Introduction
Moral distress (MD) is the distress experienced due to an individual’s inability to perform the right action despite knowing the right action due to regulations and restrictions [1, 2]. MD occurs when the individual is unable to act with ethical perceptions and is caused by factors such as political, administrative, and institutional structures; clinical practices and lack of communication within the team, individual values and professional values conflict [3, 4]. MD, which has many levels of sources, can affect nurses physically, psychologically, socially, and spiritually [5].
The impact of MD on nurses, the organization and patients is detrimental. However, it should be noted that new graduate nurses who experience a critical transition period in establishing their professional identity constitute a very special population. The transition from student to professional nursing is a critical period for newly graduated nurses (NGNs) in terms of professional growth and integrating the values acquired in education with clinical practice [6, 7]. During this period, NGNs face transition period specific ethical and moral issues [8] and challenges such as balancing personal values and professional requirements, reflecting theoretical knowledge into practice, and managing patient care and workload [9, 10]. The formation of professional identity, which involves internalizing professional roles, responsibilities, and ethical standards, is a fundamental component of this transition. NGNs must navigate their evolving identity as professionals while adapting to the demands of clinical practice, which can create additional stressors and uncertainties [7, 11].
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It is important to note that NGNs may be more vulnerable to MD in ethical decision-making processes due to several factors. These include limited clinical experience, low self-confidence, inadequate professional judgment, limited ethical knowledge and fear of exclusion. As a result, their capacity to take the right action may be reduced [7, 12, 13]. Studies show that MD levels tend to decrease as professional experience increases [14‐16], suggesting that the challenges encountered during the transition period shape the ethical decision-making skills of nurses in later years. Moreover, the experiences of MDs during nursing education can create a foundational background for dealing with ethical dilemmas in professional life [17, 18]. Therefore, supporting nurses in coping with MD is crucial [19, 20], especially in the first years of their career when ethical values are internalized and reflected in behaviors [21].
MD in nursing is a recognized concept, research examining the MD experiences of NGNs during the transition from student to professional roles is limited [7, 22]. Moreover, most studies either focus only on the frequency and levels of MD (quantitative approaches) or explore personal accounts of ethical dilemmas (qualitative approaches). However, a mixed-methods approach is required to comprehensively understand not only the prevalence and intensity of MD, but also the lived experiences, coping strategies and contextual factors that influence MD in NGNs. The mixed methods design allows for the integration of statistical data to identify levels and predictors of MD while simultaneously capturing in-depth experiences through qualitative insights. This combined approach provides a more nuanced and holistic understanding of the phenomenon, helping to develop tailored interventions and support mechanisms for NGNs [7, 21, 22].
In this context, this study aims to explore transitional MD experiences, identify levels of MD, identify predictive factors and provide a comprehensive understanding of how nurses overcome ethical challenges and develop resilience in clinical practice through a mixed-methods approach bridging quantitative assessments and personal experiences. Strengthening professional identity early in the career can help NGNs gain confidence in their role, reduce MD and develop a sense of belonging within the profession.
Methods
Study design
This study was conducted using a convergent parallel design approach. In this design, quantitative and qualitative data collection processes are conducted simultaneously, and both methods are equally important [23]. The quantitative phase of the study is predictive, and the qualitative phase is based on a descriptive phenomenological approach. The data were analyzed independently, and the findings were combined to interpret the research.
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Study settings and participants
The study population consisted of NGNs who started working in public and private hospitals in Turkey. The sample was reached by using purposive and snowball sampling approaches. The inclusion criteria were to volunteer to participate in the study to have started to work in one of the private, training and research, and university hospitals within 18 months (The transition from novice to competent nursing model of Schoessler and Waldo (2006) [21] was taken as a basis in determining the time period), and to be working as a clinical nurse. The exclusion criteria were as follows: working as a manager nurse (care services manager, assistant manager), working as a special unit nurse (education nurse, quality unit employee, infection nurse, etc.), having more than six months between starting work and graduation, and being included in the final year student sample of this study during the student period.
Quantitative phase
G*Power 3.1.9.2 program was used to calculate the sample size [24]. Through linear multiple regression fixed model r2 deviations from zero statistical tests, 204 NGNs were planned to be included in the sample by accepting the effect level as medium (0.15), power level as 95%, and significance level as 0.05. The study was completed with 205 newly graduated nurses.
Qualitative phase
The data collection phase was completed when qualitative data saturation was reached. The study was completed with 25 NGNs from five different cities and 11 different institutions.
Instruments
The study data were collected using the Newly Graduated Nurse Descriptive Data Form and MD Scale for Healthcare Professionals (MDS-HP) for the quantitative phase and the Newly Graduated Nurse Semi-structured Questionnaire for the qualitative phase.
Newly graduated nurse descriptive data form
This form, developed by researchers, consists of 16 questions designed to assess sociodemographic characteristics, professional attributes, additional ethics-related training outside the standard curriculum, and subjective perception of professional competencies (appendix).
Measure of moral distress for healthcare professionals
It was developed by Epstein et al. in 2019 to determine the MD levels of health professionals, and Cronbach’s alpha value was 0.93 [9]. The Turkish adaptation of the scale was conducted by Kovancı and Atlı Özbaş in 2023, and Cronbach’s alpha value was 0.93 [16]. The scale consists of 27 items and four sub-dimensions. The two-dimensional scale is administered in two columns. The first column measures the intensity level of MD, and the second column measures the frequency level of MD using a 5-point Likert scale. A total of 0-108 points are obtained from the frequency and intensity sections of the scale. In evaluating the scale, the frequency and intensity scores are multiplied to obtain a total MD score in the range of 0–16, and the scale’s total score ranges between 0 and 432.
New graduate nurse semi-structured questionnaire
The researchers developed the interview form to determine the MD experiences of the NGNs and their feelings and thoughts about these experiences and included ten open-ended questions (appendix).
Data collection
Quantitative data were collected online via Google Forms link between October 2023 and July 2024. At the end of the forms, participants were invited to participate in an interview. Interviews were organized according to the email or phone number provided by participants. In-depth one-on-one interviews were conducted via Zoom® online video conferencing platform. To assess the applicability of the semi-structured form, a pilot interview was conducted with two participants who met the inclusion criteria and were not included in the sample. The interviews continued until no new data on the research topic were obtained, and data saturation was considered to have been reached. In the twenty-second interview, the researchers stated that no new data existed. However, three more confirmatory interviews were conducted to confirm that no new data had emerged [25]. In-depth interviews lasted between 35 and 82 min (mean 54 min).
Data analysis
Statistical analyses of the quantitative data were performed using the IBM SPSS version 23 program. The data were analyzed to meet the assumption of normal distribution using the Kolmogorov-Simirnov test, and kurtosis and skewness values were found to meet the assumption of normal distribution. Simple linear and multiple linear regression analyses were conducted to determine the effect of participants’ identifying characteristics on MD scores. MAXQDA version 18 software was used to analyze qualitative data. Colaizzi’s seven-stage analysis approach was applied to provide a systematic framework.
Rigor
This study’s rigor was ensured to align with the credibility, transferability, confirmability, and dependability criteria proposed by Lincoln and Guba [26]. Credibility was reinforced by a structured data collection and analysis approach, with two researchers independently analyzing the data. Participant triangulation included individuals from five cities and 11 institutions, offering varied perspectives on MD among NGNs. Transferability was supported by detailed documentation of sampling, data collection, and analysis methods. Consistency was ensured by using a uniform semi-structured interview form, noting key participant statements, and maintaining a research log. Dependability was strengthened through evaluation by two experienced researchers and iterative consensus on findings during data collection and analysis.
Reflexivity
The research team consisted of two nurse academics with qualitative research experience. The researchers provided interaction awareness to minimise the impact of their own biases on data interpretation and allowed participants to freely express their experiences by using open-ended questions in the interviews. They kept a research diary to maintain objectivity and supported data analysis with multiple perspectives to increase the reliability of the findings.
Mixed methods legitimation
The study’s rigor was ensured using the 11 legitimation criteria developed by Johnson, Onwuegbuzie, and Johnson (2006). The definitions and application strategies of the legitimation criteria used in the study are provided in the appendix.
Result
Quantitative results
The mean MD score was 6.55 ± 3.51. MD frequency score was moderately low (1,94 ± 0,84), and MD intensity score was moderately high (2,77 ± 0,82). In addition, the root causes that cause MD most frequently (2.53 ± 0.91) and most intensely (3.10 ± 0.84) were found in the sub-dimension of root causes at the system level (appendix) (Table 1).
Table 1
Descriptive characteristics of the participants (n = 205)
Variable | n (%) | x̄ ± Sd | Min-Max | ||
|---|---|---|---|---|---|
Age | 24,15 ± 1,25 | 22–27 | |||
Professional working time (months) | 8,20 ± 5,99 | 1–18 | |||
Gender | |||||
Female | 155 (75,6) | ||||
Male | 50 (24,4) | ||||
Marital status | |||||
Single | 195 (95,1) | ||||
Married | 10 (4,9) | ||||
Education status | |||||
Bachelor’s degree | 168 (82,0) | ||||
Postgraduate education (ongoing) | 37 (18,0) | ||||
Hospital type | |||||
Public hospital | 97 (47,3) | ||||
University hospital | 61 (29,8) | ||||
Private hospital | 47 (22,9) | ||||
Working clinic | |||||
Internal medicine clinic | 81 (39,5) | ||||
Surgical clinic | 27 (13,2) | ||||
Intensive care clinic | 71 (34,6) | ||||
Emergency service | 26 (12,7) | ||||
Education on ethical issues | |||||
Only before graduation | 153 (74,6) | ||||
Both before and after graduation | 52 (25,4) | ||||
Level of self-confidence in solving ethical problems | 6,66 ± 1,77 | 3–10 | |||
The level of thinking that the legal regulations related to the profession are mastered | 5,88 ± 1,97 | 1–10 | |||
Level of feeling empowered in the profession in ethical and moral situations encountered | 5,24 ± 2,25 | 1–10 | |||
Level of subjective perception of fulfilling the caregiver role | 7,39 ± 1,76 | 1–10 | |||
Level of subjective perception of fulfilling educator role | 6,95 ± 1,77 | 2–10 | |||
Level of subjective perception of fulfilling researcher role | 6,93 ± 2,00 | 1–10 | |||
Level of subjective perception of fulfilling advocate role | 6,54 ± 1,99 | 1–10 | |||
Level of subjective perception of fulfilling manager role | 5,76 ± 2,14 | 1–10 | |||
Total | 205 (100) | ||||
Variables insignificant in the bivariate linear regression analysis were not included in the multiple regression analysis (appendix). Gender, type of hospital, years of experience in the profession, caregiver and manager role level of subjective perception of fulfillment levels significantly predicted the total score of MD (p < 0.001). Being female, working in a private hospital, having more experience, and performing the caregiver and manager role less frequently increased MD (Table 2).
Table 2
Multiple linear regression analysis results of newly graduated nurses
MMD-HP-Total | MMD-HP - Frequency | MMD-HP - Intensity | ||||
|---|---|---|---|---|---|---|
β (SH) | t (p) | β (SH) | t (p) | β (SH) | t (p) | |
Constant | 280,773 (26,79) | 10,47 (< 0,001) | 73,305 (8,77) | 8,12 (p < 0,001) | 104,00 (4,23) | 24,56 (p < 0,001) |
Gender (reference: Female) | -43,99 (12,23) | -3,59 (< 0,001) | -9,81 (3,56) | -2,75 (0,006) | -17,10 (2,25) | -7,57 (p < 0,001) |
Type of hospital (Reference: Public hospital) | ||||||
Private hospital | 45,84 (11,59) | 3,95 (< 0,001) | 8,09 (3,41) | 2,32 (0,021) | 8,55 (2,28) | 3,74 (p < 0,001) |
Working clinic (Reference: Intensive care clinic) | ||||||
Emergency service | -11,70 (15,14) | -0,77 (0,440) | -4,99 (4,51) | -1,10 (0,271) | -0,16 (0,16) | -0,05 (0,958) |
Professional working time | 4,97 (0,82) | 5,99 (< 0,001) | 1,31 (0,24) | 5,38 (< 0,001) | 1,01 (3,0) | 6,04 (p < 0,001) |
Education on ethical issues | 5,08 (0,24) | 1,50 (0,135) | ||||
The level of thinking that the legal regulations related to the profession are mastered | -1,86 (0,66) | -2,79 (0,006) | ||||
Level of feeling empowered in the profession in ethical and moral situations encountered | -0,23 (053) | -0,43 (0,670) | ||||
Level of subjective perception of fulfilling caregiver role | -10,02 (2,96) | -3,38 (< 0,001) | -2,67 (0,87) | -3,06 (< 0,001) | ||
Level of subjective perception of fulfilling advocate role | 1,45 (2,97) | 0,49 (0,625) | -0,22 (0,92) | -0,24 (0,981) | -1,69 (0,65) | -2,59 (0,010) |
Level of subjective perception of fulfilling manager role | -7,23 (2,90) | -2,49 (0,014) | -0,87 (0,87) | -1,00 (0,315) | -1,79 (1,39) | -2,94 (0,003) |
Regression Model Statistics | R: 0,570; R2: 0,325; F: 13,560 (p < 0,001) | R: 0,486; R2: 0,236; F: 7,588 (p < 0,001) | R: 0.643; R2: 0.414; F: 17,295 (p < 0,001) | |||
Qualitative results
The majority of the participants were female; less than half had postgraduate education, and more than half had less than one year of professional experience. Most of them work in private/foundation hospitals and internal medicine wards. Most of the participants received only pre-graduation ethics education (appendix). Four themes and 16 sub-themes were identified. (Table 3).
Table 3
Themes, sub-themes and codes related to moral distress experiences of newly graduated nurses
Themes | Sub-themes | Open codes (n (%)) |
|---|---|---|
Causes of moral distress in new graduate nurses | Violation of Ethical Principles | 1. Unnecessary treatment and triggering (18 (72%)) |
2. Futile treatment (16 (64%)) | ||
3. Intervention in treatment for the benefit of the patient (13 (52%)) | ||
4. Requesting preferential care for VIP patients (13 (52%)) | ||
5. Interference with medical records (10 (40%)) | ||
6. Failure to care for the patient at the end of life (9 (36%)) | ||
7. Implementation of DNR (9 (36%)) | ||
8. Offering privileged facilities for VIP patients (8 (32%)) | ||
9. Violation of the principle of integrity (8 (32%)) | ||
10. Violation of patient privacy (7 (28%)) | ||
11. Unnecessary physical or medical fixation (6 (24%)) | ||
12. Having the informed consent form signed without explanation (5 (20%)) | ||
13. Applying to patients to practice (4 (16%)) | ||
Team-based Causes | 1. Working with unqualified nurses (13(52%)) | |
2. Lack of communication within the team (11 (44%)) | ||
3. Not being supported by colleagues (9 (36%)) | ||
4. Value differences within the team (7 (28%)) | ||
5. Working with unqualified physicians (5 (20%)) | ||
6. Authoritarian ethical climate (5 (20%)) | ||
Institutional/Administrative Causes | 1. Manager who does not have adequate equipment and managerial skills (19 (76%)) | |
2. Management ignoring ethical and moral problems (16 (64%)) | ||
3. Lack of communication with management (15 (60%)) | ||
4. Management has expectations beyond the job description (11 (44%)) | ||
5. Frequent rotations that may affect the quality of service (7 (28%)) | ||
6. High paperwork burden (6 (24%)) | ||
7. Giving more importance to paperwork than maintenance (5 (20%)) | ||
System-based Causes | 1. Low number of nurses (23 (92%)) | |
2. Inadequate supply of materials and equipment (16 (64%)) | ||
3. Supply of poor quality materials and equipment (13 (52%)) | ||
4. Non-nursing staff performing nursing duties (10 (40%)) | ||
5. Injustice regarding payments (9 (36%)) | ||
6. Health care based on financial concerns (8 (32%)) | ||
7. High nurse turnover (6 (24%)) | ||
Causes of Being a New Graduate | 1. Feeling vulnerable to managers (17 (68%)) | |
2. Fear of harming the patient due to inexperience and lack of knowledge (13 (52%)) | ||
3. Being bullied by colleagues (10 (40%)) | ||
4. Inability to provide optimal care due to inability to work at the expected pace (9 (36%)) | ||
5. Not being included in the decision-making process (8 (32%)) | ||
6. Their opinions are not valued and listened to (7 (28%)) | ||
The effect of moral distress on new graduate nurses | Physical effects | 1. Sleep disturbance (6 (24%)) |
2. Crying behavior (4 (20%)) | ||
Emotional effects | 1. Despair (16 (64%)) | |
2. Sadness (16 (64%)) | ||
3. Anger (13 (52%)) | ||
4. Inadequacy (11 (44%)) | ||
5. Worthlessness (8 (32%)) | ||
Cognitive effects | 1. Thinking about the event often (8 (32%)) | |
2. Dreaming about the event (5 (20%)) | ||
Professional Impacts | 1. Negative view of the nursing profession (18 (72%)) | |
2. Thought of leaving the job or profession (13 (52%)) | ||
3. Burnout (5 (20%)) | ||
Coping with moral distress in newly graduated nurses | Moral courage | 1. Compensating behavior (13 (48%)) |
2. Communicating the situation to the nurse manager (9 (36%)) | ||
3. Seek legal remedies (5 (20%)) | ||
4. Fulfilling advocacy role (5 (20%)) | ||
Moral resilience | 1. Development in knowledge and skills (17 (68%)) | |
2. Increasing knowledge of laws and regulations (11 (44%)) | ||
3. Moral flexibility (9 (36%)) | ||
4. Increasing psychological resilience (6 (24%)) | ||
Moral Disengagement | 1. Ignoring ethical and moral incidents (7 (21%)) | |
2. Start acting like everyone else (6 (16%)) | ||
3. The idea that managers and supervisors should analyze ethical and moral issues (4 (20%)) | ||
4. The idea that ethical and moral incidents are unsolvable and inevitable (4 (20%)) | ||
Suggestions of new graduate nurses for reducing moral distress | Suggestions for Individuals | 1. Improving communication skills (18 (72%)) |
2. Having knowledge about the regulation and job description (15 (60%)) | ||
3. Developing empathy (11 (44%)) | ||
4. Development of scientific knowledge (9 (36%)) | ||
5. Participation in activities to increase professional competence (6 (24%)) | ||
Suggestions for Nursing Education | 1. Conducting simulation/case studies on ethical issues (16 (64%)) | |
2. Providing practical training on legal issues (11 (44%)) | ||
3. Increasing the quality and quantity of training on ethical issues (9 (36%)) | ||
4. Increasing the adaptation of vocational theoretical training to practice (9 (36%)) | ||
5. Ensuring the provision of qualified and standardized vocational training (7 (28%)) | ||
Suggestions for Institutions | 1. Managerial nurses with adequate equipment and managerial skills (21 (84%)) | |
2. Improving managers’ effective communication skills (19 (76%)) | ||
3. Increasing the quality and quantity of in-service trainings (11 (44%)) | ||
4. Improving corporate governance policies (9 (36%)) | ||
5. Standardization of practices and procedures across institutions (6 (24%)) | ||
6. Arrangement of document loads (5 (20%)) | ||
Suggestions for the system/policies | 1. Increasing the number of nurses (25 (100%)) | |
2. Expansion and clarification of mission statement (14 (56%)) | ||
3. Non-nurse staff not being employed as nurses (11 (44%)) | ||
4. Increased institutional oversight (8 (32%)) | ||
5. Changing the health system based on financial concerns (8 (32%)) |
Theme 1. Causes of moral distress
The factors and situations causing moral distress were addressed in different dimensions. Accordingly, the theme consists of five sub-themes and 39 open codes.
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Subtheme 1: violation of ethical principles
NGNs have witnessed or been involved in various ethical violations throughout their professional lives, which has caused moral distress. In particular, unnecessary treatment practices, violations of professional boundaries, and situations that undermine the principle of justice, such as giving privileged care to VIP patients (The authors use this term to describe patients whose treatment and care are prioritized by management.) are among the leading ethical problems. In conflicted practices such as DNR, the obligation to follow physician instructions and violation of patient autonomy are also frequently experienced. In addition, incidents such as some colleagues recording procedures that were not performed and violating patient privacy have been a source of moral distress.
The patient will not get better, so we are waiting for the patient to die. Unfortunately, unnecessary treatments and unnecessary practices that cause more pain and suffering are carried out in these patients. I think this is against human dignity. (Y21)
Sometimes, some people or their relatives (VIP patients) are admitted to the clinic. At those times, they tell us that we should be more careful and take better care of those patients (management). Sometimes, they say that a nurse should only care for that patient and nothing else. They especially chose nurses with more experience than us. (Y17)
Sometimes, because the patient is special (referring to VIP patients), we may have patients who go for frequent blood tests, tomography, or ultrasound every other day, even though they do not need any tests. (Y19)
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The patient was in prolonged apnea. At first, I thought we would intervene, but the doctor and supervisor sat down. We waited inside for about 50 min. They made me turn off the supports. This felt very wrong to me and made it worse. It was as if he had the gun in one hand, but someone else was pulling the trigger. This disturbed me for a while. (Participant’s DNR experience Y22)
I didn’t understand, of course, others understood, which patient was going to die. Then, they would stop the care of the patient a little bit. So, it was not as much as the care given to a patient who could have been better. This made me feel very bad. I mean, something had to be done, but it wasn’t being done. I couldn’t do anything either. I was very stressed and tired, but it bothered my conscience. (Y2)
Subtheme 2: team-based causes
The nurses stated that working with colleagues with insufficient theoretical knowledge and ethical understanding had negative effects and that lack of communication within the team disrupted patient care and caused harm to patients. It was emphasized that lack of support was an obstacle to correcting ethical problems and that team members became insensitive to moral issues. In addition, the existence of an authoritarian ethical climate in which ethical decisions are only under the control of the physician was expressed.
For those colleagues of mine, nursing is just to be there for the day, and if a patient doesn’t die, it’s okay. So, they did not communicate with the patients. For example, when a patient with psychosis swore at them, they took it personally, got angry, and threatened to put them in isolation. (Y14)
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Everything depends on the words of one person. They want whatever the clinical chief says to be done without questioning whether it is right or wrong. Our opinion is not asked in any way. For example, the patient doesn’t want to take his medicine. (Y14)
Subtheme 3: ınstitutional/administrative causes
Participants stated that managers do not have sufficient equipment and skills, ignore ethical problems, and support the powerful side. NGNs had difficulty communicating with managers and were not listened to. The expectation that they should perform tasks outside their duties led to their neglect of care. Frequent departmental changes made adaptation difficult, while the excessive paperwork burden prevented them from focusing on care services. Services.
None of our administrators are experts in the field of psychiatry and have no idea about the field. However, when you look at it, everyone from the clinic managers to the building supervisors to the managers are midwifery graduates (Y20).
There is no medical secretary in clinic. I have to do their work, too. We do everything from the patient’s admission to discharge. As such, the time I would have spent with my patients is wasted on this kind of work (Y9).
Due to the lack of staff within the hospital, they constantly send me to other clinics for support. I normally work in gynecology, but they send me to other clinics. I don’t know the patients there. I don’t know the treatments. (Y16)
Subtheme 4: system-based causes
NGNs stated that they had difficulty in providing ideal care due to an insufficient number of nurses, lack of materials, and poor quality equipment. Besides, the employment of non-nurse personnel jeopardizes patient safety. Financial concerns in the health system push the quality of care into the background. Wage injustice and high resignation rates negatively affect the functioning and patient safety.
For me to give care, I need certain ingredients. However, the cynic does not have these materials. Every time, I had to collect them from other wards, the intensive care unit, or emergency room. This was a very big deficiency. I had to collect this and give care (Y24).
The intravenous supplies are really bad. When entering the patient’s vein, it would somehow break at the bottom. We had to use these materials, which hindered care (Y13).
In my clinic, an emergency medical technician and operating room services work as nurses, and there is only a high school graduate nurse (In Turkey, nursing authorization was given with high school graduation until 2014). I am the only nurse who has a bachelor’s degree… As such, I receive a lot of training on patient safety, patient privacy, and patient care, but they try to do it without receiving them. (Y24)
Subtheme 5: causes of being a new graduate
NGNs stated that they were frequently mobbed and threatened by managers and bullied by senior colleagues, which negatively affected their psychological and professional performance. Due to inexperience and lack of knowledge, they struggled to provide ideal care and experienced hesitation in making ethical decisions. High expectations and not being included in decisions about patient care created frustration.
At first, he can say that I was bullied a lot in a practical sense. At work, I received feedback that the dressing I did was the worst dressing I had ever seen in my life. Sometimes, I have encountered situations that made me feel very bad, such as posting photos to the group and asking who did this. (Y16)
It was difficult to manage everything alone. They expected me to do everything quickly. I come knowing some things, but I don’t know how to use those tools. We were not taught them. Once I was shown, they expected me to do it. (Y1)
Theme 2. the effect of moral distress
The effects of moral distress on NGNs were grouped under four sub-themes: physical, emotional, cognitive, and occupational, and they consisted of 11 open codes.
Subtheme 1. physical effects
Some of the participants reported that the experience of moral distress had some after-effects, such as sleep disturbance and crying after thinking about the event.
……. After the incident, I started to lose sleep. I couldn’t sleep that much, not so much because of myself but because of the environment I was in.(Y15)
Some days, I cried at night. I see so many things, but I can’t do anything. That’s why… (Y24).
Subtheme 2. emotional effects
Most of the participants felt helplessness, sadness, and anger at the moment they experienced moral distress or afterward, and some of them expressed feelings of inadequacy and worthlessness.
I want to do something, but I can’t. My hands were tied. I mean, it made me feel helpless not to be able to do something when there were things we could do (Y2).
It makes me angry to be confronted with such things. That makes me want to push these incidents even more (Y10).
The fact that I am not included in any decision there shows that I am ignored as a professional. This makes me feel like an unworthy person who is just there to do what they are told. (Y20)
Subtheme 3. cognitive effects
NGN stated that they often thought about the event and sometimes even dreamt about it.
Since I am a person who obsesses and thinks a lot, I thought about it for a while after that. It stayed in my mind for a while….I thought I could have done it, or I should have done it. (Y4)
Sometimes, the things I experienced would enter my dreams at night. Patients, events, etc. (Y6)
Subtheme 4. professional impacts
Participants stated they had a negative view of the profession, that they could not work for a long time, and that they thought about leaving their jobs or going abroad. Some of them felt burnt out in a short period of time.
I actually lost some enthusiasm for the profession. I thought, “Will it always be like this?” I thought, “How can I do this profession for 20 years and 30 years?” I feel like I can’t do it for such a long time. (Y25)
That’s why I’ve been going to therapy for two months. Actually, I haven’t worked much. There are those who have been working for years and 10 years. I don’t know how they do it (Y22).
Theme 3. coping with moral distress
The NGN tried to cope with moral distress in three different ways. This theme consists of three sub-themes and 12 open codes.
Subtheme 1. moral courage
Participants reported taking active or passive steps to resolve moral distress. Some went the extra mile and tried to make amends, others communicated to managers, sought legal remedies, and engaged in patient advocacy. These efforts made them feel better, although the success rate varied.
That patient was not given much care. His condition was a bit bad. I was very upset about her situation. So, I started to care for her more. I developed a little bit of a reverse effect. I was devoting more time to her…. (Y13)
I tried to talk to my coworkers. Seriously, I told them in a polite way, wouldn’t it be better if you didn’t do it like this. They didn’t listen. At that time, I told my supervisor. He listened, he didn’t say anything, he didn’t do anything. (Y1)
Subtheme 2. moral resilience
Participants reported that even if they were unable to take action after moral distress, they recognized their shortcomings and sought ways to improve. Most chose to increase their knowledge and skills in their field and ethical issues. Others addressed knowledge gaps by learning job descriptions and laws.
I realized the points where I was incomplete and inadequate and did research to correct them…. Because I didn’t know what to do in the event that we didn’t intervene in that patient, I didn’t want to be in such a situation again. (Y8)
NGNs developed moral resilience to avoid harm and tried different methods to increase their psychological resilience.
I blamed myself for the problems I experienced in clinic. I could not solve them. I was in conflict with many people. When I went to the psychologist, he made me realize that it was not myself that I should be angry here, but things that I could not control, such as the system of the physician. When I developed this perspective, I was able to look at things more easily. (Y2)
Subtheme 3. moral disengagement
Participants developed mechanisms to cope with moral distress, such as ignoring events, shifting responsibility to others, and rationalizing events, thus avoiding moral problems and conflicts and opting for moral disengagement.
I wasn’t planning to work in that organization for a long time anyway, so I was like, you’re going to leave anyway, forget it, ignore it. I wasn’t getting involved even though I was troubled by the incidents and stuff like that. (Y12)
….I’m not the only one who sees these things. My other friends see them, the person in charge sees them, and the managers know them. I am a problem person when I say something. Managers know everything very well, let them solve it. I don’t bother anymore. (Y10)
Theme 4. suggestions for reducing moral distress
This theme had four sub-themes: individuals, nursing education, institutions, and system/policy, and 21 open codes.
Subtheme 1: individuals
Participants stated that healthcare professionals should improve their communication skills and empathy to reduce moral distress. They emphasized that moral problems arise or remain unresolved due to poor communication between team and the patient and lack of empathy.
A lot of the problem is that we don’t think of the person lying there as a human being. The patient perceives a lot of things, and we need to treat them knowing that. He deserves respect because he is a human being…. The patient is defenseless there, and there is no one with him. We need to understand what kind of situation he/she is in. (Y10)
We need to improve our own communication skills. Our tone of voice and the words we use are important when talking to a manager, physician, or colleague. We usually speak by minimizing everything. We are in a position to say things that cannot be said. Then, we are wrong when we are right. (Y8)
Participants also suggested learning about their job descriptions, updating their knowledge, and participating in academic activities.
In fact, there are many areas where we can use our decision-making skills. Only when nurses know their duties, roles, and responsibilities can they express their feelings and thoughts when they see something wrong (Y21).
Subtheme 2: nursing education
NGNs suggested that ethical and legal issues should be taught not only in theory but also in practice, that clinical practice should be increased, and that standardized and qualified training should be developed.
In ethics education, sections from the events experienced in the field can be presented. Because we see many things in education, but we do not know how to use that knowledge. At least some of these situations can be more familiarized with simulations. (Y5)
Subtheme 3: institutions
Participants suggested to employed well-equipped and competent nurse managers, close contact with managers and the staff, increased in-service training, and improved and standardized institutional policies such as paperwork.
First of all, we need a fair administrator. There needs to be someone who comes without looking at who is a relative or who is an acquaintance. It is not only the head physician, but also the head nurse, even the nurse in charge of our clinic needs to be fair. The nurse in charge needs to be behind the nurses. (Y7)
I think the institution should also provide training on ethical issues. For example, my organization did not provide any training on ethical issues. They only give it to show that they gave it. So that there will be no problems with the audit. (Y1)
Subtheme 4: the system/policies
NGNs suggested that the number of nurses should be increased, job descriptions should be clarified, non-nurse personnel should not be employed as nurses, institutional audits should be increased, and health policies focused on financial concerns should be changed.
In general, I think that the number of staff should be increased, both in terms of patient load and I think that better care will be provided in this way. If fewer patients are given, care will be better. (Y2)
First of all, health workers who haven’t had nursing training shouldn’t be employed as nurses because they don’t have the knowledge and training about care and ethical issues. Nurses receive trainings in communication and psychology, whereas they do not. Since they work in the field as nurses, the problems increase. (Y12)
The joint display, including the integration of quantitative and qualitative data, is presented in Table 4. While quantitative findings were confirmed with qualitative data, some qualitative findings could not be confirmed with quantitative data.
Table 4
Joint display screen findings for moral distress in newly graduated nurses
Domains | Qualitative data | Quantitative data | Mixed method inference |
|---|---|---|---|
Moral distress according to participants’ characteristics | Theme and sub-theme: There is no direct data on gender in any theme or sub-theme. Evidence: “…. there are things that affect me, but other female friends in the clinic are affected more. If some things do not change, I think it is necessary to adapt.” (Y11) (Unpresented data) | Variable Gender Evidence: Women experience moral distress 9.81 units more frequently and 17.10 units more intensely than men. | The link between moral distress and gender may not only be related to the frequency and intensity of moral distress, but also to how nurses recognize, make sense of, express and cope with the situation. While quantitative data show that female nurses are more aware of the situations that cause moral distress and experience more intense distress, qualitative data show that male nurses may tend to normalize the situations and minimize their impact on themselves by accepting that the situations will not change and adapting to the current system. |
Theme and subtheme: The theme of causes of morale in new graduate nurses Organizational/managerial reasons sub-theme open code 4 and 5 - Systemic reasons sub-theme 4th, 5th, 6th and 7th open code Evidence: “For example, in the hospital where I worked, patients could ask me for tea. At work, they wanted me to wear nail polish. When I say that I will not do these things, the organization tells me that whatever they say to me is OK, you are right. In fact, my profession was completely ignoring them (Y25).” | Variable Type of hospital Evidence: Private hospital employees experience moral distress 8.09 units more frequently and 8.55 units more intensely than public hospital employees | When qualitative and quantitative data are evaluated together, it is seen that the reasons behind the higher moral distress levels of newly graduated nurses working in private hospitals overlap with the institutional/managerial and systemic problems revealed in qualitative data. In private hospitals, being asked to do more work outside the job description, frequent rotation between clinics, non-nurse personnel working as nurses, injustices regarding payments, and providing more substance-anxiety-based health services may cause the participants to experience more intense moral distress. In addition, reasons such as inadequate personal rights and lack of job security in private institutions may prevent the participants from taking the actions they find right and cause moral distress. | |
Moral distress according to participants’ characteristics | Theme and subtheme: New graduate nurses coping with moral distress theme - Moral resilience sub-theme 3. open code - Moral withdrawal subtheme 1st, 2nd and 3rd open code Evidence: “I used to not mix the medicines, I used to wear them separately. I didn’t do it because I thought it was ethically wrong, because it could harm the patient. Now I have nothing to do. Nothing comes up, I don’t have the opportunity. I realized that no one else does it like me. I’m the only one doing this, so now I wear them all together (Y22).” | Variable Professional working time Evidence: A one point increase in participants’ working hours causes them to experience moral distress 1.31 units more frequently and 1.01 units more intensely. | When the qualitative and quantitative data are evaluated together, it can be concluded that participants may become more aware of and begin to make sense of moral events as they gain experience over time. From another perspective, especially in line with the qualitative data, it can be said that there is a change in the participants’ coping strategies over time and the moral distress experienced becomes more intense with the increase in their experience in the profession. |
Theme and subtheme: New graduate nurses coping with moral distress theme - Moral resilience sub-theme 2. open code The theme of suggestions for reducing moral distress in newly graduated nurses - Recommendations for individuals sub-theme 2. open code Evidence: “Actually, we have many areas where we can use our decision-making skills. So nurses should be able to make decisions or express their thoughts and feelings when something is wrong. This comes from knowing their duties, roles and responsibilities. Certainly all nurses need to master this.” (Y21) | Variable The level of thinking that the legal regulations related to the profession are mastered Evidence: A one point increase in participants’ level of The level of thinking that the legal regulations related to the profession are masteredcauses them to experience 1.86 units more intense moral distress. | When qualitative and quantitative data are analyzed, it is found that having a good command of legal regulations can facilitate coping with moral distress and make individuals more confident to do what they know is right. | |
Nursing roles and moral distress | Theme and subtheme: The theme of causes of morale in new graduate nurses - Violation of ethical principles sub-theme 3rd, 4th, 5th and 6th, open code - Institutional/managerial reasons sub-theme open code 6 and 7 - Systemic reasons sub-theme 1st, 2nd, 3rd and 6th open code Evidence: “For me to give care, I need to have some materials. But the cynic does not have these materials. Every time I had to collect them from other wards, intensive care unit or emergency room. This was a very big deficiency. I had to collect this and give care.” (Y24) | Variable Level of subjective perception of fulfilling caregiver role Evidence: A one point increase in participants’ level of fulsubjective perception of fulfilling caregiver role causes them to experience moral distress 10.02 units more often and 2.67 units more frequently. | When the quantitative and qualitative data are analyzed, the fact that the care that the participants ideally want to provide in an equal and fair manner cannot be provided due to institutional and systemic barriers, and that some of these barriers cause ethical problems, shows that it is a problem that individuals frequently face and causes them to experience more and more frequent moral distress. |
Theme and subtheme: New graduate nurses coping with moral distress theme - Moral courage sub-theme 4. open code Evidence: That patient was not given much care. His condition was a bit bad. I was very upset about her situation. So I started to care for her more. I developed a little bit of a reverse effect. The other patients were already well. I was devoting more time to her….I was doing the missing care there. (Y13) | Variable Level of subjective perception of fulfilling advocate role Evidence: A one point increase in participants’ level of subjective perception of fulfilling advocate role causes them to experience 1.69 units more intense moral distress. | When the qualitative and quantitative data are evaluated together, newly graduated nurses feel that they fulfill their advocacy role when they see an ethical and moral problem affecting the patient and take action to solve this problem. Thus, the elimination of the situation that causes moral distress and taking action for its solution may lead to a decrease in the intensity of moral distress. | |
Nursing roles and moral distress | Theme and subtheme: The theme of causes of moral distress in new graduate nurses - Institutional/managerial reasons sub-theme 1st, 2nd and 3rd open code The theme of suggestions for reducing moral distress in newly graduated nurses - Recommendations for institutions sub-theme 1st and 2nd open code Evidence: If I had felt that my colleagues or the nursing directorate were behind me, I could have stood up straighter…I could have said that I think there should be a communication before I take my patient for a test. But no one said that we can talk to the management about this problem together. (Y14) | Variable Level of subjective perception of fulfilling manager role Evidence: A one point increase in participants’ level of subjective perception of fulfilling manager role causes them to experience 7.23 units more and 1.79 units more intense moral distress. | When the qualitative and quantitative data were analyzed, although the participants did not have managerial roles, the nurse managers’ failure to fulfill their roles, failure to communicate, and failure to support nurses to do what they know is right resulted in more and more intense moral distress experienced by newly graduated nurses. |
Moral distress | Theme and subtheme: The theme of causes of moral distress in new graduate nurses Evidence: Quotes from participants given under sub-themes | Variables: Moral distress scale total, frequency and intensity scores for health workers Evidence: Participants had a mean total moral distress score of 6.55 ± 3.51, a mean moral distress frequency score of 1.94 ± 0.84 and a mean moral distress intensity score of 2.77 ± 0.82. Participants received the highest morale distress frequency (2.53 ± 0.91) and intensity (3.10 ± 0.84) scores from system-level causes. | Qualitative and quantitative data support each other. The fact that the participants see the systemic causes, especially in the qualitative data, as unsolvable and unchangeable, and that they do not have the power to intervene in the system may cause them to experience more frequent and intense mora distress in this regard. |
Moral distress | Theme and subtheme: The impact of moral distress on new graduate nurses Evidence: Quotes from participants given under sub-themes | No evidence is available. | |
Theme and subtheme: Coping with moral distress among new graduate nurses Evidence: Quotes from participants given under sub-themes | No evidence is available. | ||
Theme and subtheme: New graduate nurses’ suggestions for reducing moral distress Evidence: Quotes from participants given under sub-themes | No evidence is available. |
Discussion
In the study, the frequency of NGNs encountering MD was found to be below the median value, but the intensity was found to be above the median value. Similar results have been reported in general nurse groups. Studies in Turkey and Iran show that MD intensity is higher than frequency. In Europe and America, although MD intensity is below the median, the intensity score is higher than the frequency score; this trend is common among students, clinical, and NGNs.
There are differences in the relationship between sociodemographic and occupational characteristics and MD. While some studies have shown that women experience MD more, others haven’t found a significant relationship. O’Connell (2014) stated that women experience more MD due to “moral residue” [27]. According to Hamric and Epstein’s (2012) MD model, moral residue is both a cause and a consequence of MD [28]. Women’s higher moral sensitivity in caring and empathetic roles may increase their sensitivity to ethical issues and the risk of MD [29].
In the study, it was found that NGNs working in private hospitals experienced higher MD, which was associated with factors such as job insecurity, low salary, inadequate management support, and high patient expectations [30‐32]. In addition, it was also observed that the level of MD increased as the duration of employment increased, especially nurses with 12–18 months of experience experienced more MD. This may be explained by the increase in ethical awareness and moral residue as experience increases and the limitation of solution attempts [33‐35].
Competence perception, which fulfills the roles of caregiver and manager, is another important predictor of MD. Nurses who believe they are fulfilling these roles effectively experience less MD because they are more confident in resolving ethical issues and ensuring patient safety. This strengthens the professional identity of nurses and reduces their MD levels [36, 37].
MD is associated with ethical issues such as end-of-life decisions, violation of patient rights, unfair practices, lack of resources, and compromise of patient safety. In addition, institutional barriers, excessive workload, lack of autonomy, and exclusion from decision-making processes also significantly increase MD. These findings in the literature show that ethical problems have not only individual but also organizational and systemic effects [20, 31, 38‐40]. Our study revealed that MD, especially in new graduate nurses (NGNs), is caused by factors such as inexperience, lack of knowledge, vulnerability to managers, and peer bullying. These nurses reported that their level of moral distress increased when they were not included in ethical decisions or when they felt that their views were not taken into account. This situation leads to the reinforcement of feelings of helplessness and powerlessness in NGNs. In particular, not being involved in ethical decision-making processes and not being adequately supported in the work environment make it difficult for NGNs to adapt to their professional roles and increase their MD levels. These findings emphasize the necessity of interventions at individual, team, and institutional levels to prevent ethical problems and NGNs’ MD.
The study found that NGNs used three strategies to cope with MD: moral courage, increasing moral resilience, and moral withdrawal. Participants took action by showing moral courage to solve ethical problems; this strategy is also reported in the literature to be associated with less MD and high professional satisfaction [41, 42]. Secondly, nurses increase their moral resilience by receiving trainings to improve their knowledge and skills; the literature suggests that this approach increases the capacity to cope with MD [16, 42, 43] [16, 43, 44]. The third strategy is moral withdrawal; in this case, nurses distanced themselves from their responsibilities with a sense of helplessness in ethical conflicts. The research emphasizes that moral withdrawal leads to burnout and decreased professional satisfaction in the long term [44, 45] [45, 46].
NGNs suggested individual development, ethical awareness, emotional resilience, and increasing coping skills to reduce MD. The literature also emphasizes the importance of such educational programs [46‐50] [47‐51]. While individual interventions are effective in the short term, organizational and system-level changes require more complex and long-term solutions [52]. Open communication about ethical issues and supportive work environments are seen as important in mitigating the effects of MD at the organizational level. System-level improvements create the infrastructure to deal with ethical issues more effectively in the long term [28, 53].
Conclusion
This study revealed the individual, organizational, and systemic dimensions of this process in detail by addressing the MD experiences of NGNs. Study results show that a considerable degree of MD was observed, particularly within the 12-18-month range. Increasing awareness of ethical issues and professional responsibilities with the increase in working time causes this process to become more complex. Female new graduates and those employed in private hospitals are at an elevated risk for MD. Conversely, new graduates who possess the belief that they are capable of fulfilling their roles in both a caring and managerial capacity experience a reduced incidence of MD. The characteristics of a new graduate, including inexperience, a lack of knowledge, high expectations of the team, and a lack of inclusion in decision-making processes, contribute to the MD experience. Even if NGNs have sufficient knowledge and skills when they take their first steps into the profession, they are more likely to experience MD if they are not supported or guided in the face of ethical dilemmas they encounter in practice. It has been observed that the capacity of NGNs to perform the actions they know to be right weakens when they do not find sufficient support from managers and colleagues or in environments where the ethical climate is negative. Moral distress of NGNs is caused by inadequacies in the educational process, structural deficiencies in clinical settings, and individual characteristics. Therefore, it is necessary to improve the ethical decision-making skills of nurses in education and transition, support professional autonomy, and establish supportive guidance mechanisms in clinical practice areas.
Implications for practice
The transition process of new graduates often gives rise to the risk of MD. In order to address this risk, programs that increase moral awareness and coping skills should be developed, curricula and simulations that support ethical decision-making skills should be implemented in education, organizations should provide an ethical work environment and guidance services, and encourage open communication. Besides, policies that support nurses’ professional autonomy and clear job descriptions should be established, and ethical processes should be made transparent. Research should contribute to the management of MD by evaluating the impact of ethical education and interventions.
Acknowledgements
The authors are grateful to all participants who agreed to participate voluntarily in this study.This study is derived from a part of Mustafa Sabri Kovancı's PhD thesis prepared under the supervision of Azize Atlı Özbaş.
Declarations
Ethics approval and consent to participate
Ethical approval for the conduct of the study was obtained from the Hacettepe University Ethics Committee (GO 23/211, Date: 23.05.2023). The principles of the Declaration of Helsinki were followed in this study. Both written and verbal informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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