Iran Journal of Nursing

Introduction
Due to spending more time with patients compared to other healthcare providers, nurses are constantly confronted with complex ethical issues, which may expose them to moral distress. This condition, initially described by Jameton, occurs when individuals, despite having adequate knowledge, are unable to act ethically due to organizational constraints, leading to internal conflict and helplessness. Various studies, including those conducted in Iran and Brazil, have reported moderate levels of moral distress among nurses. This phenomenon has several negative consequences, including burnout, job dissatisfaction, a desire to leave the job and even a decline in the quality of patient care. As a result, moral distress affects not only nurses’ personal lives but also their professional performance, particularly in organizational culture and service quality. 
Quality of work life (QWL), which refers to the ability of nurses to meet both personal and professional needs in the workplace, is recognized as a key factor in enhancing job satisfaction and mitigating ethical problems. Poor QWL can threaten patient safety and reduce care quality. Studies have indicated that burnout and low QWL are associated with higher turnover intentions and lower professional behavior. Focusing on QWL not only improves organizational productivity but also contributes to the recruitment and retention of nurses. In other words, improving nurses’ QWL is considered a crucial factor in ensuring the stability of the healthcare system. 
Given the concerns in hospitals regarding non-compliance with certain ethical standards and lack of awareness of ethical principles, moral distress is currently one of the growing issues in the nursing profession, significantly impacting nurses’ work and potentially undermining their performance. Therefore, this study aimed to determine the relationship between moral distress and QWL among Iranian nurses.

Methods
This descriptive-correlational study was conducted from April to July 2023 in teaching hospitals located in Kerman province (Kerman, Bam, Jiroft cities), Iran, affiliated to Kerman University of Medical Sciences. We selected 290 nurses with at least a bachelor’s degree and six months of full-time work experience using a stratified random sampling method, after obtaining informed consent from them. Data collection tools included: a) Demographic form, surveying age, gender, department, work experience, job position, and education level; b) The moral distress scale (MDS) designed by Corley et al. [22] in 1995 and revised in 2001, which has 21 items and two dimensions: Intensity and frequency. Intensity is rated on a Likert scale from 0 (none) to 4 (very high), and frequency is rated from 0 (never) to 4 (daily). Borhani et al. [24] confirmed the reliability of the Persian version of revised MDS (MDS-R) with a Cronbach’s α coefficient of 0.93, as well as its validity with a content validity index (CVI) of 0.88; (c) the Quality of Nursing Work Life scale (QNWL) developed by Brooks, which has four dimensions and 42 items, rated on a six-point Likert scale. The dimensions are: personal home/work life (items 1 to 7), work design (items 8 to 17), work contex (items 18 to 37), and work world (items 38 to 42). Each item is scored from 1 (completely disagree) to 6 (completely agree), and the total score ranges 42-252. The content validity of the Persian version of this questionnaire was confirmed by 10 experts and faculty members of Kerman University of Medical Sciences (CVI=0.81). It was tested on 20 nurses in our study, and its reliability coefficient was calculated using Cronbach’s α, yielding a value of 0.83. The collected data were analyzed using SPSS software, version 20 and the significance level for the tests was set at 0.05.

Results
Among 290 nurses, 258(89%) were female and 32(11%) were male. Their mean age was 27.34±1.02 years, with 96 (33.1%) aged 31-40 years. Most of participants (n=227, 78.3%) were married and had more than 10 years of work experience (n=121, 41.7 %). A majority (n=236, 81.4%) held nursing positions, with 87 (30%) working in specialized units and 61(21%) in surgical departments. Furthermore, 263(90.7%) had a bachelor’s degree, 164(56.6%) had formal employment and 209(72.1%) had rotational work shifts. The mean score of MDS-R was 140.61±43.795 and the mean total score of the QNWL was 155.9±25.077. The moral distress was classified as high in 67(23.1%) nurses, moderate in 217(73.8%) nurses and low in 6(2.1%) nurses. Regarding QWL, 249(85.9%)nurses reported moderate levels, 21(7.2%) high level and 20(6.9%) low levels. 
The results of correlation test revealed the significant positive relationship of moral distress with age (R=0.728, P<0.05) and work experience (R=0.607, P<0.05). The QWL was significantly associated with work experience (R=0.105, P<0.05), marital status (R=0.031, P<0.05), and job position (R=0.119, P<0.05). Additionally, a moderate negative relationship was found between moral distress and QWL (R=-0.562, P<0.05). There was also a weak negative correlation between the intensity (R -0.042, P<0.05) and frequency (R=-0.063, P<0.05) of moral distress and QWL.

Conclusion 
This study demonstrates a significant negative correlation between moral distress and QWL among nurses working in reaching hospitals in Kerman, Iran. As moral distress of nurses increases, their QWL decreases, highlighting the need for targeted interventions to reduce nurses’ moral distress. Hospital managers should prioritize creating environments where nurses can address ethical challenges effectively without compromising their well-being. Providing support, improving staffing, offering ethics education, and redefining hospital policies can help reduce moral distress of nurses. By improving the work environment, hospital managers can enhance nurses’ job satisfaction and reduce moral distress, which in turn, can lead to better patient outcomes and more sustainable healthcare systems. Moral distress and QWL are important factors in nursing care. It is essential to pay attention to them for ensuring nurses’ well-being and high-quality healthcare delivery. Further studies should explore these dynamics using more in-depth methodologies such as interviews, to provide a richer understanding of how to mitigate moral distress in nursing practice.

Ethical Considerations

Compliance with ethical guidelines
This study was conducted according to the ethical principles. Ethical approval was obtained from the Ethics Committee of Kerman University of Medical Sciences (Code: IR.MUBAM.REC.1397.034).

Funding
This study was funded by Bam University of Medical Sciences.

Authors' contributions
Initial draft preparation: Leila Malkian and Nadia Noormohammad; Statistical analysis: Gholamreza Fouladvandi; writing: Masoumeh Fouladvandi and Soheila Maleki

Conflict of interest
The authors declare no conflicts of interest.

Acknowledgments
The authors would like to thank the Deputy for Research of Bam University of Medical Sciences for funding this study, and all nurses participated in this study for their cooperation.



 

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