this was a descriptive - analytic study investigating 264 nurses working in two medical educational hospitals and one private hospital in tehran . the investigators made arrangements with the supervisors of each ward for data collection and were informed of number of nurses in all three shift works . first , the researcher provided a general explanation about moral distress and the main goals of the research . finally , the questionnaires were distributed among the nurses and were collected in the next working shift by the researcher . the instrument used to measure moral distress was adapted for use in the iranian health care setting by the first investigator through the moral distress scale ( mds ) developed by corley15 . her mds used jameton s conceptualization of moral distress , houses and rizzos16 conflict role theory and rokeachs17 value thesis . the reliability was calculated as 90 in a sample of 214 nurses ( cronbach s alpha ) . the investigators adapted the corley s mds for an iranian population , and its reliability and validity have been established for the mds in this study15 . the scale has responses ranging from 1 ( little moral distress ) , to 7 ( high moral distress ) on intensity and frequency . our instruments included corley s 30-item moral distress scale ( mds ) questionnaire , demographic questions , and items on characteristics of the work conditions . the tool has been useful for documenting the presence and negative consequences of moral distress ( md ) in nurses11 , 15,18 , 19 . data analysis was accomplished using version 19 of spss software for descriptive statistic methods , independent t - test , anova and analysis of variance . ethical approval was obtained from the research committee of the shahid beheshti university of medical sciences . participants were asked to sign a consent form and were informed that they could withdraw from the study at any time . ethical approval was obtained from the research committee of the shahid beheshti university of medical sciences . participants were asked to sign a consent form and were informed that they could withdraw from the study at any time . all the participants ( n = 264 ) who participated in this study held bsc and msc in nursing . the majority of the participants ( 92.5% ) were female and only 7.5% were male . of the participants , 66.1% were married , 33.1% were divorced and 0.8% were widowed . table 1 demonstrates the t - test results of the sample analysis such as , gender , type of hospitals and marital status . the questionnaire return rate was 77% ; and the low return rate of questionnaires was mostly from emergency wards and neonatal intensive care units . our study is also indicative of either high or very high levels ( 65.5% ) of family support for nurses , and only 22% of the nurses indicated either a high or a very high level of support from their supervisors and the management ( table 2).place the mean moral distress score ranged from 3.56 to 5.83 , indicating moderate to high levels of moral distress . the item with the highest mean score was  working with unsafe levels of nurse staffing  ( m = 5.83 , sd = 1.43 ) . table 4 displays items with the highest mean score moral distress . characteristics of workplace items with highest moral distress the item with the lowest mean score was  giving medication intravenously to a patient who has refused to take it ( m = 3.56 , sd = 1.90 ) 
 table 5 displays items with the lowest mean score moral distress . items with lowest moral distress in respect to nursing position , the higher levels of moral distress among nurses working in wards can be attributed to their more frequent encounters with problems and their obligation to follow physicians orders . moral distress was detected to be of higher intensity in the nicu , ems and icu units ( table 3 ) . as a result of critical conditions of the patients in these wards and the urgency of the necessary diagnostic and therapeutic procedures , the level of moral distress has been higher in the nicu ward , continuous crying of children in nicu unit , their sensitivities and vulnerabilities to disease , their inability to communicate their pain and symptoms and continuous parental demands and questioning made nurses more vulnerable to experiencing moral distress ; and this can be attributed to the high load of tasks in these wards ( nicu , ems and icu ) . it must be noted that these load - heavy wards rank among those with the highest levels of moral distress . results of f - test ( anova ) between hospital wards moral distress was of lower intensity in ent , ophthalmology and surgery units . in these wards urgent diagnostic and therapeutic procedures are not frequent and nurses are less frequently prone to highly sensitive ethical situations ( table 3 ) . the level of moral distress was lower in wards with more than 30 beds handled by each nurse such as ent , ophthalmology and internal medicine units . this might be resulted from the fact that urgent diagnostic and therapeutic procedures are less frequent in these wards . nurses working in emergency wards and neonatal intensive care units ( nicu ) had the highest levels of moral distress . because of the patients conditions and urgency of medical interventions ( either diagnostic or therapeutic ) , these nurses are prone to moral distress . taking the number of patients handled by each nurse into consideration , the test shows a significant difference ( p = 0.041 ) . this result shows that the level of moral distress correlates with the number of patients in the ward handled by each nurse as well as the type of the hospital . in this study , the level of moral distress was higher in the public hospitals than in the private hospital ( table 3 ) . , the participants had only been questioned about their intention to quit their job , and there have been no questions assessing one s resignation history and its correlation with moral distress . thus , we can not comment on whether the decision to resign directly correlates with moral distress . it is possible that resignation is rooted in many factors which have remained unquestioned in our study . the findings of this study are similar to those of corley 15 , piere14 and lazzarin 20 studies . our findings in this study , together with the results of other studies , demonstrate that family and colleagues support have been effective in diminishing the level of moral distress while poor support by management has resulted in diminished job satisfaction and increased moral distress ( table 2 ) . 21 concluded that health care organizations should provide a supportive environment for the staff who provide health care services and who experience difficult situations because of the nature of their occupation . tai 22 has noted that increased support from family , friends and supervisors decreases the wish to change employment . he recommends supervisors to pay special attention to the need for support among staff members with high resignation potential . corley has concluded that nurses who have good relationships with their colleagues and comrades , patients , managers , executive management of the hospital and physicians experience lower levels of moral distress.18 in corley s study , the three factors of responsibility ( 20 questions with cronbach s alpha of 0.97 ) , disinterest for patient care ( 7 questions with cronbach s alpha of 0.82 ) and deception ( 3 questions with cronbach s alpha of 0.84 ) have been considered . considering the means and standard deviations , questions 14 , 15 , 16,17,18,19 and 20 in this study portray a high level of moral distress 15 . in our study , questions 17 and 19 were indicative of the highest levels of moral distress ( table 4 ) ; and questions 5 , 6 , 7 and 8 were indicative of the lowest levels of moral distress ( table 5 ) . this is in disagreement with corley s study , in which questions 5 , 6 , 7 , 8 , 9 and 10 were indicative of high levels of moral distress 15 . apparently , a higher degree of moral distress is observed among nurses who work in health care systems with lack of clear policies , unsupportive atmosphere , lack of guidance in complicated ethical situations and ineffective resolution mechanisms for conflicts with physicians . based on other studies conducted in this field , together with the results of this study , it is concluded that management teams should strengthen the supportive systems within the hospitals and the ministry of health should take necessary actions to promote staff - supporting systems in health centers 10.this fact signifies the high commitment and ethical standards of the nurses participating in this study . corley et al . examined the relationship between moral distress intensity and frequency and the ethical work environments in a group of 106 nurses from two large medical centers ; and they found that moral distress intensity and ethical work environments were correlated with moral distress frequency23 . nurses reported that moral distress adversely affected job satisfaction , retention , psychological and physical well - being , self - image and spirituality . the results of this study highly recommend practical and research - oriented evaluation of moral distress in the medical society in iran . the other point highlighted by this study and previous study by vaziri et al.10 and shorideh et al.6 in iran is the influence of the professional or practical competence of physicians on the moral distress of nurses . when the physician s competence is low , it results in higher rates of unnecessary laboratory tests and treatments , and therefore the nurse will suffer moral distress . thus , promotion of academic expertise and provision of continuous educational opportunities for physicians , as well as participation in congresses and seminars are highly recommended . the results of this study , as well as previous studies 10,18,20,24 , highlight the fact that strong support provided by family and colleagues are effective in decreasing moral distress levels . on the contrary , poor support from supervisors and the management results in decreased job satisfaction and increased moral distress . the results point to this fact that when the nurses are faced with specific and unsafe conditions in nicu , icu and ems , this will lead to an increase in the rate of moral distress among them . this study revealed that the intensity of moral distress was higher in ems , nicu and icu nurses than in ent , ophthalmology and internal medicine units . some nurses may become accustomed to moral distress as they gain experience , and some may suffer cumulative distress . this research received no specific grant from any funding agency in the public , commercial , or non - profit sectors .
objective : the purpose of this study was to describe the moral distress among iranian registered nurses.methods:this was a descriptive analytic study , in which 264 out of 1000 nurses were randomly selected as a sample group and completed the questionnaire . 
 the nurses moral distress was assessed using corley s 30-item moral distress scale adapted for use in an iranian population . 
 the collected data were analyzed by spss version 19.results:in this study , no correlation was found between the level of moral distress and any of the demographic data . 
 the mean moral distress score ranged from 3.56 to 5.83 , indicating moderate to high levels of moral distress . 
 the item with the highest mean score was  working with unsafe levels of nurse staffing  . 
 the item with the lowest mean score was  giving medication intravenously to a patient who has refused to take it  . 
 nurses working in ems and nicu units had the highest levels of moral distress.conclusion:a higher degree of moral distress is observed among nurses who work in health care systems . 
 the results of this study highly recommend practical and research - oriented evaluation of moral distress in the medical society in iran . 
 our findings suggest that iranian version of mds is a reliable instrument to measure moral distress in nurses .