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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 147-153

Assessing nurses' moral distress and patients' satisfaction with the observance of the patients' rights charter


1 Department of Nursing, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2 Student Research Committee, Shoushtar Faculty of Medical Science, Shoushtar, Iran
3 Department of Nursing, Shoushtar Faculty of Medical Sciences, Shoushtar, Iran

Date of Submission04-Apr-2018
Date of Acceptance15-May-2018
Date of Web Publication13-Aug-2018

Correspondence Address:
Mrs. Akram Hemmatipour
Master of Nursing, Department of Nursing, Shoushtar Faculty of Medical Sciences, Shoushtar
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JNMS.JNMS_1_18

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  Abstract 

Context: Patient's rights are one of the most fundamental rights that should be considered by the health-care providers, especially nurses. On the other hand, moral distress in nurses can lead to problems in the provision of health services for patients.
Aims: This study aimed to determine the correlation between nurses' moral distress (NMD) and patients' satisfaction with the observance of the patients' rights charter (PRC).
Setting and Design: In this descriptive-analytic study, 82 nurses were selected using purpose-based method, and 200 patients were selected in quotas in proportion to the number of beds available in the general and special wards in 2 months.
Materials and Methods: Data collection tools consisted of demographic information form, the moral distress scale-revised, and a researcher-made questionnaire on patient satisfaction with the observance of PRC.
Statistical Analysis Used: Data were analyzed using descriptive statistical in SPSS version 16.
Results: The mean score of moral distress in nurses was11 ± 33 that 59 (72%) of them had moderate distress level and the mean score of satisfaction with the observance of the charter of patients' rights was 71.6± 18.2. It was found that 120 (60%) of the patients had a satisfactory moderate level of the observance of their rights charter. There was a reverse statistically significant positive correlation between NMD and satisfaction with the observance of the PRC (P < 0.05).
Conclusion: In the present study, it was found that there is a moderate correlation between the patients' satisfaction with the observance of the PRC and the NMD.

Keywords: Moral distress, Patient satisfaction, Patients' rights charter


How to cite this article:
Rokhafrooz D, Hatami A, Hemmatipour A, Abdolahi-Shahvali E, Salehi Kamboo M. Assessing nurses' moral distress and patients' satisfaction with the observance of the patients' rights charter. J Nurs Midwifery Sci 2017;4:147-53

How to cite this URL:
Rokhafrooz D, Hatami A, Hemmatipour A, Abdolahi-Shahvali E, Salehi Kamboo M. Assessing nurses' moral distress and patients' satisfaction with the observance of the patients' rights charter. J Nurs Midwifery Sci [serial online] 2017 [cited 2019 Jun 15];4:147-53. Available from: http://www.jnmsjournal.org/text.asp?2017/4/4/147/238918


  Introduction Top


Ethics has a special place in the healthcare and treatment field,[1] and hence that the basis of this care is respect for the patient's dignity and consciousness.[2]

In 2002, the patients' rights charter (PRC) was first issued by the Ministry of Health of Iran[3] and edited and revised in 2009. In this new version, patients have five rights as follows: receiving favorable services; receiving information in an appropriate and adequate manner; selecting and deciding freely for receiving health services; respecting the patient's privacy rights and principle of confidentiality; and accessing an effective system for handling complaints.[4]

Although informing the PRC is a valuable measure for realizing patients' rights, the degree of observance of patients' rights in medical centers is different.[5],[6]

Hospitals should provide appropriate conditions for patients' care, understanding, and respect for their rights as well as the care team.[7],[8] Indeed, if the PRC is properly implemented and complied with, and leads to the patients' satisfaction, the working relationship between the medical and nursing staff with the patient will be improved, and patient recovery will be accelerated.[9] Failure to observe patients' rights and their dissatisfaction with the provided services will slow down the improvement, increase hospitalization, irritability, and increase the cost of patient treatment. Therefore, increasing the observance of patients' rights is one of the important goals of therapy group activities, which plays a significant role in improving the health of the patient.[10] Since observing patients' rights is one of the most important components of providing humanitarian and moral care, nurses are not able to face up to the challenges ahead without being aware of ethical concepts. On the other hand, nurses spend the most of their time in the clinic, which causes changes in moral problems and increases their ethical challenges.[11],[12]

For this reason, the American Nursing Association has provided moral codes for nursing activities and services, which are guides for the nurses' moral behaviors.[13] One of the ethical challenges in nursing is moral distress, and it is known as a phenomenon that impedes the proper ethical functioning of individuals, despite having the necessary knowledge.[14] Moral distress is created when the situation is opposed to individual beliefs and internal moral values, and person should act against these values as a result of those real conditions and limitations.[12] Occasionally, distresses occur in the form of behavior that a person, due to the fundamental moral distress and subsequent negative emotions, cannot continue to work.[15] The consequences of moral distress occur seriously and gradually, and in most cases, nurses not only do not have preventive strategies but also do not find it.[16]

The occurrence of moral distress can lead to different outcomes for nurses, patients, and health organizations.[12] The negative consequences of this ethical problem can lead to anger, disappointment, discomfort and feelings of inferiority, and unpleasant emotional state for the nurses, and in addition, accompanied by medical errors, burnout, career abandonment, and increased violence and disruption of the ethical atmosphere in the workplace and inappropriate observance of the charter of patients' rights and the reduced quality of health-care provision.[17],[18],[19],[20] Similarly, Pauly et al. reported a moderate moral distress in nurses.[21]

Therefore, considering the nurses' moral distress (NMD) to provide satisfactory services to patients, paying attention to patients' rights is one of the priorities of hospitals and other health service providers. Consequently, it is desirable to consider this as an essential component of the clinical service standards Therefore, it is desirable to consider this as an essential component of the clinical services standards. This study aimed to determine the correlation of NMD with patients' satisfaction with the observance of the PRC in Khatam Al-Anbia Hospital, city of Shushtar, Iran in 2017.


  Materials and Methods Top


The present study is a descriptive-correlational study that was conducted in Khatam Al-Anbia Hospital in Shushtar during 3 months from October to December 2017. The study population included two groups of nurses and patients. Patient sampling has been quotas among the patients admitted in general (internal, surgical, and neurology) and special wards (coronary care unit [CCU] and dialysis). According to the number of beds in each ward, the number of patients in that ward was selected. According to the similar studies[22] and considering a drop of 15%, 200 patients with inclusion criteria (the conscious desire to participate in the study, at least 18 years and up to 60 years of age, no mental illness, hospitalization duration at least 24 h, and being able to cooperate) were selected. Nurses were selected in a purpose-based manner with informed consent, 82 nurses were willing to attend. Furthermore, exclusion criteria for nurses and patients included the lack of response to the questionnaire.

Data gathering tools were a demographic information form, a standard questionnaire on moral distress scale (MDS-R), and a researcher-made questionnaire on patients' satisfaction with PRC, each containing two parts.

The demographic information form for patients included age, gender, educational level, occupation, and the hospitalization duration; and for nurses, it included age, gender, marital status, work experience, type of shift, and work department.

To investigate moral distress of nurses, the 18-statement MDS-R developed by Hamric et al. (2012) was used. The scoring is based on the five-degree Likert scale as follows: very high (4), high (3), moderate (2), low (1), and none (0), which is assessed two levels of distress as follows: intensity and frequency. In this tool, the number 5 represents the highest amount of moral distress, and the number 0 indicates the absence of moral distress. Given that, each item can include a range of 0–16 points, the total score for the intensity and frequency of moral distress is 0–288. Intensity and frequency of moral distress are assessed at low levels if scores are between 0 and 96. Scores between 97 and 192 show the intensity and frequency of moral distress at an average level. Scores between 193 and 288 show the intensity and frequency of moral distress at a high level. Hamric, Borcrose, and Epstein (2012) assessed its content validity, and the correlation of this tool was R = 0.22, and its reliability using Cronbach's alpha was 0.89. In the study conducted by Abbaszadeh et al., theo validity of this questionnaire was desirable, and its reliability calculated using the internal consistency method (Cronbach's alpha coefficient) was 0.93.[23]

To assess the satisfaction of patients, a researcher-made questionnaire on compliance with the rights charter, containing 23 questions, was used based on the guidelines established by the World Health Organization and the patients' rights book in Iran. The questionnaire's axes included first, getting the optimal healthcare is a right for the patient; second, the information should be provided to the patient in a satisfactory and sufficient manner; third, the right to choose and decide freely on the receipt of healthcare should be respected; fourth, the provision of health services should be based on respect for patient's privacy and adherence to the principle of confidentiality; and fifth, access to an effective system for dealing with complaints is a right for the patient. The scoring in the questionnaire was very good (5), good (4), medium (3), low (2), and very low (1) based on the five-degree Likert scale. The scores range is from 115 to 23, so that the range of 23–53 is weakness level, 54–83 is average, and 84–115 is good.

In addition, the validity of the questionnaire of the PRC was determined by the content and formal validity methods. The questionnaires were distributed among 10 faculty members related to the study topic, so that content, clarity, and simplicity of each of the tool statements were refereed and reviewed after applying corrective comments. For determining formal validity, the questionnaires were given to five patients who had the characteristics of entering into the study to assess the perceived ability and ease of use. After applying corrective comments, questionnaires were used for the present study. Furthermore, to determine the reliability, the questionnaires were distributed among 20 hospitalized patients and the internal consistency (Cronbach's alpha) obtained was α = 0.84.

To observe the moral considerations, the researcher, with the permission and coordination required by the vice-chancellor for research of Shushtar Medicine School, and with the possession of a research note, referred to the wards of Shushtar Khatam Al-Anbia Hospital and performed the necessary coordination. Then, the researcher arrived at the hospital for 3 months in different shifts and attended the bedside of patients. In addition to introducing herself and expressing the goal, and after obtaining informed written consent, the PRC questionnaire was completed by the patient in the case of the patient self-mastery to complete the questionnaire, and in the case of the inability of each of patient, they were completed by the researcher using interviewing. The researcher provided moral distress questionnaires to qualified nurses and emphasized the completion of questionnaires to complete the same shift. In case of any questions or problems regarding the questionnaire questions, the researcher did the necessary steps to resolve the ambiguity. Data normality was evaluated and confirmed using Kolmogorov–Smirnov test. Data were analyzed using descriptive statistical methods (mean, median, standard deviation, etc.), ANOVA, Chi-square, and independent t-tests in SPSS version 16 with a statistically significant level of 0.05.


  Results Top


The study population was inpatients and nurses. The nurses' mean age was 32 5±/2 and their working experience was 9.5 ± 4.5. The majority of them, i.e., 71 (86%) were the nurses with rotation work shift hours. The mean age of the patients was 29.07 ± 7.22. A total of 34 patients (12%) were admitted for the first time [Table 1].
Table 1: Frequency of demographic variables studied and its relationship with the level of the patients' rights charter and the nurse's moral distress

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The average score of satisfaction with the PRC was 71.6 ± 18.2 and severity, and frequency of NMD was 33 ± 0.11 [Table 2].
Table 2: The mean and standard deviation of patient rights charter dimensions and the nurses moral distress

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The results of this study showed that 120 patients (60%) had a moderate satisfaction, and regarding moral distress, 59 (52%) nurses had a moderate level of distress [Table 3].
Table 3: The frequency of levels of patient's satisfaction with the patient's rights charter

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Using independent t-test, there was no significant difference between NMD and demographic variables of gender, service ward, marital status, type of responsibility, and work shift (P > 0.05). Furthermore, there was no statistically significant relationship between the satisfaction with the PRC and with the education level (P = 0.023), the number of hospitalization days (P = 0.44), and gender (P = 0. 29). Meanwhile, there was a significant difference between the satisfaction with the PRC and the different hospital wards (P = 0.03). The results also showed that the highest level of satisfaction was related to the CCU ward with a mean of 68.35% and the lowest level of satisfaction was in a dialysis ward with a mean of 59.36% [Table 1].

Using Pearson correlation coefficient, there was a negative significant moderate correlation between the nurses' ethical distress and the patients' satisfaction with the PRC (P < 0.001; R = 0.606). Hence, with the increase in the level of the nurses' ethical distress, the satisfaction rate of patients has decreased from the PRC. In examining the dimensions of the PRC, it was found that there was a statistically significant intense correlation between receiving the optimal health care (P < 0.001; R-0.909) and access to information (P < 0.001; R = 0.235). There was a weak correlation between respect for the privacy of the patient and respect the principle of secrecy (P < 0.026; R = 0.267). There was a statistically significant moderate correlation between access to an effective complaints handling system (P < 0.001; R = 0.403) and respect for right to choose (P < 0.001; R = 0.416) with moral distress [Table 4].
Table 4: Pearson correlation coefficients of dimensions of the patient's rights charter with the nurse's moral distress level

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Using regression, the results showed that the coefficient of determination with the enter method of repeated combination for a linear combination of dimensions of the PRC with the NMD was 48%. In fact, predictive variables in this study could predict 48% of moral distress in the nurses [Table 5].
Table 5: The result of the regression of the dimensions of the patient's rights charter on the nurse's moral distress

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  Discussion Top


This study was conducted to investigate the relationship between the nurses' ethical distress and patients' satisfaction from the observance of the PRC. The results of this study showed that the overall mean score of moral distress in two levels of frequency and severity indicated a moderate level in nurses, which is consistent with the study by Sadeghi et al. (quoted by Shakeriniya), who showed that nurses participating in their study, endured moderate intensity of distress regarding frequency and severity.[13] It should be noted that in the study by Joolaee et al., the severity of moral distress of nurses was moderate and its frequency was at high level.[24] In the study by Elpern et al., the severity of tension among the 28 nurses participating in their study was in the moderate level.[25] However, in the median study in the United States, the level of moral distress of nurses was at a low level[26] and in the studies by Keighobadi, and Redman and Fry, the NMD was at high level,[27],[28] which is not consistent with the present study. It can be said that various factors such as pressure and workload, lack of time, workplace, economic status and the workplace facilities, and organizational rules and regulations, and nurses' ignorance of how to deal with the issue of moral distress can play a role in this regard.[24] Furthermore, there was no significant relationship between demographic variables with moral distress level in the present study. However, in the study by Keighobadi,[19] there was a significant statistical relationship between the work ward and in Sahebazzamani's study,[29] there was a statistical correlation between the work shift and the level of NMD, which is not consistent with the present study. The reason for this inconsistency with the present study can be stated that in the reviewed studies, by cause of the low number of nurses and the high workload in the wards, nurses have higher moral distress. Furthermore, at evening and night work shifts, nurses have the lowest level of individual competency, and in the morning, they had the highest rate of this competency. Providing a regular work plan to nurses, providing rest time during the shift, creating a time-out period decreases stress and work pressures in the evening, and night shift. On the other hand, hospital retraining programs should also be as easy as possible to provide practical and applicable solutions to cope with stress and work tensions. The moral distress of nurses has a negative effect on the quality of nurses' work including patient care. On the other hand, one of the essential aspects of care is respect for patients' rights. Paying attention to patients' rights as one of the criteria for assessing the quality of health services is important and leads to the reduction of physical and psychological injuries, increased care of patients, and improvement of relationships between patients and personnel.[30] In this study, it was found that patients had a relatively satisfactory level of compliance with all aspects of their rights by the medical staff, especially nurses, which is consistent with the study conducted by Asteraki et al., performed on 260 patients.[31] In the present study, the most satisfaction with the first axis was related to the receiving the optimal health care, and the least satisfaction with the third axis was related to the area of respect for the right to choose and decide freely. In the same regard, it is consistent with the study by Astearky et al., Kolahi, and Sohrabi.[31] In the study by Vaskooei Eshkevari et al., patients' satisfaction with the PRC was 53%. The lowest satisfaction was related to the respect for the right to choose and decide freely.[32] In the study by Ghazikhanlo et al., the 130 patients' satisfaction with the PRC was moderate, with the highest satisfaction related to the patient's respect and the least related to the area of access to an effective complaints handling system.[33] However, in the study by Moghaddam et al., 346 patients' satisfaction with the PRC was 53% at the desired level (high). The highest rate of satisfaction was related to receiving the optimal healthcare, and the lowest rate of satisfaction was related to the access to information.[10] Perhaps, the reason for this inconsistency regarding the charter of rights in the studies mentioned is the difference in the sampling environment. The present study was conducted in teaching hospitals. It is also noteworthy that in the governmental hospitals, health services are provided by nursing students, their lack of knowledge, and attitude toward patient's rights can reduce the patient satisfaction, and some aspects of the charter have been subjected to some restrictions. In the study of the underlying factors affecting the patients' satisfaction with the observance of the PRC in this study, there was a significant correlation with the hospitalization ward, which is consistent with the study by Gashmard et al.[34] and Mack et al.,[35] but differ regarding the type of ward. In the present study, the highest satisfaction rate was observed in CCU patients and the least in dialysis patients. Perhaps, the reason for this difference in rate of the satisfaction with wards in the studies is due to the number of nurses and due to the type of illness and high stress present in some wards. The present study showed that there is a significant negative correlation between nurses' ethical distress with the observance of the PRC, so that with increasing distress, the satisfaction level of patients has decreased. In this study, there is a strong correlation between satisfactions with ethical distress; furthermore, there is a weak correlation between satisfaction with respect to privacy and access to information. In the same way, Cynthia's study showed a significant correlation between nurses' ethical distress and patient care.[33] However, there was no significant correlation between the ethical distress of nurses and patient care in the study by Azarm.[30] In the study by Mohammadi et al., there was a significant correlation between the ethical sensitivity among the 130 nurses and the observance of the PRC.[36] The reason for this difference was the nurses' work competency, the differences in the service wards and the underlying and ethical problems of nurses.

Some of the limitations of this study were as follows: patients' and nurses' failure to express their real opinions and disappointment about the impact of such research; in this way, the problem of collaboration was somewhat solved by explaining more about the impact of research results and its practical use.


  Conclusion Top


In general, correlation of the patients' satisfaction with the PRC and the NMD is moderate. Therefore, to increase the patients' satisfaction with the PRC, understanding of the root causes of moral distress in nurses and organizing training courses and more justifying nursing staff and students are suggested.

Conflicts of interest

There are no conflicts of interest.

Authors' contributions

All authors contributed to this research.

This study was financially supported by Research of Shushtar Medical School.

Financial support and sponsorship

This study was financially supported by Research of Shushtar Medical School.

Acknowledgment

The authors would like to thank the vice-chancellor for research of Shushtar Medicine School, as well as the dear nurses and patients participating in this study.

 
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