Volume 22, Issue 3 (9-2025)
J Res Dev Nurs Midw 2025, 22(3): 29-33 |
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Mousavi M S, Keshavarz F, Mirzaei Z, Yosefpour Z, Malekzadeh M, Rastian M L. Relationship between critical thinking and moral distress in nurses: A cross-sectional study. J Res Dev Nurs Midw 2025; 22 (3) :29-33
URL: http://nmj.goums.ac.ir/article-1-1912-en.html
URL: http://nmj.goums.ac.ir/article-1-1912-en.html
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, Darab branch. 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, Darab branch. 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 ,
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There was a significant correlation between the overall score of critical thinking and the overall score of moral distress (p = 0.001, r = -0.66). The relationship between critical thinking and moral distress was negative, with a strong correlation. Additionally, moral distress showed a significant negative correlation with the subscales of analysis (p = 0.001, r = -0.68), evaluation (p = 0.001, r = -0.62), inference (p = 0.001, r = -0.64), inductive reasoning (p = 0.001, r = -0.67), and deductive reasoning (p = 0.001, r = -0.62) (Table 3).
The multiple regression analysis revealed that the model predicting moral distress had high explanatory power (R² = 0.628, F = 29.787, p = 0.001), accounting for approximately 63% of the variance in moral distress.
Among the variables included in the model, six showed significant effects: Overall critical thinking (β = -0.396, p < 0.001, 90% CI [-2.65, -1.69]) was the strongest negative predictor of distress, with each one-unit increase in critical thinking scores associated with an average 2.3-unit decrease in moral distress. The components of Analysis (β = -0.302, p = 0.001, 90% CI [-6.56, -2.71]), Inference (β = -0.221, p = 0.003, 90% CI [-5.65, -1.61]), and Induction (β = -0.217, p = 0.02, 90% CI [-5.27, -0.31]) also showed significant negative relationships with distress. 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]) had significant positive relationships with moral distress (Table 4).
Based on the findings from this study, no significant associations were found between demographic characteristics and the variables of moral distress and critical thinking (p > 0.05) (Table 4).
Discussion
This study aimed to investigate the relationship between critical thinking and moral distress among nurses. The study found that most nurses exhibited high critical thinking and low moral distress levels. A significant inverse correlation was observed between moral distress and critical thinking, including their subscales, indicating that enhanced critical thinking may alleviate moral distress. The present findings are consistent with the studies conducted by Ramos et al. (2020), who reported a positive association between moral distress and the supporting elements of moral deliberation in nurses (24), and Barry et al. (2020), who found a significant negative correlation between the total scores of professional self-concept and critical thinking (25). It appears that critical thinking is a skill that helps nurses experience less ethical conflict and make better decisions in morally challenging situations. These results suggest that while some ethical factors may increase psychological distress, an increased professional self-concept might negatively affect critical thinking. Therefore, a more detailed examination of the relationships between these variables and other underlying factors is necessary to better understand their role.
Although Álvarez-Huerta et al. (2022) focused on higher education students’ disposition toward critical thinking and creative confidence, their findings highlight the important role of openness to diversity and challenge in enhancing critical thinking skills (26). This suggests that fostering such openness in nursing education could be beneficial for developing nurses’ critical thinking abilities, which are essential for effective ethical decision-making and coping with moral distress in clinical settings. Moreover, Lake et al. (2022) demonstrated that moral distress during the COVID-19 pandemic had a significant impact on the mental health of hospital nurses. These findings highlight the importance of addressing environmental and organizational factors that can reduce moral distress. Specifically, effective leadership communication, a decrease in the number of COVID-19 patients, and adequate access to personal protective equipment were identified as key factors in alleviating moral distress (27). This indicates that improving working conditions and organizational support can play a crucial role in reducing nurses’ moral distress and preventing psychological issues arising from ethical conflicts. Consequently, strengthening these factors can contribute to better mental health and professional performance among nurses, underscoring the importance of education and policy-making in this field.
Nurses must be capable of critical and comprehensive thinking to effectively navigate challenging and unpredictable situations, applying critical thinking in clinical decision-making and patient care (28). Additionally, they should develop critical thinking skills, empathy, and moral sensitivity to enhance their confidence in bedside care and foster nurse-patient relationships based on trust and respect (29).
Considering these aspects, a key finding of this study is that higher levels of critical thinking in nurses are associated with lower levels of moral distress. This relationship may be explained by the fact that nurses with enhanced analytical and evaluative abilities can better manage the pressures of ethical conflicts and make more ethically sound decisions.
In this regard, Qiang et al. (2020) found that students with a greater inclination toward critical thinking were more likely to perceive themselves as more creative. This sense of creative self-efficacy, in turn, contributed to improved performance in both academic and innovative domains (30), a finding that aligns with the present study.
Moreover, Xue et al. (2024) reported that psychological capital plays a significant role in moral distress and job burnout. They suggested that enhancing psychological capital in nurses can help mitigate moral distress and prevent burnout (31). One potential limitation of this study is the use of self-report scales to measure moral distress and critical thinking, which may introduce reporting biases among nurses. Additionally, external factors such as work conditions, social support, and environmental pressures-which can influence moral distress-were not controlled, representing another limitation of this study.
Conclusion
The findings of this study suggest that nurses with higher critical thinking skills may experience lower levels of moral distress. This underscores the importance of enhancing critical thinking in nursing education, as training in these skills can alleviate psychological pressures and ethical dilemmas faced by nurses. Those adept at analyzing complex ethical situations are likely to encounter fewer challenges and experience reduced stress in clinical settings. These insights can inform the development of educational programs aimed at strengthening critical thinking skills, ultimately improving healthcare quality and enhancing nurses' psychological well-being. To further explore this relationship, longitudinal studies and investigations into additional influencing factors are essential. Future research should assess the effectiveness of training programs focused on problem-solving and ethical decision-making, as these may bolster critical thinking and better equip nurses to navigate ethical challenges. Given the cross-sectional nature of this study, which limits causal inferences, future investigations should utilize longitudinal or interventional designs to more accurately evaluate the impact of critical thinking development on moral distress. Additionally, qualitative methods, such as in-depth interviews, are recommended to gain deeper insights into nurses' experiences with moral distress and critical thinking.
Acknowledgement
The authors would like to express their gratitude to the Deputy of Research and Technology at Yasuj University of Medical Sciences for financially supporting this project (Approval code: 4030164), as well as to all the nurses who participated in the study.
Funding sources
This study was financially supported by the Deputy of Research and Technology at Yasuj University of Medical Sciences.
Ethical statement
This study was approved by the Vice-Chancellor of Research and Technology at Yasuj University of Medical Sciences (Ethics Code: IR.YUMS.REC.1403.149). Informed consent was obtained from all participants. They were assured of the confidentiality of their information, and participation was entirely voluntary. The principles of research ethics were followed in accordance with the Declaration of Helsinki, ensuring that all ethical guidelines were actively implemented throughout the study.
Conflicts of interest
The authors declare no conflict of interest in this study.
Author contributions
M.L.R.: Providing the study idea and its guideline; M.S.M. and M.L.R.: Providing the study design; F.K., Z.M., and Z.Y.: Conducting the research process and interventions; M.M.Z.: Analyzing the data. The initial draft of the article was prepared by M.L.R. and M.S.M., and the revisions to the article were conducted by M.L.R. and M.S.M.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Introduction
Nurses, due to their frequent exposure to a high volume of patients and the associated mortality, are at high risk of emotional conflict, and ethics plays a significant role in this profession (1). Moral distress is highly prevalent among nurses in hospital settings (2). In a study, it was shown that moral distress among nurses was high (3). Jameton introduced the term “moral distress” in the early 1980s in nursing, stating that it occurs when an individual knows the right course of action but institutional constraints make pursuing the right path nearly impossible (4). Studies have highlighted the detrimental effects of moral distress, with correlations found between higher levels of moral distress, negative perceptions of the ethical climate, and increased levels of compassion fatigue among nurses (4-6). One of the consequences of moral distress in nurses is that it makes them more prone to inappropriate reactions to morally distressing events or causes them to feel that they have lost the ability to distinguish right from wrong (7).
Therefore, methods should be employed to enhance decision-making in nurses, one of which is the use of critical thinking (8). In a study, it was shown that nurses working in intensive care units and medical-surgical wards have poor critical thinking skills (9). Scheffer and Rubenfeld stated that the ability to think critically in nursing includes analysis, applying standards, distinguishing, seeking information, logical reasoning, predicting, and transforming knowledge (10). Critical thinking is a core skill for graduate nurses. It enables nurses to apply, integrate, and understand the increasing differences between patient populations and the complex healthcare technologies (11). “Capable nurses” are expected to have creativity and the ability to cope with the daily complexities of clinical practice, especially in managing unfamiliar situations. Professional capabilities are closely related to transferable generic skills such as critical thinking and problem-solving abilities. Capable nurses have greater confidence in their clinical judgment and are expected to possess advanced clinical reasoning (12). The modern healthcare environment requires nurses to possess the ability for independent judgment, decision-making, and autonomous practice in clinical settings (13).
Urhan et al. demonstrated that the levels of critical thinking among nurses working in clinical environments in public hospitals were at a moderate level. The type of hospital, work shift, professional and educational level, and role were significantly associated with the levels of critical thinking in clinical nurses (14). On the other hand, Tajalli et al. found that the intensity and frequency of moral distress among physicians and nurses working in neonatal intensive care units are at a moderate level. Therefore, addressing this issue and making efforts to reduce it are essential, as identifying the underlying factors of moral distress can help in adopting appropriate measures for its prevention and reduction (15).
Moreover, the complexity of ethical situations in healthcare environments and nursing is increasing, affecting not only nurses but also the quality of nursing (16).
Although numerous studies have investigated moral distress and critical thinking in various contexts, none have specifically examined the relationship between critical thinking and moral distress among nurses. There still appears to be a need for further research into the relationship between these two variables. Since supporting nurses in their primary responsibility-delivering high-quality nursing care-is crucial, this gap in the literature is evident and warrants further investigation. Therefore, this study aimed to determine the relationship between critical thinking and moral distress in nurses.
Methods
This cross-sectional study was conducted among nurses working in hospitals affiliated with Yasuj University of Medical Sciences in Yasuj, Iran, in 2024. A systematic sampling method was employed to select 342 nurses. Sample size estimation was conducted using G*Power 3.1.9.7, incorporating a Type I error rate of 0.05, a 95% confidence interval, and a statistical power of 80%, with a critical Z-value of -1.64, resulting in a required sample size of 342 participants.
The key inclusion criteria for this study were: holding at least an associate degree, having a minimum of one year of clinical experience, willingness to participate in the study, and being employed in hospital departments. Additionally, participants should have no history of participation in similar studies within the past six months and no self-reported psychiatric disorders. The exclusion criteria included incomplete responses to the questionnaires.
Data were collected using a tool consisting of a demographic information form (Including age, gender, education, work experience, marital status, work shift, department, type of employment, nursing position in hospitals, history of depression or other psychiatric disorders, presence of underlying or specific diseases, and economic status), the California Critical Thinking Skills Test (CCTST-Form B), and the 18-item Revised Moral Distress Scale (MDS-R) by Hamric et al.
California Critical Thinking Skills Test - Form B (CCTST-Form B): The CCTST-Form B was developed in 1992 by Peter Facione and consists of 34 items, with some having four response options and others having five. The test comprises five subscales: Analysis (9 items), Evaluation (14 items), Inference (11 items), Inductive Reasoning (14 items), and Deductive Reasoning (16 items). Among the 34 questions, 20 have four answer choices, while 14 have five answer choices. Since each item has only one correct answer, participants receive a score of 0 or 1 per item, resulting in a total score ranging from 0 to 34. The allocated time for completing the test is 45 minutes. Facione reported the reliability of this instrument to be between 0.68 and 0.70 using the K-R₂,₃ coefficient (Or Cronbach’s alpha) (17-19).
In the study by Khalili and Hosseinzadeh, the reliability of the test was examined using the internal consistency method and the KR-20 coefficient. The construct validity of the test was also evaluated through factor analysis, internal consistency, and group difference comparison. The results indicated that the test items possessed sufficient reliability to be used as a research instrument (19). In the study by Hariri and Bagherinejad (2012), the reliability coefficient of the instrument was measured using Cronbach’s alpha, and it was reported to be 0.86 (20). In the present study, the reliability of the instrument was reassessed, yielding a Cronbach’s alpha coefficient of 0.716.
Moral Distress Scale-Revised (MDS-R) - 18-item version: The 18-item MDS-R by Hamric et al. assesses moral distress through two dimensions: frequency and intensity. Each item is rated on a 5-point Likert scale, ranging from 0 (None), 1 (Low), 2 (Moderate), 3 (High), to 4 (Very high). The score for each item is obtained by multiplying the frequency and intensity ratings, resulting in a possible score range of 0 to 16 per item. To calculate the total moral distress score, the scores of all items are summed, yielding a total range of 0 to 288, with higher scores indicating greater moral distress (21-23). Khoshkbari et al. (2022) assessed the reliability of this scale using internal consistency, reporting a Cronbach’s alpha of 0.73, demonstrating acceptable reliability (23). The instrument’s reliability was reassessed in this study, with a Cronbach’s alpha of 0.845.
The study was conducted in three hospitals. The total number of eligible nurses in each hospital was as follows: Hospital A (n = 224), Hospital B (n = 316), and Hospital C (n = 498). Using proportional systematic sampling, participants were selected from each hospital relative to its population size.
Data were collected using paper-based questionnaires. Nurses were approached directly by several researchers, who visited each hospital and invited them to complete the questionnaire. The data collection process lasted for three months. Participants were selected and thoroughly assessed for compliance with the inclusion criteria. A systematic sampling method was employed to select 342 nurses from a list of all eligible nurses (N = 1038) across the three hospitals. The list of eligible nurses was obtained from the nursing directors of the hospitals. The sampling interval was calculated by dividing the total number of eligible nurses by the desired sample size. After randomly selecting the first nurse using a simple random sampling method based on a random number table, subsequent participants were selected at regular intervals (k = 3) until the sample size was reached. After confirming eligibility, written informed consent forms were obtained. Subsequently, the participants completed the demographic information form, the CCTST-Form B, and the 18-item MDS-R by Hamric et al. for data collection.
Collected data were analyzed using SPSS software version 27. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to summarize the data. Inferential analysis was conducted using Pearson’s correlation coefficient to examine relationships between variables after confirming the test's assumptions. Multiple regression analysis was utilized to identify the most significant variables associated with moral distress. A significance level of 0.05 was considered for all statistical tests. Before conducting Pearson’s correlation analysis, the assumptions of normality, linearity, and absence of outliers were examined. Initially, the normality of continuous variables was assessed using the Kolmogorov-Smirnov test. The results indicated that the data distribution was normal (p > 0.05); therefore, parametric tests were employed for statistical analysis.
Results
In this study, a total of 342 nurses participated. The mean age of the participants was 43.33 ± 10.7 years, with an age range of 22 to 55 years. The majority of the participants were female, comprising 225 individuals (60.64%). Most participants, 127 individuals (37.10%), had 1 to 5 years of work experience. A significant number of nurses, 267 individuals (78.1%), held a bachelor’s degree and resided in urban areas, totaling 325 individuals (95%). Additionally, 216 participants (63.2%) reported a moderate economic status. In terms of employment, the largest proportion were formally employed, accounting for 39.8%, and the majority held regular staff nurse positions, totaling 285 individuals (83.3%). The emergency department had the highest representation among work units, with 80 individuals (23.4%), while neurology had the lowest representation, with 20 individuals (2.3%). Additional characteristics are presented in Table 1.
Nurses, due to their frequent exposure to a high volume of patients and the associated mortality, are at high risk of emotional conflict, and ethics plays a significant role in this profession (1). Moral distress is highly prevalent among nurses in hospital settings (2). In a study, it was shown that moral distress among nurses was high (3). Jameton introduced the term “moral distress” in the early 1980s in nursing, stating that it occurs when an individual knows the right course of action but institutional constraints make pursuing the right path nearly impossible (4). Studies have highlighted the detrimental effects of moral distress, with correlations found between higher levels of moral distress, negative perceptions of the ethical climate, and increased levels of compassion fatigue among nurses (4-6). One of the consequences of moral distress in nurses is that it makes them more prone to inappropriate reactions to morally distressing events or causes them to feel that they have lost the ability to distinguish right from wrong (7).
Therefore, methods should be employed to enhance decision-making in nurses, one of which is the use of critical thinking (8). In a study, it was shown that nurses working in intensive care units and medical-surgical wards have poor critical thinking skills (9). Scheffer and Rubenfeld stated that the ability to think critically in nursing includes analysis, applying standards, distinguishing, seeking information, logical reasoning, predicting, and transforming knowledge (10). Critical thinking is a core skill for graduate nurses. It enables nurses to apply, integrate, and understand the increasing differences between patient populations and the complex healthcare technologies (11). “Capable nurses” are expected to have creativity and the ability to cope with the daily complexities of clinical practice, especially in managing unfamiliar situations. Professional capabilities are closely related to transferable generic skills such as critical thinking and problem-solving abilities. Capable nurses have greater confidence in their clinical judgment and are expected to possess advanced clinical reasoning (12). The modern healthcare environment requires nurses to possess the ability for independent judgment, decision-making, and autonomous practice in clinical settings (13).
Urhan et al. demonstrated that the levels of critical thinking among nurses working in clinical environments in public hospitals were at a moderate level. The type of hospital, work shift, professional and educational level, and role were significantly associated with the levels of critical thinking in clinical nurses (14). On the other hand, Tajalli et al. found that the intensity and frequency of moral distress among physicians and nurses working in neonatal intensive care units are at a moderate level. Therefore, addressing this issue and making efforts to reduce it are essential, as identifying the underlying factors of moral distress can help in adopting appropriate measures for its prevention and reduction (15).
Moreover, the complexity of ethical situations in healthcare environments and nursing is increasing, affecting not only nurses but also the quality of nursing (16).
Although numerous studies have investigated moral distress and critical thinking in various contexts, none have specifically examined the relationship between critical thinking and moral distress among nurses. There still appears to be a need for further research into the relationship between these two variables. Since supporting nurses in their primary responsibility-delivering high-quality nursing care-is crucial, this gap in the literature is evident and warrants further investigation. Therefore, this study aimed to determine the relationship between critical thinking and moral distress in nurses.
Methods
This cross-sectional study was conducted among nurses working in hospitals affiliated with Yasuj University of Medical Sciences in Yasuj, Iran, in 2024. A systematic sampling method was employed to select 342 nurses. Sample size estimation was conducted using G*Power 3.1.9.7, incorporating a Type I error rate of 0.05, a 95% confidence interval, and a statistical power of 80%, with a critical Z-value of -1.64, resulting in a required sample size of 342 participants.
The key inclusion criteria for this study were: holding at least an associate degree, having a minimum of one year of clinical experience, willingness to participate in the study, and being employed in hospital departments. Additionally, participants should have no history of participation in similar studies within the past six months and no self-reported psychiatric disorders. The exclusion criteria included incomplete responses to the questionnaires.
Data were collected using a tool consisting of a demographic information form (Including age, gender, education, work experience, marital status, work shift, department, type of employment, nursing position in hospitals, history of depression or other psychiatric disorders, presence of underlying or specific diseases, and economic status), the California Critical Thinking Skills Test (CCTST-Form B), and the 18-item Revised Moral Distress Scale (MDS-R) by Hamric et al.
California Critical Thinking Skills Test - Form B (CCTST-Form B): The CCTST-Form B was developed in 1992 by Peter Facione and consists of 34 items, with some having four response options and others having five. The test comprises five subscales: Analysis (9 items), Evaluation (14 items), Inference (11 items), Inductive Reasoning (14 items), and Deductive Reasoning (16 items). Among the 34 questions, 20 have four answer choices, while 14 have five answer choices. Since each item has only one correct answer, participants receive a score of 0 or 1 per item, resulting in a total score ranging from 0 to 34. The allocated time for completing the test is 45 minutes. Facione reported the reliability of this instrument to be between 0.68 and 0.70 using the K-R₂,₃ coefficient (Or Cronbach’s alpha) (17-19).
In the study by Khalili and Hosseinzadeh, the reliability of the test was examined using the internal consistency method and the KR-20 coefficient. The construct validity of the test was also evaluated through factor analysis, internal consistency, and group difference comparison. The results indicated that the test items possessed sufficient reliability to be used as a research instrument (19). In the study by Hariri and Bagherinejad (2012), the reliability coefficient of the instrument was measured using Cronbach’s alpha, and it was reported to be 0.86 (20). In the present study, the reliability of the instrument was reassessed, yielding a Cronbach’s alpha coefficient of 0.716.
Moral Distress Scale-Revised (MDS-R) - 18-item version: The 18-item MDS-R by Hamric et al. assesses moral distress through two dimensions: frequency and intensity. Each item is rated on a 5-point Likert scale, ranging from 0 (None), 1 (Low), 2 (Moderate), 3 (High), to 4 (Very high). The score for each item is obtained by multiplying the frequency and intensity ratings, resulting in a possible score range of 0 to 16 per item. To calculate the total moral distress score, the scores of all items are summed, yielding a total range of 0 to 288, with higher scores indicating greater moral distress (21-23). Khoshkbari et al. (2022) assessed the reliability of this scale using internal consistency, reporting a Cronbach’s alpha of 0.73, demonstrating acceptable reliability (23). The instrument’s reliability was reassessed in this study, with a Cronbach’s alpha of 0.845.
The study was conducted in three hospitals. The total number of eligible nurses in each hospital was as follows: Hospital A (n = 224), Hospital B (n = 316), and Hospital C (n = 498). Using proportional systematic sampling, participants were selected from each hospital relative to its population size.
Data were collected using paper-based questionnaires. Nurses were approached directly by several researchers, who visited each hospital and invited them to complete the questionnaire. The data collection process lasted for three months. Participants were selected and thoroughly assessed for compliance with the inclusion criteria. A systematic sampling method was employed to select 342 nurses from a list of all eligible nurses (N = 1038) across the three hospitals. The list of eligible nurses was obtained from the nursing directors of the hospitals. The sampling interval was calculated by dividing the total number of eligible nurses by the desired sample size. After randomly selecting the first nurse using a simple random sampling method based on a random number table, subsequent participants were selected at regular intervals (k = 3) until the sample size was reached. After confirming eligibility, written informed consent forms were obtained. Subsequently, the participants completed the demographic information form, the CCTST-Form B, and the 18-item MDS-R by Hamric et al. for data collection.
Collected data were analyzed using SPSS software version 27. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to summarize the data. Inferential analysis was conducted using Pearson’s correlation coefficient to examine relationships between variables after confirming the test's assumptions. Multiple regression analysis was utilized to identify the most significant variables associated with moral distress. A significance level of 0.05 was considered for all statistical tests. Before conducting Pearson’s correlation analysis, the assumptions of normality, linearity, and absence of outliers were examined. Initially, the normality of continuous variables was assessed using the Kolmogorov-Smirnov test. The results indicated that the data distribution was normal (p > 0.05); therefore, parametric tests were employed for statistical analysis.
Results
In this study, a total of 342 nurses participated. The mean age of the participants was 43.33 ± 10.7 years, with an age range of 22 to 55 years. The majority of the participants were female, comprising 225 individuals (60.64%). Most participants, 127 individuals (37.10%), had 1 to 5 years of work experience. A significant number of nurses, 267 individuals (78.1%), held a bachelor’s degree and resided in urban areas, totaling 325 individuals (95%). Additionally, 216 participants (63.2%) reported a moderate economic status. In terms of employment, the largest proportion were formally employed, accounting for 39.8%, and the majority held regular staff nurse positions, totaling 285 individuals (83.3%). The emergency department had the highest representation among work units, with 80 individuals (23.4%), while neurology had the lowest representation, with 20 individuals (2.3%). Additional characteristics are presented in Table 1.
|
Table 1. Comparison of demographic characteristics of participating nurses (n=342)
.PNG) |
There was a significant correlation between the overall score of critical thinking and the overall score of moral distress (p = 0.001, r = -0.66). The relationship between critical thinking and moral distress was negative, with a strong correlation. Additionally, moral distress showed a significant negative correlation with the subscales of analysis (p = 0.001, r = -0.68), evaluation (p = 0.001, r = -0.62), inference (p = 0.001, r = -0.64), inductive reasoning (p = 0.001, r = -0.67), and deductive reasoning (p = 0.001, r = -0.62) (Table 3).
The multiple regression analysis revealed that the model predicting moral distress had high explanatory power (R² = 0.628, F = 29.787, p = 0.001), accounting for approximately 63% of the variance in moral distress.
Among the variables included in the model, six showed significant effects: Overall critical thinking (β = -0.396, p < 0.001, 90% CI [-2.65, -1.69]) was the strongest negative predictor of distress, with each one-unit increase in critical thinking scores associated with an average 2.3-unit decrease in moral distress. The components of Analysis (β = -0.302, p = 0.001, 90% CI [-6.56, -2.71]), Inference (β = -0.221, p = 0.003, 90% CI [-5.65, -1.61]), and Induction (β = -0.217, p = 0.02, 90% CI [-5.27, -0.31]) also showed significant negative relationships with distress. 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]) had significant positive relationships with moral distress (Table 4).
Based on the findings from this study, no significant associations were found between demographic characteristics and the variables of moral distress and critical thinking (p > 0.05) (Table 4).
|
Table 2. Descriptive statistics of critical thinking, moral distress, and related subscales
.PNG) Table 3. Correlation between moral distress and its subscales with critical thinking and its subscales .PNG) * Pearson correlation test Table 4. Results of multiple linear regression analysis for moral distress and critical thinking .PNG) *P-value and **P-value is significant at 0.05 |
Discussion
This study aimed to investigate the relationship between critical thinking and moral distress among nurses. The study found that most nurses exhibited high critical thinking and low moral distress levels. A significant inverse correlation was observed between moral distress and critical thinking, including their subscales, indicating that enhanced critical thinking may alleviate moral distress. The present findings are consistent with the studies conducted by Ramos et al. (2020), who reported a positive association between moral distress and the supporting elements of moral deliberation in nurses (24), and Barry et al. (2020), who found a significant negative correlation between the total scores of professional self-concept and critical thinking (25). It appears that critical thinking is a skill that helps nurses experience less ethical conflict and make better decisions in morally challenging situations. These results suggest that while some ethical factors may increase psychological distress, an increased professional self-concept might negatively affect critical thinking. Therefore, a more detailed examination of the relationships between these variables and other underlying factors is necessary to better understand their role.
Although Álvarez-Huerta et al. (2022) focused on higher education students’ disposition toward critical thinking and creative confidence, their findings highlight the important role of openness to diversity and challenge in enhancing critical thinking skills (26). This suggests that fostering such openness in nursing education could be beneficial for developing nurses’ critical thinking abilities, which are essential for effective ethical decision-making and coping with moral distress in clinical settings. Moreover, Lake et al. (2022) demonstrated that moral distress during the COVID-19 pandemic had a significant impact on the mental health of hospital nurses. These findings highlight the importance of addressing environmental and organizational factors that can reduce moral distress. Specifically, effective leadership communication, a decrease in the number of COVID-19 patients, and adequate access to personal protective equipment were identified as key factors in alleviating moral distress (27). This indicates that improving working conditions and organizational support can play a crucial role in reducing nurses’ moral distress and preventing psychological issues arising from ethical conflicts. Consequently, strengthening these factors can contribute to better mental health and professional performance among nurses, underscoring the importance of education and policy-making in this field.
Nurses must be capable of critical and comprehensive thinking to effectively navigate challenging and unpredictable situations, applying critical thinking in clinical decision-making and patient care (28). Additionally, they should develop critical thinking skills, empathy, and moral sensitivity to enhance their confidence in bedside care and foster nurse-patient relationships based on trust and respect (29).
Considering these aspects, a key finding of this study is that higher levels of critical thinking in nurses are associated with lower levels of moral distress. This relationship may be explained by the fact that nurses with enhanced analytical and evaluative abilities can better manage the pressures of ethical conflicts and make more ethically sound decisions.
In this regard, Qiang et al. (2020) found that students with a greater inclination toward critical thinking were more likely to perceive themselves as more creative. This sense of creative self-efficacy, in turn, contributed to improved performance in both academic and innovative domains (30), a finding that aligns with the present study.
Moreover, Xue et al. (2024) reported that psychological capital plays a significant role in moral distress and job burnout. They suggested that enhancing psychological capital in nurses can help mitigate moral distress and prevent burnout (31). One potential limitation of this study is the use of self-report scales to measure moral distress and critical thinking, which may introduce reporting biases among nurses. Additionally, external factors such as work conditions, social support, and environmental pressures-which can influence moral distress-were not controlled, representing another limitation of this study.
Conclusion
The findings of this study suggest that nurses with higher critical thinking skills may experience lower levels of moral distress. This underscores the importance of enhancing critical thinking in nursing education, as training in these skills can alleviate psychological pressures and ethical dilemmas faced by nurses. Those adept at analyzing complex ethical situations are likely to encounter fewer challenges and experience reduced stress in clinical settings. These insights can inform the development of educational programs aimed at strengthening critical thinking skills, ultimately improving healthcare quality and enhancing nurses' psychological well-being. To further explore this relationship, longitudinal studies and investigations into additional influencing factors are essential. Future research should assess the effectiveness of training programs focused on problem-solving and ethical decision-making, as these may bolster critical thinking and better equip nurses to navigate ethical challenges. Given the cross-sectional nature of this study, which limits causal inferences, future investigations should utilize longitudinal or interventional designs to more accurately evaluate the impact of critical thinking development on moral distress. Additionally, qualitative methods, such as in-depth interviews, are recommended to gain deeper insights into nurses' experiences with moral distress and critical thinking.
Acknowledgement
The authors would like to express their gratitude to the Deputy of Research and Technology at Yasuj University of Medical Sciences for financially supporting this project (Approval code: 4030164), as well as to all the nurses who participated in the study.
Funding sources
This study was financially supported by the Deputy of Research and Technology at Yasuj University of Medical Sciences.
Ethical statement
This study was approved by the Vice-Chancellor of Research and Technology at Yasuj University of Medical Sciences (Ethics Code: IR.YUMS.REC.1403.149). Informed consent was obtained from all participants. They were assured of the confidentiality of their information, and participation was entirely voluntary. The principles of research ethics were followed in accordance with the Declaration of Helsinki, ensuring that all ethical guidelines were actively implemented throughout the study.
Conflicts of interest
The authors declare no conflict of interest in this study.
Author contributions
M.L.R.: Providing the study idea and its guideline; M.S.M. and M.L.R.: Providing the study design; F.K., Z.M., and Z.Y.: Conducting the research process and interventions; M.M.Z.: Analyzing the data. The initial draft of the article was prepared by M.L.R. and M.S.M., and the revisions to the article were conducted by M.L.R. and M.S.M.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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]
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