The relationship betweenpersonality traitsandmoraldistressamong nurses
The relationship betweenpersonality traitsandmoraldistressamong nurses
Abstract
The purpose ofthisstudy was to investigatethe relationship betweenpersonality traitsandmoraldistressamong the nurses working working intheCoronary Care UnitinShiraz, Iran. In this cross-sectional and descriptive study, 60 nurses participated and two questionnaires of Moral Distress Scaleand NEO Five Factor Inventory were used. Data were analyzed using SPSS software and descriptive and inferential statistics. The results indicated moderate to high levels of moral distress among the nurses in the CCU. No significant relationship was observed between the demographic variables and the mean of moral distress and personality traits. Considering the high incidence of moral distress in nurses, besides examining the their personality traits in larger sample sizes and in different parts of the country, examining the environmental, organizational, and management factors that may contribute in creating ethical distress is recommended.
Keywords
Coronary Care Unit, Ethic, moral distress, nurses, personality traits
Introduction
Moral distress is a kind of ethical phenomenon in which nurses are engaged in the daily care of patients (1). Nurses always have to make moral choices in their care, and ethics plays a major role in this profession (2). Moral actions is a critical aspect of nursing care, and the development of moral competence is essential in nursing for current time and future (3). There is a probability of moral distress in an individual that makes him/her commit an act contrary to his/her moral beliefs(4). Moral distress is one of the major aspects of moral conflict, which has damaging effects on health care organizations through the impact on organizational culture, quality and success in care (5,6). Today, due to more complex nursing care and increased expectations, nurses encounter with higher moral distress. Numerous studies have emphasized the intensity and frequency of this phenomenon in critical care units than other wards due to the special conditions of the patients(6,7,8,9). Few studies have been conducted on moral distress among nurses working in CCU. Iranian nurses in CCU, internal and psychiatry wards, experience more moral distress (2). The experience is directly related to the incidence of occupational burnout, and inversely correlated with psychiatric hardiness. In a study conducted in Iran, showed that a lot of nurses feel moral distress due to lack of nursing support, disrespect for the rights of the patient, lack of professional and functional competences in physicians and carrying out unnecessary tests for patients, thus critical care nurses experience much more moral distress more than other wards(9). Since moral distress is a multi-cultural phenomenon, which comes in different levels of health care system(10), it seems necessary to investigate this phenomenon in Iranian nurses too.
Background
Moral Distress
ProfessorJametonfor the first timein 1984; defined moraldistressas thepainful feelings or lack of balance and mental relaxation. This phenomenon occurs when the nurse is unable to convert his/her choices or moral norms into moralacts(1).Moral distress as psychological imbalance and state of negative emotion such that moral decision does not lead to moral actions(11).
Moraldistress is either mental or emotional pain and discomfort, in which whilepeople are aware about themoral issues; they try to make moral judgment about an appropriate moral action. However in practice, they commit moral wrong doing due to real or mental limitations (2).
Many qualitative and quantitative studies have so far been conducted on the conceptof moraldistress, consequences and strategies for overcoming it. Researchersinvestigated the moral distress levels and its prevalence in nurses and reported moderate to high levels of moral distress(11,12,13). Corley designed moral distress scale in 2000 using the concepts suggested by Jameton and the conflict role theory proposed by House and Rizzo (14).
Wasted nursing services for the patient, prolonging patient’s suffering, performance out of clinicians’ regulations, incompetency of colleagues, inability of nurses to understand the physicians and lack of nursing knowledge in patients’ care, lack of executive supports including salary, working hour, benefits, and inappropriate working conditions such as improper management are powerful sources of distress(2,15).
In addition, the severity of illness of patients, the ratio of patients to nurses and ability of nurses to provide safe care for patient are involved in creating moral distress among nurses(15).
Failure in providing effective and proper physical care, reduction of capacity in providing care for the patients, avoiding eye contact with the patient, and incidence of problems such as lack of sleep, overeating, poor social relationships, reduced cooperation, defensive acts, loss of confidence, and loss of job satisfaction have been pointed out as the symptoms of moral distress in nurses(6,16,17). Researchers have pointed out that moral distress leads to a shift of working unit and even to leave the nursing profession (13,18,19).
Moral distress has an impact on the quality of patient care. Thus, the quality of care provided by the nurses decreases due to moral distress, which ultimately creates health secondary problems in patients(5,19,20).
Personality Traits
Moral distress is a multilateral phenomenon and several factors can deteriorate it. Moral distress has a direct relationship with its incidence. One of the most important factors in nursing profession addressed in several studies is occupational stress(1,6,21,22).
Understanding the patterns of stressors and dealing with them are different in different individuals. The nurses’ characteristics play a major role in understanding stress and the experience of moral distress in nurses(21,23).
Personality is a set of psychological traits that individuals are classified according to them. These traits have lasting influences on professional behavior, and the specific behaviors of individuals can be determined in various occupational positions based on them(24).
McCrae and Costa describe personality as big five including neuroticism, extraversion, openness experience, agreeableness, and consciousness. Neuroticism refers to tendency to experience anxiety, stress, hostility, shyness, irrational thoughts, depression, and low self-esteem. Extraversion refers to desire to be positive, decisiveness, mobile, kindness, and sociability. Openness to experience is described as tendency to curiosity, wisdom, flexibility, innovation and intellectuality. Agreeableness is considered as thedesireforforgiveness, kindness, generosity, trust,accountability, compassion, obedience, dedication,and loyalty. Finally,conscientiousness is regarded as thetendency to beorganized, efficient, reliable, trustworthy, logic-oriented and reflective (25,26).
The type and severity of reaction against stress does not always have a direct relationship with the severity of the stressor factors; rather it is primarily related tohow tounderstand theevent and the degree ofdanger and threat. Aspecificstress can create different consequencesin different people(24), and specification of personality plays a significant role in the process of dealing withmoraldistress(27). It is probable that personality traits of nurses may help the prediction of their moral distress, and mitigate the negative effects of this phenomenon. Since no study seems to have detected this relationship, here, we attempted to examine such relationship.
The study
Aims
The purpose ofthisstudy is to examinethe degreeofnurses'moraldistress anddetermine the relationship between personality traits and moraldistressamong the nursesin CCU ward in Shiraz, Iran.
Method
In thiscross-sectionalanddescriptivestudy, the Moral Distress Scale (MDS) and NEO Five Factor Inventory (NEO-FFI) questionnaireswere usedto achievethe research objectives.
Participants
Totally, 60 nursesparticipatedin the study from the Heart Centerof Shiraz as the largestpublic heart hospital. The participants announcedtheir readiness toparticipate in thestudy in a public call. Inclusion criteriawere havingat leasta bachelor's degreein nursing, aminimum of 6 months of workingexperience incoronary CCU,andwillingness toparticipate in thestudy.
Instruments
In this study, themoraldistressquestionnaire of Corley(MDS) was used. Its validity and reliabilityhavebeen evaluated in nurses'community(9). Thequestionnairehas30 questionsina 7 points likert scale. Numbers 1 and 7 indicate the minimum and maximum stress, respectively. The NEO- FFI questionnaire,preparedbyMcCraeandCosta in fivemajorfactors,provides agreat possibilityof adultpersonality traits. Thetest has been normalizedby Haghshenason502 Iranian peopleanditsreliability and validityhave been determined(25). In addition, the researcher-made questionnaire was considered for thisstudy, whichcontaineddemographic informationincluding age, gender, work experience, average weekly work hours,and marital status.
Process
After reachingtheminimumnumber of participants, the NEO-FFI and MDSquestionnaireswerecompleted by the participants from April 2012to June 2012.
Ethical considerations
Permissionto conduct the research was taken from theEthicsCommitteeof ShirazUniversityof Medical Sciences (CT-P-9372-7482)as well as thehospitalauthorities. Prior to completing the questionnaires, the participants were asked to fill out consent form anonymously tovoluntarilyparticipate in the study. They were informed about the aim of the study, the confidentiality of their information, and that they could withdraw from the study whenever they wanted to.
Data analysis
Collected data were analyzed usingSPSS software (version 15). To calculate and compare the mean scores of moral distress and personality traits, the repeated measures analysis ANOVA (Analysis Of Variance) was used. Chi-square testwas used forqualitative variables,andindependent sample t-test,ANOVAtestandPearsontestwere usedforquantitativevariables.
Results
The total of 60 nurses participated in the study, 58 females and 2 males. 30 were married and 30 others were single. Their mean age was 29.72 years. The mean score of work experience was 5.6 ± 3.75 years and the working hour average was 44.89 ± 10.65. There was no significant relationship between demographic variables with moral distress and personality traits (Table 1).
The range of moral distress was 7.10- 2.69 and the mean of moral distress of the participants was 4.5± 0.88 (Table 2).
The range of scores was 10-41 for the personality trait of neuroticism, 19-38 for the personality trait of extraversion, 16-32 for the personality trait of openness to experience, 22-44 for the personality trait of agreeableness, and 25-39 for the personality trait of conscientiousness. Reviewing the mean of moral distress in people with the lowest and highest scores in personality traits, no significant relationship was observed based on the Pearson's correlation test (Table 3).
Discussion
The results indicated moderate to high levels of moral distress among the nurses in CCU in Shiraz Heart Center and the finding of numerous studies confirm this finding; some studies have reported the moral distress as moderate (23,28,29), and some others reported it as high(30,31). Accordingly, we can conclude that the level of moral distress in nurses is moderate to high, which deserves more attention.
In this study, no relationship was observed between the demographic variables and the level of moral distress. Ebrahimi et al. conducted a study on 418 nurses in North West of Iran in 2013 and came to the conclusion that there is no significant relationship between the mean of moral distress and the variables of gender, age and experience (31). This shows the importance of teaching moral distress to all health care providers, regardless of their age, gender and experience. Also it can be inferred that the multidimensional phenomenon of moral distress and different environmental, occupational, organizational, managerial and personality factors play a role in its incidence; thus, new investigation can be conducted based on further review of these factors.
However there are other some studies that confirm the existence of a relationship between moral distress and demographic variables32(8,19,32). Corley et al.and Jolaee et al.found that there is a negative correlation between age and moral distress; these correlations may be caused by the accumulation of experiences in dealing with the moral distress over the time (14, 29). Abbasszadeh found a positive relationship between moral distress and nursing work experience (33). Positive relation between moral distress and work experience among nurses may be caused by their increased moral sensitivity during their services; however, this compatibility can be achieved after years of failing and frequent and bitter experiences of moral distress and perhaps a large number of nurses fail to achieve the compatibility in which our study confirms.
Due to the lack of ethical issues in nursing curriculum in Iran, inclusion of professional ethics issues in the educational content of nursing students and involving the nurses working in hospitals in these discussions are recommended as other studies have emphasized the issue of moral distress for the nurses(2,34).
The results of this study showed no significant relationship between personality traits and moral distress, but other studies have shown that factors involved in causing moral distress are associated with personality traits. For example, the level of occupational burnout in nurses reported in various studies(34,29) demonstrates a significant positive relationship with increased moral distress. In other word, it is one of the determinants and consequences of moral distress and varies in different personality traits of nurses.
Meltzer and Hukabayalso speak of personal factors as the main components of intolerance, inflexibility, and lack of assertiveness in dealing with others are all related to occupational burnout (32).
In addition, psychological hardiness as a personal trait in moderating the relationship between stress and physical and mental diseases has a negative relationship with moral distress (2).
Ebrahimi Nikravesh et al. considers the nurses’ personality as the key factor in the experience of stress and moral distress so that the nurses who possess conscious performance and sacrifice to the patients and are placed in an imposed overload or have multiple and long shifts may suffer more moral distress and occupational stress(21).
Nurses’ experience of moral distress is not only wide spread, but also their responses to moral distress are diverse. Those nurses, who use problem solving skills, are more able to deal with moral distress(34); however the nurses who use avoidant coping styles such as distraction and avoidant situations which causing moral distress experience physical complications(35).
In 2010, Burgess examined the personality traits and levels of environmental stress among 46 ICU nurses in Northwest England. He reached the conclusion that those who obtained high score on openness personality traits and extroversion had less stress in taking care of critically ill patients and encountering the patient s’ families. In addition, those with high scores on the personality trait of conscientiousness have experienced less environmental stress; in fact, the personality traits of openness, extraversion and conscientiousness are effective in understanding and mitigating the environmental stressors(22).
Although our study did not show a significant relationship between moral distress and personality traits, as it can be observed from Table 3, the personality traits of openness, extraversion and conscientiousness have gained Pearson scored negatively in relation to moral distress, which is consistent with the results of Burgess Study. In fact, it can be concluded that these three personality traits are in compliance with the environmental stressors, and the less experienced nurses in moral distress are more successful than other nurses. The reason why Burgess has achieved asignificant relationshipbetweenloweroccupationalstressand personality traits with lower sample size is probablydue todifferent culturalcontextsorthe different research ward. Therefore, it is recommended toinvestigatethisrelationshipindifferent wardsandin different culturalcontexts.
Borhanialso conducteda studyon 220Iraniannursesand found a positive relationship between professional stress and moral distress. He believes that nurses’ personal traits can have a positive contribution in understanding and giving meaning to stress. The more people are flexible against stress, the less stress they experience (23).Borhani has used the Corley’s moraldistressquestionnairewith 21questions, which isshorterthanthemeasuring tool of our study and some questions have been deleted. Also a largersample size was usedin her study; thus, it is recommended to carry out similar studies with much largersample sizes and indifferent wards. Regarding the results ofthisresearch,moraldistress, occupational stressandburnout can be consideredasthree sidesof a triangle, which are linked together andformadefective cycle. Thesefactors will causeandexacerbateeach other in the nursing environment. Personality traitsof openness,conscientiousnessandextroversion can be effective in reducing the environmental stresses, occupational burnout andmoraldistress, which we recommend as a hypothesis for future studies.
Ebrahimiinvestigating moral distress among 418nursesinthree big cities in the west of Iran underlines that theshortage of nursesandnurses'inabilityto deal withmoral issuesplay a significant role increatingmoraldistress inIraniannurses (31). Molazemhas points out the shortage of nurses as one of the main reasons of moral distress(37). Also Abbasszadehexamining this phenomenon among 140 nurses reached the conclusion that organizational factors such as lackof support frommanagers,jobdissatisfaction,and lack ofcollaboration betweenphysicians and nurses arepowerfulsources ofmoraldistress (33).
Conclusion
Thisstudy showed that theincidenceof moraldistressamong nurses in coronaryCCUis inmoderate to highlevels. Consideringthe negative impactof moraldistresson nursesandreduction of health carequality in patients, it seems essential to pay due attention tothis phenomenon, hold trainingclasses, establish ethical committees in hospitals and include professional ethics in the nursing curriculum of nursing students. Based on the current study results,itis recommended to investigate the environmental, organizational and managerial factors, which play a significant role in creating moral distress, and also personality traits of nurses in big sample sizes in different wards and other parts of the country.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
The present article was financially supported by Psychiatry and Behavioral Sciences Research center of Shiraz University of Medical Sciences grants No 93-7482.
Acknowledgments
The researchersneedtoappreciateall nurses whoparticipatedinthis study and thank of Psychiatry and Behavioral Sciences Research center of Shiraz University of Medical Sciences for its support.