Predictors of moral distress among nurses working in Jimma University Medical Center, South West Ethiopia

The study was conducted in Jimma University Medical Center (JUMC), Jimma Town, Jimma Zone, South West Ethiopia. Geographically, the study center is located in Jimma city 352 km southwest of the capital city of Ethiopia, Addis Ababa. JUMC is the only teaching and referral hospital in this area providing services for approximately 15,000 inpatients, 160,000 outpatient attendants, 11,000 emergency cases, and 4,500 deliveries in a year. Currently, the hospital has more than 20 specialists of different categories, 27 GP doctors, 541 nurses (185 of them are diploma holders, 343 of them are bachelor degree (BSc) holders, and 13 of them are master degree (MSc) holders), 52 midwifery professionals, 17 anesthetist professionals, 68 pharmacists, and 54 laboratory technicians. All these professionals were included under the hospital administration. However, there are a lot of other professionals, but they were included under the academic administration of Jimma University. The study was conducted from April 9 to May 9, 2019.

The Institution-based cross-sectional study design was used in this study.

A total of 248 study participants were taken, and the sample size was determined using a standard of sample size calculation formula for a single population.

A list of nurses working in JUMC was obtained from the human resource office of JUMC to obtain the study population. Out of 541 nurses, 248 nurses were calculated as a sample size by proportional allocation in each ward. A simple random sampling technique was applied. The first unit was selected by using the lottery method of sampling.

Data were collected by using structured self-administered questionnaires adapted from different sources. The questions were grouped into socio-demographic characteristics, Hamric's Moral Distress Scale-Revised (MDS-R), personal factors, and organizational factors. The socio-demographic characteristics contained nine items. MDS-R instrument was adapted from an instrument developed²⁰ by Hamric (1967), which contained nine items, Cronbach's alpha (0.74).^14,21 Personal factors (professional commitment scale instruments) were adapted from Blau (2003), which contained six items, Cronbach's alpha (0.81). Organizational commitments scale was adapted from the instrument developed by Meyer and Allen (1988, 1990), which contained five items, Cronbach's alpha (0.78). The empowerment scale was adapted from the instrument developed by Spreitzer (1995, 1996), which contained five items, Cronbach's alpha (0.80). Autonomy in practice scale was adapted from the instrument developed by Dempster, Dempster Practice Behaviors Scale (1990), which contained four items, Cronbach's alpha (0.92). Job satisfaction scale instrument was adapted from Minnesota Satisfaction Questionnaires from Portuguese Hospital Workers, which contained seven items, Cronbach's alpha (0.85) (71, 73).^{20,22,23,24,25,26,27,28,29,30,31,32} The entire above personal factor variables contained a total of 27 items, which were measured by a 4-point Likert scale. Organizational factors (Nursing working environment scale instrument) were adapted from the Practice Environment Scale of Nursing Work Index for nurses, which contained 16 items, Cronbach's alpha (0.89). Perceived organizational support scales were adapted from an instrument developed by Eisenberger et al. (1986), which contained five items, Cronbach's alpha (0.79). Perception toward the quality of nursing care scale was adapted from an instrument developed by Ledoux (2015), which contained one item, Cronbach's alpha (0.72).^33,34 All of the above organizational factors’ variables contained a total of 22 items and were measured by the 4-point Likert scale.

Four BSc nurses were data collectors and two MSc nurses were supervisors for the data collection process. Two data collectors came from Agaro hospital, one from Shebe Health Center, and the remaining one from Limu Genet Hospital. The supervisors came from Mizan Tepi University. These persons were recruited based on their experience in data collection.

Data were collected using a structured self-administered questionnaire. The data were collected in three shifts, that is, in the morning, afternoon, and night. Each selected nurse received an explanation about the purpose of the study. The supervisors supervised the data collectors daily. Finally, the principal investigator collected and compiled the collected data each day.

The principal investigator has given training to the data collectors and the supervisors for 2 days to ensure the quality of the data before the time of data collection. The supervisors and the principal investigator closely followed and monitored data collection procedures. The pre-test was done using 5% of the total sample size (12 participants) at Shenen Gibe General Hospital. The quality of the collected data was checked for its completeness, clarity, and coherence each day by the supervisors and the principal investigator.

The collected data were entered into Epidata Version 3.1, and then it was exported into SPSS Version 20. Descriptive statistics, bivariate analysis, and multivariable logistic regression analysis were used to describe, identify candidate variables, and determine predictor variables, respectively. Finally, the adjusted odds ratio at 95% CI with P-value <0.05 was considered a statistical significance.

Among the 248 study population to whom questionnaires were distributed, all respondents returned their questionnaires that make a 100% response rate. The majority of the participants were young adults (85.1%). The mean age of the respondents was 29 ± 5.85 years. Among the study participants, 68.5% of them were females and more than half of them were married. Half of the participants were orthodox (50.8%). Out of the total study participants, 175 (70.6%) of them were degree holders in the nursing profession. Among the 248 participants, 50.4% of them were 2–4 years of professional experience in the current units. More than half of the participants (73.0%) worked for 42 h/week. In addition, 66.53% of the participants earned a monthly income in the range of 2,628–5,000 birrs (Table 1).

Percentage mean score of the level of moral distress = Actual mean score ÷ Maximum potential score × 100 = (21.89 + 36) × 100 = 60.8.

Out of 248 participants, 70.16% of the participants had a high level of moral distress and only about one-third of the study participants developed a low level of moral distress (Figure 1).

Figure 1

Out of 248 participants, 50% of the nurses were not committed to their profession and their organization. Concerning professional autonomy more than half of the study participants (54.8%) were not autonomous. On the other hand, 138 (55.6%) nurses were not empowered and more than half of them (52.42%) did not have job satisfaction.

Socio-demographic variables on bivariate analysis with a P-value of <0.25 (sex, level of education, working hours per week, and monthly income) were selected as candidate variables for the final multivariable logistic regression analysis (Table 2).

According to this study, male nurses were 2.4 times (AOR: 2.42, 95% CI: 1.13–5.18) more likely to develop moral distress than females. The nurses who were worked for 42 h/week were almost 2 times (AOR: 1.96, 95% CI: 1.85–2.93) more likely to develop a high level of moral distress than nurses who were worked for 84 h/week. The nurses who were not committed to their profession were 2 times (AOR: 2.01, 95% CI: 1.08–1.92) more likely to develop a high level of moral distress than nurses who were committed to their profession. The nurses who were not autonomous were 3 times (AOR: 3.20, 95% CI: 1.89–2.64) more likely to develop a high level of moral distress than autonomous nurses. The nurses who were worked in a negative working environment were 2 times (AOR: 1.98, 95% CI: 1.05–3.72) more likely to develop a high level of moral distress than nurses who were worked in a positive working environment (Table 3).