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Study of Nurses’ Knowledge about Palliative Care: A Quantitative Cross-sectional Survey

Venkatesan prem, harikesavan karvannan, senthil p kumar, surulirajan karthikbabu, nafeez syed, vaishali sisodia, saroja jaykumar.

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Address for correspondence: Assoc. Prof. Senthil P Kumar; E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in palliative care. Several reasons have been identified including inadequacies in nursing education, absence of curriculum content related to pain management, and knowledge related to pain and palliative care.

The objective of this paper was to assess the knowledge about palliative care amongst nursing professionals using the palliative care knowledge test (PCKT).

Settings and Design:

Cross-sectional survey of 363 nurses in a multispecialty hospital.

Materials and Methods:

The study utilized a self-report questionnaire- PCKT developed by Nakazawa et al ., which had 20 items (statements about palliative care) for each of which the person had to indicate ‘correct’, ‘incorrect’, or ‘unsure.’ The PCKT had 5 subscales (philosophy- 2 items, pain- 6 items, dyspnea- 4 items, psychiatric problems- 4 items, and gastro-intestinal problems- 4 items).

Statistical Analysis Used:

Comparison across individual and professional variables for both dimensions were done using one-way ANOVA, and correlations were done using Karl-Pearson's co-efficient using SPSS version 16.0 for Windows.

The overall total score of PCKT was 7.16 ± 2.69 (35.8%). The philosophy score was 73 ± .65 (36.5%), pain score was 2.09 ± 1.19 (34.83%), dyspnea score was 1.13 ± .95 (28.25%), psychiatric problems score was 1.83 ± 1.02 (45.75%), and gastro-intestinal problems score was 1.36 ± .97 (34%). ( P = .00). The female nurses scored higher than their male counterparts, but the difference was not significant ( P > .05).

Conclusions:

Overall level of knowledge about palliative care was poor, and nurses had a greater knowledge about psychiatric problems and philosophy than the other aspects indicated in PCKT.

Keywords: Information, Nursing education, Palliative care education, Professional knowledge

INTRODUCTION

One of the important factors influencing a successful delivery of palliative healthcare is the health care professionals’ knowledge, attitudes, beliefs, and experiences, which determine not only their procedure but also their behavior during evaluation and treatment of patients.[ 1 ] After physicians, the nurses are the most valuable palliative care team members who address the physical, functional, social, and spiritual dimensions of care.[ 2 ] Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in pain. Several reasons have been identified including inadequacies education, absence of curriculum content related to pain management, and faculty attitudes and beliefs related to pain.[ 3 ]

A public health strategy, as recommended by the World Health Organization (WHO), offers the best approach for translating knowledge and skills into evidence-based, cost-effective interventions that can reach everyone in need of palliative care in developing countries.[ 4 ] The World Health Organization (WHO) pioneered a public health strategy (PHS) for integrating palliative care into a country's health care system. The WHO PHS addresses 1) appropriate policies; 2) adequate drug availability; 3) education of policy makers, health care workers, and the public; and 4) implementation of palliative care services at all levels throughout the society.[ 5 ] Education of health care workers has a great influence on their knowledge, which acts as a foundation for better clinical practice.[ 6 ] The role of multidisciplinary collaborative team work cannot be over-emphasized in the provision of palliative nursing care services.[ 2 ] Nurses considered next only to physicians, for their important role in providing palliative care and for being responsible for patients with life-limiting and/or life-threatening.[ 7 ] However, various factors affect nurses’ effective role as a health care provider, in a palliative care setting. The most important factor amongst them is knowledge about palliative care.

The knowledge and understanding about pain had undergone a paradigm shift from a biomedical dimension to a behavioral dimension.[ 8 , 9 ] In other words, an anatomical or pathological understanding is now replaced with biopsychosocial perspective for pain.[ 10 ] One such recent biopsychosocial explanation of pain is the mechanism-based classification, used by physical therapists’ management in palliative care.[ 11 ] A recent survey found that nurses had a biomedical orientation to chronic pain rather than a behavioral one.[ 12 ] Such attitudes and beliefs not only result from inadequate knowledge per se , but also vice versa .

Knowing the present levels of professionals’ knowledge facilitate appropriate training programs[ 13 , 14 ] to address identified deficits and thereby to improve the quality of provided care.

There were many studies that previously reported levels of knowledge about palliative care amongst nurses,[ 15 – 25 ] but none of the earlier studies provide information on knowledge about distinct aspects of palliative care such as philosophy, pain, dyspnea, psychiatric problems, and gastro-intestinal problems. Nakazawa et al .[ 26 ] developed and validated the palliative care knowledge test (PCKT) for evaluating knowledge on palliative care amongst health care professionals. PCKT has 5 distinct subscales for each of the above-mentioned issues in palliative care practice. To our knowledge, there is no study that evaluated the knowledge of nurses using the PCKT. The objective of the present study was to evaluate the nurses on knowledge about palliative care using the PCKT.

MATERIALS AND METHODS

The study was conducted at a multispecialty tertiary care hospital where the participants included those who attended a continuing professional development program exclusively for staff nurses. The study's ethical approval was obtained from the institutional ethics committee, and all participants were required to provide their written informed consent prior to their participation. Consented participants were then given the survey questionnaire.

The study utilized a self-report questionnaire originally used by Nakazawa et al .[ 26 ] The scale had 20 items (statements about pain) for each of which the person had to answer ‘correct,’ ‘incorrect,’ or ‘unsure.’ Items 1 and 2 indicate philosophy (2 points), 3 to 8 for pain (6 points), 9 to 12 for dyspnea (4 points), 13 to 16 for psychiatric problems (4 points), and 17 to 20 for gastro-intestinal problems (4 points). Total score for an all-correct response is 20.

The received questionnaires were then screened for their suitability of responses to get the final number of included participants’ questionnaires. Thus, we arrived at the response rate for our survey.

Comparison across individual and professional variables for both dimensions were done using one-way ANOVA (post-hoc analysis using Bonferonni test), and correlations were done using Karl-Pearson's co-efficient using SPSS version 11.5 for Windows (SPSS Inc, IL).

Out of total 392 questionnaires distributed and collected, 363 valid questionnaires were included for analysis, with a response rate of 92.6%. The overall descriptive data of the study participants is provided in Table 1 . The item-specific responses for the subscales of PCKT and their corresponding prevalence rates are shown in Table 2 and Figure 1 , respectively.

Overall descriptive data of study participants

Responses for the PCKT subscales in the study sample

Item-responses for the palliative care knowledge test (PCKT) in the study sample

Comparison of knowledge between genders

Between-group comparison [ Figure 2 ] found that female nurses had slightly higher scores than male nurses, which was not statistically significant ( P > .05).

Comparison of palliative care knowledge test (PCKT) total and subscale scores between genders

Comparison of knowledge scores between work setting categories

Between-group comparison for total PCKT score ( P = .142) and subscales’ scores (philosophy: P = .606; pain: P = .250; dyspnea: P = .752; psychiatric problems: P = .244; gastro-intestinal problems: P = .116) were not statistically significant. The schematic comparison is shown in Figure 3 .

Comparison of palliative care knowledge test (PCKT) total and subscale scores between types of work setting

Relationship of PCKT total score and subscales’ scores with age, present work experience, and total work experience

Weak correlations were found between the scores (PCKT total score and subscales’ scores) and age, present work experience, and total work experience, which were not statistically significant [ Table 3 ].

Correlations of PCKT total and subscales’ scores with age, present work experience, and total work experience

Previous systematic review identified PCKT as a single quantitative assessment tool yet to be studied and reported in healthcare professionals, be it nurses which was done in this study for the first time in Indian professional population. The principal focus for previous palliative care studies evaluating knowledge was on a website,[ 27 ] telephone advice,[ 28 ] a disease condition,[ 29 ] questionnaire development,[ 30 , 31 ] research,[ 32 , 33 ] and theory[ 34 – 36 ] of palliative care. Although this study did not evaluate interventions to improve palliative care knowledge amongst nurses, some recommendations on improving the same could be considered both for practice and for future research: Fundamental changes in nursing curriculum that includes a comprehensive information on palliative care; training programs on palliative care; and, telephone/online (web- based) advice.

This study's findings are in agreement with previous reports of inadequacies in knowledge in various issues related to palliative care such as pain management, opioid usage, and adverse drug events. However, direct comparison of this study's findings with earlier studies is not possible since this study is the first quantitative study that explored the 5 aspects of philosophy, pain, dyspnea, psychiatric problems, and gastro-intestinal problems. Future studies can evaluate palliative care knowledge across a curriculum, comparison between nurses from different work settings or educational background, in different countries across the globe.

This study included biopsychosocial factors related to nursing staff such as age, gender, work experience, and work setting. Education and clinical experience influence nurses’ knowledge, attitudes, and beliefs about palliative care. However, it would appear that the specialist nurses’ working environment and knowledge base engenders a practice theory divide, resulting in desensitization to patients’ physical pain.[ 37 ]

Inadequacies in the pain management process may not be tied to myth and bias originating from general attitudes and beliefs, but may reflect an inadequate pain knowledge.[ 38 ] This study also found that knowledge about pain was low, only less than 35% of nurses had correct responses for knowledge subscale. Future studies may assess such relationship between knowledge, attitudes, beliefs, and behaviors of nurses in real life palliative care situations.[ 39 ] The study findings are of utmost significance since individual’ own knowledge largely determines inter-individual and inter-disciplinary communication in a multidisciplinary care framework for pain and palliative care.[ 40 ] Knowledge-practice[ 41 ] translation depends upon behaviors are essential to answer inadequacies of nursing care, which directly then would facilitate appropriate educational interventions by integrating research, practice, and education in knowledge about palliative care.[ 42 – 44 ]

Being knowledgeable about palliative care assessment and management can help nurses and other healthcare providers overcome many of the barriers to successful pain control and palliative care.[ 45 ] Future studies could focus on different ways of knowing,[ 46 ] and the methods of knowledge constructions,[ 47 ] the inter-relationship with practice and research,[ 48 ] and the influence of evidence-base,[ 49 ] and cultural competence[ 50 ] in evidence-based palliative care nursing.[ 51 ]

Overall level of knowledge about palliative care was poor, and nurses had a greater knowledge about psychiatric problems and philosophy than the other aspects as indicated in PCKT. The study findings have important curricular implications for nurses and practical implications in palliative care.

ACKNOWLEDGEMENTS

The authors wish to thank nurses who participated in the study for taking their valuable time and sharing their knowledge, views, and opinions in the survey.

Source of Support: Nil.

Conflict of Interest: None declared.

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• Published: 25 August 2022

A quantitative study of nurses perception to advance directive in selected private and public secondary healthcare facilities in Ibadan, Nigeria

• Oluwaseyi Emiola Ojedoyin 1 &
• Ayodele Samuel Jegede 1  

BMC Medical Ethics volume  23 , Article number:  87 ( 2022 ) Cite this article

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The study evaluated nurses’ perceptions on the benefits, drawbacks, and their roles in initiating and implementing advance directives (AD) at private and public secondary healthcare units.

The study adopted a cross-sectional, comparative-descriptive research design and was anchored on the structural functional theory. A total of 401 nurses (131 private and 270 public) were chosen on purpose. The data was collected between January and March 2018 among nurses at the selected hospitals. Analysis was done via SPSSv28.0.1.0.

Compared to nurses working in private healthcare facilities (72.5%), the majority of nurses at the public healthcare facilities (75.2%) indicated a more favorable opinion of AD’s benefits and (61.9%) felt they had a substantial involvement in the development and execution of AD than their private counterpart (56.5%). Similarly, 60.7% of nurses employed by the government agreed that AD has some disadvantages compared to those employed by the private sector (58.8%). Significantly, Christian nurses are 0.53 times less likely than Muslims to contest AD’s benefits; 0.78 times less likely than Muslim to disagree that AD has flaws; and 1.30 times more likely than Muslim nurses to deny they contributed to the development and execution of AD, though not significant.

Making decisions at the end-of-life can be challenging, thus AD should be supported across the board in the healthcare industry. Nurses should be trained on their role in developing and implementing AD, as well as on its advantages and how to deal with its challenges.

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Introduction

Humans are born with the fundamental right to life. Due to this, many view death as undesirable, and even healthcare professionals avoid the discussion [ 1 , 2 ]. However, death is an inevitable, natural occurrence that all patients with life limiting illnesses should be prepared for in order to minimize distress at the end stage of life. Advance care planning (APC) is a method of communicating intentions that allows patients to let their loved ones and healthcare providers know in advance how they would like to be treated. One strategy in APC that aid readiness for future illness-related incapacitation, patients’ autonomy and dignity is advance directive (AD). AD is a written document or spoken declaration that enables competent people to make and document their healthcare decisions in advance [ 3 , 4 , 5 , 6 ]. Although patient’s “written directives” is a helpful tool for determining their preferences, tradition still dominates in most Africa countries. AD is yet to be legalised in Nigeria [ 7 ]. However, patients verbally expressed their preferences of care to healthcare professionals, and some even name individuals to make treatment decisions on their behalf when they are incapacitated [ 7 ]. These do not only promote patient participation in EOL discussion but also mitigate the paternalistic aspect of Nigeria’s healthcare system [ 8 , 9 ].

The Nigeria healthcare unit is divided into 3—primary, secondary and tertiary. Healthcare facilities at each unit can be privately owned or publicly owned. The difference between the two hospitals are found in their governance—the former are owned and run by an individual or group of individuals while the later are managed and funded by the government. The secondary healthcare facilities—which was the focus in this study manage advanced medical conditions [ 10 ] and it had been shown that, private hospitals are mostly used by Nigerians [ 11 ]. Nurses at these two facilities play significant roles in patients’ care. They provide medical, emotional, educational, patient-centered care and also serve as mediator between patients and doctors [ 12 , 13 ]. These put them in the best position to help in advance care planning—a procedure for communicating patients’ intentions [ 14 ]. Therefore, comparing the viewpoints of these nurses regarding AD will help to determine how end-of-life care is provided at this healthcare unit. There is a paucity of data on nurses’ perceptions of AD in Nigeria, and no study has described nurses’ perceptions at both private and public secondary healthcare facilities to the best of our knowledge. Previous researches focused on patient perception of AD and advocacy for AD inclusion in the country’s healthcare system [ 5 , 7 , 15 ]. This study therefore compared perceptions of nurses at the private and public secondary healthcare facilities on the advantages, roles and shortcoming of ADs in Ibadan, Oyo state, Nigeria.

Theoretical orientation

Structural–functional model.

A sociological theory known as functionalism views society as an organism of several elements (social institutions) that work together to maintain and reproduce the society [ 16 ]. These social institutions are typical means by which a society can attend to and satisfy both its social and individual needs. For instance, hospital is a social institution with many healthcare professionals collaborating to provide the best possible healthcare services to the community. Social institutions are also examined by functionalists in terms of the roles they played. Hence, to comprehend every part of society (e.g. doctor, nurse, teacher, AD, etc.) and how they affect social cohesion, reproduction, or the effective operation of a larger community, the functions of such institutions, beliefs, or ideologies are taken into considerations.

Merton however proposed that not all structure, custom, religion, ideology etc., serves positive purposes because they may serve both manifest and latent functions [ 17 ]. The latent functions are elements of behaviour or functions that are not openly declared, recognised, desired or intended. While the manifest functions are elements of conduct or functions that are conscious and purposefully [ 17 ]. Both the latent and manifest functions of AD was examined in the present study.

Research design

The study was a cross-sectional comparative-descriptive research design.

Participants

Nurses working in government-owned (public) and privately-owned secondary healthcare institutions as well as nursing students at the chosen hospitals participated in the survey.

Study location

The study was carried out in Ibadan, the Oyo state capital of Nigeria. Ibadan was deliberately chosen because it is Nigeria’s third-most populous city after Lagos and Kano, and because the region has historically had limited access to health care services [ 18 ]. Six out of eleven local government areas (LGAs) in Ibadan were chosen for this study—Ibadan Northeast, Ibadan Southwest, Ibadan Southeast, Ibadan North, and Egbeda. The high number of secondary health care facilities in these LGA coupled with the fact that no study on AD has been carried out among nurses in these locations were a deciding factors.

Sampling technique

A convenient non-probability sampling method was used to select nurses. This was employed due to the low staff strength, heavy workload and burnout on available staff. Five general hospitals and ten private secondary hospitals were included in the study—because of the high proportion of private secondary health facilities to public secondary health care facilities in the location and Nigeria as a whole [ 19 ]. A total of four hundred and one (401) nurses—270 nurses from public and 131 nurses from private hospitals—participated in the study.

Research instrument

Questionnaire was used to elicit information from respondents. Data was gathered in 2018 between January and March. The surveys were distributed to all nurses on-duty at their offices. A total of 430 survey was distributed out of which 401 was returned, making a 93% response rate. A total of 7% of the data was missing because several nurses worked night shifts, took the survey home, went on leave, and neglected to return the questionnaire.

The survey questions were developed after careful examination of literature from various countries [ 20 , 21 , 22 , 23 ]. Additionally, the opinions of three experts on prospective contents that required evaluation were sought. The questions’ ambiguity, relevance, clarity, and comprehensiveness were also evaluated. They assessed the questionnaire’s validity in terms of both face and content. The comments was examined, and the changes were added in the final survey. However, pilot survey was not conducted.

The questionnaire comprises two sections. The first section was on respondents’ socio-demographical characteristics. The second section was on perception and comprises 13 items—4 questions on benefits of AD, 5 questions on nurses’ roles in the initiation and implementation of AD, and 4 questions on shortcomings of AD. A 5-point likert scale was used to grade the responses of the participants ranging from strongly agree (5) to strongly disagree (0).

Data analysis

Data entry, cleaning, and analysis were performed using SPSS 28.0.1.0. Descriptive statistics was calculated for the socio-demographic and perception of nurses to AD. For questions on benefit of and nurses role in AD initiation and implementation, strongly agree and agree responses were merged to form correct perception to AD while, neutral, disagree and strongly disagree was merged as incorrect response. For questions on shortcomings of AD, strongly agree, agree and neutral responses were merged to form incorrect perception to AD while, disagree and strongly disagree was merged as correct response. The score for a correct response was two, while the score for an incorrect response was zero. The mean was calculated and response below the mean was considered as negative perceptions and those above or within the mean as positive perception.

On both the total benefits and drawbacks questions, 75% percentile (scoring three or more out of the four questions) was defined as positive perception, while 25% percentile (scored one out of the four questions) was labeled as negative view. The percentiles for the role of nurses in the initiation and implementation of AD were 60% (scoring 3 or more out of the 5 questions) and 40% (scored 2 or fewer out of the 5 questions). Differences between public and private nurses and nurses religion was examine using the odd ratios.

Reliability assessment of the questionnaire was conducted using Cronbach’s alpha coefficient based on Heden scale as cited in Peicus et al. [ 21 ] internal reliability assessment and recommendation. It stated that, a scale is reliable if the Cronbach’s alpha is > 5. The Cronbach alpha for the study is (0.62).

Ethical consideration

The Oyo State Research Ethics Review Committee, with reference number AD13/479/837, as well as administrative officers from each of the chosen hospitals and each participant, gave their approval before the data collection began.

Characteristic and representative of nurses in the study

The complete list of participants characteristics is shown in Table 1 below. The majority of respondents are women (88.9% public and 96.9% private). The majority (56.7%) of staff members at public hospitals hold diploma degrees, with one (0.4%) PhD degree holder. In contrast to the government hospitals, where 44.1% of participants had more than ten years of work experience, more than half (55.7%) of the private participants are within 1–5 years of work experience group. Predominant group are Yoruba (94%), Christians (79.3%) and more respondents from the public hospital (67.3%).

Distribution of nurses perception of benefits of advance directive

As shown in Table 2 below, most of the nurses agreed the AD is helpful when deciding how to treat patients (public-94.5% and private-93.1%); makes decision easier (public-88.2%, private-93.1%), minimize family conflict (public-85.9%, private-80.1%) and majority felt it reduced wasteful spending (public 77%, private 77%);

Perceived nurses role in advance directives

Majority agreed that nurses are crucial in educating about AD (public-78.1%, private-73.3%); in best position to access the appropriate time for end-of-life discussions (public-84.4%; private-78.6%) and are responsible to initiate end-of-life discussion (public-76%, private-57.3%). More participants in the private facilities than those at the public agreed that nurse can transfer a patient to another nurse when not comfortable with the directives.

Perceived shortcomings of advance directive

More participants in public (42.2%) than private (35.9%) disagreed that interpreting AD can be challenging. Two-thirds of private nurses (65.7%) and 55.5% of nurses in the public hospital agreed that AD can lead to requests for care not in the patient’s best interests. The little more than half of the participants felt AD might not accurately reflect patient’s current preferences (public-57.8%; private-52.7%) and uncertain (public-51.8%, private 39.7).

Classification of nurses responses into positive and negative perception

Table 3 shows how nurses generally perceived the benefits of AD, their involvement in its initiation and execution, and its perceived drawbacks. Majority of nurses in the public sector (75.2%) and private sector (72.5%) agreed AD is beneficial to patients, their families, and healthcare providers. More participants in the public sector (61.9%) than private (56.5%) thought they played a critical role in the development and implementation of AD. More nurses (60.7%) in the public sector concurred that AD had drawbacks than its private counterpart (58.8%).

Differences on nurses perception to advance directive

Table 4 below displays how Muslim nurses and Christian nurses perceive AD using odd ratios. Significantly, Christian nurses are 0.53 times less likely than Muslims to contest AD’s benefits; are 0.78 times less likely than Muslim to disagree that AD has flaws but are 1.30 times more likely than Muslim nurses to deny they contributed to the development and execution of AD, albeit, these differences are not statistically significant.

This study focused on nurses’ perceptions on the benefits, the role of nurses, and the negative aspects of AD at public and private secondary healthcare units in Ibadan, Nigeria. Positive perception regarding AD advantages was found among nurses at both public and private secondary healthcare units. This supported previous reported finding in Australia and Korea. According to these researches, AD guarantee patient autonomy, improve end-of-life care, and give patients a chance to reflect on their own dying stage and demise [ 22 , 23 , 24 ]. The study findings also agreed with prior researches where it was reported that the enforcement of ADs relieved families and patients’ financial, emotional weariness and disagreement [ 24 , 25 ] as we found that, participants agreed that AD can reduced needless stress, excessive spending and prevented or resolved conflict among healthcare practitioners, patients and patients relatives.

Nurses are more available at hospital and are closer to patients than any other healthcare practitioners. As a result, they agreed they are the best resource for patients and their families seeking information about AD. This support earlier researches in Portugal, Korea, New Zealand, and Australia [ 3 , 12 , 22 , 24 , 26 ]. The disparity reported on who is proficient in figuring out the appropriate time to initiate AD among the two group of nurses could be attributed to the quantity and quality of training enjoyed by these nurses. While more trainings are planned for nurses at the public sector, little of such training is available for nurses at the private sector in Nigeria. Davidson et al. also reported that nurses are in the best position to initiate AD [ 12 ]. On who should start the end-of-life conversation with a patient, the nurses at the two healthcare facilities had contrasting opinions. Nurses at private facilities saw it as the doctors’ obligation to begin and record the decision while they made the document readily available when needed, in contrast to nurses at public hospitals who saw it as their role. These was similar to findings in South Africa, Korea and Australia by Bull and Mash, Son et al., and Hobden et al. [ 24 , 27 , 28 ], where nurses saw themselves as the custodians of AD document rather than its initiators and/or implementers. The findings demonstrated that nurses in the private sector are more likely to refer patients whose orders they find objectionable to another nurse or facility. These both supports Siamak’s [ 23 ] findings that nurses have the autonomy to decline participation in the withdrawing or withholding of treatment if such a decision contradicts their personal and/or professional convictions and Hobden’s [ 27 ] findings where 60% of their study participants showed neutrality or disagreement that ADs will still be adhered to even if the medical team does not agree with them. Fear of litigation and the fact that nurses at the public sector enjoyed more autonomy, employment security, and public reputation than those in the private sector are some contributing factors to this [ 26 ]. Making known and reporting violation of patients’ directives were found to be nurses’ responsibilities in the present study. This was in consistent with Hobden et al. [ 27 ] that found nurses play a key role in ensuring that patients’ preferences are honored throughout end-of-life care.

Regarding AD’s shortcomings, the study demonstrates consensus that AD has some degree of negativity, but to various degrees. Over 50% of the study participants in the two sectors agreed and are neutral on the statement that many ambiguous terms are frequently used in AD without enough context or justification thereby making it difficult to interpret. Previous researchers have also noted that unclear instructions and the use of ambiguous language could lead to misreading of patients’ preferences [ 20 , 21 , 27 , 29 ]. The fact that patients’ mostly give their directives verbally when they are critically ill and sometime by their relatives in Nigeria can also contribute to the misapprehension of the directives [ 7 , 30 ]. More public sector nurses thought it was challenging to prove that AD is certain and accurately reflect patients’ current preferences and this made its implementation challenging. Reasons could be because, patients’ decisions regarding their treatment preference evolved over the illness episode due to factors like finance, relative decision, religious beliefs among others. However, these changes may not have reflected in the patient AD or known to the patient proxy. These contributed to the controversy in its implementation. Thus, decisional conflict that results from translating a written order into practice has previously been identified as an obstacle to the application of AD [ 26 , 27 , 28 ]. Ernestina et al. [ 3 ] showed that AD can fail in practice if changes in patient personal value fail to reflect in the directive. Therefore, AD should be periodically addressed and revisited for timely updates [ 21 ]. More than half of the study participants agreed that, there are chances that patients will asked for treatment that is not in their best interests in their AD. This finding supported researches conducted in Queensland, Australia, and Korea where it was reported that AD inhibited medical personnel from providing ethically and medically appropriate treatment to patient [ 20 , 26 , 29 ]. Inadequate knowledge and wrong cultural preconceptions about health, illness and treatment among patients could contributed to this perception. This study has been able to support existing knowledge that religion affiliation influence perception to end-of-life care [ 31 , 32 ]. While more Christian nurses are optimistic on the benefits of AD than Muslim nurses, more Muslim nurses believed they have a role to play in its initiation and execution than their Christians counterpart and thought AD had lesser flaws than the Christians. One of the tenets of Islam is to work for this life as if you were going to live forever and strive for the afterlife as if you were going to die tomorrow [ 33 ]. The Holy Qur’an also instructs Muslims to prepare and strategize their affairs. These may have influenced their perception that they have a greater role to play in the planning and implementation of the patient’s AD and support for AD. The Christian religion also supports AD as useful because it aids patients to avoid unbeneficial treatment [ 34 ].

In line with the theoretical explanation, the study had demonstrated that although AD has some benefits, such as quick decision-making, conflict resolution, and the prevention of wasteful spending; nurses as members of the healthcare team have a role to play in its initiation and implementation of AD. However, AD does have certain unintended consequences, which are its drawbacks [ 17 ].

This study has added to the corpus of research by identifying the perception of AD at the secondary healthcare facility in Nigeria and the chance that it will be adopted by nurses, who make up the majority of healthcare professionals. The study is limited by the use of the Likert scale to score nurses’ perceptions, which might have inhibited participants from fully expressing their perspectives on the matter. Further research should look into the acceptance of AD among terminally ill patients and their families as well as the amount of abuse or improper inducement of AD among healthcare professionals in secondary and tertiary healthcare facilities in Nigeria.

Making decisions in the final stages of life might be challenging, however AD may make these challenges easier. As a result, AD should be acknowledged in all healthcare sectors as a tool capable of granting patients’ liberty and dignity. Both in the public secondary healthcare unit and the private unit, nurses play a vital role as care providers in the development and execution of patient Ads. However, some of the difficulties in implementing AD that have been identified in this study should be addressed by stakeholders, and nurses at both sectors should be provided with necessary training on how to avoid these difficulties.

Availability of data and materials

Due to confidentiality rules, the datasets created and/or analyzed for the current work are not publically accessible, but they are available from the corresponding author upon justifiable request.

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Acknowledgements

The researchers appreciate the effort and interest of all the nurses who took part in the study, as well as the thoughtful criticism provided by the anonymous reviewers.

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OO made contributions to the concept, literature review, design, data collection, analysis, and findings discussion. AJ oversaw the study, contributed to the concept and design, and critically examined the report for key intellectual content. The final manuscript was read and approved by all writers.

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Correspondence to Oluwaseyi Emiola Ojedoyin .

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The Oyo State Research Ethics Review Committee, with reference number AD13/479/837, as well as the administrative head in each of the chosen hospitals and each participant, all approved this study. Every approach used in the study complied with the rules and regulations established by the institutional Research Committee for research involving people. All individuals participated in the study provided their written, informed consent.

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Ojedoyin, O.E., Jegede, A.S. A quantitative study of nurses perception to advance directive in selected private and public secondary healthcare facilities in Ibadan, Nigeria. BMC Med Ethics 23 , 87 (2022). https://doi.org/10.1186/s12910-022-00825-5

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DOI : https://doi.org/10.1186/s12910-022-00825-5

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Understanding quantitative research: part 1

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This article, which is the first in a two-part series, provides an introduction to understanding quantitative research, basic statistics and terminology used in research articles. Critical appraisal of research articles is essential to ensure that nurses remain up to date with evidence-based practice to provide consistent and high-quality nursing care. This article focuses on developing critical appraisal skills and understanding the use and implications of different quantitative approaches to research. Part two of this article will focus on explaining common statistical terms and the presentation of statistical data in quantitative research.

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• Quantitative research. Norkett L. Norkett L. Nurs Stand. 2013 Jun 26-Jul 2;27(43):59. doi: 10.7748/ns2013.06.27.43.59.s52. Nurs Stand. 2013. PMID: 23987722 No abstract available.

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The relationship between moral distress and clinical care quality among nurses: an analytical cross-sectional study

• Fateme Safari 1 ,
• Ali MohammadPour 1 ,
• Mahdi BasiriMoghadam 1 &
• Alireza NamaeiQasemnia 1  

BMC Nursing volume  23 , Article number:  732 ( 2024 ) Cite this article

304 Accesses

Metrics details

Nurses constitute the largest group of service providers in the healthcare system and significantly influence the quality of healthcare services. Factors such as ethical considerations may be related to the quality of care. This study aimed to determine the relationship between moral distress and the quality of clinical care among nurses working in Gonabad, Iran.

An analytical cross-sectional study was conducted on 252 nurses working in emergency, internal medicine, surgery, psychiatry, critical care and maternity wards at Allameh Bohlool Hospital from May to July 2023. This research used demographic information questionnaire, the revised Moral Distress Scale (MDS-R), and the Quality Patient Care Scale (QUALPAC). The significance level for the study was set at p  < 0.05.

There was a significant relationship between the frequency of moral distress and the quality of clinical care ( p  = 0.032), as well as between the intensity of moral distress and the quality of clinical care ( p  = 0.043). Nurses who experienced moral distress more frequently and intensely provided better quality care. However, there was no significant relationship between the effect of moral distress and the quality of clinical care ( r  = 0.032, p  = 0.619). Additionally, a significant statistical relationship was found between the intensity of moral distress and the physical dimension of clinical care quality ( r  = 0.171, p  = 0.007), indicating that increased moral distress intensity was associated with higher quality of physical care.

Conclusions

Nurses who experience higher levels of moral distress, both in terms of frequency and intensity, perform better in the care they provide and deliver it in the best possible manner, particularly in the physical dimension of care.

Peer Review reports

Introduction

Nurses are the largest group of service providers in the healthcare system and significantly impact the quality of healthcare services. Factors such as ethical considerations can influence the quality of care [ 1 ]. Nursing uses the concept of ethics to standardize and hold accountability in care [ 2 ]. The advancement of knowledge and technology has led to a focus on ethical issues in various professions, especially nursing. Nurses constantly face ethical dilemmas in their work environment, affecting all professional aspects [ 3 ]. According to Jameton, three experiences related to ethical problems that a nurse may encounter are moral uncertainty, ethical dilemmas, and moral distress [ 4 ].

Studies indicate that nurses working in developing countries report higher levels of moral distress compared to those in developed countries [ 5 ]. Moral distress, introduced by Jameton, occurs when a person is in a situation completely against their moral beliefs and, despite moral reasoning, cannot perform the ethical action due to real or perceived barriers [ 6 ]. Moral distress is influenced by environmental, occupational, organizational, and individual factors and has ambiguous consequences [ 7 , 8 ]. Epstein and Hamric described moral residue as the lasting impact felt after a morally troubling situation. Unresolved moral distress can accumulate over time, easily growing. When a nurse repeatedly experiences moral distress, the starting point for moral distress becomes higher due to accumulated moral residue. The more frequently moral distress is experienced, the more intense it becomes, known as the “Crescendo Effect” [ 9 ]. Any ethical incident, even if it occurs once with any intensity, will have acute effects on the individual; repeated occurrences lead to chronic effects [ 10 ]. Moral distress can result in negative outcomes such as headaches, insomnia, hopelessness, withdrawal from family, and fear of going to work [ 11 , 12 ]. When nurses lack the skills to successfully cope with moral distress, they may disengage morally and experience moral non-participation [ 13 ].

Positive outcomes have also been reported for moral distress. Diverse experiences in dealing with distressing conditions play a significant role in professional development and, by promoting positive values, improve patient care [ 14 ]. In a study by Wiegand and Funk, nurses noted changes after experiencing moral distress, including quicker interventions, enhanced family support, assertiveness, and consulting ethics committees. These experiences motivated them to intervene in similar situations in the future, suggesting that moral distress can catalyze positive change among nurses [ 12 ]. Traditional views of moral distress limit ethical analysis, assuming the distressed individual has already made a moral judgment. However, moral distress can prompt deeper inquiry, encouraging reflection, information gathering, and questioning of ethical judgments, empowering nurses to exercise their moral agency [ 15 ]. How nurses cope with moral distress may impact their clinical performance and personal lives, though there is some doubt about this [ 16 ].

Care is a fundamental component of healthcare services. Among the various types of care provided in healthcare settings, nursing care holds particular importance, and providing quality care is a priority in the healthcare system. In many countries, hospital accreditation is influenced by the quality of nursing care [ 17 , 18 ]. Meeting the individual needs of patients is the core of nursing care, and the ultimate goal of nurses is to provide quality patient care [ 17 , 19 ]. Today, efforts to improve quality and evaluate this variable in nursing systems are being emphasized [ 20 ]. Quality healthcare services mean achieving the most desirable health outcomes, where the services provided are effective, efficient, and cost-effective [ 21 , 22 ]. Nurses are legally and ethically accountable for the quality of care they provide, making their perspective on defining healthcare quality particularly significant. Healthcare providers define quality as “doing the right thing, at the right time, and doing it right the first time,” but patients often define quality based on what personally matters to them [ 23 ].

Moral distress may lead to a reduction in care quality, which can further cause a conflict of conscience and result in moral distress [ 24 ]. Few studies have examined the relationship between moral distress and the quality of clinical care among nurses. These studies have reported varying results, with some finding a relationship between moral distress and clinical care quality [ 25 ] and others finding no such relationship [ 26 ]. This study aimed to determine the relationship between moral distress and the quality of clinical care among nurses.

Study design

An analytical cross-sectional study was conducted in Gonabad, northeast of Iran from May to July 2023.

Setting and sample

The target group consisted of nurses working in the public sector of Gonabad County. The sample size was determined using G-power software version 7.9.1.3 and the Correlation: Bivariate normal model test from the Exact distribution family, with a correlation coefficient of -0.18 between the two quantitative variables of clinical care quality and moral distress. This calculation resulted in a required sample size of 239, which was adjusted to 250 to account for a 5% attrition rate. The correlation coefficient (r) of -0.18 was based on a similar study [ 25 ]. The 252 participating nurses were required to have at least a bachelor’s degree in nursing, a minimum of six months of work experience in hospital wards, current clinical employment, no history of severe stress based on self-report, and consent to participate in the study.

Data collection

After the study protocol was approved by Gonabad University of Medical Sciences and the ethics committee granted approval, an introduction letter was obtained from the Vice-Chancellor for Research and Technology of the university and submitted to Allameh Bohlool Hospital. Permission to access clinical wards was granted by the hospital’s research department, and introduction letters were sent to head nurses through the administrative system. After which the researcher visited the head nurse at Allameh Bohlool Gonabadi Hospital to compile a confidential list of the hospital’s employed nurses, ensuring non-disclosure of information. A total of 260 nurses met the inclusion criteria and were selected via census sampling. Allameh Bohlool Gonabadi Hospital is a public teaching hospital with seven floors and 278 active beds. It comprises emergency departments, three surgical wards, two internal medicine wards, a psychiatric ward, three intensive care units (cardiac, neonatal, and general), and obstetrics and gynecology wards.

The researcher visited the nurses during morning, evening, and night shifts, typically in the middle of the shift. After verifying the inclusion criteria, explaining the study, assuring confidentiality of the information, clarifying that names and surnames were not required, and obtaining written consent, the targeted questionnaires were distributed and completed. Completing the questionnaire took approximately 15–20 min. Given the nurses’ busy schedules, they were allowed to specify a convenient time for returning the questionnaires, which were then collected. A designated location in each ward was arranged in coordination with the head nurse for nurses to place their completed questionnaires if they chose to do so. Participating nurses were informed that their participation or non-participation would not affect their job performance evaluations. Data collection occurred over two months. Data were collected directly by the researcher, who approached the nurses, obtained written consent, and then administered the questionnaires.

Instruments

Three questionnaires were utilized in this study:

Demographic Information Form : This form gathered information on age, gender, marital status, number of children, education, employment status, work experience, shift work, number of night shifts and working hours per month, ward, economic status, executive position, and training in ethics.

Moral Distress Scale-Revised (MDS-R) : Originally developed by Jameton in 1984 and later revised by Corley and Hamric, this tool measures three dimensions of moral distress: frequency, intensity, and impact [ 27 ]. The MDS-R consists of 21 items rated on a five-point Likert scale, where frequency is scored from ‘never’ (0) to ‘daily’ [ 4 ] and intensity from ‘none’ (0) to ‘very high’ [ 4 ]. The impact of moral distress for each item is calculated by multiplying the intensity score by the frequency score, resulting in item scores ranging from 0 to 16. The total score of moral distress ranges from 0 to 336, with higher scores indicating greater moral distress. The tool also includes an open-ended question about other situations causing moral distress and two closed-ended questions about previous decisions to leave clinical practice or the nursing profession due to moral distress. These three questions do not contribute to the overall moral distress score. The internal consistency of this tool was confirmed with a Cronbach’s alpha of 0.89 in the nursing population. In Iran, it has been psychometrically validated. For instance, in the study by Mahdavi Feshtami et al. (2016), the internal consistency was 0.84 for frequency, 0.82 for intensity, and 0.86 for the overall moral distress score, with an overall Cronbach’s alpha of 0.86 [ 28 ]. Another tool, the Measure of Moral Distress for Healthcare Professionals (MMD-HP), developed in 2019 to assess the root causes of moral distress among healthcare professionals, requires further validation and has not yet been psychometrically tested in Iran. Hence, the Persian version of MDS-R was employed in this study [ 29 ].

Quality Patient Care Scale (QUALPAC) : This scale was developed by Wandelt in 1972 and has been used in the USA, UK, and Nigeria [ 23 ]. It assesses the quality of clinical care from the perspectives of nurses and patients [ 30 ]. The original questionnaire contained 68 items, which were culturally adapted and expanded to 72 items by Khoshkho in 2004 in Tabriz, Iran. The QUALPAC measures nursing care quality across three dimensions: psychosocial (33 items), physical (26 items), and communication (13 items). Each item is rated on a five-point Likert scale with options ranging from ‘not applicable’ to ‘always’. The quality of nursing care is scored as undesirable (0 to 1.89), somewhat desirable (1.90 to 2.63), and desirable (2.64 to 4). The reliability of the questionnaire was confirmed in a study by Khaki et al., where it was completed by 20 nurses, resulting in a Cronbach’s alpha of 0.96 [ 21 ].

Data analysis

Data analysis was performed using SPSS software version 19. Descriptive statistics were used to summarize the demographic data, moral distress, and clinical care quality variables, including absolute numbers (n), prevalence (%), and measures of central tendency and dispersion (e.g., mean and standard deviation) as appropriate for the data type. For inferential statistics, the normality of data distribution was assessed using the Kolmogorov-Smirnov test. Due to the non-establishment of Cochran’s condition, the Exact p -value was reported for determining the relationship between the frequency and intensity of moral distress and clinical care quality using the chi-square test. The Spearman’s rank correlation was employed to assess the relationship between the impact of moral distress and clinical care quality. Results were considered significant at a p -value of less than 0.05.

Ethical considerations

The study protocol was approved by the ethics committee of Gonabad University of Medical Sciences (Ethics Code: IR.GMU.REC.1402.015). All ethical guidelines were strictly followed, and participants were assured that their data would be kept confidential.

Characteristics of the participants

Among the total 252 nurse participants, the majority were female, young, married, had 1–2 children, held a bachelor’s degree in nursing, were officially employed, had less than 10 years of work experience, and worked rotating shifts (Table  1 ).

Frequency and intensity of moral distress

About 51.2% of the nurses reported a moderate frequency of moral distress, with a mean score of 1.56 (SD = 0.70). Additionally, 39.3% of the nurses reported a moderate intensity of moral distress, with a mean score of 1.93 (SD = 0.87). Furthermore, 57.9% of the participants reported a low impact of moral distress, with a mean score of 1.5 (SD = 0.64) (Table  2 ).

The highest mean scores in the subscale of the impact of moral distress were associated with “carrying out unnecessary physician orders” and “performing life-saving actions that merely delay patient death.”

Quality of clinical care

Approximately 87.6% of the nurses rated the quality of clinical care as desirable, with a mean score of 3.12 (SD = 0.46). Additionally, 82.3% rated the quality of clinical care in the psychosocial dimension as desirable, 86.5% in the physical dimension, and 88.5% in the communication dimension (Table  3 ).

Relationship between moral distress and quality of clinical care

There was a significant direct relationship between the frequency of moral distress and the quality of clinical care ( p  = 0.032), as well as between the intensity of moral distress and the quality of clinical care ( p  = 0.043). However, there was no significant relationship between the impact of moral distress and the quality of clinical care ( r  = 0.032, p  = 0.619). Additionally, there was a statistically significant relationship between the intensity of moral distress and the physical dimension of the quality of clinical care ( r  = 0.1, p  = 0.007) (Tables  4 , 5 and 6 ).

This study examined the relationship between moral distress and the quality of clinical care provided by nurses. The findings revealed a significant relationship between the frequency and intensity of moral distress and the quality of care, with higher distress levels correlating with better care. However, there was no significant link between the impact of moral distress and care quality. Additionally, a significant relationship was found between the intensity of moral distress and the physical dimension of care quality, showing that greater distress intensity was associated with improved physical care.

In alignment with the present study, Yu et al.‘s research on Chinese emergency nurses found that moral courage and educational workshops can reduce moral distress and improve nurses’ social performance [ 31 ]. Mert Boğa et al.‘s study in Turkey demonstrated that with increased ethical sensitivity, nurses’ perception of care quality improves, highlighting ethical sensitivity as a crucial factor in nursing care quality [ 2 ]. Ohnishi et al., in their study on psychiatric nurses in Finland and Japan, found a general relationship between moral distress and ethical sensitivity, with nurses possessing higher ethical sensitivity experiencing greater moral distress [ 32 ]. Khodavisi et al.‘s research in western Iran reported a direct and strong correlation between ethical sensitivity and safe nursing care [ 33 ]. Khorani et al. identified ethical sensitivity among nurses in Qazvin hospitals as a factor enhancing adherence to ethical principles and encouraging higher quality care. High levels of moral distress during nursing care necessitate ethical decision-making, where higher ethical sensitivity can significantly enhance nurses’ ability to make ethical decisions during care. A lack of ethical sensitivity or inability to identify and address ethical challenges may lead to suboptimal care behaviors [ 34 ]. Heydari et al. found a direct and significant relationship between the quality of nursing care and moral intelligence, defining moral intelligence as the recognition of right from wrong, guiding other forms of intelligence towards valuable actions [ 35 ].

According to Haahr et al., besides individual nurse competencies, organizational structures, policy programs, and hospital cultures influence nurses’ actions based on ethical beliefs and professional ethics [ 36 ]. Deschenes et al. highlighted the complexity of moral distress in nursing, noting its multifaceted nature. They emphasized that while external constraints such as institutional and systemic limitations contribute significantly to moral distress, internal factors like psychological imbalance and painful emotions also play a role. They proposed replacing the term “internal constraints” with “internal characteristics” to shift the focus from individual culpability to organizational responsibility, highlighting the need for systemic change. Moral distress can have detrimental effects, including blaming others, self-blame, depression, and anxiety, which may lead to burnout and compromise patient care. Conversely, resolving moral distress can lead to personal and professional growth, enhancing nurses’ ethical sensitivity and care skills [ 37 ].

Jansen et al. further explored the link between moral distress, conscience, and the quality of nursing care. They emphasized how moral distress can compromise care quality, leading to a troubled conscience. Conscience acts as a motivator for ethical reflection and can expose unethical practices, but prolonged moral distress can lead to negative physical and psychological consequences such as fatigue and insomnia. While intermittent moral distress can foster ethical reflection and alertness to ethical dilemmas, its chronic presence can result in frustration and mental and physical health issues [ 24 ].

The findings suggest that ethical sensitivity may mediate the relationship between moral distress and clinical care quality among nurses. Morley and Sankary’s study emphasized moral distress as a signal of ethical issues, prompting actions to address them [ 38 ]. However, studies such as those by Azarmi et al., Moghaddam et al., and Amiri et al. present conflicting results regarding the impact of moral distress on care quality [ 26 , 39 , 40 ].

Moral distress, if unresolved, can lead to moral numbness and burnout among nurses [ 41 ]. DeKeyser Ganz and Berkovitz found an inverse relationship between moral distress frequency and care quality, indicating that increased distress correlates with decreased care quality [ 25 ]. Situations causing moral distress demand nurses’ time and attention, potentially leading to inadequate care and decreased safety [ 39 ].

Despite these challenges, moral distress can foster autonomy and professional development. Nurses may develop strategies to cope with distress and engage in reflective practice [ 42 ]. Studies by Mahdavi Feshtami et al., Mohammadi et al., and Rahmanian et al. reported moderate levels of moral distress, while Shafiee et al. found low distress levels among hospital nurses in Bushehr [ 6 , 28 , 43 , 44 ].

However, disparities exist in the reported frequency and intensity of moral distress across studies. Factors may occur frequently but with low intensity or vice versa. For example, Sauerland et al. reported low frequency but moderate intensity of moral distress in an American teaching hospital [ 27 ].

In summary, moral distress poses challenges to care quality but also presents opportunities for professional growth. Understanding its nuances is crucial for addressing its impact on nurses and patient care.

In conclusion, ethical sensitivity emerges as a critical factor that can mediate the relationship between moral distress and clinical care quality. While moral distress often poses challenges, it also has the potential to drive nurses towards higher quality care if managed effectively. Organizational support, ethical training, and fostering a culture of ethical sensitivity are essential strategies for enhancing nurse well-being and patient care quality. Future research should continue to explore these dynamics and develop comprehensive strategies to support nurses in managing moral distress effectively.

In line with the current study, Mahdavi Feshtami et al. reported low levels of moral distress impact [ 28 ]. In the present study, “following unnecessary doctor’s orders” and “performing life-sustaining actions like resuscitation that only delay patient death” had the highest mean scores for the impact of moral distress. Sabri-Kouanchi et al. reported that situations causing the most moral distress include futile care to prolong death, unnecessary tests and treatments, and working with incompetent healthcare personnel [ 45 ]. Beheshtin et al. found that factors contributing to moral distress before and after COVID-19 were similar, with futile care and end-of-life issues being the main causes [ 46 ].

Differences in findings may be due to variations in research settings, samples, and data collection tools. Studies were conducted in different departments, cities, and time periods. Measurement tools for moral distress vary in terms of target population and specific items.

A significant correlation was found between the frequency of moral distress and age, work experience, and the number of children. Specifically, as age and the number of children increased, the frequency of moral distress decreased, while it increased with longer work experience. There was also a significant relationship between the intensity of moral distress and shift work, with nurses working rotating shifts experiencing higher intensity. Conversely, a significant inverse relationship was found between the impact of moral distress and both the number of children and work experience, with increased numbers of children and work experience reducing the impact of moral distress.

Similar results were observed in Brandi Showalter et al.‘s study, where an inverse correlation between moral distress and age was reported [ 47 ]. Sadeghi et al. and Rahmanian et al. also found a significant inverse relationship between age and the frequency of moral distress [ 44 , 48 ].

Contrary to the present study, Mohammadi et al. found a significant relationship between the department and moral distress [ 43 ]. Sadeghi et al. found an inverse relationship between moral distress and work experience, with higher frequency of moral distress reported in emergency and psychiatric nurses, and higher intensity in emergency, orthopedic, and ICU nurses [ 48 ]. Mahdavi Feshtami et al. reported a positive relationship between the number of nurses and beds in a ward and the three dimensions of moral distress [ 28 ].

There are varying findings on the relationship between demographic variables and moral distress. It is unclear whether moral distress intensifies over time or diminishes with experience. There may be significant differences in the experience of moral distress depending on the environment and patient population [ 42 ]. In Petersen and Melzer’s study among German home care nurses, no demographic variables were associated with the level of disturbance caused by moral distress [ 49 ], suggesting the possibility of differences in study focuses—our study examined the frequency and intensity of moral distress rather than its consequences.

The clinical care quality score and its relationship with demographic characteristics indicated that clinical care quality was generally satisfactory among most nurses, with the highest quality reported in the communication dimension. Amiri et al. similarly reported the highest care quality in the communication dimension and the lowest in the physical dimension [ 40 ]. Gaalan et al., in their study in Mongolia, reported an overall satisfactory level of nursing care quality [ 50 ], and Mert Boğa et al. found high levels of perceived care quality among nurses [ 2 ].

In contrast, Moghaddam et al. reported the highest nurse performance in the dimensions of safe nursing care and physical safety [ 39 ]. Khorani et al. found that most nurses rated the quality of care as satisfactory, with the highest quality in the physical dimension and the lowest in the psychosocial dimension [ 34 ]. No significant relationship was found between any demographic variables and clinical care quality or its dimensions.

Bostani et al. and Heydari et al. similarly reported no significant relationship between demographic variables and nursing care quality [ 35 , 51 ]. However, Khorani et al. found that female nurses provided higher quality care than males, and nurses with lower economic status reported lower care quality compared to those with a moderate economic status. In Khorani et al.‘s study, ethical sensitivity, gender, and economic status were the most significant predictors of nursing care quality [ 34 ]. Derzi-Ramandi et al. found higher care quality among female nurses, married individuals, and nurses with a master’s degree compared to those with a bachelor’s degree, with a direct relationship between work experience and care quality [ 52 ].

Gholami et al. found that among demographic variables, only age had a significant negative impact on care quality [ 53 ]. Given the diverse settings and cultures in which these studies were conducted, such varied results are not unexpected. Nonetheless, the necessity for further complementary studies on this important issue is evident.

Limitations

Data collection was based on self-reporting. Therefore, given the workload and additional responsibilities of the nurses at the time of responding to the questions, caution should be exercised in generalizing the results. Potential reporting biases should also be considered, as nurses may not accurately convey their experiences or fully understand the psychological and professional impacts they face.

Nurses who experience higher frequencies and intensities of moral distress tend to perform better in providing care within the scope of their practice, where no support from the system or physician orders is required. This is particularly evident in the physical aspect of care, where nurses can directly and immediately contribute to improving patient conditions.

Recommendations

Given the complex nature of the phenomenon under discussion, it is recommended that qualitative studies be conducted to elucidate the factors contributing to moral distress and determine to what extent a nurse can deliver optimal performance despite experiencing moral distress. Additionally, studies that consider the three variables of moral distress, moral sensitivity, and quality of clinical care in various public and private centers with diverse demographic characteristics of nurses are suggested. This approach can provide a better understanding of how these variables interact and influence clinical care quality.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Revised Moral Distress Scale

Quality Patient Care Scale

Standard deviation

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Acknowledgements

Authors would like to extend our sincere gratitude and appreciation to the esteemed Deputy of Research and Technology at Gonabad University of Medical Sciences, as well as all the participants who took part in this study. Their valuable contributions and cooperation were essential to the successful completion of this research.

The authors received no financial support for the research, authorship, and/or publication of this article.

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Department of Medical Surgical Nursing, School of Nursing, Nursing Research Center, Gonabad University of Medical Sciences, Gonabad, Iran

Fateme Safari, Ali MohammadPour, Mahdi BasiriMoghadam & Alireza NamaeiQasemnia

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All the authors were involved in designing the study. S. F: data acquisition, data analysis, drafted the paper, M.A: design of the work, revising the paper, B.M: data analysis and interpretation, revising the paper, N.A: design of the work, data acquisition. All authors reviewed the manuscript.

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Ethics approval and consent to participate The research proposal was approved by the Ethics Committee of Gonabad University of Medical Sciences (code: IR.GMU.REC.1402.015), and informed consent was obtained from participants. All procedures were carried out in accordance with the 1964 Helsinki declaration.

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Safari, F., MohammadPour, A., BasiriMoghadam, M. et al. The relationship between moral distress and clinical care quality among nurses: an analytical cross-sectional study. BMC Nurs 23 , 732 (2024). https://doi.org/10.1186/s12912-024-02368-z

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Received : 17 August 2024

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Published : 09 October 2024

DOI : https://doi.org/10.1186/s12912-024-02368-z

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Mapping desistance research: a systematic quantitative literature review from 2011 to 2020

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