Moral Distress in South African Professional Nurses: Instrument Development

Nurses experience stress, fear and anger while they are trying to reconcile their ideals/ goals about health care with its inadequacies and abuses, while at the same time trying to stay true to their convictions.  Moral distress is experienced when nurses cannot adhere to these goals.  Conflicting moral principles, stress-provoking and contradicting demands weaken the nurse’s sense of control, power and autonomy.  The current descriptions of moral distress inadequately define the concept, and this might lead to the inconsistent use of the term moral distress.  Therefore, conceptual clarity is needed.  Current available instruments measure antecedents and situations causing moral distress.  Therefore, an instrument measuring the attributes of moral distress is urgently needed.  Such an instrument might be used in a variety of clinical departments because it is not based on department-specific situations but on the attributes of moral distress.  Moral distress has a great impact on the nurse, patient care and the organization. 

This research used Benson and Clark’s method of instrument development as a theoretical framework.  It is the aim of this study to develop and validate an instrument to measure moral distress in the clinical health care context of the professional nurse.  In order to attain this aim the following objectives were set: To conduct an integrative literature review to identify antecedents, consequences, attributes and empirical indicators of moral distress; to conduct interviews to explore professional nurses’ experience of moral distress; to develop an instrument to measure moral distress in professional nurses; to validate the instrument.  A qualitative and quantitative research design with explorative, descriptive and contextual strategies was used. 

The research process was divided into phases.  During Phase One, an integrative literature review was conducted and the population included all available national and international data on moral distress in nurses/ nursing and sampling included all-inclusive sampling.  Data analysis was performed through descriptive synthesis.  Phase One also included semi-structured interviews and the population included professional nurses working in hospitals and clinics in the North-West Province in South Africa.  The sampling method applied was purposive sampling.  Tesch’s method was used as data analysis method.  During Phase Two, a content validation was conducted and the population included experts in the field of moral distress and instrument validation, and purposive sampling was applied.  Data collection was done through the instrument that was developed and data analysis was the content validity index.  Phase Two also included a qualitative evaluation which was conducted and the population consisted of professional nurses working in hospitals and clinics in the North-West Province in South Africa and purposive sampling was applied.  Data was collected through the developed instrument and a focus group session.  Data analysis was conducted through a consensus discussion.  During Phase Three, a pilot study was conducted and the population was professional nurses working in a hospital with different departments and clinics in the Free State Province.  All-inclusive sampling was applied and the instrument that was developed was used as data collection.  Data analysis included: Descriptive statistics, factor analysis (exploratory, confirmatory and Bartlett’s test of spherity), Cronbach’s alpha coefficient, correlations and ANOVA.  According to the results from the face-, content-, exploratory and confirmatory, discriminant- as well as divergent validity, the instrument has been shown to be valid.  The Cronbach’s alpha for the Moral Distress Instrument was deemed reliable.  Finally, the research was evaluated and limitations were identified.  Recommendations for nursing education, -practice, research and policy were formulated.