Article

Nursing Ethics
2017, Vol. 24(2) 209–224
Moral distress in Turkish ª The Author(s) 2015
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intensive care nurses 10.1177/0969733015593408
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Serife Karagozoglu and Gulay Yildirim

Cumhuriyet University, Turkey
Dilek Ozden
Dokuz Eylül University, Turkey
Ziynet Çınar
Cumhuriyet University, Turkey

Abstract
Background: Moral distress is a common problem among professionals working in the field of healthcare.
Moral distress is the distress experienced by a professional when he or she cannot fulfill the correct action
due to several obstacles, although he or she is aware of what it is. The level of moral distress experienced by
nurses working in intensive care units varies from one country/culture/institution to another. However, in
Turkey, there is neither a measurement tool used to assess moral distress suffered by nurses nor a study
conducted on the issue.
Aim/objective: The study aims to (a) validate the Turkish version of the Moral Distress Scale–Revised to
be used in intensive care units and to examine the validity and reliability of the Turkish version of the scale,
and (b) explore Turkish intensive care nurses’ moral distress level.
Method: The sample of this methodological, descriptive, and cross-sectional design study comprises 200
nurses working in the intensive care units of internal medicine and surgical departments of four hospitals in
three cities in Turkey. The data were collected with the Socio-Demographic Characteristics Form and The
Turkish Version of Moral Distress Scale–Revised.
Ethical considerations: The study proposal was approved by the ethics committee of the Faculty of
Medicine, Cumhuriyet University. All participating nurses provided informed consent and were assured
of data confidentiality.
Results: In parallel with the original scale, Turkish version of Moral Distress Scale–Revised consists of 21
items, and shows a one-factor structure. It was determined that the moral distress total and item mean
scores of the nurses participating in the study were 70.81 + 48.23 and 3.36 + 4.50, respectively.
Conclusion: Turkish version of Moral Distress Scale–Revised can be used as a reliable and valid
measurement tool for the evaluation of moral distress experienced by nurses working in intensive care
units in Turkey. In line with our findings, it can be said that nurses suffered low level of moral distress.
However, factors which caused the nurses in our study to experience higher levels of moral distress are
inadequate communication within the team, working with professionals they considered as incompetent,
and futile care.

Corresponding author: Serife Karagozoglu, Division of Nursing, Department of Fundamentals of Nursing, Faculty of Health
Sciences, Cumhuriyet University, 58140 Sivas, Turkey.
Email: serifekaragozoglu@gmail.com
210 Nursing Ethics 24(2)

Keywords
Intensive care, intensive care nursing, moral distress, Moral Distress Scale, validity and reliability

Introduction
Moral distress is an ethical problem affecting the quality, quantity, and cost of the care and treatment.1–5
Moral distress is the stress suffered by a professional, when he or she cannot achieve the right action due
to obstacles, although he or she knows what the right action to take is.6–14 In several studies, it has been
reported that nurses working in intensive care settings suffer moral distress more.8–11,14–22
There are several factors causing moral distress. One of them is that nurses directly witness patients’ suf-
fering and distress with the technological advances and changes in healthcare.9,14,23–26 Another one is that
the patient, family, members of the health team, and health service managers have difficulty in the decision-
making process because care and treatment services which have complex and flexible structure can be
affected by political and economic processes.6,27,28 The next one is that nurses spend more time with the
patient in the intensive care units (ICUs).6,25–30 The last one is that person-specific systematic care cannot
be planned and thus cannot be provided.28 Among the other factors that cause moral distress are the effects
of paternalistic healthcare system,31,32 lack of effective communication and team collaboration,28–30,33–35
lack of clear task descriptions related to the treatment and care in these areas, and inadequate staff and
increased workloads.28,33,35,36 Another factor that significantly causes moral distress is that nurses are not
the professionals taking part in the decision-making but they just put the already made decisions into
practice.26,37,38
Several studies report that moral distress causes anger, frustration, and emotional distress among
nurses,19,39 discourages nurses from providing care for patients,20,39 reduces the quality of the care, causes
inability in coping,14,22 burnout,20,22,25,30,32,36,40–43 decrease in job satisfaction,25,32,43 and causes nurses to
quit their present job or even their profession.6,16,18,32,33,36,43,44 Whereas some studies on the issue indicated
that nurses suffered medium level of moral distress,17,32,45,46 some other studies revealed that they suffered
high level of moral distress.15,19,24,36,47
Due to the frequent occurrence of moral distress among nurses and various effects of moral distress on
them, for the sake of the healthcare system and nursing, it is important to understand and appropriately eval-
uate moral distress, to identify stressors and to develop strategies to avoid these stressors.14,19,23,28,42,48,49

1. Moral stress definition (internationally)

Jameton50 defined the concept of moral distress as stress occurring ‘‘when one knows the right thing to do,
but institutional constraints make it nearly impossible to pursue the right course of action.’’ Jameton’s def-
inition is widely used in nursing and healthcare settings, and highlights institutional and external barriers
nurses encounter in their practices when they want to implement them ethically.7,22,34 This definition refers
to barriers not only in nurses’ individual controls and in working conditions of various institutions but also
in their moral competence.50,51

2. Moral stress related factors and causes

Moral distress experienced by health professionals in healthcare settings is associated with many factors.
Several studies indicate that a lot of individual and institutional factors lead to moral distress.2,22,52,53
Among the individual factors, the leading ones are self-depreciation and lack of motivation due to following
reasons: inability to define the ethical problems, increased ethical sensitivity, feeling weak, self-doubt,
inadequate assertiveness, and not feeling himself or herself as the member of the team.2,3,16,19,30,34,43 In her
Karagozoglu et al. 211

study, Gutierrez54 reports that nurses suffer moral distress because they cannot display assertive behaviors
in the team, the communication between the nurse, patient, and physician is not effective enough, or the
time needed is limited. However, it is emphasized that it is the institutional factors that often cause moral
distress.
The leading institutional factors are lack of communication and collaboration among the team members,
different ethical perspectives of professionals, increased workload due to lack of staff, limited resources,
lack of administrative support, inconsistency between institutions and health policies, and negative ethical
climate.2,3,9,22,26,32,43,47,54–56

3. ICU nurses’ moral stress status and studies

The factors that cause moral distress can prevent the care and treatment from being performed at an
expected level.9,15,16,21,43,47,52,56–59 Inadequate treatment and care can also be the cause of moral distress
among nurses.1,3,47,52,53,59 Silen et al.1 report that nurses suffer high levels of moral distress when patients
are not provided with safe and appropriate care, and that individual and institutional barriers negatively
affect the administration of such care. In her study, Gutierrez54 reports that nurses suffering moral distress
are not willing to provide care for the patients, have difficulty in communicating with patients and their
families, and are not satisfied with the care they provide.
The differences between health professionals regarding their perception of ethical climate and their satis-
faction from the service they provide can affect the level of moral distress.15,22,32,56 It is emphasized that it is
the value conflicts which are the basis of moral distress.6,19 It is indicated that autonomy and capacity to
make decisions, the role of families in decision-making, dignity of the person, safety, quality end-of-life
care, and accessibility of care resources form the basis for these value conflicts.44 Nurses’ perception that
patients do not benefit from the care they provide, that limited resources are used ineffectively, and that the
autonomy of patients and their relatives is not taken into account causes them to consider that the service
they provide is worthless and to suffer moral distress.21,26
Moral distress threatens not only health professionals but also the healthcare system and thus should be
carefully dealt with.4,12,21,42 The assessment tool widely used in many international studies to measure
moral distress is the Moral Distress Scale. Moral Distress Scale was first developed as a 38-item assessment
tool by Corley60 in 1995. According to the study, nurses suffered high levels of moral distress. After con-
ducting a study to determine the validity and reliability of the scale used to assess moral distress suffered by
intensive care nurses, Corley et al.8 reported that the scale could be used as a valid and reliable tool to assess
moral distress in adult intensive care nurses, and recommended that other scales should be prepared to
assess moral distress in nurses working in other areas. Then, Hamric and Blackhall16 who concentrated
on end-of-life care revised and shortened the scale because it was too long and difficult to use. Hamric
et al.12 performed the latest revision of the scale, and they considered it as valid and reliable. They also rec-
ommended that further studies should be conducted in order to determine the validity and reliability of the
scale in different cultures and populations. Several studies have been conducted to determine the validity
and reliability of the different versions of the scale in different countries.17,33,39,45,55,61–63 In line with the
wide use of the scale in many studies, the moral distress scale was preferred in our study too.

4. Moral distress level in ICU nurses in Turkey

The level of moral distress experienced by nurses working in ICUs varies from one country/culture/
institution to another.21,30,33,36,39,63–65 Therefore, there is a need for studies performed at an international
level and the results demonstrated by these studies. In Turkey, many nurses working in intensive care set-
tings may experience feeling of worthlessness and lack of autonomy and motivation or may not feel himself
or herself as the member of the team. The following are the reasons why they have such feelings: working in
212 Nursing Ethics 24(2)

shifts with a small number of nurses in inappropriate physical environments, inadequate opportunities for
promotion, inadequate payments, inequalities, uncertainties in job description, and inappropriate health and
institutional policies.21,25,56 These obstacles may cause nurses to suffer moral distress as a result of not
being able to pursue the right course of action. Therefore, it is believed that moral distress experienced
by nurses working in ICUs in Turkey should be assessed. However, in the Turkish literature, there is neither
a measurement tool used to assess moral distress suffered by nurses nor a study conducted on the issue.

The study aims

The study aims to (a) validate the Turkish version of the Moral Distress Scale–Revised (MDS-R) which was
originally developed by Hamric et al.12 to be used in ICUs and to examine the validity and reliability of the
Turkish version of the scale, and (b) explore Turkish intensive care nurses’ moral distress level.
The questions to be answered within the scope of the study are as follows:
1. Is the Turkish version of the MDS-R a valid and reliable instrument?
2. What is the moral distress level of intensive care nurses in Turkey?

Methods
Sample and setting
This methodological and cross-sectional design study was conducted in the ICUs of the internal medicine
and surgery departments of four hospitals in a province located in Central Anatolia in Turkey from
November 2012 to February 2013.
The nurses working in ICUs of the internal diseases and surgery departments comprised the sample. No
sampling method was used in the study. It was aimed to reach the entire study population. However, of the
nurses, those who worked less than 1 year or were not at the institution when the study was conducted and
those who did not agree to participate in the study were not included in the sample. The sample of the study
comprised nurses who had been working in the ICUs of these departments of the hospitals for more than a
year and volunteered to participate in the study. The population of the study included 230 nurses working in
the ICUs of three university hospitals and one teaching hospital located in Central Anatolia in Turkey. Of
the nurses, 110 were in hospital A, 40 in hospital B, 40 in hospital C, and 40 in hospital D. Of these 230
nurses, 200 (101 (50.5%) from hospital A, 37 (18.5%) from B hospital, 36 (18.0%) from hospital C, and
26 (13.0%) from hospital D) who agreed to participate in the study and filled out the surveys appropriately
were included in the study. The study participation rate was 87%.

Instruments
The Socio-Demographic Characteristics Form and The Turkish Version of MDS-R were used for data
collection.
The Socio-Demographic Characteristics Form. The questionnaire includes questions on the nurses’
age, gender, marital status, educational status, total length of employment, the clinics the nurses
worked in, and the length of employment in these clinics.
The Turkish Version of MDS-R. The original 32-item ‘‘Moral Distress Scale (MDS) Nurse Question-
naire’’ was developed by Corley60 in 1995. She used the scale to assess the frequency and intensity
of moral distress suffered by intensive care nurses working in a hospital. In the scale first developed
by Corley, there were 32 items on prolonging life, performing unnecessary tests and treatments,
Karagozoglu et al. 213

telling lies to patients, and physicians’ performing ineffective and improper treatment, and three
sub-dimensions (aggressive care, honesty, and action response). The scale was revised by Hamric
et al.12 in 2012. The number of items in the revised scale is 21. The scale has two parts: frequency
and level of disturbance. Another two questions of this scale were prepared by Hamric et al. These
questions which were open-ended questions regarding the other conditions that cause moral dis-
tress in practice were as follows: (a) Have you ever left or considered quitting a clinical position
because of your moral distress related to the way patient care was handled at your institution?
(b) Are you considering leaving your position now? These two open-ended questions do not affect
the scores. These two open-ended questions are also included in the Turkish Version of MDS-R,
but do not have any impact on the scores as they do in the original scale. When Hamric et al.12
revised the scale developed by Corley et al.,8 their purpose was to shorten it so that it could be used
in various clinical settings. The Moral Distress Scale revised by Hamric et al.12 has only one dimen-
sion and 21 items on problems experienced about the quality, security, and continuation of care and
treatment; futility practices; compliance with the family’s and physicians’ demands; improper
diagnosis; witnessing the treatment process and patient’s pain; and working with unreliable and
incompetent professionals.
Likert-type scoring of Corley’s original scale ranged from 1 to 7. However, it ranged from 0 to 4 in the
scale revised by Hamric et al.12 Each item product of frequency (0–4) and intensity (0–4) ranges from 0 to
16. To obtain a composite score of moral distress, these individual item products should be added
together. Using this scoring scheme allows all the items marked as never experienced or not distressing
to be eliminated from the score, giving a more accurate reflection of actual moral distress. The possible
resulting score to be obtained from the 21 items will range between 0 and 336. According to the reliability
and validity results of the MDS-R scale, Cronbach’s alpha coefficient is 0.88 and test–retest correlation
coefficient is 0.58.12
Item scores of the Turkish Version of MDS-R were obtained by multiplying the frequency score of each
item (0–4) with the intensity score of each item (0–4). When calculating the score of an item in the scale,
scores for frequency and intensity are multiplied with each other, and then one single score is obtained.
Therefore, the lowest and highest possible scores to be obtained from an item are 0 and 16 (4  4), respec-
tively, and the total score to be obtained from the scale can range from 0 to 336. The possible total score to
be obtained from the scale ranges from 0 to 336, and higher scores indicate that the level of distress is high.
Based on the validity and reliability results of the scale, Cronbach’s alpha coefficient and the test–retest
correlation coefficient were determined as 0.85 and 0.82, respectively.

Studies on the language equivalence of the scale

After the scale was separately translated to Turkish by the researchers and three faculty members working in
the English Language and English Literature department of a university, a translator who can understand
and speak both languages (English and Turkish) very well translated the scale back to the original language.
The back translation of the scale was compared with the original scale in terms of grammar and then pre-
sented to experts to obtain their opinions.
Five experts working in different areas evaluated both the Turkish and the original English forms in
terms of language and content validity. Of the five experts, three were academicians in the nursing faculty
and two were in the ethics and history of medicine department. For the evaluation of expert opinions, con-
tent validity index (CVI) was used.66–68
The evaluation criteria of the CVI are as follows: ‘‘1—not appropriate, 2—a little appropriate (items/
statements must be revised), 3—quite appropriate (appropriate, but requires slight changes), 4—very
214 Nursing Ethics 24(2)

Table 1. Content validity based on expert opinion.

Scale Content validity

items Very appropriate Quite appropriate A little appropriate Not appropriate index (CVI)

1 4 1 0 0 1
2 5 0 0 0 1
3 5 0 0 0 1
4 5 0 0 0 1
5 4 1 0 0 1
6 5 0 0 0 1
7 5 0 0 0 1
8 4 1 0 0 1
9 5 0 0 0 1
10 4 1 0 0 1
11 5 0 0 0 1
12 5 0 0 0 1
13 5 0 0 0 1
14 5 0 0 0 1
15 4 1 0 0 1
16 5 0 0 0 1
17 5 0 0 0 1
18 5 0 0 0 1
19 5 0 0 0 1
20 5 0 0 0 1
21 5 0 0 0 1

appropriate.’’ CVI values for the candidate items in the scale were obtained by dividing the total score of the
items rated as very appropriate and quite appropriate by the experts by the total number of the experts.
Because the CVI value in our study was greater than 80%,68 the scale was considered appropriate in terms
of content validity (Table 1). In line with the experts’ opinions, certain statements in items 1, 5, 8, 10, 15
were revised. The revisions made on five items in line with the expert’s opinion were very insignificant
changes and include only a few words. In order to assess the clarity of the questionnaire whose language
validity was performed, it was first administered to a group of nurses (n ¼ 20) not included in the sample
group. After the pilot study, it was decided not to make any more revisions on the questionnaire. The time
needed to administer the questionnaire was determined to be approximately 20–25 min.

Data collection
The nurses included in the study from each unit were informed orally and in writing about the purpose and
the scope of the study by the researchers. They were also told that data collection forms and written consent
forms would be given to clinic charge nurses in two separate sealed envelopes. Because of the heavy work-
load in the ICUs, the nurses were requested to fill in the forms at any appropriate time in a comfortable envi-
ronment in the hospital and to return the forms in sealed envelopes to clinic charge nurses. To facilitate the
data collection process, the researchers cooperated with the clinic charge nurses. In the data collection pro-
cess, the questionnaires were given to the nurse managers for the clinic and then the study data were col-
lected in the participants’ own work environments. When the data were collected, the nurse managers were
told that they could fill in the questionnaires not only in the ICUs but also in any place in the hospital where
they could feel comfortable. The nurse managers returned the questionnaires to the researchers after they
Karagozoglu et al. 215

were filled out. Of the 200 participants, 55 who were randomly chosen during the first implementation of the
scale were asked to find a nickname for themselves and to indicate it in the questionnaire. One of the basic
rules which should be considered when the test–retest reliability analysis is conducted is that the measure-
ment tool should be administered to more than 50 randomly selected individuals.69 Therefore, in our study,
when 55 people out of 200 people were selected, the systematic sampling method was used, and it was
decided to include one out of four individuals in the sample. The same scale was implemented to the test
group 2 weeks later, and they were asked to write the same nickname again on the questionnaire. Then the
questionnaires with the same nickname were paired and the retest results were obtained.

Ethical considerations
In order to assess the validity and reliability of the moral distress scale in Turkey, written permissions by
email were obtained from Corley who developed the scale and Hamric who revised the scale. Before the
study was carried out, the approval of the ethics committee of the Faculty of Medicine, Cumhuriyet Uni-
versity (decision no. 2012-12/14), and the written permissions of the institutions where the study was to
be conducted were received. After the nurses participating in the study were informed about the study, their
verbal and written informed consents were obtained and they were asked to fill in the questionnaires.

Data analysis
The same questionnaires were used to determine the validity and reliability of the Turkish version of the
scale and nurses’ moral distress levels. The validation process of the Turkish version of the questionnaire
was achieved in three steps. During the first step of the process, the linguistic equivalence of the scale was
studied. After the scale’s linguistic equivalence was considered acceptable, its reliability and validity anal-
ysis was performed. During the second stage of the process, the reliability of the scale was assessed with the
test–retest method. In the third stage of the process, the construct validity and reliability of the scale were
analyzed and the validity and reliability stages of the study were completed. Then, the data related to the
nurses’ moral distress levels, and findings regarding the nurses’ intention to leave the job or profession due
to moral distress were obtained from the 200 questionnaires collected during the data collection process.
Analysis and evaluation of the data collected were performed with the SPSS 15 (SPSS Inc., Chicago, IL,
USA) computer software. Suitability of the data for factor analysis was analyzed using Kaiser–Meyer–
Olkin (KMO) value and Bartlett’s test. In order to assess the reliability of the scale, item analysis,
Cronbach’s alpha coefficient, and test–retest correlations showing invariance over time were used. For the
assessment of construct validity, factor analysis was used.

Results
Characteristics of the sample
The population of the study included 200 nurses working in the ICUs. The mean age of the nurses surveyed
was 27.19 + 5.11 (min ¼ 18, max ¼ 43). Of them, 73.5% were women, 59.0% were single, and 70.0% had a
bachelor’s degree in nursing. Nurses’ total length of employment was 5.01 + 4.81 and their mean length of
employment in ICUs was 2.20 + 3.41 (Table 2).

Reliability of the scale

In order to assess the reliability of this 21-item scale, item–total correlations, Chronbach’s alpha, and the
test–retest method were used. According to the results of the reliability and validity of the scale, Cronbach’s
216 Nursing Ethics 24(2)

Table 2. Nurses’ moral distress levels in terms of their socio-demographic characteristics (n ¼ 200).

Demographic characteristics N (%) X + SD Level of significance

Age (X ¼ 27.19 + 5.11)

18–25 (92) 46.0 69.52 + 44.45
26–32 (73) 36.5 69.32 + 45.57 KW ¼ 0.196
33–40 (31) 15.5 77.29 + 63.28 p ¼ 0.978
40 and above (4) 2.0 80.00 + 69.46
Gender
Female (147) 73.5 69.68 + 46.34 t ¼ 0.515
Male (53) 26.5 73.94 + 53.48 p ¼ 0.609
Marital status
Married (82) 41.0 77.70 + 55.85 t ¼ 1.575
Single (118) 59.0 66.25 + 41.52 p ¼ 0.117
Educational level
Health High School (37) 18.5 69.40 + 47.87
Associate Degree (13) 6.5 73.53 + 62.30 KW ¼ 2.212
Baccalaureate (140) 70.0 68.60 + 45.08 p ¼ 0.530
Masters (10) 5.0 103.50 + 66.51
Length of employment (X ¼ 5.01 + 4.81)
1–4 years (121) 60.5 69.06 + 38.95
5–9 years (46) 23.0 72.53 + 56.96 KW ¼ 0.247
10–14 years (20) 10.0 76.72 + 66.68 p ¼ 0.970
15 and above years (13) 6.5 71.35 + 59.65
Length of employment in intensive care units (X ¼ 2.20 + 3.41)
1–4 years (175) 87.5 71.31 + 47.26
5–9 years (14) 7.0 67.14 + 58.70 KW ¼ 2.586
10–14 years (5) 2.5 56.60 + 70.69 p ¼ 0.460
15 and above years (6) 3.0 76.66 + 40.13
Total (200) 100.0 70.81 + 48.23

SD: standard deviation; KW: Kruskal-Wallis.

alpha coefficient was 0.85 and the item–total correlation coefficient of the scale was 0.845. Item–total cor-
relations of the scale ranged from 0.84 to 0.85 (Table 3).
According to the evaluations conducted with an interval of 2 weeks, the test–retest correlation was
r ¼ 0.820, and the relationship was statistically significant (Table 4). The total values for test–retest
measurements were close to each other. The mean scores for the first test and post-test were 70.81 and
79.74, respectively. The results indicate that the difference between the means was not significant and
that the scale is a reliable instrument.

Construct validity and reliability

Construct validity of the scale was evaluated by factor analysis. Prior to the analysis, KMO value and
Bartlett’s test of Sphericity results were examined and determined as 0.810 (KMO) and X2 ¼ 1184.937
(Bartlett’s test of Sphericity) with a significance level of p ¼ 0.001, therefore criteria to proceed with factor
analysis were met (Table 5).
In the factor analysis, the items were grouped into four sub-factors. The first factor loading was deter-
mined as 4.65, the second one as 1.63, the third one as 1.15, and the fourth one as 1.04. However, each of the
three factors included only one item, and each of the 1st, 3 rd, and 14th items formed a different factor.
Karagozoglu et al. 217

Table 3. Item–total score correlations of the scale (n ¼ 200).

Corrected item–
Items r total correlation X SD

1. Provide less than optimal care due to pressures from administrators or 0.849 0.309 1.70 3.40
insurers to reduce costs
2. Witness that healthcare providers give ‘‘false hope’’ to a patient or family 0.847 0.395 1.77 3.20
3. Comply with the family’s wishes to continue life support even though I believe 0.850 0.318 3.53 4.72
it is not beneficial to the patient
4. Start extensive lifesaving actions which I think only prolong dying process 0.843 0.492 4.56 5.55
5. Comply with the family’s wishes not to talk with the dying patient asking 0.850 0.311 3.39 4.64
questions about death
6. Conduct tests and treatments which I consider unnecessary upon the 0.844 0.448 4.62 5.22
physician’s orders
7. Continue to take part in the care of a hopelessly ill person who is being 0.848 0.395 4.16 5.77
sustained on a ventilator in case there is no one to make a decision to
withdraw support
8. Not to denounce physicians or nurse colleagues to authorities when I find out 0.844 0.464 2.53 3.87
they have made a medical error and not informed authorities of the situation
9. Assist a physician who, in my opinion, provides insufficient care 0.842 0.506 4.03 4.83
10. Request care for patients who I do not believe should receive care 0.846 0.424 3.52 5.22
11. Witness medical students perform painful procedures on patients solely to 0.845 0.422 3.08 4.45
increase their skill
12. Provide care that does not relieve the patient’s suffering because the 0.846 0.406 2.90 3.77
physician fears that increasing the dose of pain medication will cause death
13. Comply with the physician’s order not to discuss the patient’s prognosis with 0.847 0.386 3.70 4.54
the patient or family
14. Increase the dose of sedatives/drugs which, I consider, will only accelerate the 0.848 0.362 2.25 3.37
dying process of an unconscious patient
15. Not to inform superiors about ethical problems which arise because 0.843 0.503 2.60 4.21
someone who is in authorized position or a staff member involved in the case
has asked me not to do anything
16. Comply with the family’s request for the care of the patient due to fear of 0.849 0.341 1.64 3.09
litigation even though I disagree
17. Work with nurses or other healthcare providers who are not competent 0.841 0.520 4.36 5.46
enough to fulfill the patient care
18. Witness insufficient patient care quality due to poor communication within 0.842 0.505 5.05 5.32
the team
19. Ignore the situations in which necessary information is not given when the 0.842 0.498 4.02 5.00
informed consent is obtained
20. Witness a patient’s suffering because of a lack of continuity of care providers 0.846 0.416 3.18 4.19
21. Work with nurses or other care providers that I consider unsafe 0.840 0.565 4.17 4.73
SD: standard deviation.

Table 4. Correlations of the nurses’ MDS-R test–retest scores.

Test Second test Level of significance

First test r ¼ 0.820 p ¼ 0.001

p < 0.05
MDS-R: Moral Distress Scale–Revised.
218 Nursing Ethics 24(2)

Table 5. Kaiser–Meyer–Olkin (KMO) and Bartlett’s results.

KMO measure of sampling adequacy 0.810

Bartlett’s test of Sphericity Approx. chi-square 118.937

df 210
Sig. 0.001
df: degree of freedom; sig: significant.

Table 6. Factor loadings and rate of total variation.

Initial eigen values Extraction sums of squared loadings Rotation sums of squared loadings

% of Cumulative % of Cumulative % of Cumulative

Component Total variance % Total variance % Total variance %

1 4.650 29.063 29.063 4.650 29.063 29.063 3.109 19.432 19.432

2 1.632 10.197 39.260 1.632 10.197 39.260 1.978 12.363 31.796
3 1.159 7.244 46.504 1.159 7.244 46.504 1.793 11.208 43.003
4 1.041 6.503 53.007 1.041 6.503 53.007 1.601 10.004 53.007
5 0.968 6.052 59.059
6 0.899 5.616 64.675
7 0.814 5.088 69.763
8 0.752 4.698 74.461
9 0.713 4.456 78.917
10 0.599 3.747 82.664
11 0.572 3.575 86.239
12 0.549 3.429 89.668
13 0.512 3.198 92.865
14 0.404 2.527 95.392
15 0.379 2.368 97.761
16 0.358 2.239 100.000

However, because the difference between the first factor and these three factors was 10%, these three fac-
tors were assigned to the first factor. Thus, the 21-item scale was represented by a single factor, and this
factor accounted for 53.1% of the total variation (Table 6).

Moral distress level of intensive care nurses

It was determined that the moral distress total and item mean scores of the nurses participating in the study
were 70.81 + 48.23 and 3.36 + 4.50, respectively. When the mean scores obtained from the scale were taken
into account, it was also determined that they had a low level of moral distress (Table 7). Our study revealed
that nurses’ moral distress levels regarding the items ‘‘Witness insufficient quality of patient care due to poor
communication within the team’’ (5.05 + 5.32), ‘‘working with professionals they consider as incompetent’’
(4.36 + 5.46), ‘‘continuing to administer tests, treatment, and interventions non-beneficial to the patient’’
(4.62 + 5.22), ‘‘prolongation of the death process’’ (4.56 + 5.55), and ‘‘life support non-beneficial to the
patient’’ (3.53 + 4.72) were higher than those regarding the other items of the scale. While 24.0% of the
nurses considered resigning due to moral distress but did not, 16.0% of them considered quitting his/her job.
Karagozoglu et al. 219

Table 7. Distribution of nurses’ Turkish version of MDS-R total and item mean scores (n ¼ 200).

Turkish version of MDS-R Min Max X + SD

Total score 22.00* (0.00)** 180.00* (336.00)** 70.81 + 48.23

Item score 1.64 (0.00) 5.05 (16.00) 3.36 + 4.50
MDS-R: Moral Distress Scale–Revised; SD: standard deviation.
*The minimum and maximum scores that individuals received from the scale.
**The numbers in parentheses are the minimum and maximum values that can be obtained from the scales.

There was no significant difference between moral distress levels in terms of socio-demographic char-
acteristics (p > 0.05).

Discussion
Moral distress is one of the serious problems faced by nurses and affects nurses in all areas of the health-
care.1,4,10,16,55,62,70 In order to reduce the negative impacts of moral distress on institutions, patients, and
professionals, the first thing to be done is to evaluate moral distress with a valid and reliable instrument.
In this study conducted to determine the validity and reliability of the Turkish version of the MDS-R,
important findings indicating that MDS-R could be used for intensive care nurses were obtained. Our
Cronbach’s alpha result for Turkish version of MDS-R is similar to the values obtained in previous studies.
Corley et al.9 found the Cronbach’s alpha as 0.96 in their study conducted in 2001, and they determined it as
0.98 for the intensity of moral distress and as 0.90 for the frequency of moral distress in 2005. Later, in the
(MDS-R) scale revised by Hamric et al.12 the Cronbach’s alpha coefficient for nurses was found as 0.89.
Lazzarin et al.55 performed the validity and reliability study of the Italian version of the scale revised by
Hamric et al.12 with the nurses working in oncology and hematology units and found the Cronbach’s alpha
coefficient as 0.96. Barlem et al.71 conducted a study on nurses in Brazil and found the Cronbach’s alpha
value as 0.95. In their other study, Barlem et al.18 found it as 0.93. In their study of intensive care nurses,
Wilson et al.14 determined the Cronbach’s alpha coefficient as 0.90.
In our study, test–retest correlation showing the stability of the instrument over time of the Turkish
version of the scale was determined as quite high. Our findings indicate that the Turkish version of the
scale was consistent and capable of providing similar measurement values during repetitive measure-
ments. Corley et al.8 determined the test–retest correlation of their MDS as 0.86. Hamric et al.12 identified
the test–retest reliability coefficient of the 21-item MDS-R scale as 0.58. Although ‘‘70%’’ is generally
accepted as a criterion for reliability coefficients, in assessment instruments with fewer items, values of
50% are considered acceptable. The test–retest reliability coefficient may also vary according to the
length of time elapsed between tests. Because some changes may occur in the property assessed if the
time between the two tests is longer and because ensuring the same conditions at every assessment is not
possible, reliability coefficient will be lower. Therefore, determining the appropriate time intervals at
repeated measures is very important.69 Thus, it is possible to observe subjective differences between
test–retest coefficients for the different versions of a scale.
In our study, factor analysis was used for the assessment of construct validity. The factor analysis indi-
cated that the scale had the one-factor structure. In their validity and reliability study of the 32-item moral
distress scale, Corley et al.8 identified that the scale had the three-factor structure. However, in their
validity and reliability study of the 21-item MDS-R scale, Hamric et al.12 identified that the scale had the
one-factor structure.
When the mean scores obtained from the scale were taken into account, it can be said that nurses
suffered low level of moral distress. While several studies in the literature determined different
220 Nursing Ethics 24(2)

results,8,9,12,14,24,63 in studies by Wilson et al.14 and Ganz et al.,32 nurses’ moral distress level was
determined as low, which is similar to our findings. Redman and Fry72 reported that one out of three
nurses suffered moral distress. However, due to the nature of moral distress, nurses do not express this
experience.14 In an earlier study too, it was reported that nurses had difficulty to express what led
them to suffer moral distress.54 That nurses in our study had low levels of moral distress might be
associated with the fact that they felt that they were not competent or authorized enough in the
decision-making process in the team when problems causing moral distress were solved, or that phy-
sicians displayed a paternalistic approach. This idea was also supported in the literature. It is stated
that in the healthcare system, physicians feel that they hold a more powerful position and perceive
themselves more autonomous in decision-making processes.12,31,32 In her study of moral distress
among nurses, Gutierrez54 reports that nurses pretend that they share the physicians’ views and thus
remain in the background when the decisions are made. Nurses frequently perceive themselves to be
weak or to have very little authority in their institutions. They also feel that they have neither author-
ity nor influence over the patients and that they cannot efficiently tackle with the situations threaten-
ing the patients.32,73 In their study investigating the perceptions of nurses and physicians regarding
end-of-life decisions, Ferrand et al.74 state that 90% of the physicians and nurses believe that coop-
eration is essential in the decision-making process, but that only 27% of the nurses are included in
this process.
Another reason why the nurses in our study suffered low levels of moral distress may be attributed to the
fact that the participants were younger and less experienced. Younger and less experienced nurses may feel
that they are not supposed to be at the forefront of ethical decision-making process at the beginning of their
work life and thus suffer less stress.21 However, they may suffer higher levels of moral distress in the ethical
decision-making process as their experience and responsibilities increase.3,8,9,25,53,75 This may be associ-
ated with the fact that younger nurses especially who are supposed to take on responsibilities in critical areas
cannot be aware of the ethical dilemmas and problems they experience and decide wisely and/or cannot
cope with problems due to their limited knowledge and skills.
It was determined that the item ‘‘Witness insufficient quality of patient care due to poor communication
within the team’’ caused the nurses in our study to suffer higher levels of moral distress than the other items
did. Similar to our findings, Barlem et al.71 report that nurses experienced moral distress due to the poor com-
munication in the team. Another factor which caused the nurses in our study to experience higher levels of
moral distress is that they work with other professionals who, they consider, are not competent enough. Work-
ing with professionals who are not competent enough and unclear task definitions can lead to moral distress in
many cases.2,8,16,41,43,45,47,52,54,57,76 Nurses’ distress regarding this situation can be associated with their con-
cerns that the patient can get harm or that they fail to fulfill their responsibilities for the patient. Other studies
on the issue support this conclusion too.14,41,47,62 Another factor that caused the nurses in our study to suffer
higher levels of moral distress is futile care (items 3, 4, 6, 7). In other studies in the literature, it is reported that
the moral distress levels of nurses working in ICUs regarding futile care are higher.14,15,22,24,34,40,41,47,77 In line
with our findings, it can be said that factors such as ‘‘life support non-beneficial to the patient,’’ ‘‘continuing to
administer tests, treatment, and interventions non-beneficial to the patient,’’ and ‘‘prolongation of the death
process’’ cause nurses to suffer moral distress more.
Moral distress affects nurses professionally too3,8,10,16,17,47,52,53,71 and causes negative conditions in
nurses such as reluctance to go to work, wishing to be transferred to other clinics, and quitting the job or
even the profession.1,4,8,16,17,19,34,43,45,59 In our study, it was also determined that 24.0% of the nurses con-
sidered resigning due to moral distress but did not whereas 16.0% of them still considered quitting his or her
job. In other studies too, it is reported that nurses resigned due to the moral distress,8 or considered quitting
his or her job10 or being transferred to another unit.55,78 In line with these findings, it can be said that as
nurses’ moral distress level increases so does their tendency to quit working.
Karagozoglu et al. 221

Limitation
The study was limited by lack of data on participants’ work settings. It should be noted that although this
study offers an extensive amount of valid, reliable, and trustworthy results, it does not represent an attempt
to develop an in-depth understanding of all aspects and consequences of moral distress for individual
nurses.

Conclusion
In our study conducted to determine the validity and reliability of the Turkish Version of MDS-R, it was
considered that the scale should include 21 items and have the one-factor structure. With this structure, the
scale can be used as a valid and reliable tool for the assessment of moral distress experienced by nurses
working in ICUs in Turkey.
This assessment tool can contribute to the assessment of moral distress levels of nurses working in ICUs,
to the development of institutional solutions aiming to reduce nurses’ moral distress, and to the attempts
targeting to increase nurses’ personal and professional well-being levels.
It was determined that the nurses who participated in this study suffered low levels of moral distress, but
high levels of moral distress regarding the scale items such as inadequate communication within the team,
working with professionals they considered as incompetent, and futile care.

Acknowledgements
With the submission of this article, I would like to undertake that the above mentioned article has not been
published elsewhere, accepted for publication elsewhere, or under editorial review for publication else-
where. All authors approve the content of the article and have contributed significantly to research
involved/the writing of the article. The protocol for the research project has been approved by the ethics
committee of the Faculty of Medicine, Cumhuriyet University (decision no. 2012-12/14). The study was
performed in accordance with the principles of the Helsinki Declaration. All participants gave informed
consent for the research, and their anonymity was preserved.

Conflict of interest
The authors declare that there is no conflict of interest.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-
profit sectors.

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