An analytical study was conducted to investigate the relationship between moral distress and perception of self-efficacy in nurses working in Intensive Care Unit (ICU), Cardiac Care Unit (CCU) and dialysis unit of the selected hospitals affiliated to Tehran University of Medical Sciences: Imam Khomeyni Hospital, Vali-e-Asr Hospital, Shahid Rajaei Hospital, Sina Hospital, and Cancer Institute. The duration of study was from August 2017 to December 2017. The participants were 300 nurses (head nurses and staff nurses) i.e., 100 nurses (33.3%) in ICU, 100 (33.3%) in CCU and 100 (33.3%) in dialysis unit. To calculate the sample size, the formula of difference between two populations was used according to a similar study [19] and considering 12 as the mean difference between the two populations, the standard deviation was calculated as 26, alpha as 0.05, the study power as 90% and the sample size in each group as 99 and the present authors have taken sample size as 100 in each group. Written informed consent was taken from the participants in the local language and the study was approved by: Institutional Ethics Committee (Registration NO. IR.ARAKMU.REC.1395.172.) of the Arak University of Medical Sciences.

Inclusion criteria were having BA or higher degree of nursing and at least one year work experience in intensive care units. The exclusion criteria were not willing to participate in the study and necessity of therapeutic intervention while completing the questionnaire. Data collection tools were demographic information questionnaire, Corley’s moral distress scale, and Riggs et al. self-efficacy beliefs questionnaire. Corley’s moral distress scale known as Moral Distress Scale (MDS) measures frequency and intensity of moral distress in nurses through 24 questions based on a 5-point Likert’s scale. To examine the validity of the questionnaire, 15 faculty members of the Faculty of Nursing Department reviewed the statements. Then, the statements were modified based on their comments. Also, the validity was quantitatively evaluated using the CVI and CVR indexes. The relevance of 89% was calculated based on the CVI index. To determine CVR, the experts were also requested to review each item based on a 3-point scale (necessary, useful but not necessary and not necessary). The content validity ratio was 91%. To assess the reliability of the tool, the questionnaire was given to 20 Critical care units’ personnel. The reliability through Cronbach’s Alpha for the emergency medical personnel was 0. 913. The frequency of moral distress in this questionnaire means the number of times one is faced with distressful factors ranging from “never faced with distressful factors” (score of 0) to “faced with distressful factors many times” (score of 4). The intensity of moral distress in this questionnaire means the degree of distress felt by the person when faced with distressful situations ranging from “doesn’t make me distressed” (score of 0) to “makes me highly distressed” (score of 4). The range of scores in each of the dimensions of frequency and intensity in this questionnaire is between 0 to 96 and the higher the score, the higher the frequency or intensity of the moral distress in the individual. Scores for intensity and frequency of moral distress in this questionnaire are categorised as follows: the score of 0-31 shows low, the score of 32-64 shows moderate, and the score of 65-96 shows high intensity or frequency of moral distress [19]. Riggs et al., self-efficacy beliefs questionnaire includes 10 questions based on a 5-point Likert’s scale from “strongly disagree” to “strongly agree”. The questions number 2, 3, 4, 6, 8, and 10 including negative concepts are scored inversely. The total score which can be acquired on this questionnaire is 0-50, the higher the score of a person the higher the level of perceived self-efficacy in that individual. The categorisation of the perceived self-efficacy level in this questionnaire is as follows: the score of 0-16 shows low, the score of 17-33 shows moderate, and the score of 34-50 shows high level of perceived self-efficacy [19]. After obtaining legal permissions from the relevant authorities, the researcher referred to the medical centers in different shifts and distributed the questionnaires among all qualified nurses for this study. After two hours, the researcher collected the filled out questionnaires.

The data were analysed using SPSS version 16.0. The relationships between main variables of the study including moral distress and self-efficiency level were analysed based on average and using Pearson’s correlation coefficient. p<0.05 was considered as significant.

Average age of nurses participating in this study was 36.7±7.5 years and the majority of them were female (70%). Work experience of the nurses was 1-23 years with mean and SD of 7.3±6.3. The majority of nurses had BA (91%) and MA (6.7%) and worked in rotating shifts (63.34%). [Table/Fig-1].

The results showed that the mean frequency and intensity of moral distress form total score of 96 were 47.4±14.12 and 46.4±16.13, respectively. And the mean self-efficacy from total score of 50 was 28.6±3.51 and all the three variables were at moderate level in the majority of participants [Table/Fig-2].

There is a negative significant relationship between intensity of moral distress and self-efficacy (p=0.03 and r=-0.19) and between frequency of moral distress and self-efficiency (p=0.03 and r=-0.14). In this way, an increase in intensity and frequency of moral distress decreases the level of perceived self-efficacy in nurses [Table/Fig-3].

The results of this study showed that the Intensity of moral distress and Frequency of moral distress of nurses in educational-medical centres of critical care units of the selected hospitals affiliated to Tehran University of Medical Sciences were 46.4±16.13 and 47.4±14.12 which is compatible with the results of the study of Ebrahimi H et al., [20]. The study of Corley MC et al., reported the level of moral distress of nurses working in ICU as moderate-to-high [21]. Also, the study of Elpern EH et al., reported the level of moral distress in Medical Intensive Care Unit (MICU) as 3.66 out of 7 [22]. Another study by Maiden J et al., estimated the average distress of nurses in ICU as 3.89 out of 7 [23] which is compatible with the results of the present study.

Norman LD et al., in a study reported that the level of moral distress of nurses as high and the relationship between moral distress and quitting the job as positive [24]. Cummings CL, also reported the relationship between moral distress and tendency to quit the job as positive [25]. According to Ebrahimi H et al., the major sources of job stress for nurses, especially ICU nurses, is overwork, job difficulty, conflict with coworkers and authorities, insufficiency of staff and resources, emotional demands of patients and their families and facing with death and loss of patients. The findings of the present study are nearly in the same line with the above results [26]. Papathanassoglou ED et al., reported the moral distress of nurses of ICUs as moderate (73/67±39/19) [27]. The results of the study of Maiden in United States of America showed that the average moral distress of nurses working in ICUs was 3.89 out of 7 [23]. The results of the previous study showed that the average intensity and frequency of moral distress of nurses were in moderate range, which was in agreement with the present study. As there is an increase in intensity and frequency of moral distress there is decrease in the level of perceived self-efficacy of nurses. Contrary to the result of this study Hosseini M and Azimzadeh E, rated the self-efficacy score of nurses in Critical Care Units, emergency Wards and surgical wards of the Naft Hospital between 19 and 29 (29.82±4.66). According to the results of his study, 83.7% of the nurses in the study had a high average self-efficacy score (score 25), and only 16.3% had a self-efficacy score less than the average [28], which contradicted the results of the study. This study can be used to differentiate the facilities available in educational hospitals in Tehran and Naft Hospital, as well as because of the differences in the tools used, because the General Self-Efficacy Questionnaire (GSEQ) was used in that study, but Riggs et al., ‘S self-efficacy questionnaire was used in present study. It was used to perceive individual self-efficacy in the field of education in addition, only Critical Care Units (ICU, CCU, and dialysis) has been studied in present study, while in the study conducted by Hosseini M and Azimzadeh E, in addition to Critical care units, the surgery wards and the emergency wards were also considered [28].

In this study, a negative significant relationship was observed between moral distress and self-efficiency of nurses. The results of the study of Leggett JM et al., also showed that teaching self-efficiency skills for 60 minutes in a day for a month significantly decreased the moral distress of nurses working in burn intensive care units [29].

This study was conducted in small population of nurse’s critical care unit and there is need to be known about the Moral Distress and its effects on self-efficacy of the all nurses working in hospitals affiliated to Tehran University of Medical Sciences.

The present study showed that there is a significant negative relationship between moral distress and the level of perceived self-efficacy. The complexity of the work done by ICU nurses and also their daily facing with moral distress, it is recommended that healthcare system should employ strategies for reducing and controlling moral distress in nurses to prevent occurrence of undesired negative consequences like decreased level of self-efficacy in them.