Moral Distress and relationship between Physician and Nurses

Somayeh Mohammadi, Fariba Borhani, Mostafa Roshanzadeh



Introduction: In critical care units, due to their unique atmosphere, nurses are constantly faced with significant challenges, especially ethical ones. One of the ethical challenges that can have different effects on nurses, patients and the health care system is moral distress. This phenomenon occurs when nurses encounter a situation that despite their awareness of the morally right action because of the existing situation cannot act morally in functioning as a nurse. In other words, the nurses have to commit ethical wrongdoing. One of the important reasons causing moral distress faced by nurses and doctors and nurses is that they take unnecessary care and do not have the necessary competence for patient care. The relationship between physicians and nurses is an ethical and central component in the health system so any disruption of this relationship can have different effects. Effective communication between team members can improve and enhance health care services provided to patients and reduce the rate of hospital admissions in healthcare environments. Such an effective relationship also provides work place atmosphere for effective performance and reduces the differences between the treatment team. In this condition, the health care team, including nurses will gain confidence and dissatisfaction with the work environment will be minimal. The ideal relationship between physicians and nurses in intensive care units could prevent many causes of moral distress and the conditions that create moral distress. This can also help the better management of distress and, therefore, reduction of negative effects. In general, we can say a good and healthy relationship between doctors and nurses as persons who have the most contact with the patients will have a very influential impact on improving the ethical climate and prevention of moral distress. This study aimed to determine the relationship between moral distress and the relationship between physicians and nurses in intensive care units in South Khorasan province.


Methods: This research is a cross-sectional study that was conducted in 2015. The samples were 215 nurses employed in hospitals affiliated to Birjand University of Medical Sciences. Research subjects were selected via convenience sampling method in critical care units [neonatal intensive care unit (NICU), coronary care unit (CCU), intensive care unit (ICU) and dialysis] in South Khorasan province. Inclusion criteria was included having at least a bachelor's degree in nursing and a year's work experience in critical care unit. The data collection tool was a two-part questionnaire. The first part includes demographic data: age, sex, education, number of years of service, type of employment and type of service unit and the second part consisted of the 21-item Corly moral distress questionnaire with a 0.93 Cronbach's alpha and the 21-item communication between physicians and nurses in critical care unit questionnaire with validity (CVI) of 0.86 and 0.83 Cronbach's alpha. Inventory options of the intensity of moral distress was from ever (0) to very high (5) and the frequency of moral distress was the never (0) to repeatedly (5) is arranged. Inventory of the questions on the questionnaires of the relationship between physicians and nurses was arranged on a Likert scale from strongly disagree (1) to strongly agree (5). After meeting the legal requirements and obtaining permission, the questionnaires were distributed and collected in a week. Of the total of 240 questionnaires distributed, 215 questionnaires were collected (response rate: 89.58%). The total duration of collecting data from relevant sections was 21 days. The collected data were analyzed using SPSS version 16 software and considering the objectives of the study, descriptive statistics (frequency, percentage, mean and standard deviation) and analytical (Pearson correlation and analysis of variance and chi-square) were used.

Ethical Considerations: After obtaining permission from the university and ethics committee, the questionnaires were distributed and they were informed and instructed as to how to respond to the questionnaire. The nurses were also informed that participation in the study was voluntary, and they had freedom to participate or withdraw from the study. Verbal consent was collected from all participants for the study. Also, all of the nurses were assured about the anonymity of the questionnaires and confidentiality of information.


Results: The mean intensity of moral distress was 3±0.56 and the mean frequency of moral distress was 3.66± 0.5. The mean of the relationship between doctors and nurses score was 3.2±1.1. The mean of the relationship between physicians and nurses score with the frequency of moral distress was significant (r: 0.34, P<0.05). The mean of the relationship between physicians and nurses and the severity of moral distress was not significant (P>0.05). The mean of the relationship between physicians and nurses and the mean age (r: 0.17, P<0.05) and years of service (r: 0.3, P<0.05) was significant. A significant inverse relationship between moral distress and age (r:-0.22, P<0.05) and the number of years of service (r:-0.3, P<0.05) was observed. Score of moral distress according to the type of ward was also significant (P<0.05). The highest moral distress was observed in ICU ward nurses with an average of 4.11± 0.68 and the least distress was seen in dialysis nurses with an average of 2.4±0.11. There were no significant relationships between moral distress and gender and between the doctors and nurses relationship and ward and sex (P>0.05).


Conclusion: Noticing the undeniable role of good communication between physicians and nurses in reducing the incidence of moral distress, understanding the factors affecting this relationship as well as providing effective communication strategies to promote the atmosphere to reduce this phenomenon is necessary. The presence of experienced nurses along with other nurses is recommended in the workplace in order to protect and better manage stressful situations. On the other hand, experienced nurses with better relations with physicians and other health team members will be able to prevent many challenges of a difficult relationship.


Please cite this article as: Mohammadi S, Borhani F, Roshanzadeh F. Moral distress and relationship between Physician and nurses. Med Ethics J 2016; 10(36): 7-14.


moral distress; nurses; physicians and nurses relationship; critical care unit

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