An evaluation of moral distress among healthcare workers during COVID‐19 pandemic in Palestine

Abstract

Background

Moral distress among healthcare workers (HCWs) is considered a serious issue in all aspects of healthcare divisions, which needs an urgent intervention.

Aims

The study aims at evaluating moral distress among HCWs which will help the healthcare management and decision‐makers in hospitals and health centers to act in a comprehensiveness and effective way by reinforcing moral thinking and behavior in selected coronavirus (COVID‐19) quarantine centers across Palestine.

Methods

Ninety‐four HCWs were selected by convenience sampling method. Data were collected using revised Corley's Standard Moral Distress (MD) Scale and analyzed using SPSS software version 23.

Results

The mean score of MD for HCWs was low (1.24 ± 0.71). The mean score of MD severity was moderate (1.4 ± 0.93). The severity and frequency of MD in HCWs had a significant reverse relationship with years of experience, number of children of worker, and duration of work with COVID‐19 patients.

Conclusion

It is important to create a professional psychological support system for HCWs to decrease MD when facing moral issues.

1. INTRODUCTION

Moral distress (MD) among healthcare workers (HCWs) is considered a serious issue in all aspects of healthcare divisions, which needs an urgent intervention. MD is generally a common concept that is unfortunately ignored frequently in nursing, where many HCWs suffer such as MD. ¹ MD in the healthcare sector was introduced for the first time in 1984 by Andrew Jameton ² as a phenomenon that limits a person to act in an ethical way, despite having the knowledge about moral obligations. Wilkinson ³ developed the concept of MD as “the existence of negative emotion and mental imbalance which is made due to the individual's inability to enforce ethical decisions.” In such situations, nurses have the knowledge and the ability to use moral judgment; however, they commit moral error due to actual or mental limitations. ⁴ Such distress occurs when HCWs are well aware of the valid moral action in an occasion, but it needs an action which is not possible due to some legal or organizational restrictions. Consequently, HCWs with a high degree of professional morality act in a way which opposes their character and professional values. ⁵

MD is traumatic and painful for HCWs, ⁶ and can have negative and destructive consequences on them, their patients, and the overall healthcare system. ⁷ HCWs who experience MD can demonstrate various symptoms such as anxiety and frustration, sadness, and depression. ⁸ , ⁹ , ¹⁰ Over time, MD would result in job dissatisfaction, and eventually to quit job. ¹¹ , ¹² Consequently, MD affects patients who receive poor or inadequate care by distressed HCWs, which can prolong the duration of patient hospital stay. ¹³ Also, morally distressed HCWs avoid exposure to sick patients which decreases the quality of care they provide, as shown by Corley. ⁷ Additionally, ¹⁴ reported that morally distressed HCWs exhibit a serious complication shown as a fear of facing their patients. A significant relationship has been reported between MD and practical experience, while it was low to moderate according to gender, marital status, transition status, age groups, marital status, and educational level. ¹⁵

There are various reported risk factors which contribute to start MD in HCWs including lack of human resources, inadequate patient care given by physicians and HCWs, incompetent colleagues, and conflicting medical teams, ¹⁶ in addition to patient‐related factors such as patient condition, patient family, receiving insults from patients, and feeling untrusted by a patient, ¹⁷ all of which can elevate the level of MD in HCWs. Various studies have discussed variables influencing MD levels in nurses such as age, income, work experience, and educational level. ¹¹ , ¹⁸ It is also suggested that women experience MD more than men in clinical settings. ¹⁹ , ²⁰

MD is commonly experienced in healthcare practice, where HCWs believe they know how to provide patient care and treatment but they are unable to manage such treatment due to various constrains. ²¹ Although MD is shared by various HCWs, there are different points of view about MD depending on the related specialty. ²² The average degree of MD for HCWs in selected hospitals of the Iranian Social Security Organization measured using Corley's Standard MD and Olson's Hospital Ethical Climate Scales was moderate, ²³ in addition to critical care HCWs who reported a moderate level of MD in Saudi Arabia. ²⁴ Usually, HCWs encounter daily complicated practical and moral troubles that pose huge psychological impact while making decisions opposing their beliefs and moral values that are essential in providing immediate moral patient care in the work environment. ²⁵

Various analytical studies ²² , ²⁶ have discussed MD and proved that psychological distress experienced in healthcare sector results from a moral incidence, and therefore is considered as a moral distortion. MD has been shown in many studies in the field of nursing, especially in decision‐making, ²⁷ which became one of main moral challenges that attracted the attention of many researchers since 2007.

There are many growing medical subspecialties in which HCWs deal with stressful situations. For example, MD levels varied greatly based on the perceived use of palliative care. Participants who notice less frequent use of palliative care tend to experience higher levels of MD where HCWs working in the field of oncology and organ transplantation suffer more MD than other HCWs. ²¹ , ²⁸ Other studies on sterile care show that it has different effects on HCWs and results in MD, fatigue, and exhaustion. ²⁹ The results showed a positive moral relationship between MD and sterile care. ²² Another study presented that HCWs in mental hospitals suffer from lower levels of MD. ³⁰ Also, in one study, the measure of MD for HCWs scores were higher for those considering quitting their positions than for those not willing to quit. ³¹ Critical and palliative care nurses are prone to MD. Therefore, it is essential to examine factors that may influence their MD. ²¹ The effect of MD needs more analysis so that researchers can make necessary changes and construct better moral healthcare environment. ¹ The Moral Distress Scale‐Revised (MDS‐R) was used in this study because it is a commonly used valid and reliable instrument in the evaluation of MD among HCWs. ³² , ³³ , ³⁴

On March 11, 2020, the World Health Organization declared Coronavirus COVID‐19 a pandemic. ³⁵ Such instant and unforeseen life‐threatening event can lead to a huge level of psychologic pressure on HCWs, as previously reported during SARS or Ebola epidemics. ³⁶ HCWs reported high levels of MD, depression, and anxiety.  ³⁷ , ³⁸ The importance of this study stems from being the first to evaluate MD among HCWs of COVID‐19 quarantine centers in Palestine. Our vision is to increase the ability of health sector management and decision‐makers in hospitals and health centers to act in a comprehensive and effective ways by reinforcing moral thinking and behavior.

2. METHODS

2.1. Study design and sample/participants data collection

The present study is a descriptive‐analytical study in which we intentionally approached all HCWs working in quarantine centers. The total number of HCWs was 124. The collected sample consisted of 94 HCWs working at novel coronavirus (COVID‐19) quarantine governmental centers across Palestine. The sample size was calculated using (Raosoft, Inc.), with 95% confidence interval and 0.05 error. The study took place in COVID‐19 quarantine centers, with the participation of HCWs who work there. All COVID‐19 quarantine centers belong and work under governmental rules. The centers were not very crowded during the study period. The infection rate was about 1–5 people/day. However, as can be seen worldwide with the passage of time, the infection rate increased. Ninety‐four HCWs in COVID‐19 quarantine centers participated. After obtaining permission from the ministry of health, all of them were informed about the study through an e‐mail message, WhatsApp, and Facebook groups, which also reported an anonymous link that enabled them to be enrolled in the study after giving an informed consent to comply with ethical considerations, and approve their agreement to participate in the study. The e‐mail was sent on April 5, 2020 and data collection was discontinued on May 5, 2020. The whole study was performed using online questionnaire implemented using Google Forms. The questionnaire was translated into Arabic for ease‐of‐use since it is the first language of participants. The translation was performed according to the recommended translation procedure by European Organization for Research and Treatment of Cancer EORTC. ³⁹ The demographics and distribution of participants in the study sample are shown in Table 1.

Table 1.

Distribution of participants according to characteristics

Field	Variable	Count	%
Sex	Male	71	75.5
	Female	23	24.5
Years of experience	1–4	24	25.5
	5–9	11	11.7
	10–14	26	27.7
	15 or more	33	35.1
Marital status	Married	68	72.3
	Single	26	27.7
Age (years)	<28	17	18.1
	28–37	44	46.8
	38–46	18	19.1
	>46	15	16.0
Duration of work with COVID‐19 patients	>1 month	22	23.4
	1–2 months	18	19.1
	>2 months	54	57.4
Job nature with COVID‐19 patients	Direct	53	56.4
	Indirect	41	43.6
Total numbers	(n = 94)

2.2. Ethical considerations

According to the 2000 Declaration of Helsinki for ethical standards, the study was approved by the Research Ethics Committee of Al‐Quds University, Palestine (Ref No: 167/REC/2021). Informed consent was obtained from each participant before his/her participation. The survey was anonymous, and all data confidentiality was assured.

2.3. Measurement of MD

The MD Scale (MDS) designed in 2001 by Corley et al., ⁷ is common tool used to assess MD among nurses in the intensive care unit. ⁴⁰ The current study uses a modified version of the original MDS, called MDS‐R, prepared by Hamric et al., ⁴¹ which is in accordance with the standard Corley questionnaire. It is composed of 21 elements, each displaying a stressful situation and asking respondents to record the MD they encounter in each case. The Corley scale illustrates the frequency and severity of ethical disorder among HCWs based on Likert scale of 5 points from 0 to 4.

To determine the degree of severity, options range from “it does not cause me distress” (Score 0) to “it causes me great distress” (Score 4) was used. To determine the frequency of perceived distress, options ranging from “I have never experienced any moral distress” (Score 0) to “I have experienced a lot of moral distress” (Score 4) were used. The lowest Score (0) indicates the minimum perceived distress in the intended condition. Descriptive statistics assessed the level of MD for HCWs among the sampled population using the following key: 1.33 and less indicated a low level, 1.34–2.67 indicated an average level. and 2.68 and above indicated a high level of MD.

2.4. Instrument validity

To check the validity of the study tool, the questionnaire was distributed to five experts in the field to get a comprehensive evaluation of the content domain of the questionnaire. It was also checked using Pearson correlation coefficient for questionnaire questions and parts.

2.5. Instrument reliability

The study tool has been evaluated for validity and reliability in several countries (e.g., Iran, ⁴² , ⁴³ Turkey, ⁴⁴ Italy, ⁴⁵ India, ⁴⁶ China, ⁴⁷ and Brazil. ⁴⁸ The stability of the study tool was determined using Cronbach alpha. Results indicate that the original English study tool was suitable to apply on study population (Cronbach α = .94). The reliability of the Arabic translated version was 0.80, which was applied on the sample population and the total number of collected and analyzed questionnaires was 94.

2.6. Statistical analysis

Data statistical analysis was carried out using SPSS v. 23 (SPSS Inc.). Means and SDs for every part of the questionnaire using t‐test, one‐way ANOVA, and Pearson correlation coefficient were reported. A p < .05 was regarded as statistically significant.

3. RESULTS

3.1. Characteristics of the sample

In total, 94 questionnaires were completed by the HCWs and then analyzed. The sample consisted of 94 participants who work as healthcare providers at COVID‐19 quarantine centers across Palestine. Overall, 75.5% of the HCWs (n = 71) were male, and 46.8% of the participants (n = 44) ranged in age from 28 to 37 years.

3.2. Level of MD

Results show that the total mean and SD for MD among HCWs were (M, 1.24; SD, 0.71) for the total frequency of occurrence of MD, respectively, which indicated low‐frequency MD. Whereas the total mean and SD were (M, 1.4; SD, 0.93) related to the severity of MD, which indicates moderate severity of MD among HCWs, as shown in Table 2.

Table 2.

Mean score of MD for HCWs according to characteristics

Field	Variable	Frequency	Frequency of MD		Severity of MD		Statistical test
			Mean	p Value	Mean	p Value
Sex	Male	71	1.20	.29	1.49	.41	Independent T‐test
	Female	23	1.36		1.36
Years of experience	1–4	24	1.73	.00*	1.87	.07	One‐way analysis of variance
	5–9	11	1.08		1.46
	10–14	26	1.22		1.33
	>14	33	.97		1.26
Marital status	Married	68	1.05	.00*	1.26	.00*	Independent T‐test
	Single	26	1.75		1.98
Age (years)	<28	17	1.89	.00*	2.05	.01*	One‐way analysis of variance
	28–37	44	1.13		1.39
	38–46	18	1.11		1.04
	>46	15	1.00		1.48
Duration of work with COVID‐19 patients	>1 month	22	1.54	.06	1.89	.00*	One‐way analysis of variance
	1–2 months	18	1.08		0.97
	>2 months	54	1.18		1.44
Job nature with COVID‐19 patients	Direct	53	1.20	.51	1.52	.48	Independent T‐test
	Indirect	41	1.30		1.38

Abbreviations: HCW, healthcare workers; MD, moral distress.

^* p < .05.

The item “Patient care quality decreased due to lack of collaborative work among healthcare workers” had the highest mean (M, 2.21; SD, 1.45), whereas the item “Follow the family's wishes for the patient's care when I do not agree with them, but do so because of fears of a lawsuit” had the lowest mean (M, 0.70; SD, 0.95), While the lowest average for the paragraph was to follow the patient's family's wishes in caring for him while I do not agree with them, but for fear of filing a lawsuit in the courts (M, 0.70; SD, 0.95) to the point of repetition, and (M, 1.65; SD, 1.37).

Results show there are no significant differences according to sex (p, .29), for the total frequency of occurrence of MD, and (p, .41) related to the severity of MD, whereas there were significant differences in MD according to years of experience in the favor of 1–3 years of experience (M, 1.73; p, .00) related to the frequency of occurrence of MD compared to a higher level of experience (Table 2). Results also show significant difference observed between single and married HCWs regarding the mean scores of frequency (M, 1.75; p, .00) and severity (M, 1,98; p, .00) of MD in the favor of single workers compared to those who are married (mean scores of frequency (M, 1.05) and severity (M, 1.26). Results also show significant difference observed according to worker age in the favor of those who are younger than 28‐year‐old (M, 1.89; p, .00) for mean scores of frequencies and (M, 2.05; p, .01) for severity (Table 2).

There was no significant difference observed according to duration of work with COVID‐19 patients (p, .06) for mean score of frequency, whereas there was a significant difference observed according to duration of work of less than a month with COVID‐19 patients (M, 1.89; p, .00) for MD severity. Also, no significant difference was observed between direct or indirect work nature for both MD frequency (p, .51) and severity (p, .48).

The results showed that the severity and frequency of MD in HCWs had a significant reverse relationship with related variables: years of experience, number of children of worker, and duration of work with COVID‐19 patients (Table 3). This means that a worker who is more experienced, had more children, or worked for longer periods with COVID‐19 patients, shows lower degree of the severity and frequency of MD. Additionally, MD also affected when any person himself got COVID‐19 or one of his/her family was infected or dead from the COVID‐19.

Table 3.

Pearson correlation coefficient between study variables and MD

Field	Frequency of MD		Severity of MD
	R	p	R	p
Years of experience	0.000	−.386**	0.013	−.256*
Number of children	0.000	−.421**	0.001	−.342**
Duration of work with patients	0.074	−.185	0.178	−.140

Abbreviation: MD, moral distress.

^*Correlation is significant at the .05 level.

^**Correlation is significant at the .01 level (two‐tailed).

4. DISCUSSION

To the best of our knowledge, this is the first study on the issue of COVID‐19 MD symptoms among Palestinian HCWs. The current study aims at evaluating MD among Palestinian HCWs according to study variables of (sex, age, marital status, years of experience, duration of work with COVID‐19 patients, and nature of work). According to the results of our study, the mean scores of frequencies and severity of MD in HCWs indicated low MD among study participants, which could be explained by their resilience which drives and motivates them to act and perform better during stressful situations. A local study that explored ethical dilemmas and the willingness of HCWs to work during COVID‐19 in Palestine showed that HCWs with longer professional experience showed lower stress levels and more willing to work (p, .03). ⁴⁹ Various MD studies among nurses have reported different results, ¹⁵ , ²³ , ²⁴ and indicated a moderate level of MD in nurses, which showed good agreement with our results. Also, our findings agree with a study by Eizenberg et al., ³⁰ which indicated low MD among HCWs.

The variability between our study and other studies could pertain to different scales used by various researchers, and due to differences in participants’ work type and location, and the current health status with the outbreak of COVID‐19 in various countries. Also, participants who reported a high level of MD may have some interference from own fears that could lead to much of distress and anxiety while responding to the study questionnaire.

Some studies also reported higher levels of MD compared to our study, which could be due to personal and organizational factors that increase MD among HCWs. ⁵⁰ , ⁵¹ These factors include the lack of organizational support and budget constraints, ⁵⁰ in addition to disproportionality between number of empty beds and number of HCWs in hospitals, or the presence of incompetent physicians and management, and vice versa. The medical hierarchy system in which physicians do not consult nurses or other HCWs about the patients' treatment and/or condition ³⁶ , ⁴³ affects the way of patient care, since HCWs have to obey the physician's orders without further questioning, which leads to low self‐confidence and less motivation. ¹³ Therefore, when the previously mentioned factors are the opposite, the quality of work will be better and there will be the lower level of MD. Accordingly, the role of healthcare organizations is obvious in controlling MD through providing HCWs with moral support and enabling them to provide a high level of patient care. Also, the administrative team should provide support for HCWs during all work conditions and especially during moral distressful situations. Therefore, to understand and mitigate MD among Palestinian HCWs during COVID‐19 pandemic, national healthcare organizations should establish and adopt psychologic support systems that will manage emotional responses of HWCs and prevent MD.

The item “Witness diminished patient care quality due to poor team communication” showed the highest mean for MD. The outbreak of COVID‐19 was sudden; both the international and local medical and health systems became exhausted. The Palestinian health system is especially weak due to lack of mental support, and insufficient medical equipment and various life support technologies. This result conforms with a study showing that nurses suffer MD due to not being able to show brave behavior in front of medical team and colleagues, which in turn affect their communication with patients and colleagues. ⁵²

The way of thinking and dealing with daily life situations gets influenced for those who work under pressure. The lack of knowledge and ambiguity around the COVID‐19, in addition to lack of medications and equipment necessary for testing and life support, and the few numbers of quarantine centers, all led to a flounder in decision‐making at the health system level and affected overall healthcare services. Although medical ethics is covered in the curriculum of all healthcare specialties, it does not emphasize well on MD issues faced on duty and during similar pandemics. Fresh graduates and low experienced HCWs have less knowledge about MD and how to get ethical consultations. ⁴³

The item “Follow the family's wishes for the patient's care when I do not agree with them, but do so because of fears of a lawsuit” showed the lowest mean for MD. During COVID‐19 pandemic, HCWs have many priorities; they deal with very dark stressful situations accompanied by scarce medical, technical, and moral resources. The Palestinian Ministry of Health therefore had to deploy additional medical staff to the HCWs who already work in quarantine centers to overcome the hard situation. Also, other ministries support those staff until the pandemic is over. The last thing that HCWs should worry about is to face lawsuit due to not following a patient family's wishes.

The results also show significant differences in the frequency of MD among HCWs based on years of experience “1–4 years,” which means that HCWs with lower experience have fewer incidences of dealing with moral stressful situations. With the onset COVID‐19, inexperienced HCWs get growing stress while dealing with newly introduced moral situations due to lack of expertise, as reported by Shorideh et al., ⁴³ that graduate nursing students have little knowledge about MD. Also, there were significant differences in both of the frequency and severity of MD between single and married HCWs. It could be interpreted by the outbreak of COVID‐19 in Palestine, which led to the closure of all types of festivals and gatherings, especially wedding ceremonies which are huge and famous in the Middle East. This led to emotional instability for singles due to lack of supporting partners who provide support, comfort, and most importantly, reduce MD for their partners. Also, younger HCWs (<28 years old) reported higher frequency and severity of MD, which is attributed to the lack of experience in dealing with moral stressful situations, as mentioned earlier by Shorideh et al. ⁴² This could result in fears from not being able to cope with MD situations. The HCWs who worked for short durations (<1 month) with COVID‐19 patients reported a higher level of MD severity. HCWs who worked for short periods with COVID‐19 have less knowledge about the disease and how to deal with patients. Consequently, the way that HCWs serve patients and the level of MD is noticeable compared to those who served longer periods in quarantine centers. Additionally, results show no significant difference among HCWs based on gender and the work nature. The spread of COVID‐19 pandemic was equally shocking for all mankind. No differences were noted based on gender, type of qualification, or work nature. HCWs must unite and face the pandemic together. Everyone does their job and complete assigned roles and tasks.

Finally, results of MD based on years of experience, number of children, and period of dealing with COVID‐19 patients, showed a reverse correlation between these variables with MD. While years of experience, number of children, and period of dealing with COVID‐19 patients increase, the level of MD decrease, and vice versa. This can be interpreted as the aforementioned variables are interconnected. As experience grows, or HCWs have more children (older, responsible, and experienced parent), or the duration of dealing with the disease increases, hence the knowledge and life experiences become greater. Experienced HCWs are more stable and able to deal with stressful situations and face new complicated challenges containing moral distressful situations.

Importantly, HCWs should adopt coping strategies to reduce MD, which could have positive effects on their physical and mental health. Such strategies include educational resources on adequate measures of disease prevention, effective communication with friends and family members, walking, listening to music, adequate nutrition, having enough sleep, expressing their feelings with fellow workers, and establishment of support groups and counseling service at different working sites. ⁵³ Additionally, it is important that institutional strategies support HCWs through effective communications between leaders and HCWs, managing workloads and offering financial compensation for HCWs serving during the pandemic. ⁵⁴

The results of this study should be considered in light of limitations. First, MD was evaluated only using online questionnaires, not with a professional psychiatric interview. Second, we could not meet HCWs personally to obtain detailed information regarding previous psychiatric illness history. Third, no information was obtained about any kind of psychiatric support received by HCWs. Although the current study sample is not quite large compared to similar studies around the world, it gives a clue about the MD experienced by HCWs in a region of the world with rare similar investigations. There should be further studies to address this issue in the whole territories.

5. CONCLUSION

Clearly, the outbreak of COVID‐19 has placed an enormous pressure on HCWs facing the pandemic, which made them struggle psychologically and morally distressed through encountered ethical and emotional challenges. The study showed a reverse correlation between MD and variables of the study. The healthcare organizations should take care of HCWs and provide them with psychological support to enable them to sustain high quality of work and care given to patients. While COVID‐19 pandemic is hitting worldwide, little guidance is provided to HCWs in many areas of the world. Related authorities and organizations should establish training programs and guidelines for HCWs to teach them how to express and deal with MD, and how to mitigate distressful situations, especially for younger HCWs with few years of work experience, most importantly, during the current heard times of COVID‐19 pandemic outbreak, and after the pandemic is over.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

Informed consent was obtained from all individual participants included in the study

ALMasri H, Rimawi O. An evaluation of moral distress among healthcare workers during COVID‐19 pandemic in Palestine. Nurs Forum. 2022;57:1220‐1226. 10.1111/nuf.12829

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.