1 Introduction

Any profession that is directly related to the needs of clients requires morality; while ethics is required in all jobs, it is an inseparable part of the nursing profession [1]. Nurses are more likely to encounter ethical issues and make moral decisions than other healthcare providers. This is because they have extensive patient interactions and spend significant time at patients' bedsides [2]. Moral distress (MD), which has been defined as understanding the ethically correct action to take but feeling unable to act on that conviction due to internal and external constraints is one of the ethical issues in nursing [3]. MD in the nursing profession is defined as performing nursing tasks that contradict nurses' ethical beliefs, thus preventing the most moral act [4].

The sources of moral distress can vary, but mainly can be caused by clinical conditions, environmental sites, and external and internal factors [5]. Power imbalances, poor communication, violence in the workplace, and organizational policies interfering with client requests are examples of external factors. Internal factors include nurses’ perceptions of powerlessness, unwillingness, or inability to resolve ethical issues [6, 7]. Additionally, the majority of nurses' moral distress can be related to dying patients, unnecessary tests, unsatisfactory and incomplete care provided by colleagues, pain, and resentment decided to bring on by invasive diagnostic and treatment procedures, and treating patients to satisfy the needs of the organization [8].

Moral distress has a detrimental effect on nurses, patients, and healthcare organizations, resulting in reduced job satisfaction, high staff turnover, retirement from a job, and the onset of medical and psychological problems [9, 10], including anger, guilt, disability, depression, and frustration, which ultimately reduces patient care quality. As a result, it becomes a top priority for healthcare institutions [11].

Worldwide, moral distress has been studied in an increasing number of countries, including Iran[12], Israel [13], Japan[14], Taiwan [15], China [16], Korea [17], and India [18], as well as African countries such as Malawi[19], South Africa [20], and Uganda[21]. However, little is known about moral distress and associated factors among nurses in African countries, especially in Ethiopia, and only a few studies in Ethiopia indicated that the magnitude of moral distress ranged from 70.16% to 83.7%. Thus, the purpose of the present study was to assess the magnitude of moral distress and associated factors among nurses working in Adama Comprehensive Specialized Hospital Medical College (ACSHMC), central Ethiopia.

The current study's findings will help hospitals, nurses, local policymakers, the government, and other stakeholders enhance nursing practice and patient treatment outcomes, as well as performance and well-being, which can impact the quality, quantity, and cost of nursing care. It could also be useful for scholars who want to do further research on this topic.

2 Methods and materials

2.1 Study design, setting and period

A facility-based cross-sectional study was conducted at ACSHMC of Adama Town, East Showa zone, Oromia regional state, Ethiopia from January 1 to January 30, 2023. Adama is a town located 100 km southeast of Addis Ababa. It is one of Ethiopia's major cities, with a total area of 29.86 square kilometers and a population of over 500,000 people.

According to information from the Adama Town Health Bureau, there are four hospitals, eight public health centers, and over a hundred thirty private healthcare facilities in the town. ACSHMC is the town’s first and only public referral hospital. According to ACSHMC's administrative office, the hospital serves a catchment population of more than 6 million from five regions (Oromia, Amhara, Afar, Somali, and Dire-Dawa). In the Hospital, there are more than 1300 staff, 308 of them are nurses.

2.2 Population and eligibility criteria

All nurses working in ACSHMC were considered as the source population, whereas all selected nurses working in ACSHMC were taken as the study population. Nurses having at least six months of clinical work experience in the hospital and not suffering from anxiety disorders (self-report) were included in the study. Nurses who were on annual leave during the data collection period and those unwilling to continue cooperation in the study were excluded.

2.3 Sample size determination

The sample size for the study was determined using the single population proportion formula by considering a 95% confidence level, 5% of margin of error, and an 83.7% proportion of moral distress from the study conducted in Northwest Amhara regional state referral hospitals [22]. With this assumption, the estimated sample size was 209. Finally, by adding a 5% non-responsive rate, the final sample size becomes 219.

2.4 Sampling technique and procedure

The total number of nurses working in ACSHMC was obtained from the human resource office of the hospital and the calculated sample size was proportionally allocated to each department based on the size of nurses in the department. Once the sample was allocated proportionally, the study participants then were selected randomly (Fig. 1).

Fig. 1
figure 1

Schematic presentation of sampling procedure of magnitude of moral distress and associated factors among nurses working in ACSHMC, central Ethiopia, 2023

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2.5 Operational definition

Moral distress Nurses who were found to have greater or equal eight symptoms from the 21 items moral distress scale-revised (MDS-R) were considered as having moral distress [23, 24] and those who were found to have less than eight symptoms from the 21 items moral distress scale-revised (MDS-R) were considered as not having moral distress.

2.6 Data collection procedure and measurement

Data were collected by using self-administered structured and pretested questionnaires consisting of two parts by trained health professionals. The first part focused on socio-demographic and occupational information of the subjects (Age, sex, marital status, religion, ethnicity, educational level, monthly income, work experience, current position, and working time shifts), while the second part assessed moral distress using Corley's Moral Distress Scale (MDS) revised by Harmic (MDS-R). The MDS-R is used to quantify moral distress in particular situations. Respondents are asked to indicate the frequency of the situation as well as the degree of the disturbance. The MDS-R is made up of 21 items that consist of Internal factors (lack of self-confidence, fear, perceived powerlessness), External factors (inadequate number of staffs, poor communication, organizational support), and Clinical factors (incompetent coworkers, inappropriate care). Responses are given on a 5-point Likert scale, with 0 representing never, 1 representing rarely, 2 representing occasionally, 3 representing frequently, and 4 representing always/very frequently. Taking the responses, nurses who answered rarely, occasionally, frequently, and always were considered to have moral distress, whereas study participants who answered never were considered to have no moral distress. Total moral distress scores were obtained from the total scores of each questionnaire item (N = 21). The reliability coefficient of the questionary was deemed reliable, with a Cronbach's alpha of 0.88.

2.7 Data quality control

Before actual data collection to ensure the validity, the questionnaire was pre-tested on 5% of the estimated sample size (11 Nurses) at Olenciti Hospital, and then adjustments and corrections were made based on the pretest results. To ensure data quality the principal investigator provided two days of adequate training and orientation to the data collectors and supervisors on the study's objective and data collection methods. Furthermore, the supervisors and principal investigators closely monitored the completeness, coherence, and clarity of the data throughout the data collection period.

2.8 Data processing and statistical analysis

After data completeness was checked, it was entered into the Epi-info vision 7 and exported to IBM SPSS version 26 statistical software for analysis. The frequency, percentage, median, and inter quartile range (IQR) were calculated as descriptive statistics. Binary logistic regression analysis was run to identify independent predictors of moral distress. Variables with a p-value of < 0.25 in the bivariable regression analysis were included in the final multivariable logistic regression analysis model. Hosmer and Lemeshow's goodness-of-fit analysis was used to assess the logistic regression model's fitness, and it gave a p-value of 0.71. The multicollinearity between explanatory variables was also checked using variance inflation factor and tolerance and found within a tolerable range. For the multivariable logistic regression; an Adjusted odds ratio (AOR) with a 95% confidence interval (CI) was calculated. The variable showing p-value < 0.05 in the multivariate logistic regression model was considered statistically significant and independently associated with moral distress. Finally, the result was presented in the form of statements, Tables, Figures, and Pie-Charts.

3 Results

3.1 Socio-demographic characteristics of the respondents

A total of 212 participants were enrolled in the study giving a response rate of 96.8%. The majority 136 (64.2%) of the nurses were female. The median (IQR) age of study participants was 31.50 [28,29,30,31,32,33,34,35,36,37,38] years. With regards to their marital status,136 (64.4%) of the participants were married, nearly half (51.4%) of them were Orthodox Christians by religion, and 162 (76.4%) were Oromo by ethnicity. Of the total respondents, 177(83.5%) were degree holders in nursing. The median (IQR) monthly salary of the respondents was 7171.00 (7000–9051) Ethiopian Birr (Table 1).

Table 1 Frequency distribution of socio-demographic characteristics of nurses working in acshmc, central ethiopia, 2023 (n = 212)
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3.2 Internal, external, and clinical factors

Among respondents, 113 (53.3%) responded that they had Perceived powerlessness in decision-making, and about 151 (71.2%) study participants had a lack of -confidence in decision making. One hundred sixty-one (75.9%) of the participants had reported inadequate staffing, while 146 (68.9%) had reported poor organization policies. Of the total, 169 (79.7%) respondents had given futile care, and 109 (51.4%) had given false hope (Table 2).

Table 2 Internal, external, and clinical factors of moral distress among nurses working in acshmc, central ethiopia, 2023 (n = 212)
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3.3 Magnitude of moral distress

The overall magnitude of moral distress was found to be 86.8% (95% CI: 82.1%, 91.0%), it was 55.6% among females and 31.2% among male nurses in a separate analysis (Fig. 2).

Fig. 2
figure 2

Magnitude of moral distress among nurses working in acshmc, central ethiopia, 2023

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3.4 Factors associated with moral distress

In bivariate binary logistic regression analysis, variables like age, fear, perceived powerlessness, lack of confidence, provision of inadequate pain relief, perceived poor communication, perceived weak organizational support, inadequate staffing, working with incompetent co-workers, inadequate informed consent, inappropriate care, futile care were selected as a candidate variable at a p-value of < 0.25 for multiple logistic regression.

However, in multivariate binary logistic regression analysis perceived powerlessness, lack of confidence, inadequate staffing, and perceived weak organizational support persisted to be statistically significant variables associated with moral distress.

Accordingly, nurses who experienced perceived powerlessness had 6 times higher odds of experiencing moral distress than those with unperceived powerlessness (AOR = 6.08 95% CI 1.69–11.8). The odds of developing moral distress were 7 times higher in nurses who lacked confidence than in those who did not (AOR = 7.08, 95%CI) (2.05–14.4). There were 13 times higher odds of moral distress among nurses working in areas of inadequate staffing compared with an area with adequate staffing (AOR = 13.4 95% CI 3.28–15.15). Further, Moral distress was also 11- times more common in respondents who perceived weak organization policies than those with unperceived (AOR = 11.5 95% CI 2.8–17.3) (Table 3).

Table 3 Bi-variable and multi-variable logistic regression analysis of factors associated with moral distress among nurses working in acshmc, central ethiopia, 2023
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4 Discussion

This study aimed to assess the magnitude of Moral distress and associated factors among nurses working in at Adama Comprehensive Specialized Hospital Medical College, central Ethiopia, 2023. The result of this study showed that the overall magnitude of moral distress (MD) was 86.8% (82.1–91.0). Perceived powerlessness, lack of confidence, inadequate staffing, and perceived weak organizational support have shown a statistically significant association with moral distress.

In this study, 86.8% (82.1–91.0) of participants had M\moral distress. The finding is consistent with studies done in Rhode Island College (89%) [25], and North West Amhara, Gondar (83.7%) [22]. But higher than the studies conducted in the US (65%), Canada (58%), Australia (72%), and the study done at Jimma university medical center, Ethiopia (70.6%) [6, 26,27,28]. These differences could be due to differences in sociocultural factors inside a society that affect people's values, relationships, ideas, emotions, and behaviors, as well as economic differences, study time, study settings, sample size, and work environment.

Moral distress was significantly higher among participants who had perceived powerlessness. This study finding is supported by the study done in the USA, UK, United Arab Emirates, and North West Amara, Gondar [13, 26, 29]. This might be due to the lack of power in making patient care decision frequently drives nurses to intervene in ways that contradict their beliefs and values, as well as to deny their knowledge, and expertise resulting in moral distress that appears to be associated with their professional ideals, limiting their self-efficacy [30].

According to this study, nurses who lack confidence had higher odds of having moral distress than nurses who do not lack confidence. This finding is in line with the studies done in India [31, 32]. This might be due to individuals lacking confidence may perform poorly for the challenge and exhibit negative reactions when confronted with failures, negative events, and psychosocial risk factors such as high workload, lack of support, patients' deaths and their families' grief, working in highly stressful wards, and patients suffering from chronic diseases and cancers. As a result, moral distress increases [33].

This study showed that nurses who work in environments with inadequate staffing are more likely to experience moral distress than nurses who work in areas with adequate staffing. The finding is in agreement with other studies done in Iran, Uganda, and North West Amara, Gondar [13, 21, 34, 35]. This could be due to nurses working in environments with insufficient staffing faces an enormous workload that necessitate overtime hours to provide care quickly and effectively without having sufficient time to achieve the standard of care and comprehensive patient treatments. This results in increased medical errors, decreased patient safety, high emotional exhaustion, and decreased productivity, leading them to believe that they are compromising their ethical duty to protect patients from harm, causing moral distress [18, 36].

In this study, perceived weak organizational support was an important variable statistically associated with MD. This finding is consistent with the study done in Jordan, and India [37,38,39]. Lack of organizational support in terms of supply of equipment and human resources along with ineffective managerial approaches could lead to nurses’ mental distress and emotional exhaustion, negative attitudes toward the profession, decreased and poor service quality, employee turnover, and early retirement [40, 41]

5 Limitations of the study

A cross-sectional study design was used, which may not be the best design for determining a temporal relationship. The study may have missed workers who had experienced moral distress and had already left the workplace, resulting in a selection bias as a result of the "healthy worker effect phenomenon."

6 Conclusion

The magnitude of moral distress is found to be high among nurses in the study area. Perceived powerlessness, lack of confidence, inadequate staffing, and perceived weak organizational support, were independent determinants of moral distress. Thus, creating adequate number of staff, and establishing acceptable organizational policies are ways to reduce moral distress.