The Association between Moral Distress and Job Satisfaction of Filipino Nurses in the Philippines and Saudi Arabia

Received: 12-Jun-2022, Manuscript No. ijmrhs-22-66446 ; Editor assigned: 15-Jun-2022, Pre QC No. ijmrhs-22-66446 (PQ); Reviewed: 21-Jun-2022, QC No. ijmrhs-22-66446 (Q); Revised: 21-Jun-2022, Manuscript No. ijmrhs-22-66446 (R); Published: 30-Jun-2022

Introduction

Job satisfaction has a positive effect on the quality of care and how well patients do, but this could be changed by things like moral distress that hurt the quality of care.

Due to the high amount of human contact in the nursing profession, moral discomfort and professional stress are unavoidable challenges for nurses. Moral distress occurs when an individual’s views and inner moral standards are in conflict with his or her environment and he or she is forced to behave against these principles as a result of these situations and genuine limits [1].

Moral distress can have varying effects on nurses, patients, and healthcare institutions [2]. Faced with this confusion, contradiction, futility, and suffering, prolonged exposure to these situations might deplete their resistance resources and lead to occupational unhappiness. Those who keep working despite these problems, however, have to deal with stress, burnout, and dissatisfaction [3].

In the 1980s, Jameson invented the phrase “moral distress” and characterized it as unhappiness resulting from inconsistency between one’s actions and beliefs. In other words, one recognizes that doing the right thing is the right thing to do but is unable to do so due to errors in judgment, personal failure, character flaws, or even external conditions [4]. Moral distress is characterized by anger, frustration, guilt, loss of self-worth, melancholy, nightmares, suffering, resentment, frustration, grief, anxiety, helplessness, and impotence [5]. When nurses are pressed between incompatible moral commitments, they frequently feel that their moral integrity is compromised. Studies show that nurses have thought about leaving their jobs or professions because they did not feel right about what they were doing [6].

Moral distress hinders nurses’ capacity to offer optimal patient care and achieve great patient outcomes. Furthermore, nurses experiencing moral discomfort may endure burnout and ultimately quit their jobs [7-10]. In addition, a lack of organizational rules and support, inter-professional disputes, and legal requirements enhance the experience of moral suffering [11-13]. In addition, the consequences of nursing care delivery models that are not patient-centered and teamoriented may undermine patient outcomes and nursing outcomes, resulting in work unhappiness [14]. Additionally, some healthcare environments are associated with greater degrees of moral anguish [14-18].

The highest quality of care is achieved when the nursing team is thoroughly satisfied with their jobs. In contrast, work dissatisfaction, like burnout, leads to high turnover rates and may also have negative impacts on the individual. Therefore, retention of nurses is crucial, since shortages of nurses might result in work overload, fatigue, and a lack of job satisfaction among the remaining nurses, hence raising the possibility of even higher turnover rates and potentially reducing nursing care standards. According to the findings of Corley’s study, 15% of nurses quit their former employment due to moral anguish [2]. These results demonstrate the importance of the work environment in retaining nurses. This led the researcher, who is also a nurse who has experienced moral anguish in the hospital, to investigate the present degree of moral distress among staff nurses in private hospitals in Cabanatuan City, Philippines, and its relationship to job satisfaction. The outcome of this study will serve as a foundation for nurse supervisors and hospital administrators to develop a strategy for maintaining the workforce not just in the city, but throughout the entire nation [19].

Job satisfaction is not necessarily a result of the existence of these factors. In contrast, their absence will result in sadness. According to Herzberg’s theory, intrinsic and extrinsic variables influence separate work satisfaction characteristics. In the nursing profession, Herzberg’s theory was utilized to comprehend work satisfaction among nurses, including the sanitary and motivating components of cardiology ward nurses [20]. This research provides a new perspective on job happiness by comparing the job satisfaction of locally-employed nurses to that of overseas Filipino nurses.

The objective of this study was to examine the degree, frequency, and intensity of moral distress and job satisfaction among nurses working in medical-surgical units in public and private hospitals in Pangasinan, Philippines, and Hail, Saudi Arabia.

This study aims to (1) determine the level of (a) general job satisfaction and (b) moral distress experienced by locallyemployed Filipino nurses and overseas Filipino nurses; (2) determine whether there is a significant relationship between the moral distress and job satisfaction of locally-employed Filipino nurses and overseas Filipino nurses; and (3) determine whether there are significant differences in the (a) job satisfaction and (b) moral distress of locallyemployed Filipino nurses and overseas Filipino nurses.

In light of these objectives, the following hypotheses were developed: (a) There is no significant relationship between moral distress and job satisfaction among locally employed and overseas nurses; (b) There is no significant difference between the levels of general job satisfaction and morale distress among locally employed and overseas Filipino nurses.

Methodology

Research Design

This study utilized a cross-sectional design. This approach was chosen by the researchers because it defines variables, investigates associations, and compares variables, but does not establish cause-and-effect links between variables [21,22].

Population and Sampling Scheme

The researchers gathered information from the frontline Filipino nurses working in tertiary private or public hospitals in Pangasinan and Hail. This study employed purposive sampling.

During the pandemic health crisis, the respondents should have been giving nursing care to patients with coronavirus sickness as frontline workers at a health care institution. Since there was no published information on the number of nurses in Pangasinan and Hail, the researchers obtained the number of nurses by calling the nursing office directly. In Pangasinan, it is expected that 450 nurses are employed in the medical-surgical fields, whereas in Hail, it is anticipated that 300 nurses are employed in these fields. Using the Lynch calculation with a 95% confidence level and a 5% confidence interval, the researchers required a minimum of 207 nurses in Pangasinan and 169 nurses in Hail [23]. The researchers collected 207 responses in Pangasinan. Meanwhile, in Hail, there were 166 respondents.

Instrumentation

To guarantee that replies meet the inclusion requirements, preliminary questions are included in the Google form. The initial preliminary inquiry is, “Have you treated a patient diagnosed with COVID-19?” If the respondent selects “no,” the form is forwarded to a thank-you page. If the respondent responded affirmatively, the form will proceed to the second preliminary question, “What region are you assigned to?” and then to the main inquiry.

A survey form was the primary data-gathering tool for this research and is composed of three (3) parts. Part I covers the demographic profile of the respondents. Part 2 was adapted from the Moral Distress Questionnaire by Sedaghati, et al. with a scale content validity index of 0.97 and internal consistency of 0.84 in their original [24]. The questionnaire is organized as 0=never, 1=rarely, 2=sometimes, 3=often, 4=always.

Finally, Part 3 was adapted from Lu, et al., which measures the job satisfaction of nurses with Cronbach’s alpha was 0.89 in her original study. The questionnaire is organized as 1=very dissatisfied, 2=dissatisfied, 3=neutral, 4=satisfied, 5=very satisfied) [25].

Since these questionnaires are not yet used in a single study, the researcher conducted a pilot study to check the reliability of the questionnaire. Two groups of nurses answered the questionnaire. The two groups are nurses who are not working on the medical-surgical floors in Hail Saudi Arabia and Pangasinan, the Philippines. Cronbach’s alpha scored 0.87 and 0.84, respectively, which means the questionnaire has relatively high reliability.

Ethical Consideration

This research study was granted ethical approval by the Research Ethics Committee of the University of Hail with approval number H-2021-28 and by the Colegio de Dagupan Research Office with approval number CDDETH-2021-01.

In addition, the questionnaire comprises informed consent, which specifies the time, the objective of the study, and any potential downsides. No monetary compensation was offered for participation in this study. In addition, there was no force involved in non-participation.

Data Collection

The survey was uploaded to an internet survey site (google forms). The link to the survey was emailed to nursing authorities and shared with their nursing staff. The data collecting began in May 2021 and continued until October 2021.

Tools for Data Analysis

The collected data had undergone a normality test; Kolmogorov- Smirnov and Shapiro-Wilk showed that the data were not normally distributed (p ≤ 0.001). Hence, the data needs to be normalized using Derivative of Inverse Function (Idf. Normal).

After normalizing the data, interpretation of the collated data was processed using the SPSS version 25.

To answer objective 1, frequency and percentage, mean and standard deviation were used to describe the data. Below is the statistical range and interpretation that was used in this study (Table 1).

To answer objective 2, Pearson-r will be used.

To answer objective number 3, a t-test was utilized.

Results

Table 2 shows the Moral Distress and Job Satisfaction of the Nurses in Pangasinan and Hail.

In places, most (74.87%), (73.49%) of the nurses are experiencing low moral distress. Further, some (24.15%) (25.30%) of nurses in Pangasinan and Hail experience moderate moral distress, respectively. Furthermore, very few (0.98%) (1.21%) nurses are experiencing a high level of moral distress. Finally, both locations have a mean low moral distress level (Pangasinan M (SD)=1.05 (0.65)), (Hail M (SD)=0.92 (0.66)).

Regarding job satisfaction, it shows that very few (2.42%), (1.81%) are very dissatisfied in Pangasinan and Hail, respectively. Also, very few (8.21%) and few (16.87%) are dissatisfied with Pangasinan and Hail, respectively. Almost half (44.44%) (42.17%) of the nurses are indecisive in Pangasinan and Hail. Some (37.68%), (36.75%) nurses are satisfied in both places. Finally, very few (7.25%), (2.40%) nurses in both places are delighted. Finally, both locations have a mean indecisive job satisfaction (Pangasinan M (SD)=1.05 (0.65)), (Hail M (SD)=0.92 (0.66)).

In Table 3, Pearson-r revealed that there is a moderate negative relationship between the moral distress and job satisfaction of Filipino nurses in Pangasinan, Philippines, and Hail, Saudi Arabia (r(371)= -0.35, p ≤ 0.001). This signifies that if their moral distress increases, job satisfaction decreases, and vice versa. This finding is also depicted in Figure 1. This finding is supported by the study of Llego and Pangket, wherein they found out that there is a significant negative relationship between moral distress and job satisfaction [26,27].

Figure 1. Scatterplot of the existing relationship between moral distress and job satisfaction

Table 4 shows no significant difference between the level of moral distress of Filipino nurses in Pangasinan, Philippines, and Hail, Saudi Arabia (t(371)=1.90, p=0.59). This means that they are experiencing the same level of moral distress regardless of their location. This finding may be related because the race understudy is that all Filipinos and Asians have the same context of moral distress, which is truth-telling, while other races, like European context, are more on overtreatment.

Table 5 shows no significant difference between the level of job satisfaction of Filipino nurses in Pangasinan, Philippines, and Hail, Saudi Arabia (t(371)=1.51, p=0.13). This means that job satisfaction does not vary regardless of their location.

The study showed that Filipino nurses employed locally and overseas are indecisive about their level of general job satisfaction; this contradicts the study of Ea et al., which found that Filipino nurses overseas have a moderate level of job satisfaction [28]. However, it differed from the study of Rosales, et al., which found locally employed nurses to be slightly unsatisfied with their jobs [29].

Discussion

Job satisfaction is not necessarily a result of the existence of these factors. In contrast, their absence will result in sadness. According to Herzberg’s theory, intrinsic and extrinsic variables influence separate work satisfaction characteristics. In the nursing profession, Herzberg’s theory was utilized to comprehend work satisfaction among nurses, including the sanitary and motivating components of cardiology ward nurses [20]. This study gives a new look at job happiness by comparing the job satisfaction of Filipino nurses who work in the Philippines to that of nurses who work in the Philippines.

On the other hand, job satisfaction directly affects the sentiments of an individual in either a positive or negative way. The state of a representative’s mind will also be affected by the satisfaction with his or her work. It is the general disposition towards the job.

Nurses’ job satisfaction differs from that reported by care aides in nursing homes and nurses working in acute care settings, indicating the need for distinct measures to increase nurses’ job happiness in nursing homes [30]. In addition, according to Herzberg’s theory, external variables can contribute to work discontent if they are absent or poorly managed. Therefore, nurse administrators and the government should adopt strategies and regulations that take these extrinsic elements into account to enhance the working circumstances of nurses. By getting more nurses to work locally, for example, problems with nurses’ workloads caused by too few nurses per patient can be fixed.

One factor that affects nursing satisfaction is the concept of workplace stress. Meltzer and Huckabay addressed the idea of moral distress in nurses working in acute care settings. Moral distress has been defined as a stress response experienced by nurses when they deal with stressful situations such as cardiac arrests, withdrawal of life support, and other ethical dilemmas [31]. Moral distress and other stress-related variables have affected nursing retention [31-33].

Regarding the relationship between moral distress and job satisfaction of the respondents, the finding of this study is supported by the results of Ramos, in Brazil; a quantitative, analytical cross-sectional study was conducted with 157 nurses. Pearson’s correlation found a moderate association between moral distress among nurses [29]. Also, in Japan, they conducted a study on 130 psychiatric nurses that aimed to (1) examine relationships among moral distress, sense of coherence, mental health, and job satisfaction and (2) clarify the most predictive variable of job satisfaction. Results showed that the Moral Distress Scale subscales for Psychiatric nurses negatively correlated to the sense of coherence and Job Satisfaction. Multiple regression analysis showed that “Acquiescence to patients’ rights violations” of the Moral Distress Scale for Psychiatric nurses and “Meaning” of the sense of coherence influenced Job Satisfaction much more than other variables. These two variables were correlated to the job satisfaction scale, and other variables without them did not significantly correlate to the job satisfaction scale. These results suggest that moral distress is negatively related to the sense of coherence and job satisfaction, a subscale of the Moral Distress Scale for Psychiatric nurses, and that the sense of coherence affected the job satisfaction the most [34].

Nurses’ job satisfaction is essential to ensure that they can give their best in providing nursing care. Moreover, studies have found that work satisfaction correlates with other factors, such as professional commitment, necessary to reduce turnover rates, ultimately addressing the nursing shortage problem [35,36]. In addition, intrinsic and extrinsic factors influence nurses’ job satisfaction, so making strategies that consider both types of aspects is essential.

However, this will only be achievable if work satisfaction criteria that might encourage nurses are there, such as higher salary, fringe benefits, and prospects for advancement in comparison to what they can earn abroad. These tactics may encourage nurses to remain and work locally while pressuring Filipino nurses to return to the Philippines. This study demonstrates that nurses’ job satisfaction is an important part of nursing management that requires attention.

In light of the present number of nurses in the United States and the significance of job satisfaction among nurses, the study recommends additional investigation into nurses’ job happiness. For example, research may be conducted on the comparison of job satisfaction among nurses working in public and private hospitals and its relationship to other aspects such as organizational commitment, desire to leave, and retention.

Limitations of the Study

This study is confined to quantitative analysis; hence the researchers advocate qualitative analysis for future studies. This study is restricted to a few Philippine and Saudi Arabian provinces. Therefore, the experts advise that future studies use a larger population plan.

Conclusion

The following conclusions are drawn: Filipino nurses, both locally and overseas, are uncertain if they are satisfied with their job or not. Even if they are employed locally, their moral distress level and job satisfaction do not vary. Finally, their job satisfaction is influenced by their experience of moral distress.

Declarations

Conflict of Interest

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

Acknowledgment

The researchers would like to acknowledge the respondents who have given their time to be part of this study. Likewise, the researchers would like to acknowledge the 2021 Executive Committee of the Philippine Nurses Association Hail Region Chapter for their support in this research project.

Funding

This study was funded by Colegio de Dagupan with grant number CdD-Res-2021-01.

References

1. Corley, Mary C., et al. "Nurse moral distress and ethical work environment." Nursing Ethics, Vol. 12, No. 4, 2005, pp. 381-90.
   Google Scholar          Crossref
2. Corley, Mary C. "Nurse moral distress: A proposed theory and research agenda." Nursing Ethics, Vol. 9, No. 6, 2002, pp. 636-50.
   Google Scholar          Crossref
3. Cummings, Cynthia L. "The effect of moral distress on nursing retention in the acute care setting." University of North Florida, 2009.
   Google Scholar
4. Hardingham, Lorraine B. "Integrity and moral residue: Nurses as participants in a moral community." Nursing Philosophy, Vol. 5, No. 2, 2004, pp. 127-34.
   Google Scholar          Crossref
5. Nathaniel, Alvita K. "Moral reckoning in nursing." Western Journal of Nursing Research, Vol. 28, No. 4, 2006, pp. 419-38.
   Google Scholar          Crossref
6. Hamric, Ann B., and Leslie J. Blackhall. "Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate." Critical Care Medicine, Vol. 35, No. 2, 2007, pp. 422-29.
   Google Scholar          Crossref
7. Huffman, Dolores M., and Leslie Rittenmeyer. "How professional nurses working in hospital environments experience moral distress: A systematic review." Critical Care Nursing Clinics, Vol. 24, No. 1, 2012, pp. 91-100.
   Google Scholar          Crossref
8. Epstein, Elizabeth Gingell, and Ann Baile Hamric. "Moral distress, moral residue, and the crescendo effect." Journal of Clinical Ethics, Vol. 20, No. 4, 2009, pp. 330-42.
   Google Scholar
9. Varcoe, Colleen, et al. "Moral distress: Tensions as springboards for action." HEC Forum, Vol. 24, No. 1, 2012, pp. 51-62.
   Google Scholar          Crossref
10. Varcoe, Colleen, et al. "Nurses’ perceptions of and responses to morally distressing situations." Nursing Ethics, Vol. 19, No. 4, 2012, pp. 488-500.
    Google Scholar          Crossref
11. Brazil, Kevin, et al. "Moral distress experienced by health care professionals who provide home-based palliative care." Social Science & Medicine, Vol. 71, No. 9, 2010, pp. 1687-91.
    Google Scholar          Crossref
12. Pauly, Bernadette M., Colleen Varcoe, and Jan Storch. "Framing the issues: Moral distress in health care." Hec Forum, Vol. 24, No. 1, 2012.
    Google Scholar          Crossref
13. Papathanassoglou, Elizabeth DE, et al. "Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses." American Journal of Critical Care, Vol. 21, No. 2, 2012, pp. e41-e52.
    Google Scholar          Crossref
14. Fernandez-Parsons, Robin, Lori Rodriguez, and Deepika Goyal. "Moral distress in emergency nurses." Journal of Emergency Nursing, Vol. 39, No. 6, 2013, pp. 547-52.
    Google Scholar          Crossref
15. Gutierrez, Karen M. "Critical care nurses' perceptions of and responses to moral distress." Dimensions of Critical Care Nursing, Vol. 24, No. 5, 2005, pp. 229-41.
    Google Scholar          Crossref
16. McCaffree, Donald. "Moral distress and the intensive care unit." Critical Care Medicine, Vol. 34, No. 12, 2006, pp. 3049-50.
    Google Scholar          Crossref
17. Mobley, William H. "Intermediate linkages in the relationship between job satisfaction and employee turnover." Journal of Applied Psychology, Vol. 62, No. 2, 1977, pp. 237-40.
    Google Scholar          Crossref
18. St Ledger, Una, et al. "Moral distress in end‐of‐life care in the intensive care unit." Journal of Advanced Nursing, Vol. 69, No. 8, 2013, pp. 1869-80.
    Google Scholar          Crossref
19. Millicent Marie Watson-Subia, R.N., M.A.N., "Moral distress and job satisfaction of nurses in private hospitals." SSRG International Journal of Nursing and Health Science, Vol. 5, No. 2, 2019, pp. 1-5.
    Crossref
20. Somense, Carolina Bueno, and Erika Christiane Marocco Duran. "Hygiene and motivation factors of nursing work in a cardiology ward." Gaucha Journal of Nursing, Vol. 35, No. 3, 2014, pp. 82-89.
    Google Scholar          Crossref
21. Boswell, Carol, and Sharon Cannon. "Introduction to nursing research: Incorporating evidence-based practice." Jones & Bartlett Learning, 2022.
    Google Scholar
22. Polit, Denise, and Cheryl Beck. "Essentials of nursing research: Appraising evidence for nursing practice." Lippincott Williams & Wilkins, 2020.
    Google Scholar
23. Plichta, Stacey Beth, and Laurel S. Garzon. "Statistics for nursing and allied health." Lippincott Williams & Wilkins, 2009.
    Google Scholar
24. Sedaghati, Ali, et al. "Moral distress and its influential factors in the nurses of the nursing homes in khorasan provinces in 2019: A descriptive-correlational study." Iranian Journal of Nursing and Midwifery Research, Vol. 25, No. 4, 2020, pp. 319-24.
    Google Scholar          Crossref
25. Lu, Hong, Alison E. While, and K. Louise Barriball. "Job satisfaction and its related factors: A questionnaire survey of hospital nurses in Mainland China." International Journal of Nursing Studies, Vol. 44, No. 4, 2007, pp. 574-88.
    Google Scholar          Crossref
26. Llego, Jordan H., and Petelyne P. Pangket. "A comparative study on the level of moral distress of medical-surgical nurses in Hail Saudi Arabia during the Covid-19 pandemic." Texila International Journal of Nursing, Vol. 7, No. 2, 2021, pp. 20-26.
    Google Scholar          Crossref
27. Llego, Jordan H., and Petelyne P. Pangket. "Moral distress work motivation and job satisfaction of medical-surgical nurses during the Covid-19 pandemic: A correlation study." Texila International Journal of Nursing, Vol. 7, No. 2, 2021, pp. 27-33.
    Google Scholar          Crossref
28. Ea, Emerson E., et al. "Job satisfaction and acculturation among Filipino registered nurses." Journal of Nursing Scholarship, Vol. 40, No. 1, 2008, pp. 46-51.
    Google Scholar          Crossref
29. Ramos, Aline Marcelino, et al. "Cross-cultural adaptation and validation of the Moral Distress Scale-Revised for nurses." Brazilian Journal of Nursing, Vol. 70, 2017, pp. 1011-17.
    Google Scholar          Crossref
30. Aloisio, Laura D., Mary Coughlin, and Janet E. Squires. "Individual and organizational factors of nurses' job satisfaction in long-term care: A systematic review." International Journal of Nursing Studies, Vol. 123, 2021, p. 104073.
    Google Scholar          Crossref
31. Meltzer, Lilia Susana, and Loucine Missak Huckabay. "Critical care nurses’ perceptions of futile care and its effect on burnout." American Journal of Critical Care, Vol. 13, No. 3, 2004, pp. 202-08.
    Google Scholar          Crossref
32. Brooks, Beth A., and Mary Ann Anderson. "Defining quality of nursing work life." Nursing Economics, Vol. 23, No. 6, 2005, pp. 319-26.
    Google Scholar
33. Hayhurst, Anna, Coleen Saylor, and Diane Stuenkel. "Work environmental factors and retention of nurses." Journal of Nursing Care Quality, Vol. 20, No. 3, 2005, pp. 283-88.
    Google Scholar          Crossref
34. Ando, Michiyo, and Masashi Kawano. "Relationships among moral distress, sense of coherence, and job satisfaction." Nursing Ethics, Vol. 25, No. 5, 2018, pp. 571-79.
    Google Scholar          Crossref
35. Salem, OA, Fatma Baddar, and Hind M. AL-Mugatti. "Relationship between nurses job satisfaction and organizational commitment." IOSR Journal of Nursing and Health Science (IOSR-JNHS). Vol. 5, No. 1, 2016, pp. 49-55.
36. Oktizulvia, C., D. Dachriyanus, and V. Vionalisa. "Job satisfaction factors and nurses’ intention to quit in type C hospitals." Journal of Nursing & Care, Vol. 6, No. 03, 2017.
    Google Scholar