Mohammad Sajjad Mousavi1 
, Fatemeh Keshavarz2 , Zeinab Mirzaei2 , Zahra Yosefpour2 , Mohammad Malekzadeh3 , Mohammad Latif Rastian4
, Fatemeh Keshavarz2 , Zeinab Mirzaei2 , Zahra Yosefpour2 , Mohammad Malekzadeh3 , Mohammad Latif Rastian4
1- Department of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2- Department of Nursing, Dar.C., Islamic Azad University, Darab, Iran
3- Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
4- Department of Nursing, School of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran ,r115rastian@gmail.com
2- Department of Nursing, Dar.C., Islamic Azad University, Darab, Iran
3- Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran
4- Department of Nursing, School of Nursing, Yasuj University of Medical Sciences, Yasuj, Iran ,
Abstract: (307 Views)
Background: Nurses, as one of the key pillars of the healthcare system, constantly face complex ethical challenges that can impact the quality of care provided and their mental well-being. Enhancing critical thinking skills in this group may help them analyze ethical issues more effectively and make better decisions, ultimately reducing moral distress. Therefore, this study aimed to determine the relationship between critical thinking and moral distress in nurses.
Methods: This cross-sectional study involved the selection of 342 nurses from educational hospitals affiliated with Yasuj University of Medical Sciences in Iran in 2024, utilizing a systematic probability sampling method. Participants were required to have a minimum of one year of clinical experience and to be currently employed in hospital departments, ensuring a relevant background for the study. Data collection was conducted using the California Critical Thinking Skills Test – Form B and the modified 18-item Hamric Moral Distress Scale. The findings were analyzed employing both descriptive and inferential statistical tests, including the Kolmogorov–Smirnov test for normality, Pearson correlation, and multiple linear regression, which were used to examine relationships between variables utilizing SPSS version 27.
Results: The mean age of participants was 43.33 ± 10.7 years; 221 individuals (64.40%) were female, and 127 persons (37.10%) had 1 to 5 years of work experience. Nurses had an average critical thinking score of 21.25 ± 8.64 and a moral distress score of 116.08 ± 50.82. A significant negative correlation was found between critical thinking and moral distress scores (r = -0.66, p = 0.001). A multiple regression model significantly predicted moral distress, explaining 63% of its variance (R² = 0.628, F = 29.787, p = 0.001). Six predictors were significant. Overall critical thinking was the strongest negative predictor (β = -0.396, p = 0.001, 90% CI [-2.65, -1.69]). The analysis, inference, and induction components were also significant negative predictors. In contrast, the deduction component (β = 0.197, p = 0.029, 90% CI [0.24, 4.39]) and place of residence (β = 0.072, p = 0.037, 90% CI [1.01, 32.60]) were positive predictors of moral distress.
Conclusion: The findings suggest that as critical thinking skills improve, moral distress tends to decrease among nurses. Therefore, it is recommended to implement educational programs aimed at enhancing critical thinking skills in nursing practice, which could potentially alleviate feelings of moral distress.
Methods: This cross-sectional study involved the selection of 342 nurses from educational hospitals affiliated with Yasuj University of Medical Sciences in Iran in 2024, utilizing a systematic probability sampling method. Participants were required to have a minimum of one year of clinical experience and to be currently employed in hospital departments, ensuring a relevant background for the study. Data collection was conducted using the California Critical Thinking Skills Test – Form B and the modified 18-item Hamric Moral Distress Scale. The findings were analyzed employing both descriptive and inferential statistical tests, including the Kolmogorov–Smirnov test for normality, Pearson correlation, and multiple linear regression, which were used to examine relationships between variables utilizing SPSS version 27.
Results: The mean age of participants was 43.33 ± 10.7 years; 221 individuals (64.40%) were female, and 127 persons (37.10%) had 1 to 5 years of work experience. Nurses had an average critical thinking score of 21.25 ± 8.64 and a moral distress score of 116.08 ± 50.82. A significant negative correlation was found between critical thinking and moral distress scores (r = -0.66, p = 0.001). A multiple regression model significantly predicted moral distress, explaining 63% of its variance (R² = 0.628, F = 29.787, p = 0.001). Six predictors were significant. Overall critical thinking was the strongest negative predictor (β = -0.396, p = 0.001, 90% CI [-2.65, -1.69]). The analysis, inference, and induction components were also significant negative predictors. In contrast, the deduction component (β = 0.197, p = 0.029, 90% CI [0.24, 4.39]) and place of residence (β = 0.072, p = 0.037, 90% CI [1.01, 32.60]) were positive predictors of moral distress.
Conclusion: The findings suggest that as critical thinking skills improve, moral distress tends to decrease among nurses. Therefore, it is recommended to implement educational programs aimed at enhancing critical thinking skills in nursing practice, which could potentially alleviate feelings of moral distress.
Type of study: Original Article |
Subject:
Nursing
References
1. Salari N, Shohaimi S, Khaledi-Paveh B, Kazeminia M, Bazrafshan M-R , Mohammadi M. The severity of moral distress in nurses: a systematic review and meta-analysis. Philos Ethics Humanit Med. 2022;17(1):13. [View at Publisher] [DOI] [PMID] [Google Scholar]
2. Arends SA, Steenbergen M, Thodé M, Francke AL , Jongerden IP. Moral distress among nurses involved in life-prolonging treatments in patients with a short life expectancy: a qualitative interview study. Patient Educ Couns. 2022;105(7):2531-6. [View at Publisher] [DOI] [PMID] [Google Scholar]
3. Da-Conceição-Jorge E, Paulo-Vitorino J, Donna M , Utuari-de-Andrade-Coelho F. Moral distress in critical care nurses caring for patients undergoing ECMO: A cross-sectional study. Enferm Intensiva (Engl Ed). 2025;36(2):500533. [View at Publisher] [DOI] [PMID] [Google Scholar]
4. Morley G, Bradbury-Jones C , Ives J. What is 'moral distress' in nursing? A feminist empirical bioethics study. Nursing Ethics. 2020;27(5):1297-314. [View at Publisher] [DOI] [PMID] [Google Scholar]
5. Morley G, Ives J, Bradbury-Jones C , Irvine F. What is 'moral distress'? A narrative synthesis of the literature. Nursing Ethics. 2019;26(3):646-62. [View at Publisher] [DOI] [PMID] [Google Scholar]
6. Alimoradi Z, Jafari E, Lin C-Y, Rajabi R, Marznaki ZH, Soodmand M, et al. Estimation of moral distress among nurses: A systematic review and meta-analysis. Nursing Ethics. 2023;30(3):334-57. [View at Publisher] [DOI] [PMID] [Google Scholar]
7. Eche IJ, Phillips CS, Alcindor N , Mazzola E. A systematic review and meta-analytic evaluation of moral distress in oncology nursing. Cancer Nurs. 2023;46(2):128-42. [View at Publisher] [DOI] [PMID] [Google Scholar]
8. Shirazi F , Heidari S. The relationship between critical thinking skills and learning styles and academic achievement of nursing students. J Nurs Res. 2019;27(4):e38. [View at Publisher] [DOI] [PMID] [Google Scholar]
9. Ali-Abadi T, Babamohamadi H , Nobahar M. Critical thinking skills in intensive care and medical-surgical nurses and their explaining factors.Nurse Educ Pract. 2020;45:102783. [View at Publisher] [DOI] [PMID] [Google Scholar]
10. Li S, Ye X , Chen W. Practice and effectiveness of "nursing case-based learning" course on nursing student's critical thinking ability: A comparative study. Nurse Educ Pract. 2019;36:91-6. [View at Publisher] [DOI] [PMID] [Google Scholar]
11. Bilik Ö, Kankaya EA , Deveci Z. Effects of web-based concept mapping education on students' concept mapping and critical thinking skills: A double blind, randomized, controlled study. Nurse Educ Today. 2020;86:104312. [View at Publisher] [DOI] [PMID] [Google Scholar]
12. Yeung MM-Y, Yuen JW-M, Chen JM-T , Lam KK-L. The efficacy of team-based learning in developing the generic capability of problem-solving ability and critical thinking skills in nursing education: A systematic review. Nurse Educ Today. 2023;122:105704. [View at Publisher] [DOI] [PMID] [Google Scholar]
13. Wu H-Z , Wu Q-T. Impact of mind mapping on the critical thinking ability of clinical nursing students and teaching application.J Int Med Res. 2020;48(3):300060519893225. [View at Publisher] [DOI] [PMID] [Google Scholar]
14. Urhan E, Zuriguel‐Perez E , Harmancı Seren AK. Critical thinking among clinical nurses and related factors: A survey study in public hospitals. J Clin Nurs. 2022;31(21-22):3155-64. [View at Publisher] [DOI] [PMID] [Google Scholar]
15. Tajalli S, Rostamli S, Dezvaree N, Shariat M , Kadivar M. Moral distress among Iranian neonatal intensive care units' health care providers: a multi-center cross sectional study. J Med Ethics Hist Med. 2021;14:12. [View at Publisher] [DOI] [PMID] [Google Scholar]
16. Park S-K , Jeong Y-W. Relationship between hospital ethical climate, critical thinking disposition, and nursing task performance. BMC Nursing. 2024;23(1):696. [View at Publisher] [DOI] [PMID] [Google Scholar]
17. Facione PA. Critical thinking: A statement of expert consensus for purposes of educational assessment and instruction-The Delphi report. Millbrae, CA: California Academic Press; 1990. [View at Publisher] [Google Scholar]
18. Jacobs SS. Technical characteristics and some correlates of the California Critical Thinking Skills Test, Forms A and B. Res High Educ .1995;36:89-108. [View at Publisher] [DOI] [Google Scholar]
19. Khalili H , Hosseinzadeh M. Investigation of reliability, validity and normality Persian version of the California Critical Thinking Skills Test; Form B (CCTST). J Med Educ. 2003;3(1):e105016. [View at Publisher] [DOI] [Google Scholar]
20. Hariri N , Bagherinejad Z. Evaluation of critical thinking skills in students of health faculty, Mazandaran University of Medical Sciences. J Mazandaran Univ Med Sci. 2012;20(1):166-73. [View at Publisher] [Google Scholar]
21. Hamric AB , Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med. 2007;35(2):422-9. [View at Publisher] [DOI] [PMID] [Google Scholar]
22. Hamric AB, Borchers CT , Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research. 2012;3(2):1-9. [View at Publisher] [DOI] [Google Scholar]
23. Khoshkbari Z, Rejeh N , Tadrisi SD. Relationship between Moral Distress and Job Burnout in Nurses of Critical Care Units of Hospitals. J:Medical Ethics Year. 2022;16(47):e6. [View at Publisher] [DOI] [Google Scholar]
24. Ramos FRS, Brehmer LCdF, Dalmolin GdL, Silveira LR, Schneider DG , Vargas MAdO. Association between moral distress and supporting elements of moral deliberation in nurses. Rev Lat Am Enfermagem. 2020;28:e3332. [View at Publisher] [DOI] [PMID] [Google Scholar]
25. Barry A, Parvan K, Sarbakhsh P, Safa B , Allahbakhshian A. Critical thinking in nursing students and its relationship with professional self-concept and relevant factors. Res Dev Med Educ .2020;9:7. [View at Publisher] [DOI] [Google Scholar]
26. Álvarez-Huerta P, Muela A , Larrea I. Disposition toward critical thinking and creative confidence beliefs in higher education students: The mediating role of openness to diversity and challenge. Think Skills Creat. 2022;43:101003. [View at Publisher] [DOI] [Google Scholar]
27. Lake ET, Narva AM, Holland S, Smith JG, Cramer E, Rosenbaum KEF, et al. Hospital nurses' moral distress and mental health during COVID‐19. J Adv Nurs. 2022;78(3):799-809. [View at Publisher] [DOI] [PMID] [Google Scholar]
28. Riegel F, Crossetti MdGO, Martini JG , Nes AAG. Florence Nightingale's theory and her contributions to holistic critical thinking in nursing.Rev Bras Enferm. 2021;74(2):e20200139. [View at Publisher] [DOI] [PMID] [Google Scholar]
29. Qu Z, Sun J, Li L, Zhao L, Jiang N, Fan J, et al. The effect of simulated problem learning in nursing ethics on moral sensitivity, empathy and critical thinking of nursing students: A quasi-experimental study. Nurse Educ Pract. 2024;80:104119. [View at Publisher] [DOI] [PMID] [Google Scholar]
30. Qiang R, Han Q, Guo Y, Bai J , Karwowski M. Critical thinking disposition and scientific creativity: The mediating role of creative self‐efficacy.
J Creat Behav. 2020;54(1):90-9. [View at Publisher] [DOI] [Google Scholar]
31. Xue B, Wang S, Chen D, Hu Z, Feng Y , Luo H. Moral distress, psychological capital, and burnout in registered nurses. Nurs Ethics. 2024;31(2-3):388-400. [View at Publisher] [DOI] [PMID] [Google Scholar]
Send email to the article author
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
