Moral comfort and its influencing factors from intensive care unit nurses’ perspective

Abstract

Background

Intensive Care Unit (ICU) nurses face ethical challenges during decision-making in terms of the sophisticated nature of in-patients. Moral comfort is known as a phenomenon with a positive effect on moral decision-making and moral actions of nurses.

Aim

This study investigated ICU nurses’ level of moral comfort and factors affecting it.

Research Design

This study used a cross-sectional descriptive design.

Participants and research context

A total of 350 ICU nurses were selected with the convenience sampling method. The data collection tool included the Demographic Characteristics Questionnaire and the Moral Comfort Questionnaire. The data were analyzed with SPSS19 using descriptive and inferential statistics.

Ethical Considerations

Upon the Committee of Ethics in Human Research’s acceptance of the research concept, approvals were secured, and informed written consent was acquired from all participants. They were assured of the information confidentiality of participation.

Findings

The mean moral comfort score was 112.75 ± 13.18. The mean score of personal factors related to ethics was higher than the external factors pertaining to the environment/organization. The mean scores of “moral comfort in a specific situation” and “moral comfort in general” were 50.52 ± 5.08 and 62.32 ± 9.31, respectively. The mean moral comfort score of nurses was significantly correlated with age, clinical work experience, ICU work experience, marital status, education, and employment status (p < .05). Regression analysis revealed that ICU work experience as the strongest predictor variable predicted 17.7% of moral comfort variance.

Conclusion

Although moral comfort score was at a favorable level, ICU nurses did not feel comfortable when making decisions in moral situations, and nursing managers did not support the decisions of nursing staff. Consequently, this issue warrants the attention of nursing managers and policy-makers. They need to enhance the quality of healthcare by offering more support and addressing the variables influencing the moral comfort of nurses.

Keywords

Ethics moral comfort nurse Intensive Care Unit ICU

Introduction

The Intensive Care Unit (ICU) is a place where patients with life-threatening conditions are treated using various invasive interventions.¹ In the ICU, treatment involves intricate interventions² that necessitate the formulation of critical and challenging decisions.³ Nursing performance is influenced by ethical decision-making and ethical actions in order to deliver safe and ethical care.⁴ To make moral decisions in this environment, nurses suffer from moral adversities. In response to various types of these adversities, they experience moral suffering including moral distress, conflict, and damage.⁵

Moral comfort is a person’s sense of comfort in decisions and actions related to moral problems.⁶ In fact, the positive outcome of a moral situation or dilemma is moral comfort. The principle of moral comfort derives from the nurse’s ability to do the right thing for themselves or their patients and subsequently arises from experiencing the feeling of comfort associated with their actions.⁷ Moral comfort happens when the expert can make choices that benefit the patients, incorporate his or her thoughts about the patient into the treatment plan, or reduce or alleviate the patient’s suffering.⁶ Wurzbach⁸ first introduced the concept of moral comfort in 1996. He described comfort as a moral principle in performing and feeling. This feeling is the nurse’s sense of peace in connection with their actions. The opposite of this situation occurs when nurses see their acts as inconsistent with the ethical principles of exemplary nursing practice.⁷ The nurse’s willingness to perform moral action despite the personal consequences and mental peace related to moral action are two defining characteristics of moral comfort.⁶

Moral comfort is enhanced by the presence of personal factors such as moral competence, and environmental factors such as managers’ support, and positive moral atmosphere.^6,9 Nonetheless, studies indicate contradictory findings of the effect of factors such as culture, gender, religion, age, years of experience, and effect of the organization on ethical concepts.^10–13 Personal and environmental factors that foster moral comfort yield beneficial results for nurses, patients, and organizations, including the retention of nursing staff, a decrease in instances of lost nursing care, and a reduction in occupational burnout. Consequently, this mitigates adverse outcomes such as nurse turnover, and staff shortages, which jeopardize patient safety and lead to detrimental patient outcomes.⁹

The potential of moral comfort for positive outcomes demands studies focusing the moral comfort. It is essential to understand nursing phenomena such as moral comfort, which contribute to ethical decision-making and/or ethical actions.⁹ Nevertheless, sporadic studies have been conducted on moral comfort and factors affecting it. Hence, this study was conducted to determine the level of moral comfort in ICU nurses and factors affecting it.

Methodology

Study design

This descriptive cross-sectional study was conducted in 2024.

Participants

The statistical population of the study compromised ICU nurses working in Iranian hospitals. Considering a correlation coefficient of 0.16, as determined by a pilot study, and a 10% subject attrition rate, the sample volume was estimated to be 350 nurses with a significance level of 95% and a test power of 80%. The sample was a convenience sample of eligible nurses who self-selected to participate. The inclusion criteria were: having at least a BS degree, working in a hospital as a nurse, and having at least 6 months of ICU work experience. Exclusion criteria were: unwillingness to participate in the study and leaving or transferring to other centers. In so doing, after obtaining the necessary permissions, the questionnaire link was provided in virtual groups to be completed with the coordination of the group manager after providing the necessary explanations.

Data collection

To glean the required data, two questionnaires were used as the following.

(A) The Demographic Characteristics Questionnaire: It consisted of 6 items about age, gender, marital status, education level, shift work, clinical work experience, ICU work experience, and employment status.

(B) Moral Comfort Questionnaire (MCQ): This questionnaire was first developed by Bermudez (2020).¹⁴ It entails 35 items in two parts: the items of the first part are related to the specific situation and the second part pertains to the general experience of nurses. In the initial section, the participant is required to respond to 15 items regarding a specific moral situation or dilemma that occurred within the past 6 months. In the subsequent section, the participant is required to evaluate their general knowledge in order to respond to 20 items. Items are scored using a 4-point Likert scale as follows: 4 = strongly agree, 3 = somewhat agree, 2 = somewhat disagree, and 4 = strongly disagree. This questionnaire has two dimensions wherein 21 items pertain to personal factors dimension related to ethics and 14 items pertain to external factors dimension related to the environment/organization. Moral comfort is measured by summing up the points obtained by each item in the instrument (ranging from 35 to 140), with higher scores indicating higher levels of moral comfort and vice versa. Items can be individually scored to identify specific areas that may affect the overall score. Bermudez¹⁴ investigated the validity of the questionnaire using content, construct and differential validity. In the reliability test, the test-retest results showed a strong positive correlation between time 1 and time 2 (r = 0.769, P < .001), as well as Cronbach’s α = 0.785.¹⁴ Using the forward-backward method, Abbasivand et al.¹⁵ translated the questionnaire into Persian and verified the face, content, and construct validity of the Persian version of questionnaire. The results confirmed the questionnaire’s validity. In confirmatory factor analysis (CFA), the indices confirmed the appropriate fit of the model. A Cronbach’s α of 0.888 and intra-class correlation coefficient of 0.825 indicated the reliability of the questionnaire. Criterion-referenced validity indicated an inverse and significant relationship between the Persian version of the questionnaire and moral distress.

Ethical considerations

After approval of the project proposal in Committee of Ethics in Human Research at the university with code of ethics: IR.IAU.KHUISF.REC.1403.035, the questionnaires were provided to the research units after obtaining legal permissions. To comply with the ethical principles of the research, the informed written consent was completed by all participants. Besides, the confidentiality and anonymity of information was emphasized to the participants. All participants were aware of the objectives of the research and the voluntary nature of their participation.

Data analysis

The data were imported into SPSS19 after coding. Descriptive statistics such as absolute and relative frequency, mean, and standard deviation were used for data analysis. Smirnov–Kolmogorov test was employed to verify the normality of the data distribution. The data distribution was normal, as evidenced by the results (p > .05). Parametric tests such as t test, one-way analysis of variance (One-way ANOVA), and Pearson’s correlation coefficient were used to analyze the data (p = .05). Also, a step-by-step linear multiple regression was used with moral comfort as the dependent variable and demographic characteristics as the independent variables.

Results

A total of 350 ICU nurses participated, all 350 voluntarily completed the questionnaires, for a response rate of 100%. The mean age of the participants was 33.01 ± 5.01 years. The mean work experience was 10.09 ± 5.09 years and the mean ICU work experience was 97.71 ± 61.30 months. The majority of nurses were female (53.1%), married (56.0%), and held a bachelor’s degree (74.6%). Additionally, 62.3% were assigned alternating work shifts. Regarding employment status, 54.3% were registered nurses, and 64.4% did not have a secondary occupation (Table 1). The results indicated a significant correlation between “nurses’ moral comfort” and “age, clinical work experience, ICU work experience, marital status, education, and employment status” (p < .05) (Table 1).

Table 1.

Demographic characteristics of participants and their relationship with moral comfort.

Variables	Mean ± SD	Moral comfort
Variables	Mean ± SD	r	p-value
Age (year)	33.01 ± 5.01	0.27	<0.001^a
Clinical work experience (year)	10.09 ± 5.09	0.31	<0.001^a
ICU work experience (month)	97.71 ± 61.30	0.42	<0.001^a

Variables		N (%)	Mean ± SD	p-value
Gender	Male	164 (46.9)	113.60 ± 12.27	0.31^b
	Female	186 (53.1)	112.18 ± 13.93
Marital status	Married	196 (56.0)	114.31 ± 12.52	0.01^b
	Single	154 (44.0)	110.98 ± 13.78
Education level	BS.	261 (74.6)	113.73 ± 14.04	0.01^b
	M.Sc. and higher	89 (25.4)	110.26 ± 9.85
Work shift	Fixed	132 (37.7)	114.43 ± 11.11	0.08^b
	Rotational	218 (62.3)	111.95 ± 14.23
Employment status	Formal	190 (54.3)	116.80 ± 12.44	<0.001^c
	Obligatory service	14 (4.0)	119.57 ± 1.34
	Contractual	44 (12.6)	109.36 ± 13.10
	Corporate force	21 (6.0)	112.42 ± 8.85
	Contract	81 (23.1)	104.43 ± 12.50
Second job	Yes	114 (32.6)	111.98 ± 10.99	0.35^b
	No	234 (67.4)	113.27 ± 14.12

SD: standard deviation, r: correlation coefficient, N: number, M.Sc.: Master of Science.

Note. Statistical tests.

^aPearson correlation coefficient.

^bt test.

^cANOVA.

The mean score of “moral comfort in a specific situation” in ICU nurses was 50.52 ± 5.08. The mean score higher than 3.50 was for six items—3: “I was concerned about the well-being of my patient,” 4: “I had a duty to help,” 5: “My nursing expertise gave me confidence in this ethical decision-making,” and 10: “I was willing to fully accept responsibility for my actions,” 14: “I did everything I could to ensure that my patient received good care,” 15: “I am at peace with the approach I used in this situation.” The lowest mean score (2.90 ± 0.78) related to item 1: “I felt comfortable about the decision-making regarding this moral situation.” The mean scores of remaining eight items ranged from 3.00 to 3.50 (Table 2).

Table 2.

Mean and standard deviation of moral comfort items in ICU nurses.

A	Reflecting on the patients you have cared for within the past 6 months, please think about a time when you encountered moral situation or moral dilemma, and evaluate your level of agreement or disagreement with each of the following statements	Mean ± SD
1	I felt comfortable about the decision-making regarding this moral situation	2.90 ± 0.78
2	In ethical decision-making, I was confident in my ability to distinguish between right and wrong	3.27 ± 0.64
3	I was concerned about the well-being of my patient	3.63 ± 0.51
4	I had a duty to help	3.59 ± 0.57
5	My nursing expertise gave me confidence in this ethical decision-making	3.52 ± 0.50
6	In my decisions, I considered the preferences of my patients	3.29 ± 0.69
7	My actions were based on ethical principles	3.48 ± 0.62
8	I was willing to act in the interest of my patient, regardless of the consequences	3.22 ± 0.62
9	I was willing to voice my concerns, even if others did not agree with me	3.21 ± 0.66
10	I was willing to fully accept responsibility for my actions	3.52 ± 0.57
11	I was able to act on my moral decisions without fear of punishment	3.14 ± 0.80
12	I was able to freely ask my questions to the entire healthcare team	3.20 ± 0.85
13	I feel that I made the right decision	3.41 ± 0.64
14	I did everything I could to ensure that my patient received good care	3.58 ± 0.51
15	I am at peace with the approach I used in this situation	3.55 ± 0.66
Total score of moral comfort in a specific situation		50.52 ± 5.08
B	Generally, reflecting on your nursing practice over the past 6 months, please evaluate your level of agreement or disagreement with each of the following statements	Mean ± SD
1	I can be supportive of my patients' decisions, even if their decisions differ from mine	2.89 ± 0.83
2	I reflect on my personal moral beliefs and values	3.26 ± 0.67
3	I respect the moral beliefs and values of my patients	3.35 ± 0.76
4	I clearly understand the scope of nursing practice	3.35 ± 0.71
5	I am usually able to think through situations	3.33 ± 0.66
6	I reflect on my past experiences in dealing with moral dilemmas to guide my decision-making	3.30 ± 0.62
7	I have the ability to freely voice my concerns about patients' medical care plans	3.10 ± 0.87
8	My boss (supervisor) supports my ethical decisions and actions	2.87 ± 1.00
9	I have the authority to independently design nursing care plans for my patients	2.83 ± 0.92
10	I am competent in the area of clinical reasoning	3.23 ± 0.64
11	In my hospital, nursing administrators (matron) are supportive of nursing staff decisions	2.55 ± 0.97
12	I have the autonomy to advocate for my patients	2.90 ± 0.78
13	My patients rely on me to do the right thing	3.27 ± 0.78
14	I have control over my own nursing practice	3.47 ± 0.61
15	I am supported when I question medical orders	3.26 ± 0.75
16	I am a respected member of the healthcare team	3.43 ± 0.64
17	My nurse colleagues are supportive of my decisions and actions	3.05 ± 0.69
18	My organization promotes an ethical culture	3.00 ± 0.84
19	In my organization, good nursing care is more important than avoiding lawsuits	2.92 ± 0.77
20	My organization’s policies promote good nursing care	2.97 ± 0.71
Total moral comfort score in general		62.32 ± 9.31

SD: standard deviation.

The mean score of “Moral comfort in general” was 62.32 ± 9.31. None of the items had a score higher than 3.50. In this section, 13 items (2, 3, 4, 5, 6, 7, 10, 13, 14, 15, 16, 17, and 18) had an average score of 3.00 to 3.50. Item 14, that is, “I have control over my own nursing practice,” obtained the highest mean score (3.47 ± 0.61). The average score of remaining seven items was below 3.00. The item: “In my hospital, nursing administrators (Matron) are supportive of nursing staff decisions.” obtained the lowest score with a mean score of 2.55 ± 0.97 (Table 2).

The mean moral comfort was at a favorable level (112.75 ± 13.18). The mean score of personal factors related to ethics was higher than the external factors related to the environment/organization (Table 3).

Table 3.

Descriptive statistics of moral comfort and its dimensions.

Variables	Number of items	Min	Max	Mean ± SD	Mean ± SD on the base of 100
Personal factors related to ethics	21	52	84	70.14±6.76	78.10±01.73
External factors related to environment /organization	14	18	56	42.70±7.73	68.18±34.42
Moral comfort (total)	35	76	140	112.75±13.18	74.12±14.55

Min: minimum, Max: maximum, SD: standard deviation.

Using regression analysis, changes in dependent variable (moral comfort) caused by independent variables (demographic characteristics) were predicted. The relevant demographic variables were included into the regression analysis. Regression analysis identified four predictors of moral comfort: ICU work experience, age, job position, and education (Table 4). Based on the results presented in Tables 4, in the first step, ICU work experience as the strongest predictor predicted 17.7% of moral comfort. The results of ANOVA showed that this value of R² was significant (p < .001, F (1, 348) = 75.90).

Table 4.

Summary of step-by-step linear multiple regression model.

Criterion variable	Model	Predictor Variable	Beta	t	Sig	R	R²	Adjusted R²
Moral comfort	1					0.423	0.179	0.177
		(Constant)		36.44	>0.001
		Work experience in the ICU	0.42	8.71	>0.001
	2					0.498	0.248	0.244
		(Constant)		19.18	>0.001
		Work experience in the ICU	0.99	8.92	>0.001
		Age	−0.63	−5.65	>0.001
	3					0.515	0.265	0.259
		(Constant)		19.58	>0.001
		Work experience in the ICU	0.90	7.77	>0.001
		Age	−0.61	−5.48	>0.001
		Employment status	−0.15	−2.82	0.005
	4					0.523	0.274	0.265
		(Constant)		19.74	>0.001
		Work experience in the ICU	0.86	7.37	>0.001
		Age	−0.58	−5.24	>0.001
		Employment status	−0.17	−3.16	0.002
		Education	−0.09	−2.04	0.04

Sig: significant, R: correlation coefficient, R²: coefficient of determination.

Discussion

ICU nurses regularly face patient-related ethical dilemmas requiring their ability to make sound ethical decisions and act on them to achieve the best outcomes for patients and healthcare organizations. As such, it is necessary to understand the nursing phenomena that hinder or potentially promote ethical decision-making and/or ethical actions of nurses. This study investigated the level of moral comfort and the factors affecting it in ICU nurses.

The findings indicated that ICU nurses had substantial moral comfort. Moreover, personal ethical variables had a greater influence on their moral comfort than external environmental or organizational ones. In this regard, Bermudez⁹ concluded in a qualitative research that the foreground and beginning of moral comfort is the presence of a moral dilemma or moral situation. Without a moral dilemma, the outcome of moral comfort neither occurs nor exists. He identified the antecedents of moral comfort and classified them as internal (personal) and external (environmental) factors.⁹ In other studies, internal factors affecting moral comfort were mentioned. These factors are moral commitment to “good nursing practice,”⁸ having moral competence (knowledge) and moral courage that motivate action/moral agency,⁶ and expertise and experience with previous moral dilemmas.¹⁶ Corley & Minick enumerate external factors affecting moral comfort as: nursing empowerment via administrative support, availability of material and human resources, access to organizational information, opportunities to participate in decisions related to nursing performance, organizational mission and ethical atmosphere, and clarity of the nurse’s role with defined boundaries.⁶

The findings indicated that the mean score of “moral comfort in a specific situation” among ICU nurses was 50.52 ± 5.08, and the lowest mean score was related to “I felt comfortable when making a decision in relation to this moral situation.” In this regard, Crisham¹⁷ states that nurses feel pressure in the decision-making process regarding ethical dilemmas. She asserts that this may result from environmental factors, including organizational policies that conflict with nurses' notions of justice, adherence to physician directives, time limitations, allegiance to the nursing profession, the patient, and the hospital, the continual escalation of professional information demands, and the intricacy of optimizing the utilization of this information.¹⁷ Bermudez points to internal factors (moral commitment, moral competence, and moral courage with nursing experience and expertise) and external factors (administrative support/empowerment, participation in decision-making, access to information and human/material resources, moral climate, and role/boundary clarity) as antecedents of moral comfort.⁹ Most studies show the sophisticated and challenging role of ICU nurses during the decision-making process.^18,19 In this regard, Heradstveit concluded in a qualitative systematic review that ICU nurses make ethical decisions to protect patients' concerns, guide the family’s decision-making process, and assume the role of mediator.¹⁹ The results of another study in northern Turkey showed that nurses had moderate decision-making ability when faced with ethical dilemmas and that their ethical decisions were influenced by environmental factors such as the nurses' perception of the support provided by the organization.⁴

The mean score for “moral comfort in general” was 62.32 ± 9.31. The item “In my hospital, the nursing director (matron) supports the decisions of the nursing staff” obtained the lowest score. This finding confirms the results of previous studies.^20,21 Organizational support has been investigated in many studies and its level was evaluated in a low range.^20,21 Nevertheless, the study conducted by Gorji et al.²² in emergency nurses and the research conducted by Jay Maningo-Salinas²³ in oncology nurses both reported moderate levels of perceived support. The discrepancy between the results of the studies may be attributed to the diverse leadership styles and organizational climates of the managers. Studies show that leadership plays an important role in developing and maintaining nursing ethics. Ethical nurse leaders create work environments that affect employees' choices, behaviors, and values^24,25 The nurse manager should support the staff in performing appropriate ethical care for ethical reflection.²⁶

The findings suggested that there was a significant relationship between “nurses' moral comfort” and “age, clinical work experience, ICU work experience, marital status, education, and employment status.” No research was identified to compare the relationship between these variables and moral comfort as a result of the sporadic studies on moral comfort. However, the findings of prior research on moral distress, which is the antithesis of moral comfort, indicated that reports of moral distress may be influenced by culture, gender, age, and years of performance.^13,27,28 Despite the results of the present study in effect that there is no relationship between moral comfort and gender, other studies showed that female nurses reported more moral comfort than males.^27,28 Some studies report that younger nurses experience higher levels of moral distress.^11,29 Nurses with older age reported more moral comfort. Finally, contrary to the result of the present study, which stated the relationship between moral comfort and work experience and that work experience in the ICU was the strongest predictive variable in moral comfort, some studies showed that nurses with more nursing experience or years in a clinical situation had higher levels of moral distress.^30,31 Hence, it is stated that these differences depend on the working environment and the patients' community.³²

Limitations of the study

One of the limitations of the present study was the self-reporting of the questionnaires. Social desirability bias is a problem that should be considered using self-report instruments. Moreover, a cross-sectional design was used in this research making causality impossible.

Conclusion

Even though the moral comfort score was at a favorable level, ICU nurses expressed that they did not feel comfortable when making decisions in moral situations, and nursing managers, as expected, did not support the decisions of nursing staff. Thus, nursing managers and policymakers should carefully evaluate this problem. They should improve healthcare quality by offering additional assistance and taking into account the elements that influence nurses’ morale. Nursing managers and officials can create more moral comfort in nurses, especially ICU nurses by supporting the decisions of nurses, which affects mental health and improves the quality of patient care. The results of this research can be used in micro and macro policies regarding planning to improve the obtained results.

Footnotes

Acknowledgments

The researchers should thank all the participants that helped us in the completion of this study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Maasoumeh Barkhordari-Sharifabad

References

Boulton

Slowther

A-M

Yeung

, et al. Moral distress among intensive care unit professions in the UK: a mixed-methods study. BMJ Open 2023; 13: e068918.

Choe

Kang

Park

. Moral distress in critical care nurses: a phenomenological study. J Adv Nurs 2015; 71: 1684–1693.

Sprung

Cohen

Sjokvist

, et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003; 290: 790–797.

Rizalar

Baltaci

. Ethical decision-making levels of nurses and it’s affecting factors. Int J Caring Sci 2020; 13: 42–52.

Rushton

. Conceptualizing moral resilience. Moral Resilience: Transforming Moral Suffering in Healthcare 2018; 15: 125–149.

Corley

Minick

. Moral distress or moral comfort. In Bioethics Forum. Midwest Bioethics Center, 2002, pp. 7–14.

Wurzbach

ME.

Experiencing moral uncertainty in practice. General Submissions: Nursing as Profession. 2024; 19. https://www.sigmarepository.org/gen_sub_np/19.

Wurzbach

. Comfort and nurses' moral choices. J Adv Nurs 1996; 24: 260–264.

Bermudez

. A concept analysis of moral comfort in nursing. Nursing & Health Sciences Research Journal 2022; 5: 37–46.

10.

Davis

Schrader

Belcheir

. Influencers of ethical beliefs and the impact on moral distress and conscientious objection. Nurs Ethics 2012; 19: 738–749.

11.

DeKeyser Ganz

Berkovitz

. Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. J Adv Nurs 2012; 68: 1516–1525.

12.

Ganz

Wagner

Toren

. Nurse middle manager ethical dilemmas and moral distress. Nurs Ethics 2015; 22: 43–51.

13.

Whitehead

Herbertson

Hamric

, et al. Moral distress among healthcare professionals: report of an institution‐wide survey. J Nurs Scholarsh 2015; 47: 117–125.

14.

Bermudez

. Psychometric evaluation of the moral comfort questionnaire. J Nurs Meas 2023; 32: 141–151. DOI: 10.1891/JNM-2022-0035.

15.

Abbasivand

. Translation and psychometric analysis of the “moral comfort” questionnaire in nurses working in the Intensive Care Units of hospitals affiliated to Tehran University of Medical Sciences in 2024. Yazd Branch. Yazd: Islamic Azad University, 2024.

16.

Corley

. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9: 636–650.

17.

Crisham

. Measuring moral judgment in nursing dilemmas. Nurs Res 1981; 30: 104–110.

18.

Power

Plummer

Baldwin

, et al. Intensive care decision-making: Identifying the challenges and generating solutions to improve inter-specialty referrals to critical care. J Intensive Care Soc 2018; 19: 287–298.

19.

Heradstveit

Larsen

Solberg

, et al. Critical care nurses' role in the decision‐making process of withdrawal of life‐sustaining treatment: a qualitative systematic review. J Clin Nurs 2023; 32: 6012–6027.

20.

Kwak

Chung

, et al. Relationship of job satisfaction with perceived organizational support and quality of care among South Korean nurses: a questionnaire survey. Int J Nurs Stud 2010; 47: 1292–1298.

21.

Bobbio

Bellan

Manganelli

. Empowering leadership, perceived organizational support, trust, and job burnout for nurses: a study in an Italian general hospital. Health Care Manage Rev 2012; 37: 77–87.

22.

Gorji

Etemadi

Hoseini

. Perceived organizational support and job involvement in the Iranian health care system: a case study of emergency room nurses in general hospitals. J Educ Health Promot 2014; 3(58): 41–47.

23.

Maningo-Salinas

. Relationship between moral distress, perceived organizational support and intent to turnover among oncology nurses. Minneapolis, MN: Capella University, 2010.

24.

Zhang

Gong

, et al. Effects of ethical leadership on nurses’ service behaviors. Nurs Ethics 2019; 26: 1861–1872.

25.

Özden

Arslan

Ertuğrul

, et al. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics 2019; 26: 1211–1225.

26.

Devik

Munkeby

Finnanger

, et al. Nurse managers’ perspectives on working with everyday ethics in long-term care. Nurs Ethics 2020; 27: 1669–1680.

27.

O’Connell

. Gender and the experience of moral distress in critical care nurses. Nurs Ethics 2015; 22: 32–42.

28.

Papathanassoglou

Karanikola

Kalafati

, et al. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. Am J Crit Care 2012; 21: e41–e52.

29.

Woods

Rodgers

Towers

, et al. Researching moral distress among New Zealand nurses: a national survey. Nurs Ethics 2015; 22: 117–130.

30.

Hamric

Borchers

Epstein

. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research 2012; 3: 1–9.

31.

Sauerland

Marotta

Peinemann

, et al. Assessing and addressing moral distress and ethical climate, part 1. Dimens Crit Care Nurs 2014; 33: 234–245.

32.

McAndrew

Leske

Schroeter

. Moral distress in critical care nursing: the state of the science. Nurs Ethics 2018; 25: 552–570.