghanbari A. The relationship between professional autonomy and moral distress in ICU nurses of Guilan University of Medical Sciences in 2017. Nurs Pract Today 2019. [URL:] [DOI:10.18502/npt.v6i3.1256]
43. Altaker KW, Howie-Esquivel J, Cataldo JK. Relationships among palliative care, ethical climate, empowerment, and moral distress in intensive care unit nurses. Am J Crit Care 2018;27(4): 295-302. [PMID: 29961665] [DOI:10.4037/ajcc2018252]
44. Ameri M, Mirhashemi B, Hosseini SS. Moral distress and the contributing factors among nurses in different work environments. Nurs Midwifery Sci 2015: 2(3): 44-9. [URL:]
45. Challinor JM, Alqudimat MR, Teixeira TO, Oldenmenger WH. Oncology nursing workforce: challenges, solutions, and future strategies. Lancet Oncol 2020;21(12): e564-e74. [PMID: 33212044] [DOI:10.1016/S1470-2045(20)30605-7]
46. Hopia H, Heino-Tolonen T. Families in paediatric oncology nursing: critical incidents from the nurses' perspective. J Pediatr Nurs 2019;44: e28-e35. [PMID: 30528181] [DOI:10.1016/j.pedn.2018.10.013]
47. Newman AR. Pediatric oncology nurses' experiences with prognosis-related communication. Number 3 May 2018. Oncol Nurs Forum 2018;45(3): 327-37. [PMID: 29683123] [DOI:10.1188/18.ONF.327-337]
48. Gunther M, Thomas SP. Nurses' narratives of unforgettable patient care events. J Nurs 2006;38(4): 370-6. [PMID: 17181086] [DOI:10.1111/j.1547-5069.2006.00129.x]
49. Holsclaw PA, editor Nursing in high emotional risk areas. Nursing Forum; 1965: Wiley Online Library. [DOI:10.1111/j.1744-6198.1965.tb00308.x]
50. Ferrell BR, editor Understanding the moral distress of nurses witnessing medically futile care. Oncol Nurs Forum 2006;33(5):922-30. [PMID: 16955120] [DOI:10.1188/06.ONF.922-930]
51. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care 2005;14(6): 523-30. [PMID: 16249589] [DOI:10.4037/ajcc2005.14.6.523]
52. Araghian Mojarad F, Shafipour V. Intensive Care Nurses' Experiences of Moral Distress in the COVID-19 Pandemic. J Mazandaran Univ Med Sci 2023;33(222): 124-34. [URL:]
53. Schaefer R, Zoboli ELCP, Vieira M. Moral distress in nurses: a description of the risks for professionals. Texto Contexto Enferm 2018;27: e4020017. [URL:] [DOI:10.1590/0104-07072018004020017]
54. Sheppard KN, Runk BG, Maduro RS, Fancher M, Mayo AN, Wilmoth DD, et al. Nursing moral distress and intent to leave employment during the COVID-19 pandemic. J Nurs Care Qual 2022;37(1): 28-34. [PMID: 34538814] [DOI:10.1097/NCQ.0000000000000596] [PMCID: PMC8607915]
55. Hopia H, Miettinen S, Miettinen M, Heino-Tolonen T. The voice of paediatric oncology nurses: A longitudinal diary study of professional development. Eur J Oncol Nurs 2019;42: 28-35. [PMID: 31446261] [DOI:10.1016/j.ejon.2019.07.009]
56. Meltzer LS, Huckabay LM. Critical care nurses' perceptions of futile care and its effect on burnout. Am J Crit Care 2004;13(3): 202-8. [PMID: 15149054] [DOI:10.4037/ajcc2004.13.3.202]
57. Lazzarin M, Biondi A, Di Mauro S. Moral distress in nurses in oncology and haematology units. Nurs Ethics 2012;19(2): 183-95. [PMID: 22457383] [DOI:10.1177/0969733011416840]
58. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002;9(6): 636-50. [PMID: 12450000] [DOI:10.1191/0969733002ne557oa]
59. Pauly BM, Varcoe C, Storch J, editors. Framing the issues: moral distress in health care. Hec forum; 2012: Springer. [PMID: 22446885] [DOI:10.1007/s10730-012-9176-y] [PMCID: PMC3348467]
60. Thorne S, Konikoff L, Brown H, Albersheim S. Navigating the dangerous terrain of moral distress: understanding response patterns in the NICU. Qual Health Res 2018;28(5): 683-701. [PMID: 29357751] [DOI:10.1177/1049732317753585]
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