Volume 19, Issue 1 (1-2022)                   J Res Dev Nurs Midw 2022, 19(1): 46-49 | Back to browse issues page

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Pejmankhah S, Pezhmankhah S. Consequences of Moral Distress in faculty member in the field of nursing: a qualitative Study. J Res Dev Nurs Midw 2022; 19 (1) :46-49
URL: http://nmj.goums.ac.ir/article-1-1271-en.html
1- Assistant Professor of Nursing Department, School Of nursing and midwifery, Iranshahr University Of Medical Sciences, Iranshahr, Iran , khodaa90@gmail.com
2- MSc Public Health, University East of London & MSc Nursing Islamic Azad Tehran Medical Branch, Tehran, Iran
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Highlights:
What is current knowledge?
Research on the consequences of moral distress in the clinical domain is available. There is evidence that this is also happening in academia, but studies that deal with the consequences of moral distress in teaching are very rare.
What is new here?
This research reveals the experiences of nursing faculty members regarding the consequences of moral distress, including ineffective training and organizational silence.
1. Introduction
Moral distress occurs Clinical and academic settings. Some evidences shows that moral distress poses as a serious challengeable phenomenon in educational environments. At the same time, observing ethical principles in universities not only helps professors by observing teaching standards, but can also play a role in the formation of mutual and effective interactions between students and other colleagues. Teachers are one of the most important internal pillars of educational organizations (1). Therefore, the quality and quantity of their work have a significant relationship in improving or reducing the level of higher education system (2, 3).
One of the main parts of the natural interactions of the teaching profession is ethics. Disruption of this value component in teaching may cause a range of different moral distress. As a result, the moral distress of nurses working in teaching is an ethical and professional conflict. Because, it is clear that they can play as a role model and their manner can affect on a learning pattern of students. (4-6). Despite this, teachers in their activities face a variable range of issues and problems that make them advance the process of thinking and discovery. Moreover, if they could not be able to eliminate their barriers with the spreading and reinforcing of their knowledge and experience, they would face the amount of stress which leads to having type of dissatisfaction in their profession (7, 8). As a result, this relevant dissatisfaction could be caused moral distress as one of these main parts in their teaching (8). The moral distress can be demonstrated a circumstance when the teachers do not have the proper potency to decide moral issues which make the extended restrictions and contrasts among the right moral decision and the right practice. This essential phenomenon of moral issues was noticed by Jameton in first time in 1993(9).
Consequences of moral distress leading to discouragement from professional life, decreased job satisfaction, job burnout, disgust with work, decrease in job retention, Job status change, leave the profession and finally, at least interaction with the patient and the family and the shortage of nursing staff intensifies. Studies have shown that the consequences of moral distress in nurses, endangers patient care and may be evident in behaviors such as withdrawing from patient care. Nurses have also experienced frustration, anger, and frustration and cannot meet the needs of patients and some of them experience a sense of inability to perform their duties and obligations to patients. Following of under these conditions would lead unpleasant effects that make the treatment environment unsafe. Nurses may provide poor quality care or even in extreme cases, avoid approaching the patient and providing care. Unfortunately, the result of this practice is the inadequacy of care provided and ultimately indifference or leaving the profession (10-12).
Following this case, it is a necessary step in “recognizing the consequences of moral distress” by faculty, although difficult but important. By negligence of the teachers’ moral distress, their occupational dissatisfaction to increase and alternatively empathy, ethics or professionalism could reduce and it could be also influenced the quality of work period, stress management, satisfied job and quality of personal life (10, 13, 14).
Profession Moreover, there is variable cultural context in every certain community that can be made different results of moral distress. Therefore, researchers can interpret teachers’ experiences because they deal with in human activities and the qualitative study provides to clarify, explain and elaborate about various aspects of the teachers’ moral distress experience. (1, 2, 15)
 According to literature (2, 5 ,15) to assess moral distress in faculty member in the field of nursing, the factors such as communicate with staff and students, educational dishonesty, compulsory hierarchy and inability in education have been considered as causes of moral distress in these studies and it has been stated that moral distress has consequences such as dissatisfaction and change job, reducing organizational commitment, and also there has been a decrease in job attachment and a decrease in job satisfaction among faculty member in the field of nursing. Some researches in Iran on the moral distress of faculty member in the field of nursing did not present the clear ways to resolve. Also have mainly dealt with the mediating factors due to the common limit theorem of specially the type of phenomenon which associated with human’s perception and behavior so as result, it requires the total objective research with qualitative study (16). Moreover, there is variable cultural context in every certain community which can be made different results of moral distress. Our aim of this study was to explore consequences of moral distress amongst faculty member in the field of nursing.
2. Methods
This qualitative content analysis study has been applied in schools of nursing and midwifery in Tehran, Iran in 2017. 13 eligible faculty members in the field of nursing recruited through purposeful sampling method. Inclusion criteria was having at least two years of teaching experience and the academic rank from instructor to professor.
In advance, the purpose of study was explained to the participants and they signed the written informed consent including permission to tape-record the interview. They were ensured that their information would remain confidential and that they could leave the study whenever they wished. Moreover, there was principle of confidentiality to having access to the results which upon a request of the participants.
A semi-structured and in-depth interview method was used for collecting the data. In the interview faculty member in the field of nursing were asked to describe consequences of moral distress, they had experienced through their teaching profession when they were faced to choose a challenging and critical situation in which they had had difficulty in deciding the right way to act, sampling was continued until data saturation.
The interviews were begun with a broad question. Follow-up questions were then asked to explore their experience of applying teaching and to provide an opportunity for clarifying the misunderstanding of the interviewer. At the end, the interviewees’ were asked if there were more issues which needed to be explained. Then the interview lasted about 45-90 minutes. All interviews were recorded by the Sony Digital Sound Recorder (ICD-UX560F)   and were transcribed verbatim for subsequent analysis.
Data collection and data analysis were conducted simultaneously. The data was analyzed using Graneheim and Lundman (2004) content analysis approach initially, the interviews were transcribed verbatim. We listened to the interviews and read their transcripts several times to arrive at a general perception of their content. After immering in the data, unit of analysis consisted of words, sentences, and paragraphs was extracted. Meaning units were groups of words or sentences which gave an identical meaning or were relevant to the same concept in some ways. Accordingly, meaning units were condensed and coded. The codes were compared with each other and classified into more abstract categories according to their resemblances. Finally, the categories were compared with each other and sorted into higher-level main categories (17). Data analyze was conducted alongside data collection simultaneously.
As a result conformability, it has been tried to carefully transcript all recorded interviews to allow review by other researchers. Also, during a review of the monitoring, it was ensured that the results of this research were matched with the experience for evaluating trustworthiness. In addition, the text of the interviews, codes and categories were reevaluated with two faculty member of school of Nursing and Midwifery who were known with the certain method of qualitative research and also had experience studies on the moral distress. Also to ensure the transferability of the data, an attempt was made to fully explain the field under study and to quote the participants with precision in their own words and selection of contestants with the extreme variety lead to a promotion in the data validity.
3. Results
Thirteen faculty member in the field of nursing participated in this study. The majority of them were female (70%). The mean age of participants was 46.61±9.52 years with an average work experience 18.30 year (Table 1).
Four main categories and and 8 subcategories were emerged based on the experience of nursing faculty member about the consequences of moral distress, which included ineffective training, organizational silence, decreased sense of professional development and job burnout (Table 2).


3.1. Ineffective training
Ineffective education is considered as an ineffective and passive activity that requires the teacher to experience moral distress, which leads to a decrease in the quality of teaching and ineffective communication in the educational environment. Also, lack of work commitment and motivation of the staff causes the lack of responsibility and accountability of other faculty members. Moreover, there are ineffective measures in teaching and learning such as not having enough dominant of the subject, not evaluating students' academic progress and also lack of comprehension and transfer of curriculum lead to the consequence of moral distress.

3.1.1. Decreased teaching quality
The faculty member in the field of nursing expressed that the effect of moral distress leads to disrupting the teacher's focus on reminders and preservation. Consequently, it disrupts the necessary measures to prepare for the continuation of their teaching process.
It often happens that teachers hear things from students' judgments about a teacher who does not teach well and it is obvious that what the students say is not confidential and it spreads, and students usually get tired of low-quality instructors soon and unfortunately, the educational environment will not be satisfactory for them.
"These issues can affect the quality of teaching one hundred percent. We are not focused at all, and when we are looking for educational materials, we think about that issue or issues." (Participant No.1).

3.1.2. Ineffective communication in the educational environment
The participants say that because they cannot solve their moral distress in the real world, they avoid their colleagues. They sometimes consider every request and please from others as an imposition by others and strongly resist or oppose it for no reason. That is why they are constantly in conflict with those around them. They do not defend their rights and prefer resignation to effort. The exchange of effective communication between colleagues is reduced and leads to a lack of trust among teachers.
As teachers talk in the workplace, on various issues, even issues that are ignored and silenced by illegal or immoral actions or developments that violate personal, moral, or legal standards and the educational environment is disrupted.
"In order to experience less moral distress, let me make the same withdrawal, I will not have any verbal confrontation (Participant No.5).

3.2. Organizational silence
Moral distress leads to the employees of the organization refusing to participate in desirable activities in the workplace for various reasons. In other word, organization's staff do not tend to be an active participation in diverse subjects for the reason of organizational silence which making two subcategories. The first silent protests, and second the Organization personnel suffer from team performance impairment which given in the below.

 3.2.1. Silent protest
It was determined from the statements of the participants, the greater the perceived moral distress in the workplace, the less effort there is to improve activities. Use time and facilities at work for personal work, Time to cut work processes and work again, Decreased creativity and innovation, Disgust and excuses for work increase and it can also lead to failure to commit to the organization.
"I think most teachers who are at work, but their mental and physical abilities because of the problems or problems of their work environment or the difficult work pressures that the organization puts on them Leads them to symbolize their work." (Participant No.10).

3.2.2. Team Performance Injury
Data analysis indicated that, Conditions that create moral distress can replace constructive criticism with slander and absenteeism and some faculty members do not accept useful suggestions and criticisms to achieve organizational goals and are reluctant to listen to and apply the opinions of others and give their opinion to others. But mostly in the organization due to the reduction of collective agreement that the situation of moral distress has required, Trust in each other is diminished and most suggestions or criticisms are taken as slander and this leads to teachers having irrational tensions and prefer individual work to group work.
"Sometimes I see some co-workers hitting each other or, for example, behaving in front of the group manager in such a way that he has their supporters, so I get upset with those co-workers and reduce my contact with them And this is a problem because we are not used to working in a team, and the system is such that everyone just wants to do their own thing "(Participant No. 5).

3.3. Decreased sense of professional development
Decreased sense of professional development leads to a decrease in working relationships and also continuous quality improvement in professional activities or missions, which exacerbates stress and job depression. So in regard, it challenges professional growth and the instructor experiences the threat of professional identity and stagnant growth which presented more details in the below subcategories.

3.3.1. Threat to professional identity
The participants express unpleasant experiences in connection with moral distress that prevent them from enjoying work and relationships. As the teacher feels that in the most important aspects of his personality, he is an undesirable, bad. When the teacher feels worthless the most common emotion that accompanies them is professional embarrassment and frustration. These things are not visible to others and are internal and private in nature.
The personality and identity of the teaching profession is deeply involved. People who feel this way feel helpless. This awareness of incontinence causes them to downplay their role in organizational decisions.
"Sometimes I feel like I don't have much choice in my work environment, a series of predefined units or programs and tell me to do them, but unfortunately I am usually not consulted about them" (Participant No.10).

3.3.2. Stagnation of professional growth
Participants shared their experiences of moral distress, pointing to the fact that it leads to a loss of motivation to progress, which in turn can lead to falling and not trying to advance in the profession. The teacher may lose all motivation for teaching. Lack of a sense of accomplishment, a tendency toward negativity, and a negative attitude toward the workplace can lead to lack of progress.
"I was faced with so many different moral challenges in my work that I think sometimes that I just spent my days but I did not understand how it went. What I routes are crossed. I believe that in our profession we should be motivated, but the reality is that in some places only I filled my unit and performed my duties without any motivate "(Participant No.11).
3.4. Job burnout
The participants pointed that their experiences was that increasing environmental demands and reducing the teacher's ability to respond to them exacerbates stress and burnout. Long-term times, nursing teachers are exposed to stress in relation to their organization and work environments, which were associated with emotional, physical and mental breakdown.

3.4.1. Psychological reactions
Data analysis showed that participants expressed anxiety, feelings of anxiety and regret, remorse, irritability, feelings of impotence, decreased tolerance for events, decreased patience, and the likelihood of hostile behavior toward others due to moral distress.
"For me, who teaches over 25 credits, I could not be promoted due to my many roles. It has made me feel helpless, frustrated, anxious and depressed ... especially in the last seven or eight years, this issue has increased because when I look around, I feel that I be weaken. "(Participant No.2).

3.4.2. Physical reactions
The participants' statements showed that they had insomnia, headache, anorexia, digestive problems, heart palpitations, musculoskeletal pain, and a feeling of tiredness from the consequences of moral distress.
"Sometimes I get so much headache during the day because of the dialog and things I did not do in relation to my co-workers that I burst into confusion that I can no longer continue my work." (Participant No.6).
Discussion
The evidence from this study showed the main task of faculty members in the face of moral distress is to maintain moral integrity. As stated by Davis et al (2012), participants act on what is right based on their moral beliefs. Alternatively, according to other studies a reduction of the quality of education and ineffective communication in the academic environment can be caused by moral distress (7,18, 19).
The ethics in organizational atmosphere in educational centers should be provided for teachers as a valuable resource to prevent negative consequences on their behavior. In following, not only experts consider the field of ethics in the formulation of the principles of educational ethics but also they confirm its neglect of the moral atmosphere in educational organizations and its consequences.
Barnett and McCormick (2011) indicated that the students could been abused in the classroom, which results from a lack of effective management of classroom and consequently of teachers' ineffective teaching and learning for the students. Also, the lack of interactions of teachers with each other in the work environment and the hierarchy in the organization and the rules governing it can cause distress in teachers, which results in ineffective teaching (19).
In addition, it became apparent that there was consequences of anxiety and worry for the teachers who feels they has not taught properly. There is ample evidence that if the teacher experiences a lot of distress in his field of work that may lead to depression, poor performance, or changes in personality and attitudes can even lead to illness and early retirement (19).
One of the abstract categories in this study was non effective communication in the educational environment of faculty member in the field of nursing. Kürşad (2008) Lack of trust in the organization causes avoidance of response, feelings of suspension and jealousy, gossip, trying to distance oneself from work and dishonesty in organizational goals (20) that equaled to our findings of this study which indicated whenever teachers disagreed with each other, resulting in interpersonal problems and ineffective communication in the educational environment.
In this study, silent protest was one of the main classes. Cummings (2012) and Borhani (2015) in their study also positively relationship reported the relationship between moral distress and the desire to leave the profession (21, 22, 23).
McCarthy (2008) stated that inability to make decisions, having to execute orders which associated with moral distress, made the subcategory which named the decreased sense of professional development. Also, Job burnout is one of the consequences of moral distress.
Regarding the limited number researches carried out about moral distress among nursing teachers in Iran where predominantly conservative state in which family beliefs and religion are highly valued, the findings may not generalized beyond the sample. Repeated studies, using greater and more diverse population are required that explore the consequences of moral distress on the making decision amongst nursing teachers. More specifically results related to nursing teachers' low awareness in term of consequences of moral distress. Further limitation of this study is that relevant consequences of moral distress are not a similar or unitary concept influences and further investigation should be evaluated to occur conditions that make up level of consequences in moral distress. Moreover, lack of sufficient time for cooperation of some nursing teachers due to multiple tasks.
Conclusion
These findings showed that throughout their educational task, nursing faculty member confront moral conflicts that its consequence impact on their working potential and also may cause mental and physical effects.  In this way teachers' moral distress can be evoked as unpleasant negative emotions such as anger, frustration, anxiety and depression that lead to a decrease in effective teacher performance and also interactions of the students. Meanwhile, according to the findings of this study, teachers are faced with problems in a process of thinking and exploring, and if they cannot solve the problem by expanding their knowledge and experience, they will suffer from moral distress. The distress of faculty member in the field of nursing compared to other professions needs its own interpretation. As the result, the moral distress of nursing teachers should be still required to have more discussion sufficiently as a global issues among international researchers and authors.
Also, this research can provide useful information in the managers and officials of nursing and midwifery schools. Regarding to attention in this area will achieve the desired educational and executive outcomes in quality of learning which leds to ultimately organizational improvement.
Acknowledgements
This article was extracted from Ph.D dissertation in the field of nursing which was approved by the ethic commeetee of Shahid Beheshti school of Nursing and Midwifery (Code: IR.SBMU.PHNM.1394.120). Hereby the author feels obliged to great appreciate who all helped in conducting this present research.
Funding source
This research did not receive any grant from funding agencies.
Ethical statement
  The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences.
Conflict of interest
  The authors declare that there is no conflict of interest.
Author contributions
  SH PEJ designed, analyzed and collection data the study. SH PEZH contributed in, interpretation and the writing of the manuscript. Authors read and approved the final manuscript.
Type of Study: Original Article | Subject: Nursing

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