ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES

SCHOOL NURSING AND MIDWIFERY

DEPARTMENT OF NURSING

MORAL DISTRESS AND ASSOCIATED FACTORS AMONG

NURSES WORKING IN WEST ARSI ZONE PUBLIC

HOSPITALS, ETHIOPIA, 2023

PRINCIPAL INVESTIGATOR: LEMMA DESALEGN (BSc)

A THESIS SUBMITTED TO NURSING DEPARTMENT,

SCHOOL OF NURSING AND MIDWIFERY, COLLAGE OF

HEALTH SCIENCE, ADDIS ABABA UNIVERSITY IN

PARTIAL FULFILLMENT OF REQUIREMENT FOR THE

DEGREE OF MASTERS IN ADULT HEALTH NURSING

MAY 2023

ADDIS ABABA, ETHIOPIA

 ADDIS ABABA UNIVERSITY
COLLEGE OF HEALTH SCIENCES
SCHOOL NURSING AND MIDWIFERY
DEPARTMENT OF NURSING
MORAL DISTRESS AND ASSOCIATED FACTORS AMONG NURSES
WORKING IN WEST ARSI ZONE PUBLIC HOSPITALS, ETHIOPIA,
2023
PRINCIPAL INVESTIGATOR: LEMMA DESALEGN (BSc)

ADVISORS:
1. Mr. DEBELA GELA (MSc, Assistant Professor)
2. Mr. ABDISA BOKA (BSc, Msc, Mph/Rh, Assistant Professor)

A THESIS SUBMITTED TO NURSING DEPARTMENT, SCHOOL OF

NURSING AND MIDWIFERY, COLLAGE OF HEALTH SCIENCE,
ADDIS ABABA UNIVERSITY IN PARTIAL FULFILLMENT OF
REQUIREMENT FOR THE DEGREE OF MASTERS IN ADULT
HEALTH NURSING.

MAY 2023

ADDIS ABABA, ETHIOPIA

 APPROVAL SHEET
ADDS ABABA UNIVERSITY

COLLEGE HEALTH SCIENCE SCHOOL OF ALLIED SCIENCES DEPARTMENT OF

NURSING AND MIDWIFERY

 I, the undersigned MSc student, declare that I have submitted my original work on a title moral
distress and associated factors among nurses in West Arsi zone public hospitals, south-east
Ethiopia, 2023 for the examination.

Submitted by:

Lemma Desalegn (BSc) ___________ ____________

Name of student Signature Date

This thesis work has been submitted for examination with my approval as an advisor.

Approved by:

3. Mr. Debela Gela

(MSc, Assistant Professor) ____________ _____________
Name of Major Advisor Signature Date

4. Mr. Abdisa Boka

(MSc, MPH/RH, and Assistant Professor) ________ _________

Name of Co-Advisor Signature Date

 APPROVAL BY THE BOARD OF EXAMINATION
This thesis by ___________ is accepted in its present form by the board of examiners as satisfying
thesis requirement for the degree of masters in Adult health nursing.

INTERNAL EXAMINER:

_______________________ ________ ____________ _____________

NAME RANK SIGNITURE DATE

External EXAMINER:

_______________________ ________ ____________ _____________

NAME RANK SIGNITURE DATE

RESEARCH ADVISORS:

Mr. Debela Gela

(MSc, Assistant Professor) ________ ____________ _____________

NAME RANK SIGNITURE DATE

Mr. Abdisa Boka

(MSc, MPH/RH, and Assistant Professor) ________ _________ _____________

NAME RANK SIGNITURE DATE

DEPARTMENT HEAD

Dr. Girum Sebsibe

(PhD, Associate Professor) ________ __________ ______

NAME RANK SIGNITURE DATE
 STATEMENT OF DECLARATION
By my signature below, I declare and affirm that this thesis is my own work. I have followed all
ethical principles of scholarship in the preparation, data collection, data analysis and completion
of this thesis. All scholarly matter that is included in the thesis has been given recognition through
citation. I affirm that I have cited and referenced all sources used in this document. Every effort
has been made to avoid plagiarism in the preparation of this thesis.

This thesis is submitted in partial fulfilment of the requirement for a master’s degree from the
Addis Ababa University at College of Health Sciences, School of Allied Health Sciences
department of Nursing and Midwifery. The thesis is deposited in the Addis Ababa University
Digital Library and is made available to local, national and international scientific community. I
solemnly declare that this thesis has not been submitted to any other institution anywhere for the
award of any academic degree, diploma or certificate.

Brief quotations from this thesis may be used without special permission provided that accurate
and complete acknowledgement of the source is made. Requests for permission for extended
quotations from, or reproduction of, this thesis in whole or in part may be granted by the Head of
the Department or all advisers of the theses when in his or her judgement the proposed use of the
material is in the interest of scholarship and publication. In all other instances, however, permission
must be obtained from the author of the thesis.

STUDENT

Name: Lemma Desalegn (BSc) Signature: _________ Date: ____________

RESEARCH ADVISORS:

Mr. Debela Gela

(MSc, Assistant Professor) ________ ____________ _____________

NAME RANK SIGNITURE DATE

Mr. Abdisa Boka

(MSc, MPH/RH, and Assistant Professor) ________ ___________ _____________

NAME RANK SIGNITURE DATE
 ACKNOWLEDGEMENTS
My heartfelt gratitude goes to AAU University's College of Health Sciences, School of Allied
Health Sciences, and Department of Nursing and Midwifery for allowing me to do this research.
My heartfelt thanks and appreciation go to my advisor, Mr. Debela Gela (MSc, Assistant
Professor), for his unwavering guidance, constructive comments, and invaluable assistance from
the beginning to the end of my thesis. I would like to thank Mr. Abdisa Boka (MSc, MPH/RH, and
Assistant Professor) for his unshakable encouragement and for providing pertinent comments and
guidance (as co-advisor) for the composition of this thesis. Finally, my appreciation would also go
to all those who helped me with all-round support.

I
 ABBREVIATIONS /ACRONYMS
AAU………...…………. Addis Ababa University

ANA……………………. American Nursing Association

CAN……………………. Canadian Nursing Association

CI………………………. Confidence-Interval

Epi Info….........................Epidemiological Information

IRC………………….…. Institutional Ethical Review Committee

KM………………..….... Kilometre

MD………………………Moral Distress

MDS-R…….......………. Moral Distress Revised Scale

OR…………………..…. Odds Ratio

SD………………………Standard Deviation

SPSS……...……………. Statistical Package for Social Science

UK………………………United Kingdom

USA……………………. United States of America

II
 Table of contents
ACKNOWLEDGEMENTS ............................................................................................................. I
ABBREVIATIONS /ACRONYMS................................................................................................ II
LIST OF TABLES ......................................................................................................................... V
LIST OF FIGURES ...................................................................................................................... VI
ABSTRACT ................................................................................................................................. VII
1. INTRODUCTION ...................................................................................................................... 1
1.1. Background .......................................................................................................................... 1
1.2. Statement of the problem ..................................................................................................... 3
1.3. Significance of the study ...................................................................................................... 5
2. LITERATURE REVIEW ........................................................................................................... 6
2.1. Proportion of moral distress ................................................................................................. 6
2.2. Factors Associated with Moral Distress ............................................................................... 7
2.2.1. Socio-demographic factors ............................................................................................ 7
2.2.2. Environmental factors.................................................................................................... 8
2.2.3. Personal factors.............................................................................................................. 9
2.3. Conceptual framework ................................................................................................... 10
3. OBJECTIVES ........................................................................................................................... 11
3.1. General objective................................................................................................................ 11
3.2. Specific objective ............................................................................................................... 11
4. METHODOLOGY ................................................................................................................... 12
4.1. Study area and period ......................................................................................................... 12
4.2. Study design ....................................................................................................................... 12
4.3. Population........................................................................................................................... 12
4.3.1. Source population ........................................................................................................ 12
4.3.2. Study population .......................................................................................................... 12
4.4. Eligibility............................................................................................................................ 12
4.4.1. Inclusion criteria .......................................................................................................... 12
4.4.2. Exclusion criteria ......................................................................................................... 13
4.5. Sample size determination and sampling procedure .......................................................... 13
4.5.1. Sample size .................................................................................................................. 13

III
 4.5.2. Sampling Procedure ..................................................................................................... 14
4.6. Operational definitions ....................................................................................................... 16
4.7. Study variables ................................................................................................................... 17
4.7.1. Dependent variable ...................................................................................................... 17
4.7.2. Independent Variables ................................................................................................. 17
4.8. Data Collection Methods and Instruments ......................................................................... 17
4.8.1. Instruments and measurement ..................................................................................... 17
4.8.2. Data collector ............................................................................................................... 18
4.9. Data management and analysis procedures ........................................................................ 18
4.10. Data quality assurance ...................................................................................................... 18
4.11. Ethical considerations ...................................................................................................... 18
4.12. Dissemination of results ................................................................................................... 19
5. RESULT ................................................................................................................................... 20
5.1. Sociodemographic characteristics of study respondents .................................................... 20
5.2. Level of Moral Distress ...................................................................................................... 23
5.3. Personal and environmental Factors .................................................................................. 24
5.5. Factors associated with moral distress among nurses ........................................................ 25
6: DISCUSSION ........................................................................................................................... 27
6.1 Strengths and Limitations of the study................................................................................ 28
6.1.1 Strength of the study ..................................................................................................... 28
6.1.1 Limitations of the study ................................................................................................ 28
7. CONCLUSION AND RECOMMENDATION ........................................................................ 29
7.1. Conclusion.......................................................................................................................... 29
7.2. Recommendation ................................................................................................................ 29
8. REFERENCE ............................................................................................................................ 30
9. ANNEXES ................................................................................................................................ 35

IV
 LIST OF TABLES

Table 1: Sociodemographic characteristics of nurses working in West Arsi Zone public

hospitals, south-east Ethiopia, March 2023 (n = 349). .......................................... 20

Table 2: Personal and environmental factors of nurses working in West Arsi Zone public
hospitals, south-east Ethiopia, March 2023 (n = 349). .......................................... 24

Table 4: Factors associated with moral distress among Nurses working in West Arsi zone
public hospitals, south east Ethiopia, March, 2023 (n = 349)................................ 25

V
 LIST OF FIGURES

Figure 1: A conceptual framework on the potential determinants of a nurse's moral

distress was developed by adapting and modifying various literatures
(5,16,19,20,36,37,41,42). ....................................................................................... 10

Figure 2: Schematic Presentation of the Sampling Procedure ..................................... 15

Figure 3: Proportion of moral distress among nurses working in West Arsi Zone public
hospitals, south-east Ethiopia, March 2023 (n = 349). .......................................... 23

VI
 ABSTRACT

Background: Healthcare personnel, particularly nurses, are at a significant risk of developing and
experiencing moral distress globally. African nurses' moral suffering has not been the subject of
many research. Existing publications mostly focused on qualitative studies. Furthermore, data on
the prevalence and associated variables of moral distress among Ethiopian nurses and across all
working units in public hospitals is scarce.

Objective: The aim of this study was to assess the level and associated factors of moral distress
among nurses working in the West Arsi zone, south-east Ethiopia, in 2023.

Methods: An institutional-based cross-sectional study was carried out from February 13 to March
2, 2023. A total of 349 study participants were selected by a simple random sampling method.
Data was collected using a structured self-administered questionnaire, entered into EpiData 3.1,
and exported to SPSS V.26 statistical software for further analysis. Descriptive statistics and
logistic regression analysis were performed. Then, finally, statistical significance was determined
using a p value < 0.05 and 95% CI.

Results: A total of 349 participants were enrolled in this study, with a response rate of 98.5%. The
mean (SD) age of the participants was 39.2 ± 7.0. Among all of the participants, 194 (55.6%) were
female. The majority of the nurses, 293 (84.0%), hold a bachelor's degree in the nursing profession.
The mean year of experience was 7.7 ± 6.9. The proportion of high moral distress among nurses
was 73.1%. Being female nurse [AOR: 0.457, 95% CI (0.283, 0.740)], job dissatisfaction
[AOR=7.67, 95% CI: 3.075, 19.121], and unfavourable working environment [AOR=4.069, 95%
CI: 1.915, 8.648] were significantly associated with high level of moral distress.
Conclusion and recommendation: According to this study, the proportion of nurses experiencing
moral distress was high. Female nurses, job dissatisfaction, and unfavourable working
environment were shows significant association with high level of moral distress. More qualitative
research is needed to identify the fundamental cause of the problem and its relationship to female
nurses, job dissatisfaction, and unfavourable working environment.

Keywords: moral distress, ethical conflict, MDS-R, nurse, Ethiopia

VII
 1. INTRODUCTION

1.1. Background
Moral distress can be characterised as the psychological disequilibrium, unpleasant feeling state,
and pain experienced by nurses who make a moral decision and then either do not or believe they
are unable to carry out the selected action due to institutional restraints (1). Jameton defined moral
distress (MD) as "when one knows the right thing to do, but internal and institutional constraints
make it practically impossible to pursue the proper path of action" (2). Following that, MD
obtained growing attention in nursing research, which was primarily conducted in North America
but is now spreading to South America, Europe, the Middle East, and Asia (1).

According to the American Association of Critical Care Nurses, MD happens when a person is
aware of the ethically proper action to take but is unable to perform it. You operate in ways that
are inconsistent with your personal and professional ideals, undermining your integrity and
authenticity (3). Several studies have highlighted the negative effects of MD, finding links between
higher levels of MD and negative judgements of the ethical atmosphere (1,4).

When compared to other health workers, nurses are at a higher risk of developing moral distress.
This is due to nurses having long periods of direct contact with patients and dealing with several
ethical issues (5). MD is a common phenomenon in nursing that can cause issues while connecting
with patients and giving appropriate care. Moral distress can have a negative impact on society's
health patterns by interfering with efforts to attain healthcare system goals (6). MD is a common
occurrence in the nursing profession and is one of the leading reasons for job dissatisfaction,
burnout, and nurse resignations (7).

When nurses know what is morally proper to do but are unable to do so owing to a variety of
constraints, they experience distinct but not restricted symptoms such as guilt, anger, and
frustration. MD can also serve as a stimulus for introspection, growth, and advocacy (8).
According to studies conducted in the United States of America (USA), Australia, and Saudi
Arabia, the proportion of nurses experiencing moral distress is 93%, 72%, and 75.7%, respectively
(9–11). Similarly, research conducted in Ethiopia found that two-thirds of hospital nurses had MDs
(5). So far, research has concentrated on assessing moral distress in specialised working units such

1
as ICUs and emergency rooms (12–15). The limitation of the previous study was not identifying
the magnitude of moral distress across the working units, which will be useful to determine which
nurses in which working units are more likely to experience moral distress (16). Furthermore, little
is known regarding the level of moral distress among Ethiopian nurses, and no similar study has
yet been undertaken in the Arsi Zone.

The working environment and perceived organisational support are environmental determinants
of MD experience among nurses (5,17). Personal or internal predictors of moral distress include
self-doubt, lack of assertiveness, socialisation to obey commands, perceived powerlessness, job
unhappiness, perceived inadequate communication, and a lack of comprehension (1,16,18).

MD is associated with a lack of nursing staff, gender, insufficient nursing experience, a lack of
organisational and professional support, insufficient nursing education and knowledge, poor
physician-nurse collaboration, a lack of ethical awareness and teamwork, a heavy workload, poor
quality of care, and moral violence (15,19,20).

2
1.2. Statement of the problem
Globally, healthcare professionals are known to experience moral distress. Unresolved moral
distress may result in burnout, quitting the field, or a withdrawal from the moral aspects of patient
care (21). According to a study conducted in America, the magnitude of MD among nurses
working for the American Association of Critical-Care Nurses is 93% (9).

A systematic literature review and meta-analysis done in Germany shows nurses experienced a
significantly higher level of moral distress than physicians, psychologists, and pastoral counsellors
(22). According to a South African study, nurses experienced moderate levels of MD (23). A study
shows the frequency and severity of moral distress are high and are serious problems in the nursing
profession (24).

Moral distress affects nurses, patients, medical professionals, and the healthcare system negatively.
Moral distress can be lessened in the healthcare industry, but it won't ever be totally removed (25).
As a major issue affecting nurses in all health care facilities, the nursing profession is experiencing
MD. The conflict between knowing what to do and not doing it in the right way results in moral
distress for nurses (26). These limitations may be brought on by individual, professional, or
organizational circumstances. To put it another way, moral distress is expected when a nurse is
compelled to act against their convictions because of restrictions like a lack of resources or power
(7).

One of the main causes of professional burnout, job withdrawal, fatigue, and avoiding patient care
among nurses is MD, which is widespread in nursing practise (15). The consequences of MD are
serious and can lead nurses to burnout and dissatisfaction with the work environment, so that the
quality of care provided for the patient faces some problems (20). When nurses view ethical issues
as being at odds with their professional values, they experience MD, which is characterized by
negative stress symptoms (27).

Moral distress has a deleterious effect on nurses' physical and psychological health that can
negatively impact nurses, patients, and health care facilities (19). Nurses experience the common
signs of MD, including physical symptoms like headaches, inappetence, palpitations, gastro-
intestinal problems, and powerlessness, as well as psychological symptoms like anger, frustration,
guilt, impotence, and loss of self-esteem (5,8).

3
Studies conducted in Ethiopia show the proportions of moral distress among nurses are 83.7% and
70.16%, respectively. Sex, working hours, professional commitment, autonomy, and working
environment; work experience; perceived poor communication; perceived powerlessness in
decision-making; inadequate staffing; and the appropriate provision of care were significantly
associated with moral distress (5,16). African nurses' moral suffering has not been the subject of
much research. Existing publications are mostly focused on qualitative studies.

According to studies conducted in Ethiopia, the proportion of moral distress among nurses is
83.7% and 70.16%, respectively. Work experience, perceived poor communication, powerlessness
in decision-making, inadequate staffing, and improper provision of care were all substantially
associated with moral distress (5,16). There have not been many studies on the moral distress of
African nurses. Existing articles are primarily focused on qualitative research.

To the best of my knowledge, the working unit has not yet been included as a variable in the
published studies on the prevalence of moral distress and associated factors in Ethiopia.
Additionally, previous studies were conducted on the referral hospitals and in different zones of
this study. Even though moral distress is a popular research topic internationally, there has not
been much research on or discussion about it in Ethiopia. As a result, the topic remains mostly
unexplored and understudied. Therefore, the primary aim of this research is to assess the level of
moral distress and associated factors among nurses in West Arsi zone public hospitals, south-east
Ethiopia, in 2023.

4
1.3. Significance of the study
Identifying the psychological challenge nurses face as a profession can be done by determining
the level of moral distress. Finding characteristics linked to moral distress has important
significance for identifying viable intervention techniques to treat this negative psychological
experience that nurses confront on a regular basis at work. Furthermore, the result of this study
will be distributed to many governmental and non-governmental organisations, and nurses' mental
health will receive special attention. Aside from that, there have been insufficient studies on moral
discomfort in Ethiopia. As a result, both academics and policymakers can benefit from this work.
It can also provide knowledge to the scientific community by including the working unit as a
variable, which was a restriction of prior studies. This study is significant for me as a researcher
since it is my first-hand experience, and I am also the one who is vulnerable as a profession. In
general, this study will be useful to nurses, the community, policymakers, researchers, and
governmental and non-governmental organisations striving to alleviate moral distress among
nurses.

5
 2. LITERATURE REVIEW
Moral distress arises in situations where nurses know or believe the right thing to do but, for
various reasons (including fear or circumstances beyond their control), cannot take the right action
or prevent a particular harm. When values and commitments are compromised in this way, nurses’
identity and integrity as moral agents are affected (28). A high level of moral distress in nurses is
a major factor that affects their performance and will cause them to burn out. (24)

2.1. Proportion of moral distress

A cross-sectional study conducted in Australia shows that the level of moral distress among health
care providers was 72% (10). According to a study conducted by Corley, 80% of nurses
experienced moral distress (26). A survey conducted among members of the American Association
of Critical-Care Nurses shows 93% of study participants experienced moral distress (9). Studies
conducted in Saudi Arabia, Brazil, and Iran revealed that the magnitude of severe moral distress
is 33.8%, 41.5%, and 24.3%, respectively (11,27,29).

According to a cross-sectional study conducted in the south-western part of Ethiopia in 2019,

70.16% of nurses had experienced a high level of moral distress (5). An institutional-based cross-
sectional study done in the northern part of Ethiopia among eligible nurses shows that the
proportion of moral distress was 83.7% (16).

6
2.2. Factors Associated with Moral Distress
2.2.1. Socio-demographic factors
A study conducted on the prevalence of severe moral distress among nurses in Saudi Arabia
identified a significant association between severe moral distress and age, specifically that younger
nurses are more likely to experience moral distress than older nurses (11). A descriptive cross-
sectional study conducted in 2019 among Iranian nursing professional’s shows that the level of
moral distress was significantly higher among those under 30 years of age, female nurses, nurses
with less than 10 years’ work experience, and nurses with a higher level of education. According
to this study, the severity of moral distress decreased as nurses' age and years of experience
increased (15).

A descriptive cross-sectional study done in north-west Ethiopia revealed that the proportion of
moral distress among single nurses was 87.8% when compared with married nurses (16). An
institutional-wide survey revealed that providers working in adult or intensive care unit (ICU)
settings had higher levels of moral distress than did clinicians in paediatric or non-ICU settings. A
descriptive quantitative study conducted in the USA shows that females reported statistically
significantly higher moral distress scores than did males (19). An institutional-based cross-
sectional study done in 2019 among nurses revealed the total score of moral distress was
significantly higher among male nurses than female nurses (7). A similar study conducted in
Ethiopia shows male nurses are 2.4 times more likely to develop moral distress than female nurses
(5).

Studies show nurses with a higher level of education experience a higher level of moral distress
than nurses with a low level of education (7,15). Nurses who had a high moral distress level were
three times more likely to consider leaving their position compared with respondents who had a
medium or low moral distress level (8.7% and 2.9%, respectively) (27).

Studies conducted in Iran and Canada show that nurses with work experience less than 10 years’
experience moral distress more than nurses with work experience greater than 10 years (15,30).
Similarly, researchers discovered that nurses with 11–20 years of experience were twice as likely
as nurses with 0–10 years of experience to experience moral distress (16). A study done by

7
Watson-Subia on moral distress and job satisfaction found that those staff nurses who have a low
salary have a high level of moral distress (18).

2.2.2. Environmental factors

[Link]. Working Environment
Moral distress declines and job satisfaction rises when nurses feel supported in a secure, moral
atmosphere where their clinical judgement and reasoning are recognised (31). Studies identified a
negative work environment as a significant predictor of moral distress (5,32). Similarly, a
descriptive-analytical-correlational study conducted among Iranian nurses shows that creating a
positive work environment for nurses decreases their moral distress and their tendency to leave
their job or even their profession (6). Compared to their counterparts, nurses who felt their work
environment was morally distressing were nine times more likely to consider leaving their job
(33). A study conducted in Ethiopia also revealed that nurses who worked in unfavourable
conditions had higher levels of moral distress than those who did (5).

[Link]. Perceived organisational support

According to a survey conducted in the United States, there is a significant relationship between
moral distress and perceived organisational support (34). A correlational descriptive study
conducted in 2018 among nurses found a strong association between a low level of perceived
organisational support and high moral distress (17).

8
2.2.3. Personal factors
[Link]. Level of job satisfaction
A study found a negative correlation between moral distress and job satisfaction, meaning that the
respondents' job satisfaction decreased as their moral distress increased (35). Lack of job
satisfaction for nurses in the health care facility was highly correlated with a high level of moral
distress (18). Similarly, according to a study conducted in Iran, nurses who experience a high level
of moral distress have low levels of job satisfaction (36). Lower job satisfaction, inadequate staff
communications, and an instrumental leadership style were all strongly associated with moral
distress among nurses, according to a study on the topic conducted in the Netherlands (37). A study
found that there is a high correlation between moral distress and job dissatisfaction. According to
this research, 42.8% of research participants expressed a willingness to quit their jobs (9).

[Link]. Autonomy
According to a study conducted among European intensive care nurses, a lower level of autonomy
was associated with an increase in the frequency and intensity of moral distress (38). A descriptive
correlation study done in Iran revealed that a lack of autonomy makes it difficult for nurses to
practise effectively and efficiently, and it even has the potential to cause moral distress (14).
However, one study found a substantial correlation between professional autonomy and moral
distress. This link was attributed to nurses' increased emphasis on making their own judgements
and using their own knowledge, which led to more conflicts and more moral distress (39).

[Link]. Professional commitment

According to a study conducted in the Netherlands, moral distress among caregivers can result
from failing to fulfil a professional commitment to provide care when necessary (40). Similarly, a
study conducted in south-west Ethiopia reported that nurses who were not committed to their
profession experienced more moral distress than the committed ones (5).

9
 2.3. Conceptual framework

Socio-demographic Factors: Environmental Factors:

 Age of nurses  Working environment

→→→
 Gender of the nurse  Perceived

 Marital status of nurses organisational support

 Working unit
 Income in Birr
 Educational level of
nurses
 Experience in year
 Position in the hospital
Moral distress

Personal Factors:

 Level of job satisfaction

 Autonomy
 Professional Commitment

Figure 1: A conceptual framework on the potential determinants of a nurse's moral

distress was developed by adapting and modifying various literatures
(5,16,19,20,36,37,41,42).

10
 3. OBJECTIVES

3.1. General objective

 To assess the moral distress and associated factors among nurses in West Arsi zone public
hospitals, south-east Ethiopia, 2023.

3.2. Specific objective

 To determine the proportion of moral distress among nurses in West Arsi zone public hospitals,
south-east Ethiopia, 2023.
 To identify factors associated with moral distress among nurses in West Arsi zone public
hospitals, south-east Ethiopia, 2023.

11
 4. METHODOLOGY

4.1. Study area and period

The study was conducted among nurses working at West Arsi zone public hospitals in the Oromia
Regional State, which is located in Ethiopia's centre area, from February 13 to March 2, 2023. The
study was conducted in four hospitals (Shashemene referral hospital, Dodola general hospital,
Melka Oda general hospital, and Loke primary hospital). Shashemene, the administrative centre
of the zone, is located 165 km from Addis Abeba and is one of the 20 zones that comprise the
Oromia regional state. The West Arsi zone is home to 2,929,894 people. Shashemene Referral
Hospital, Melka Oda General Hospital, Dodola General Hospital, Kokosa Primary Hospital, Loke
Primary Hospital, and three private/NGO hospitals (Negele Arsi General Hospital, Feya Primary
Hospital, and Gambo Primary Hospital) are located in the zone. There are also 81 functional health
centres, 351 functional health posts, 179 private clinics, 1 non-governmental organisation clinic,
and 95 pharmacies and drug stores.

4.2. Study design

An institutional-based cross-sectional study was employed.

4.3. Population
4.3.1. Source population
All nurses working in West Arsi Zone public hospitals were the source of population.

4.3.2. Study population

The study population consisted of all nurses working in selected public hospitals in the West Arsi
Zone.

4.4. Eligibility
4.4.1. Inclusion criteria

All nurses in selected public hospitals on active duty during the study period were included in this
study.

12
4.4.2. Exclusion criteria
Nurses who provide free services were excluded from this study.

4.5. Sample size determination and sampling procedure

4.5.1. Sample size

The sample size for this study was determined using a single population proportion formula by
assuming the following assumptions: By considering the proportion of moral distress among
nurses (70.16%, obtained from a study conducted in Jimma referral hospital) (5).

𝑧2 𝑝(1 − 𝑝)
𝑛=
𝑑2

Where n= the required sample size.

Z= the standard score corresponding to the 95% CI and was equal to 1.96.

P= the proportion of moral distress, which was assumed to be 70.16%.

d= level of precision (margin of error), which was taken at 5%.

𝑧2 𝑝(1−𝑝) (1.96)2 0.7016(1−0.7016)

𝑛= 𝑛= = 322.
𝑑2 0.052

By adding 10% non-response rate, 322+32 = 354.

13
4.5.2. Sampling Procedure
There are eight public hospitals in the West Arsi zone, with four of them chosen by a simple
random sampling procedure. The total number of nurses in these four hospitals was 447
(Shashemene referral hospital = 180, Melka Oda General Hospital = 90, Dodola General Hospital
= 97, and Loke Primary Hospital = 60). 354 nurses were chosen from among the 427
participants based on size. The study included 149 patients from Shashemene Referral Hospital,
75 from Melka Oda General Hospital, 80 from Dodola General Hospital, and 50 from Loke
Primary Hospital. To identify study participants, a simple random sampling procedure was used.
The sample size was allocated proportionally using the following formula: =

𝒏.𝑵𝑯
:𝒏𝑯 = =
𝑵

Where; nH = required sample size from each hospital

n= the total sample size (354).

NH= number of nurses in a specific hospital.

N= total number of nurses in three hospitals.

𝑛.𝑁𝐻 354.180
𝑛 𝑆ℎ𝑎𝑚𝑒𝑛𝑒𝑛𝑒 𝑅𝐻 = = = 149
𝑁 427

𝑛.𝑁𝐻 354.90
𝑛 𝑀𝑒𝑙𝑘𝑎 𝑂𝑑𝑎 𝐺𝐻 = = = 75
𝑁 427

𝑛.𝑁𝐻 354.97
𝑛 𝐷𝑜𝑑𝑜𝑙𝑎 𝐺𝐻 = = = 80
𝑁 427

𝑛.𝑁𝐻 354.60
𝑛 𝐿𝑜𝑘𝑒 𝑃𝐻 = = = 50
𝑁 427

14
 West Arsi Zone public hospitals

SRS (Lottery method)

Shashemene Melka Oda Loke primary

Dodola General
referral hospital General Hospital N= 60
Hospital N= 97
N= 180 Hospital N=
90

Proportional allocation

n= 80 n= 50
n= 149 n= 75

Simple random sampling

n=354

Figure 2: Schematic Presentation of the Sampling Procedure

15
4.6. Operational definitions
Moral distress is a type of mental distress brought on by moral restraints or conflicts. The
participant's level of moral distress was measured by nine items. Based on the mean score, below
the mean was considered low moral distress, and greater than or equal to the mean was considered
high moral distress (5).

Working environment: a setting where nurses worked clinically with various experts Based on
the mean score of participants' responses, it was considered a not conducive working environment
for below the mean score and a conducive working environment for greater than or equal to the
mean score (43).

Perception of organisational support: This is the nurses' perception of the organisational

assistance they received while working in the hospital. Based on the mean score of the participants'
responses, it was considered poor perception for a score less than the mean and good perception
for a score greater than or equal to the mean (17).

Job satisfaction is treated as a collection of feelings associated with a job situation, or simply how
the nurses feel about their job. Based on the mean score of the participants' responses, it was
considered not satisfied for scores less than the mean and satisfied for scores greater than or equal
to the mean (44).

Professional autonomy is the nurse’s freedom or right to make decisions in the clinical
environment. Based on the mean score of the participants' responses, it was considered not
autonomous for less than the mean score and autonomous for greater than or equal to the mean
score (45).

Professional commitment refers to nurses' internal attitude towards their professions. Based on
the participants' responses, it was considered not committed for less than the mean and committed
for greater than or equal to the mean score (41,46).

16
 4.7. Study variables
4.7.1. Dependent variable
 Moral distress

4.7.2. Independent Variables

Socio-demographic factors: age, sex, marital status, working unit, income, educational level,
experience in the past year, and position in the hospital

Personal factors: level of job satisfaction; autonomy; professional commitment.

Environmental factors: working environment, and perceived organizational support

4.8. Data Collection Methods and Instruments

4.8.1. Instruments and measurement

A structured questionnaire was used to collect data from nurses. The questionnaire was prepared
based on previous literature. It was constructed by adopting and modifying previous research done
on the same topics. The questionnaire was written in English. The questionnaire consisted of four
parts and a total of 57 items. The first part contains information about the socio-demographic
factors of the nurses; the second part consists of Hamric's Moral Distress Scale-Revised (MDS-R)
(43,47), the third part is about environmental factors; and the last one is about personal factors.
The socio-demographic characteristics contained nine items. The Moral Distress Scale Revised
instrument, which contains nine items, was used. Environmental factors include the working
environment, which consists of 16 items, and the perception of organisational support, which
consists of 5 items. Totally, the above environmental factors and variables contain 21 items. All
the variables was measured on a 4-point Likert scale ranging from 1: strongly disagree to 4:
strongly agree. Personal factors are: level of job satisfaction, which consists of 7 items;
professional autonomy, which consists of 4 items; and professional commitment, which consists
of 6 items. All the above personal factor variables are 17 items. The moral distress scale, working
environment scale, perception of organisational support scale, level of job satisfaction scale,
professional autonomy scale, and professional commitment scale were adopted from a study done
by Beyaffers et al. (5).

17
4.8.2. Data collector

Data was collected using a structured, self-administered questionnaire by six BSc nurses and
supervised by one MSc student. Each selected nurse received a clear explanation of the purpose of
the study. The supervisors supervised the data collectors daily. Finally, the principal investigator
collected and compiled the collected data.

4.9. Data management and analysis procedures

The data was entered into a computer using EpiData 3.1 software and exported to SPSS V.26
statistical software for cleaning and further analysis of the data. Descriptive statistics were used to
describe the study populations using measures of frequency, central tendency, and dispersion that
were displayed using tables. Logistic regression was used to determine the association of the
different independent variables with the outcome variable. The necessary assumption of logistic
regression was checked. Then, finally, statistical significance was determined using a p value <
0.05 and a 95% CI.

4.10. Data quality assurance

To assure quality of the data the following measures was undertaken; during the actual data
collection process, supervisor cross checked the data frequently for completeness. The data
collection tool was pre-tested in Gambo primary hospital prior to the actual data collection on 5%
of the calculated sample size of 18 nurses, those who are not the actual study participants. A pre-
test questionnaire containing basic sociodemographic variables, the Hamric's Moral Distress
Scale—Revised (MDS-R), environmental factors, and personal factors. The data was cleaned for
inconsistencies and missing values and amendment was considered as needed before data analysis.

4.11. Ethical considerations

Ethical approval and clearance were obtained from the Institutional Ethical Review Committee
(IRC) of Addis Ababa University college of Health Science and School of Nursing. Permission
was also obtained from Oromia health bureau and West Arsi Zone health office. Written informed
consent was obtained from nurses after a clear explanation was given about the aim of the study.
Confidentiality and privacy were maintained during data collection, analysis, and reporting, in

18
which the information obtained from the respondents was not shared with anyone other than the
data collectors and principal investigator.

4.12. Dissemination of results

The result of this study will be disseminated to the Ministry of Health, the Oromia regional health
bureau, the West Arsi zonal health office, and the AAU School of Nursing and Midwifery. The
findings will also be disseminated to different concerned organizations that will make
contributions to improve the psychological health condition of the nurses through the presentation
and publication of the paper

19
 5. RESULT

5.1. Sociodemographic characteristics of study respondents

A total of 349 participants were enrolled in this study with a response rate of 98.5%. The mean
and SD age of the respondents was 31.92 ± 7.0 years with the majority of them 276(76.5%) were
18-35 years of age. Among all of the participants, 194(55.6%) of them were females. The majority
of the respondents were Oromo 303(86.8%) and almost half of the participants were Muslims
175(50.1%). Out of 349 participants, 293(84.0%) hold a bachelor of degree in nursing profession.
The mean and SD year of experience was 7.7±6.9. Among 349 participants, 275(78.8%) of them
have 0-10 years of professional experience. The majority of the respondents 249(71.3%) were
senior in their position. (Table 1)

Table 1: Sociodemographic characteristics of nurses working in West Arsi Zone public

hospitals, south-east Ethiopia, March 2023 (n = 349).

Variables Category Frequency Percent (%)

Age 18 -35 267 76.5

36 – 45 59 16.9

45 -60 23 6.6

Sex Male 155 44.4

Female 194 55.6

Ethnicity Oromo 303 86.8

Amhara 32 9.2

Tigre 8 2.3

Others* 6 1.7

20
Religion Orthodox 104 29.4

Muslim 175 50.1

Protestant 66 18.9

Others** 4 1.1

Marital status Single 119 34.1

Married 215 61.6

Divorced 11 3.2

Widowhood 4 1.1

Working unit Medical ward 52 14.9

Surgical ward 56 16.0

Emergency 50 14.3

ICU 23 6.6

Paediatrics ward 47 13.5

Gynaecology 39 11.2

NICU 34 9.7

OPD 48 13.8

Educational status Diploma 43 12.3

Degree 293 84.0

Msc 13 3.7

Monthly income 4605-7162.2 ETB 219 62.8

7162.3-11305 ETB 130 37.2

21
Experiences(years) 0-10 275 78.8

11-20 52 14.9

21-30 22 6.3

Position Junior 71 20.3

Senior 249 71.3

Nurse manager 29 8.3

*(Sidama and Wolaita), ** (Adventist and wakefata)

22
5.2. Level of Moral Distress
Out of 349 participants, 255 (73.1%) and 94 (26.9%) reported high and low levels of moral distress,
respectively. The respondents' mean and standard deviation for moral distress was 22.8 + 10.8.

Level of moral distress

26.9

73.1

high moral distress

low moral distress

Figure 3: Proportion of moral distress among nurses working in West Arsi Zone public
hospitals, south-east Ethiopia, March 2023 (n = 349).

23
5.3. Personal and environmental Factors
Out of 349 participants 208 (59.6%) not satisfied in their job. Similarly, from 349 participants of
this research around 185(53.0%) of them are not autonomous in practicing their profession. One
hundred seventy (48.7%) of the 349 participants worked in an unfavourable environment.
According to their assessment of organisational support, 206 (59.0%) nurses had a negative
perception towards their organisation. (Table 2)

Table 2: Personal and environmental factors of nurses working in West Arsi Zone public
hospitals, south-east Ethiopia, March 2023 (n = 349).

Variables Category Frequency Percent (%)

Job Not satisfied 141 40.4

Satisfaction Satisfied 208 59.6

Autonomy Not autonomous 185 53.0

Autonomous 164 47.0

Professional commitment Committed 162 46.4

Not committed 187 53.6

Working environment Not conducive 170 48.7

Conducive 179 51.3

Perception of organizational Poor perception 143 41.0

support Good perception 206 59.0

24
5.5. Factors associated with moral distress among nurses
In, bivariate analysis socio demographic characteristics (sex, working unit, monthly salary and
years of experience), personal factors (job satisfaction, autonomy, and professional commitment),
and Organizational factor (working environment) were had p-value < 0.25 and candidate for the
multivariable logistic regression analysis. In, multivariable logistic regression analysis sex, job
satisfaction and working environment were associated with moral distress among nurses.
According to this study the nurses who were male were 54% [AOR (95% CI)], [0.46 (0.274 -
0.914)] and (P = .023) less likely to develop high level of moral distress compared to female. The
nurses who were not satisfied 8 times [AOR (95% CI)], [7.668(3.075, 19.121)] and (P = .000)
more likely to develop high level of moral distress compared with satisfied ones. The nurses who
were worked in not conducive environment were 4 times [AOR (95% CI)], [4.069(1.915, 8.648)]
and (P = .023) more likely to have high level of moral distress. (Table 4)

Table 3: Factors associated with moral distress among Nurses working in West Arsi zone
public hospitals, south east Ethiopia, March, 2023 (n = 349).

Variables Category Moral COR AOR

distress

High Low

Sex Male 100 55 0.46 (0.28, 0.74)* 0.5 (0.27, 0.91)*

Female 155 39 1 1

Working unit Medical ward 35 17 0.48 (0.19, 1.20) * 0.54 (0.18, 1.64)

Surgical ward 37 19 0.45 (0.18, 1.12) * 0.36 (0.12, 1.06)

Emergency 41 9 1.05 (0.38, 2.92) 0.99 (0.30, 3.30)

ICU 18 5 0.83 (0.24, 2.84) 0.55 (0.12, 2.50)

Paediatrics ward 32 15 0.49 (0.19, 1.27) * 0.46 (0.15, 1.44)

25
 Gynaecology 24 15 0.37 (0.14, 0.97) * 0.41 (0.13, 1.29)

NICU 29 5 1.34 (0.41, 4.42) 0.76 (0.19, 3.03)

OPD 39 9 1 1

Monthly salary 4605-7162.2 168 51 1.63 (1.01, 2.64) 1.59 (0.75, 4.00)

7162.2-11305 87 43 1 1

Years of experience 0-10 200 75 1.52 (0.61, 3.78) 0.74 (0.21, 2.59)

11-20 41 11 2.13 (0.71, 6.36) * 1.72 (0.45, 6.58)

21-30 14 8 1 1

Job satisfaction Not satisfied 134 7 13.76 (6.13, 30.89)* 7.67 (3.08, 19.12)*

Satisfied 121 87 1 1

Autonomy Not autonomous 145 40 1.78 (1.10, 2.87)* 1.16 (0.62, 2.15)

Autonomous 110 54 1 1

Professional Not committed 129 33 1.89 (1.16, 3.09)* 0.76 (0.39, 1.47)

commitment Committed 126 61 1 1

Working Not conducive 157 13 9.98 (5.28, 18.89)* 4.07 (1.92, 8.65)*

environment Conducive 98 81 1 1

Perception of Poor perception 130 13 6.48 (3.43, 12.23)* 1.78 (0.77, 4.01)

organizational Good perception 125 81 1 1

support

*Adjusted odd ration at (95%) of CI with p value < 0.05 were statistical significance.
AOR: Adjusted odd ratio, COR: Crude odd ratio

26
 6: DISCUSSION
In this study we have found the level of moral distress and associated factors among nurses
working in Arsi zone public hospitals. This cross sectional study involved 349 nurses from eight
working units. The analysis of this study suggested that almost three fourth (73.1%) of the study
participants experienced high level of moral distress.

The magnitude of higher moral distress in this study is in line with study conducted in Australia
(72%) and Jimma (70.16%) (5,10). This might be due to similarity in study design, number of
sample size, method of data collection and tool used to assess the level of moral distress. The result
of current study was higher than studies conducted in Saudi Arabia (33.8%), Brazil (41.5%), and
Iran (24.3%)(11,27,29). The difference could be attributed to study setting, socio-economic
difference, working environment, work load, and technological advancement.

But, it is relatively low compared to studies done in America (80%) and northern part of Ethiopia
(83.7%) (16,26). The discrepancy could be due to difference in socio demographic, culture, basic
environmental, personal characteristics of the respondents and tools used to measure the level of
moral distress.

The study also demonstrated from sociodemographic factors sex of the nurses showed significant
association. Comparing female nurses to male nurses while controlling for all other factors, female
nurses reported higher levels of moral distress, which is supported by research’s from Iran (15)
and the USA (19). This could be due to women are more morally sensitive than men and experience
guilt when they know the correct thing to do but are unable to carry it out because of differing
environmental and personal restrictions (19). However, this finding contradict with the studies
done in Ethiopia (5,16). This could be as a result of the socio-cultural influences on the women in
the research area.

Controlling the other variables, job satisfaction were the only factor showed significant association
with high level of moral distress. Nurses who were not satisfied in their job were nearly eight times
more likely to have high moral distress compared to nurses who were satisfied [AOR=7.67, 95%
CI: 3.075, 19.121]. This is in line with studies done in USA (9), Philippines (18), south west Iran
(35), south eastern united states (36), and Netherland (37) respectively. This might be due to not

27
being satisfied in their job will lead to sadness and discouragement which finally end up in conflict
of an individual’s views or inner moral standards and his /her environment.

After controlling for all other variables, the working environment remained the significant variable
of environmental factors. The study found that nurses working in an unfavourable working
environment were four times more likely to have high moral distress than their counterparts or
nurses working in a favourable working environment [AO=4.069, 95% CI:1.915, 8.648]. This
study's findings are similar to those of research conducted in Iran (6), Canada (32), Virginia (33),
the south-eastern United States (36), and Jimma (5). This might be due to a lack of managerial
ability, unhealthy relationship with other professionals, or a reduction in the quality of nursing
care. Furthermore, unfavourable working conditions induce moral distress and burnout. This also
in turn affects patient centred care, health team communication, patient’s family, community, and
health institution.

6.1 Strengths and Limitations of the study

6.1.1 Strength of the study
 Using moral distress revised scale (MDS-R)
 It was tried to cover the different demographic and social-economic, personal and
environmental factors that were supposed to determine moral distress
6.1.1 Limitations of the study
 Recall bias may occurred
 Being a cross sectional study design
 Respondents difference in perception and knowledge on the definition of moral distress,
some personal and environmental factors
 The research was limited to the public hospitals. Thus, the finding did not generalize for
health centres

28
 7. CONCLUSION AND RECOMMENDATION

7.1. Conclusion
From this study we concluded that three fourth of nurse have experienced high level of moral
distress. The major predictors of moral distress among nurses were sex, job satisfaction, working
environment.

7.2. Recommendation
Based on the study's findings, the following recommendations are given to reduce the proportion
of moral distress among nurses.
 According to this study, public hospital administrators and managers should prioritise the
prevention and reduction of moral distress among nurses.
 Arsi zone public hospitals should prioritise female nurses, improve working conditions,
and increase job satisfaction; and plan training and workshops to provide educational
programmes and emotional support in order to identify and reduce the variables that
contribute to the development of moral distress.
 We also urge that the Ethiopian Nursing Association undertake initiatives to decrease
nurses' moral suffering.
 In reaction to the challenge, the AAU School of Nursing and Midwifery should strengthen
its ethical education approaches.
 By using this finding as a base line data and limitation of this study as gap we also
recommend researchers to conduct mixed type of research and identify the root cause of
this problem.

29
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47. Original A. Psycometric Characteristics of the Moral Distress Scale Características

Psicométricas Da Moral Distress Scale Em. 2014;

34
 9. ANNEXES
ANNEX I:
INFORMATION SHEET
Hello dear?
Dear respondent Hello, my name is ____________.I am here to collect data for a study entitled,
"Magnitude of Moral Distress and Associated Factors among Nurses in West Arsi Zone Public
Hospitals, South East Ethiopia, 2023." The study is being conducted by Lemma Desalegn, an MSc
Adult Health Nursing student at Addis Ababa University College of Health Sciences, School of
Nursing and Midwifery. For this study, you are selected as a participant, and before getting your
consent or permission for your participation, you need to know all necessary information related
to the study. Thus, this information will be detailed, as the objective of this study is to assess the
moral distress and associated factors among nurses in West Arsi Zone public hospitals, south-east
Ethiopia, in 2023. You are being asked to take part in this study and to respond honestly. You are
selected to be involved by chance. Your cooperation and willingness are greatly helpful in
identifying problems in the mentioned area. This questionnaire may take 15 to 20 minutes to
complete. There is no possible risk to participating in this study. Your name will not be written on
this form, and all the information you give us will be kept confidential. Your participation is
voluntary, and if you feel uncomfortable with any of the questions, it is your right to drop or stop
filling out the questionnaire. If you have questions regarding this study or if you wish to know the
result after its completion, it would be our pleasure to give you our phone number.

Are you willing to participate in this study? If yes, please proceed to the consent form.
Thank you

Please contact the principal investigator.

Mr. Lemma Desalegn
Tel. no – +251925348798 Email:lemmadesalegn2015@[Link]

35
ANNEX II: CONSENT FORM
Hello. How are you? My name is Lemma Desalegn. I am a final year Post Graduate Adult Health
Nursing Student at Addis Ababa University. The assessment of Magnitude of Moral Distress and
Associated Factors among Nurses in Arsi Zone Public Hospitals, South East Ethiopia, 2023, made
for the partial fulfilment of my Master’s degree in Adult Health Nursing. The aim of this study is
to assess Magnitude of Moral Distress and Associated Factors among Nurses in West Arsi Zone
Public Hospitals. The results of the study will be used as baseline information to design appropriate
interventional strategies to provide comprehensive psychotherapy care for nurses. The information
you provide is confidential and is used only for the purpose of this study. Your cooperation and
participation until the completion of the questionnaire is very necessary for the successful
completion of the assessment. You will neither get harmed nor will you get benefit as a result of
participating in this study. I therefore ask your genuine willingness. However, you have the right
to decline if you do not volunteer to participate at any time. If you have any question and confusion
regarding the questions, you have the right to ask me at any point or you can contact me on the
following address.

Email:lemmadesalegn2015@[Link]
Phone number. +251925348798
Are you willing to participate? Yes, No Data collector: Name_________________

Signature________________Date_________________

36
ANNEX III: QUESTIONNAIRE

Part 1: Socio-demographic characteristics

[Link] Sociodemographic characteristics

101 Age in year ___________In years

102 Sex [Link]

[Link]

103 What is your ethnicity 1. Oromo

2. Amhara

3. Tigray

4. Others (specify)

104 What is your religion? 1. Orthodox

2. Muslim

3. Protestant

4. Others (specify)

105 What is your marital status? 1. Single

2. Married

3. Divorced

4. Widowhood

106 What is your working unit?

107 What is your educational status? 1. Diploma

37
 2. Degree

3. Msc and above

108 What is your monthly income? ___________In birr

109 How many years of experience do you have? ___________In years

110 What is your position? 1. Junior nurse

2. Senior nurse

3. Nurse manager

Part 2. Moral distress:

The following questions are statements that represent possible feelings that individuals might have
about moral feelings. With respect to your own feelings about these statements, please indicate
the degree of your agreement or disagreement by ticking () on one of the four alternatives beside
each statement.
1= strongly disagree 2= disagree 3= agree 4= strongly agree

SD=1 D=2 A=3 SA=4

Sr. No Number of items

201 Provide less than optimal care due to pressures

from administrators or insurers to reduce costs.
202 Follow the family’s wishes to continue life
support even though I believe it is not in the best
interest of the patient.

38
 203 Carry out the physician’s orders for what I
consider unnecessary tests and treatments.
204 Continue to participate in care for a hopelessly ill
person who is being sustained on a ventilator,
when no one will make a decision to withdraw
support
205 Assist a physician providing incompetent care.
206 Be required to care for patients I don’t feel
qualified to care
207 Work with nurses or other healthcare providers
who are not as competent as the patient care
requires
208 Witnessed diminished patient care quality due to
poor team communication.
209 Work with levels of nurse or other care provider
staffing that I consider unsafe

Part 3: Environmental factors

I. Working environment: The following questions are statements that represent possible feelings
that individuals might have about the condition of working environment with respect to your
own feelings about these questions please indicate the degree of your agreement or disagreement
with each statement by ticking () on one of the four alternatives beside each statement from 1 to
4 according to each subheading. SD = strongly disagree D = disagree A = agree SA =
strongly agree

Sr. No Number of items SD=1 D= 2 A=3 SA=4

Nurse manager, ability leadership and

support

39
301 A nurse manager or immediate supervisor
who is a good manager and leader
302 A nurse manager who backs up the nursing
staff in decision making, even if conflict is
with a doctor
303 A supervisory staff that is supportive of the
nurses
304 Administration to listens and responds to
employee concerns
Nurse participation in the workplace
305 Opportunities for advancement
306 Active staff development or continuing
education program for nurses
307 Nurse are involved in the internal governance
of the hospital
Staffing and resource adequacy
308 Enough staff to get work done
309 Adequate support services allow me to spend
time with my patients.

310 Enough time and opportunity to discuss

patient/client/resident care problems with
other nurses.
311 Working with nurses who are clinically
competent.
Nursing foundations for quality care
312 Written, up to date nursing care plans for all
patients/clients/residents.
313 Patients/clients/residents care assignments
that foster continuity of care

40
 314 Nursing care is based on a nursing model,
rather than a medical model
Collegial Nurse physician Relations
315 Doctors and nurses have good working
relationships
316 Collaboration between nurses and doctors

II. Perception of organizational support: The following questions are statements that represent
possible feelings that individuals might have about perceived organizational support with
respect to your own feelings about these questions please indicate the degree of your agreement or
disagreement with each statement by ticking () on one of the four alternatives beside each
statement from 1 to 4.
SD = strongly disagree D = disagree A = agree SA = strongly agree
Sr. No Number of items SD=1 D=2 A=3 SA=4

318 The organization that I have worked for have

strongly considered my goals and values as an
employee

319 The organization that I have worked for have

really cared about my well-being

320 The organization that I have worked for have

taken pride of my accomplishment at work

321 The organization that I have worked for have tried

to make my job as interesting as possible
322 The organization that I have worked for have
made me feel that if I have a problem, help is
always available

41
Part 4: personal factors

I. Job satisfaction: The following questions are statements that represent possible feelings that
individuals might have about satisfied or not satisfied on their professional job respect to your
own feelings about these questions please indicate the degree of your satisfaction or dissatisfaction
with each statement by ticking () on one of the four alternatives beside each statement from 1 to
4. 1= “very dissatisfied, 2=“dissatisfied, 3=“satisfied, 4 =“very satisfied
Sr. No Number of items 1 2 3 4

401 The way my boss handles his/her workers.

402 The competence of my supervisor in making decisions
403 The chance to do something that makes use of my abilities
404 My payment and the amount of work I do.
405 The chances for advancement on this job
406 The praise I get for doing a good job
407 The feeling of accomplishment I get from the job

II. Autonomy: The following questions are statements that represent possible feelings that
individuals might have about autonomy or right to make decision in the hospital with respect
to your own feelings about these questions please indicate the degree of your agreement or
disagreement with each statement by ticking () on one of the four alternatives beside each
statement from 1 to 4.
SD = strongly disagree D = disagree A = agree SA = strongly agree

[Link] Number of items SD=1 D=2 A= 3 SA=4

408 The program I follow is highly compatible with my

choices and interests
409 I feel very strongly that I have the opportunity to make
choices with respect to the way I practice.
410 I feel extremely comfortable when with the other
practice participants

42
 411 I feel there are open channels of communication with
the other practice Participants.
III. Professional commitment: The following questions are statements that represent possible
feelings that individuals might have about commitment to their profession with respect to your
own feelings about these questions please indicate the degree of your agreement or disagreement
with each statement by ticking () on one of the five alternatives beside each statement from 1 to
4. SD = strongly disagree D = disagree A = agree SA = strongly agree
[Link] Number of items SD=1 D=2 A =3 SA=4

412 My career is a central interest in my life.

413 Working in my current profession is important to me.
414 Pursuing my career is important to my self-image.
415 I would recommend my profession as a career.
416 I think my profession is a rewarding career.
417 I would not want to work outside my profession.

43