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© 2018 Journal of Nursing and Midwifery Sciences | Published by Wolters Kluwer - Medknow 147
Assessing nurses’ moral distress and patients’ satisfaction with
the observance of the patients’ rights charter
Darush Rokhafrooz1, Ali Hatami2, Akram Hemmatipour3, Elham Abdolahi-Shahvali 3, Masomeh Salehi Kamboo3
1Department of Nursing, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, 2Student Research
Commiee, Shoushtar Faculty of Medical Science, 3Department of Nursing, Shoushtar Faculty of Medical Sciences, Shoushtar, Iran
INTRODUCTION
Ethics has a special place in the healthcare and treatment
eld,[1] and hence that the basis of this care is respect for
the patient’s dignity and consciousness.[2]
In 2002, the patients’ rights charter (PRC) was rst issued
by the Ministry of Health of Iran[3] and edited and revised
in 2009. In this new version, patients have ve rights as
follows: receiving favorable services; receiving information
in an appropriate and adequate manner; selecting and
deciding freely for receiving health services; respecting the
patient’s privacy rights and principle of condentiality; and
accessing an effective system for handling complaints.[4]
Context: Patient’s rights are one of the most fundamental rights that should be considered by the health-
care providers, especially nurses. On the other hand, moral distress in nurses can lead to problems in the
provision of health services for patients.
Aims: This study aimed to determine the correlation between nurses’ moral distress (NMD) and patients’
satisfaction with the observance of the patients’ rights charter (PRC).
Setting and Design: In this descriptive-analytic study, 82 nurses were selected using purpose-based method,
and 200 patients were selected in quotas in proportion to the number of beds available in the general and
special wards in 2 months.
Materials and Methods: Data collection tools consisted of demographic information form, the moral distress
scale-revised, and a researcher-made questionnaire on patient satisfaction with the observance of PRC.
Statistical Analysis Used: Data were analyzed using descriptive statistical in SPSS version 16.
Results: The mean score of moral distress in nurses was11 ± 33 that 59 (72%) of them had moderate
distress level and the mean score of satisfaction with the observance of the charter of patients’ rights was
71.6± 18.2. It was found that 120 (60%) of the patients had a satisfactory moderate level of the observance
of their rights charter. There was a reverse statistically significant positive correlation between NMD and
satisfaction with the observance of the PRC (P < 0.05).
Conclusion: In the present study, it was found that there is a moderate correlation between the patients’
satisfaction with the observance of the PRC and the NMD.
Keywords: Moral distress, Patient satisfaction, Patients’ rights charter
Abstract
Address for correspondence: Mrs. Hemmapour Akram, Master of Nursing, Department of Nursing, Shoushtar Faculty of Medical Sciences, Shoushtar, Iran.
E-mail: Hemapour.a64@gmail.com
Received: 04 April 2018; Accepted: 15 May 2018; Published: 13 August 2018
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DOI:
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Original Article
How to cite this article: Rokhafrooz D, Hatami A, Hemmatipour
A, Abdolahi-Shahvali E, Salehi Kamboo M. Assessing nurses' moral
distress and patients' satisfaction with the observance of the patients'
rights charter. J Nurs Midwifery Sci 2017;4:147-53.
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Darush, et al.: Nurses' Moral Distress and Patients' Satisfaction
148 Journal of Nursing and Midwifery Sciences | Volume 4 | Issue 4 | October-December 2017
Although informing the PRC is a valuable measure for
realizing patients’ rights, the degree of observance of
patients’ rights in medical centers is different.[5,6]
Hospitals should provide appropriate conditions for
patients’ care, understanding, and respect for their rights
as well as the care team.[7,8] Indeed, if the PRC is properly
implemented and complied with, and leads to the patients’
satisfaction, the working relationship between the medical
and nursing staff with the patient will be improved, and
patient recovery will be accelerated.[9] Failure to observe
patients’ rights and their dissatisfaction with the provided
services will slow down the improvement, increase
hospitalization, irritability, and increase the cost of
patient treatment. Therefore, increasing the observance
of patients’ rights is one of the important goals of
therapy group activities, which plays a signicant role in
improving the health of the patient.[10] Since observing
patients’ rights is one of the most important components
of providing humanitarian and moral care, nurses are not
able to face up to the challenges ahead without being
aware of ethical concepts. On the other hand, nurses
spend the most of their time in the clinic, which causes
changes in moral problems and increases their ethical
challenges.[11,12]
For this reason, the American Nursing Association has
provided moral codes for nursing activities and services,
which are guides for the nurses’ moral behaviors.[13] One of
the ethical challenges in nursing is moral distress, and it is
known as a phenomenon that impedes the proper ethical
functioning of individuals, despite having the necessary
knowledge.[14] Moral distress is created when the situation
is opposed to individual beliefs and internal moral values,
and person should act against these values as a result of
those real conditions and limitations.[12] Occasionally,
distresses occur in the form of behavior that a person, due
to the fundamental moral distress and subsequent negative
emotions, cannot continue to work.[15] The consequences
of moral distress occur seriously and gradually, and in most
cases, nurses not only do not have preventive strategies but
also do not nd it.[16]
The occurrence of moral distress can lead to different
outcomes for nurses, patients, and health organizations.[12]
The negative consequences of this ethical problem can
lead to anger, disappointment, discomfort and feelings
of inferiority, and unpleasant emotional state for the
nurses, and in addition, accompanied by medical errors,
burnout, career abandonment, and increased violence
and disruption of the ethical atmosphere in the workplace
and inappropriate observance of the charter of patients’
rights and the reduced quality of health‑care provision.[17‑20]
Similarly, Pauly et al. reported a moderate moral distress
in nurses.[21]
Therefore, considering the nurses’ moral distress (NMD)
to provide satisfactory services to patients, paying attention
to patients’ rights is one of the priorities of hospitals and
other health service providers. Consequently, it is desirable
to consider this as an essential component of the clinical
service standardsTherefore, it is desirable to consider
this as an essential component of the clinical services
standards. This study aimed to determine the correlation
of NMD with patients’ satisfaction with the observance of
the PRC in Khatam Al‑Anbia Hospital, city of Shushtar,
Iran in 2017.
MATERIALS AND METHODS
The present study is a descriptive‑correlational study that
was conducted in Khatam Al‑Anbia Hospital in Shushtar
during 3 months from October to December 2017.
The study population included two groups of nurses
and patients. Patient sampling has been quotas among
the patients admitted in general (internal, surgical, and
neurology) and special wards (coronary care unit [CCU] and
dialysis). According to the number of beds in each ward,
the number of patients in that ward was selected. According
to the similar studies[22] and considering a drop of 15%,
200 patients with inclusion criteria (the conscious desire to
participate in the study, at least 18 years and up to 60 years
of age, no mental illness, hospitalization duration at least
24 h, and being able to cooperate) were selected. Nurses
were selected in a purpose‑based manner with informed
consent, 82 nurses were willing to attend. Furthermore,
exclusion criteria for nurses and patients included the lack
of response to the questionnaire.
Data gathering tools were a demographic information
form, a standard questionnaire on moral distress
scale (MDS‑R), and a researcher‑made questionnaire on
patients’ satisfaction with PRC, each containing two parts.
The demographic information form for patients included
age, gender, educational level, occupation, and the
hospitalization duration; and for nurses, it included age,
gender, marital status, work experience, type of shift, and
work department.
To investigate moral distress of nurses, the 18‑statement
MDS‑R developed by Hamric et al. (2012) was used. The
scoring is based on the ve‑degree Likert scale as follows:
very high (4), high (3), moderate (2), low (1), and none (0),
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Darush, et al.: Nurses' Moral Distress and Patients' Satisfaction
Journal of Nursing and Midwifery Sciences | Volume 4 | Issue 4 | October-December 2017 149
which is assessed two levels of distress as follows: intensity
and frequency. In this tool, the number 5 represents the
highest amount of moral distress, and the number 0
indicates the absence of moral distress. Given that, each
item can include a range of 0–16 points, the total score
for the intensity and frequency of moral distress is 0–288.
Intensity and frequency of moral distress are assessed at
low levels if scores are between 0 and 96. Scores between 97
and 192 show the intensity and frequency of moral distress
at an average level. Scores between 193 and 288 show the
intensity and frequency of moral distress at a high level.
Hamric, Borcrose, and Epstein (2012) assessed its content
validity, and the correlation of this tool was R = 0.22,
and its reliability using Cronbach’s alpha was 0.89. In the
study conducted by Abbaszadeh et al., theo validity of this
questionnaire was desirable, and its reliability calculated
using the internal consistency method (Cronbach’s alpha
coefcient) was 0.93.[23]
To assess the satisfaction of patients, a researcher‑made
questionnaire on compliance with the rights charter,
containing 23 questions, was used based on the guidelines
established by the World Health Organization and the
patients’ rights book in Iran. The questionnaire’s axes
included rst, getting the optimal healthcare is a right for
the patient; second, the information should be provided to
the patient in a satisfactory and sufcient manner; third, the
right to choose and decide freely on the receipt of healthcare
should be respected; fourth, the provision of health
services should be based on respect for patient’s privacy
and adherence to the principle of condentiality; and fth,
access to an effective system for dealing with complaints is
a right for the patient. The scoring in the questionnaire was
very good (5), good (4), medium (3), low (2), and very low
(1) based on the ve‑degree Likert scale. The scores range
is from 115 to 23, so that the range of 23–53 is weakness
level, 54–83 is average, and 84–115 is good.
In addition, the validity of the questionnaire of the PRC
was determined by the content and formal validity methods.
The questionnaires were distributed among 10 faculty
members related to the study topic, so that content, clarity,
and simplicity of each of the tool statements were refereed
and reviewed after applying corrective comments. For
determining formal validity, the questionnaires were given to
ve patients who had the characteristics of entering into the
study to assess the perceived ability and ease of use. After
applying corrective comments, questionnaires were used for
the present study. Furthermore, to determine the reliability,
the questionnaires were distributed among 20 hospitalized
patients and the internal consistency (Cronbach’s alpha)
obtained was α = 0.84.
To observe the moral considerations, the researcher,
with the permission and coordination required by the
vice‑chancellor for research of Shushtar Medicine School,
and with the possession of a research note, referred
to the wards of Shushtar Khatam Al‑Anbia Hospital
and performed the necessary coordination. Then, the
researcher arrived at the hospital for 3 months in different
shifts and attended the bedside of patients. In addition
to introducing herself and expressing the goal, and after
obtaining informed written consent, the PRC questionnaire
was completed by the patient in the case of the patient
self‑mastery to complete the questionnaire, and in the case
of the inability of each of patient, they were completed by
the researcher using interviewing. The researcher provided
moral distress questionnaires to qualified nurses and
emphasized the completion of questionnaires to complete
the same shift. In case of any questions or problems
regarding the questionnaire questions, the researcher did
the necessary steps to resolve the ambiguity. Data normality
was evaluated and conrmed using Kolmogorov–Smirnov
test. Data were analyzed using descriptive statistical
methods (mean, median, standard deviation, etc.), ANOVA,
Chi‑square, and independent t‑tests in SPSS version 16 with
a statistically signicant level of 0.05.
RESULTS
The study population was inpatients and nurses. The
nurses’ mean age was 32 5±/2 and their working experience
was 9.5 ± 4.5. The majority of them, i.e., 71 (86%) were
the nurses with rotation work shift hours. The mean age of
the patients was 29.07 ± 7.22. A total of 34 patients (12%)
were admitted for the rst time [Table 1].
The average score of satisfaction with the PRC was
71.6 ± 18.2 and severity, and frequency of NMD was
33 ± 0.11 [Table 2].
The results of this study showed that 120 patients (60%)
had a moderate satisfaction, and regarding moral distress,
59 (52%) nurses had a moderate level of distress [Table 3].
Using independent t‑test, there was no signicant difference
between NMD and demographic variables of gender,
service ward, marital status, type of responsibility, and work
shift (P > 0.05). Furthermore, there was no statistically
signicant relationship between the satisfaction with the
PRC and with the education level (P = 0.023), the number
of hospitalization days (P = 0.44), and gender (P = 0. 29).
Meanwhile, there was a signicant difference between
the satisfaction with the PRC and the different hospital
wards (P = 0.03). The results also showed that the highest
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150 Journal of Nursing and Midwifery Sciences | Volume 4 | Issue 4 | October-December 2017
level of satisfaction was related to the CCU ward with a
mean of 68.35% and the lowest level of satisfaction was
in a dialysis ward with a mean of 59.36% [Table 1].
Using Pearson correlation coefcient, there was a negative
significant moderate correlation between the nurses’
ethical distress and the patients’ satisfaction with the
PRC (P < 0.001; R = 0.606). Hence, with the increase in
the level of the nurses’ ethical distress, the satisfaction rate
of patients has decreased from the PRC. In examining
the dimensions of the PRC, it was found that there was
a statistically significant intense correlation between
receiving the optimal health care (P < 0.001; R‑0.909) and
access to information (P < 0.001; R = 0.235). There was
a weak correlation between respect for the privacy of the
patient and respect the principle of secrecy (P < 0.026;
R = 0.267). There was a statistically signicant moderate
correlation between access to an effective complaints
handling system (P < 0.001; R = 0.403) and respect
for right to choose (P < 0.001; R = 0.416) with moral
distress [Table 4].
Using regression, the results showed that the coefcient
of determination with the enter method of repeated
combination for a linear combination of dimensions of the
PRC with the NMD was 48%. In fact, predictive variables
in this study could predict 48% of moral distress in the
nurses [Table 5].
Table 1: Frequency of demographic variables studied and its relationship with the level of the patients’ rights charter and the
nurse’s moral distress
Variable Group
Patients,
n (%)
Nurses,
n (%)
Significance level using independent t‑test (P<0.05)
Satisfaction with the PRC Nurse’s moral distress
Gender
Woman 90 (45) 72 (87.80) 0.29 0.32
Man 110 (55) 10 (12.19)
Frequencies of hospitalization
1 time 34 (12) ‑ 0.44 ‑
2 times 38 (14) ‑
3 times 25 (13.7) ‑
4 times and more 28 (14) ‑
Unknown 78 (39) ‑
Education level
Less than the high school diploma 83 (41.5) ‑ 0.23 0.78
High school diploma 67 (33.5)
Bachelor 40 (20) 67 (81.70)
Master’s degree and higher 10 (5) 15 (18.29)
Marital status
Single 85 (42.5) 33 (40.24) 0.23 0.06
Married 115 (57.5) 49 (59.75)
Ward
Internal 45 (22.5) 18 (21.95) 0.03* 0.63
Neurology 45 (22.5) 18 (21.95)
Surgery 45 (22.5) 18 (21.95)
Dialysis 35 (17.5) 12 (14.63)
CCU 30 (15) 16 (19.51)
Position
Nurse ‑ 71 (86.58) ‑ 0.73
Responsible for the ward ‑ 11 (5.5)
Shift type
Morning work ‑ 11 (5.5) ‑ 0.78
Rotation work shift ‑ 71 (86.58)
PRC: Patient’s rights charter, CCU: Critical Care Unit
Table 2: The mean and standard deviation of patient rights charter dimensions and the nurses moral distress
Variable Dimensions Mean±SD
Dimensions of PRC Receiving the optimal health care 17.3±4.7
Access to information 16.2±3.1
Respect for the right to choose and decide freely 9.8±3.1
Respect for the privacy of the patient and respect the principle of secrecy 17.4±3.5
Access to an effective complaints handling system 10.8±4.8
Total 71.6±18.2
Distress Repeated moral distress 33±0.11
Severity of moral distress 33±0.11
PRC: Patient’s rights charter, SD: Standard deviation
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Journal of Nursing and Midwifery Sciences | Volume 4 | Issue 4 | October-December 2017 151
DISCUSSION
This study was conducted to investigate the relationship
between the nurses’ ethical distress and patients’ satisfaction
from the observance of the PRC. The results of this study
showed that the overall mean score of moral distress in
two levels of frequency and severity indicated a moderate
level in nurses, which is consistent with the study by Sadeghi
et al. (quoted by Shakeriniya), who showed that nurses
participating in their study, endured moderate intensity of
distress regarding frequency and severity.[13] It should be
noted that in the study by Joolaee et al., the severity of moral
distress of nurses was moderate and its frequency was at
high level.[24] In the study by Elpern et al., the severity of
tension among the 28 nurses participating in their study
was in the moderate level.[25] However, in the median study
in the United States, the level of moral distress of nurses
was at a low level[26] and in the studies by Keighobadi, and
Redman and Fry, the NMD was at high level,[27,28] which is
not consistent with the present study. It can be said that
various factors such as pressure and workload, lack of time,
workplace, economic status and the workplace facilities, and
organizational rules and regulations, and nurses’ ignorance
of how to deal with the issue of moral distress can play a
role in this regard.[24] Furthermore, there was no signicant
relationship between demographic variables with moral
distress level in the present study. However, in the study by
Keighobadi,[19] there was a signicant statistical relationship
between the work ward and in Sahebazzamani’s study,[29]
there was a statistical correlation between the work shift and
the level of NMD, which is not consistent with the present
study. The reason for this inconsistency with the present
study can be stated that in the reviewed studies, by cause
of the low number of nurses and the high workload in the
wards, nurses have higher moral distress. Furthermore, at
evening and night work shifts, nurses have the lowest level
of individual competency, and in the morning, they had the
highest rate of this competency. Providing a regular work
plan to nurses, providing rest time during the shift, creating
a time‑out period decreases stress and work pressures in
the evening, and night shift. On the other hand, hospital
retraining programs should also be as easy as possible to
Table 3: The frequency of levels of patient’s satisfaction with the patient’s rights charter
Desirable level Weak Moderate Good
Dimensions of PRC 23‑53 54‑83 84‑115
Receiving the optimal health care, n (%) 6 (3) 76 (38) 118 (59)
Access to information, n (%) 10 (20) 87 (43.5) 16 (8)
Respect for the right to choose and decide freely, n (%) 52 (26) 134 (67) 14 (28)
Respect for the privacy of the patient and respect the principle of secrecy, n (%) 8 (4) 130 (65) 62 (31)
Access to an effective complaints handling system, n (%) 22 (11) 134 (82) 14 (7)
Total score, n (%) 38 (19) 120 (60) 42 (21)
The Frequency of levels of the nurses’ moral distress
Desirable level Weak Moderate Intense
0‑96 97‑192 193‑288
Moral distress of nurses (frequency and severity), n (%) 18 (22) 59 (72) 5 (6)
PRC: Patient’s rights charter, MOD: Moral distress
Table 4: Pearson correlation coefficients of dimensions of the patient’s rights charter with the nurse’s moral distress level
Dimensions 1 2 3 4 5 6 7
Dimensions of
PRC
Receiving the optimal health care 1 0.709 0.476 0.647 0.916 0.427 −0.909
Access to information 1 0.477 0.582 0.815 0.315 −0.235
Respect for the right to choose and decide freely 1 0.409 0.643 0.210 −0.416
Respect for the privacy of the patient and respect the principle of secrecy 1 0.817 0.219 −0.267
Access to an effective complaints handling system 1 0.394 −0.403
PRC (total) 1 −0.606
Moral distress 1
Significance at the level of P=0.001. PRC: Patient’s rights charter
Table 5: The result of the regression of the dimensions of the patient’s rights charter on the nurse’s moral distress
Predictor variable R2Criterion variable (moral distress)
FSE B b
Receiving the optimal health care 0.21 30.69 0.02 0 .14 0.46*
Access to information 0.41 39.05 0.04 −0.25 0.49**
Respect for the right to choose and decide freely 0.47 33.26 0.07 0.27 0.37
Respect for the privacy of the patient and respect the principle of secrecy 0.47 24.83 0.08 0.04 0.03
Access to an effective complaints handling system 0.48 20.59 0.05 −0.07 −0.12
SE: Standard error
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152 Journal of Nursing and Midwifery Sciences | Volume 4 | Issue 4 | October-December 2017
provide practical and applicable solutions to cope with
stress and work tensions. The moral distress of nurses has
a negative effect on the quality of nurses’ work including
patient care. On the other hand, one of the essential aspects
of care is respect for patients’ rights. Paying attention to
patients’ rights as one of the criteria for assessing the
quality of health services is important and leads to the
reduction of physical and psychological injuries, increased
care of patients, and improvement of relationships between
patients and personnel.[30] In this study, it was found that
patients had a relatively satisfactory level of compliance
with all aspects of their rights by the medical staff, especially
nurses, which is consistent with the study conducted by
Asteraki et al., performed on 260 patients.[31] In the present
study, the most satisfaction with the rst axis was related
to the receiving the optimal health care, and the least
satisfaction with the third axis was related to the area of
respect for the right to choose and decide freely. In the
same regard, it is consistent with the study by Astearky et al.,
Kolahi, and Sohrabi.[31] In the study by Vaskooei Eshkevari
et al., patients’ satisfaction with the PRC was 53%. The
lowest satisfaction was related to the respect for the right
to choose and decide freely.[32] In the study by Ghazikhanlo
et al., the 130 patients’ satisfaction with the PRC was
moderate, with the highest satisfaction related to the
patient’s respect and the least related to the area of access
to an effective complaints handling system.[33] However, in
the study by Moghaddam et al., 346 patients’ satisfaction
with the PRC was 53% at the desired level (high). The
highest rate of satisfaction was related to receiving the
optimal healthcare, and the lowest rate of satisfaction was
related to the access to information.[10] Perhaps, the reason
for this inconsistency regarding the charter of rights in
the studies mentioned is the difference in the sampling
environment. The present study was conducted in teaching
hospitals. It is also noteworthy that in the governmental
hospitals, health services are provided by nursing students,
their lack of knowledge, and attitude toward patient’s rights
can reduce the patient satisfaction, and some aspects of
the charter have been subjected to some restrictions. In
the study of the underlying factors affecting the patients’
satisfaction with the observance of the PRC in this study,
there was a signicant correlation with the hospitalization
ward, which is consistent with the study by Gashmard
et al.[34] and Mack et al.,[35] but differ regarding the type of
ward. In the present study, the highest satisfaction rate was
observed in CCU patients and the least in dialysis patients.
Perhaps, the reason for this difference in rate of the
satisfaction with wards in the studies is due to the number
of nurses and due to the type of illness and high stress
present in some wards. The present study showed that
there is a signicant negative correlation between nurses’
ethical distress with the observance of the PRC, so that
with increasing distress, the satisfaction level of patients
has decreased. In this study, there is a strong correlation
between satisfactions with ethical distress; furthermore,
there is a weak correlation between satisfaction with respect
to privacy and access to information. In the same way,
Cynthia’s study showed a signicant correlation between
nurses’ ethical distress and patient care.[33] However, there
was no signicant correlation between the ethical distress
of nurses and patient care in the study by Azarm.[30] In
the study by Mohammadi et al., there was a signicant
correlation between the ethical sensitivity among the 130
nurses and the observance of the PRC.[36] The reason
for this difference was the nurses’ work competency, the
differences in the service wards and the underlying and
ethical problems of nurses.
Some of the limitations of this study were as follows:
patients’ and nurses’ failure to express their real opinions
and disappointment about the impact of such research;
in this way, the problem of collaboration was somewhat
solved by explaining more about the impact of research
results and its practical use.
CONCLUSION
In general, correlation of the patients’ satisfaction with the
PRC and the NMD is moderate. Therefore, to increase
the patients’ satisfaction with the PRC, understanding of
the root causes of moral distress in nurses and organizing
training courses and more justifying nursing staff and
students are suggested.
Conflicts of interest
There are no conicts of interest.
Authors’ contributions
All authors contributed to this research.
Financial support and sponsorship
This study was financially supported by Research of
Shushtar Medical School.
Acknowledgment
The authors would like to thank the vice‑chancellor for
research of Shushtar Medicine School, as well as the dear
nurses and patients participating in this study.
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