Moral Distress and Associated Factors among Nurses Working in Public Hospitals in West Arsi Zone, Ethiopia, 2023

Moral Distress and Associated Factors among Nurses Working in Public Hospitals in West Arsi Zone, Ethiopia, 2023 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Moral Distress and Associated Factors among Nurses Working in Public Hospitals in West Arsi Zone, Ethiopia, 2023 Lemma Desalegn¹, Debela Gala², Abdisa Boka² This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7398556/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Moral distress is a psychological response experienced by nurses when they are prevented from acting according to their ethical beliefs due to internal or institutional constraints. Although moral distress is widely studied in high-income countries, limited evidence exists regarding its prevalence and associated factors in low-resource settings such as Ethiopia. Objective To assess the prevalence and associated factors of moral distress among nurses working in public hospitals of the West Arsi Zone, southeast Ethiopia, in 2023. Methods An institutional-based cross-sectional study was conducted from February 13 to March 2, 2023, among 349 nurses randomly selected from four public hospitals. Data were collected using a structured, self-administered questionnaire incorporating the Moral Distress Scale–Revised (MDS-R) and tools assessing personal and environmental factors. Data were analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with high levels of moral distress. Statistical significance was determined at p < 0.05 with 95% confidence intervals (CI). Results Of the 349 respondents (98.5% response rate), 73.1% reported high moral distress. Male nurses were less likely to report high distress compared to females [AOR = 0.46; 95% CI: 0.27, 0.91]. Nurses who were dissatisfied with their jobs had nearly eight times greater odds of experiencing high moral distress [AOR = 7.67; 95% CI: 3.08, 19.12]. Similarly, nurses working in unfavorable environments had significantly higher odds of moral distress [AOR = 4.07; 95% CI: 1.92, 8.65]. Conclusion Moral distress among nurses in West Arsi Zone public hospitals is alarmingly high. Key contributing factors include female gender, job dissatisfaction, and an unfavorable working environment. Interventions focusing on improving job satisfaction and working conditions are urgently recommended. Moral distress Nurses Public hospitals Job satisfaction working environment Ethiopia Figures Figure 1 Introduction Moral distress is a psychological response that occurs when an individual is aware of the ethically appropriate action to take but feels powerless to act due to institutional or systemic constraints. First introduced by Jameton in 1984, moral distress has become a widely recognized challenge in healthcare, particularly for nurses who provide frontline care but often have limited decision-making authority ( 1 ). Nurses are especially vulnerable to moral distress because of their continuous and close contact with patients, the hierarchical nature of healthcare systems, and conflicting demands between professional ethics and institutional policies. Repeated exposure to morally distressing situations can erode a nurse’s sense of professional integrity and contribute to emotional exhaustion, reduced job satisfaction, and compromised quality of patient care( 2 – 4 ). Globally, several studies have highlighted the widespread nature of moral distress among nurses. In high-income countries such as the United States, Canada, Australia, and Saudi Arabia, prevalence rates of moral distress among nurses have ranged from 72% to over 90%( 5 – 7 ). Factors associated with moral distress include inadequate staffing, poor organizational support, lack of autonomy, and ethical conflicts with colleagues or management [8–10]. In low-income countries, however, moral distress is less well studied, and much of the available evidence comes from isolated hospital units such as emergency departments or intensive care settings. In Ethiopia, few studies have explored the magnitude of moral distress across general hospital settings or examined the broader institutional and environmental factors that may contribute to it [11–12]. Given the increasing burden on nurses in Ethiopia’s public healthcare system often characterized by high patient loads, resource limitations, and systemic inefficiencies understanding moral distress in this context is critical. Identifying the contributing factors will inform institutional policies, enhance job satisfaction, and improve patient care. This study, therefore, aims to assess the prevalence and associated factors of moral distress among nurses working in public hospitals in the West Arsi Zone of southeast Ethiopia. Methods Study Design and Setting An institutional-based cross-sectional study was conducted from February 13 to March 2, 2023, in four public hospitals of the West Arsi Zone, located in the Oromia Regional State, southeast Ethiopia. The selected hospitals included Shashemene Referral Hospital, Dodola General Hospital, Melka Oda General Hospital, and Loke Primary Hospital. These hospitals provide services to a large population in both urban and rural communities. Study Population and Eligibility Criteria The source population comprised all nurses working in the public hospitals of the West Arsi Zone. Nurses who had been actively employed for at least one month were eligible to participate in the study. Nurses providing unpaid (volunteer) services were excluded. Sample Size Determination and Sampling Procedure The sample size was calculated using a single population proportion formula, assuming a 70.16% ( 8 ) prevalence of moral distress from a previous study conducted in Jimma, Ethiopia, with a 5% margin of error and 95% confidence level. After adding a 10% non-response rate, the final sample size was 354 nurses. Where n = the required sample size. Z = the standard score corresponding to the 95% CI and was equal to 1.96. P = the proportion of moral distress, which was assumed to be 70.16%. d = level of precision (margin of error), which was taken at 5%. By adding 10% non-response rate, 322 + 32 = 354. Four hospitals were selected randomly from the eight public hospitals in the zone. Proportional allocation was applied based on the number of nurses at each hospital. Participants were selected using a simple random sampling (lottery) method from nursing staff lists obtained from the human resource departments. Data Collection Tools and Procedures Data were collected using a structured, self-administered questionnaire composed of four sections: Socio-demographic characteristics (9 items), Moral Distress Scale–Revised (MDS-R) (9 items), Environmental factors (21 items covering working environment and perceived organizational support), and Personal factors (17 items covering job satisfaction, autonomy, and professional commitment) ( 8 – 10 ) Each item was measured on a 4-point Likert scale. The MDS-R tool and other items were adapted from validated instruments and previous literature. The questionnaire was initially developed in English and pretested among 5% of the sample (18 nurses) at Gambo Hospital to ensure clarity, consistency, and reliability. Six trained BSc nurses collected the data under supervision from an MSc nursing graduate. Supervisors monitored the process daily for completeness and consistency. Variables of the Study Dependent variable: Moral distress (categorized as high or low based on the mean score of the MDS-R items) Independent variables: Socio-demographic factors: age, sex, marital status, educational level, monthly income, work experience, unit of assignment, and job position. Personal factors: job satisfaction, autonomy, professional commitment Environmental factors: working environment, perceived organizational support Operational Definitions Moral distress is a sort of psychological distress caused by moral restrictions or conflicts. Nine items were used to gauge how morally distressed the subject was. Low moral distress was defined as falling below the mean, and high moral discomfort was defined as exceeding the mean( 8 ). Working environment a place where nurses collaborated therapeutically with different specialists Based on the mean score of the participants' responses, it was determined that a working environment was not conducive if it was less than the mean score and a conducive working environment if it was greater than or equal to the mean score ( 11 ). Perception of organizational support This describes how the nurses felt about the organizational support they got while working in the hospital. According to the participants' responses' mean score, it was deemed to have poor perception if the participant received a score below the mean and good perception if the participant had a score above or equal to the mean ( 12 ). Job satisfaction is viewed as a grouping of emotions related to a professional setting, or simply how the nurses feel about their work. It was deemed not satisfied for scores below the mean and satisfied for scores higher than or equal to the mean based on the mean score of the participants' responses ( 13 ). Professional autonomy is the nurse's discretion or authority to choose in a clinical setting. It was deemed autonomous for responses that were greater than or equal to the mean score, and not autonomous for responses that were less than the mean score ( 14 ). Professional commitment refers to the internal attitude that nurses have toward their jobs. According to the participants' responses, it was deemed committed for scores greater than or equal to the mean and not committed for scores lower than the mean ( 9 , 10 ). Data Processing and Analysis The collected data were checked for completeness and consistency, then coded and entered into EpiData version 3.1 and exported to SPSS version 26 for analysis. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize the data. Bivariate logistic regression was performed to identify candidate variables (p < 0.25) for the multivariable model. Multivariable logistic regression analysis was then used to determine independent predictors of moral distress. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were calculated, and statistical significance was declared at p < 0.05. Ethical Considerations Ethical clearance was obtained from the Institutional Review Board (IRB) of Addis Ababa University, College of Health Sciences (protocol No.14/SNM/15). Official permission was secured from the Oromia Health Bureau and the respective hospital administrations. Written informed consent was obtained from each participant prior to data collection. Confidentiality and anonymity were ensured by using coded identifiers and secure data handling. Participation was voluntary, and nurses were informed of their right to withdraw at any point. Result Sociodemographic characteristics of study respondents A total of 349 participants were enrolled in this study with a response rate of 98.5%. The mean and SD age of the respondents was 31.92 ± 7.0 years with the majority of them 276(76.5%) were 18–35 years of age. Among all of the participants, 194(55.6%) of them were females. The majority of the respondents were Oromo 303(86.8%) and almost half of the participants were Muslims 175(50.1%). Out of 349 participants, 293(84.0%) hold a bachelor of degree in nursing profession. The mean and SD year of experience was 7.7 ± 6.9. Among 349 participants, 275(78.8%) of them have 0–10 years of professional experience. The majority of the respondents 249(71.3%) were senior in their position. (Table 1 ) Table 1 Sociodemographic characteristics of nurses working in West Arsi Zone public hospitals, south-east Ethiopia, March 2023 (n = 349). Variables Category Frequency Percent (%) Age 18–35 267 76.5 36–45 59 16.9 45–60 23 6.6 Sex Male 155 44.4 Female 194 55.6 Ethnicity Oromo 303 86.8 Amhara 32 9.2 Tigre 8 2.3 Others* 6 1.7 Religion Orthodox 104 29.4 Muslim 175 50.1 Protestant 66 18.9 Others** 4 1.1 Marital status Single 119 34.1 Married 215 61.6 Divorced 11 3.2 Widowhood 4 1.1 Working unit Medical ward 52 14.9 Surgical ward 56 16.0 Emergency 50 14.3 ICU 23 6.6 Paediatrics ward 47 13.5 Gynaecology 39 11.2 NICU 34 9.7 OPD 48 13.8 Educational status Diploma 43 12.3 Degree 293 84.0 Msc 13 3.7 Monthly income 4605-7162.2 ETB 219 62.8 7162.3-11305 ETB 130 37.2 Experiences(years) 0–10 275 78.8 11–20 52 14.9 21–30 22 6.3 Position Junior 71 20.3 Senior 249 71.3 Nurse manager 29 8.3 *(Sidama and Wolaita), ** (Adventist and wakefata) Level of Moral Distress Out of 349 participants, 255 (73.1%) and 94 (26.9%) reported high and low levels of moral distress, respectively (Fig. 1 ). The respondents' mean and standard deviation for moral distress was 22.8 + 10.8. Personal and environmental Factors Out of 349 participants 208 (59.6%) not satisfied in their job. Similarly, from 349 participants of this research around 185(53.0%) of them are not autonomous in practicing their profession. One hundred seventy (48.7%) of the 349 participants worked in an unfavorable environment. According to their assessment of organizational support, 206 (59.0%) nurses had a negative perception towards their organization. (Table 2 ) Table 2 Personal and environmental factors of nurses working in West Arsi Zone public hospitals, south-east Ethiopia, March 2023 (n = 349). Variables Category Frequency Percent (%) Job Satisfaction Not satisfied 141 40.4 Satisfied 208 59.6 Autonomy Not autonomous 185 53.0 Autonomous 164 47.0 Professional commitment Committed 162 46.4 Not committed 187 53.6 Working environment Not conducive 170 48.7 Conducive 179 51.3 Perception of organizational support Poor perception 143 41.0 Good perception 206 59.0 Factors associated with moral distress among nurses In, bivariate analysis socio demographic characteristics (sex, working unit, monthly salary and years of experience), personal factors (job satisfaction, autonomy, and professional commitment), and Organizational factor (working environment) were had p-value < 0.25 and candidate for the multivariable logistic regression analysis. In, multivariable logistic regression analysis sex, job satisfaction and working environment were associated with moral distress among nurses. According to this study the nurses who were male were 54% [AOR (95% CI)], [0.46 (0.274–0.914)] and (P = .023 ) less likely to develop high level of moral distress compared to female. The nurses who were not satisfied 8 times [AOR (95% CI)], [7.668(3.075, 19.121)] and (P = .000 ) more likely to develop high level of moral distress compared with satisfied ones. The nurses who were worked in not conducive environment were 4 times [AOR (95% CI)], [4.069(1.915, 8.648)] and (P = .023 ) more likely to have high level of moral distress. (Table 3 ) Table 3 Factors associated with moral distress among Nurses working in West Arsi zone public hospitals, south east Ethiopia, March, 2023 (n = 349). Variables Category Moral distress COR AOR High Low Sex Male 100 55 0.46 (0.28, 0.74)* 0.5 (0.27, 0.91)* Female 155 39 1 1 Working unit Medical ward 35 17 0.48 (0.19, 1.20) * 0.54 (0.18, 1.64) Surgical ward 37 19 0.45 (0.18, 1.12) * 0.36 (0.12, 1.06) Emergency 41 9 1.05 (0.38, 2.92) 0.99 (0.30, 3.30) ICU 18 5 0.83 (0.24, 2.84) 0.55 (0.12, 2.50) Pediatrics ward 32 15 0.49 (0.19, 1.27) * 0.46 (0.15, 1.44) Gynecology 24 15 0.37 (0.14, 0.97) * 0.41 (0.13, 1.29) NICU 29 5 1.34 (0.41, 4.42) 0.76 (0.19, 3.03) OPD 39 9 1 1 Monthly salary 4605-7162.2 168 51 1.63 (1.01, 2.64) 1.59 (0.75, 4.00) 7162.2-11305 87 43 1 1 Years of experience 0–10 200 75 1.52 (0.61, 3.78) 0.74 (0.21, 2.59) 11–20 41 11 2.13 (0.71, 6.36) * 1.72 (0.45, 6.58) 21–30 14 8 1 1 Job satisfaction Not satisfied 134 7 13.76 (6.13, 30.89)* 7.67 (3.08, 19.12)* Satisfied 121 87 1 1 Autonomy Not autonomous 145 40 1.78 (1.10, 2.87)* 1.16 (0.62, 2.15) Autonomous 110 54 1 1 Professional commitment Not committed 129 33 1.89 (1.16, 3.09)* 0.76 (0.39, 1.47) Committed 126 61 1 1 Working environment Not conducive 157 13 9.98 (5.28, 18.89)* 4.07 (1.92, 8.65)* Conducive 98 81 1 1 Perception of organizational support Poor perception 130 13 6.48 (3.43, 12.23)* 1.78 (0.77, 4.01) Good perception 125 81 1 1 *Adjusted odd ration at (95%) of CI with p value < 0.05 were statistical significance. AOR: Adjusted odd ratio, COR: Crude odd ratio Discussion In this study we have found the level of moral distress and associated factors among nurses working in Arsi zone public hospitals. This cross sectional study involved 349 nurses from eight working units. The analysis of this study suggested that almost three fourth (73.1%) of the study participants experienced high level of moral distress. The magnitude of higher moral distress in this study is in line with study conducted in Australia (72%) and Jimma (70.16%) ( 8 , 15 ). This might be due to similarity in study design, number of sample size, method of data collection and tool used to assess the level of moral distress. The result of current study was higher than studies conducted in Saudi Arabia (33.8%), Brazil (41.5%), and Iran (24.3%)( 7 , 16 , 17 ). The difference could be attributed to study setting, socio-economic difference, working environment, work load, and technological advancement. But, it is relatively low compared to studies done in America (80%) and northern part of Ethiopia (83.7%) ( 18 , 19 ). The discrepancy could be due to difference in socio demographic, culture, basic environmental, personal characteristics of the respondents and tools used to measure the level of moral distress. The study also demonstrated from sociodemographic factors sex of the nurses showed significant association. Comparing female nurses to male nurses while controlling for all other factors, female nurses reported higher levels of moral distress, which is supported by research’s from Iran ( 20 ) and the USA ( 4 ). This could be due to women are more morally sensitive than men and experience guilt when they know the correct thing to do but are unable to carry it out because of differing environmental and personal restrictions ( 4 ). However, this finding contradict with the studies done in Ethiopia ( 8 , 19 ). This could be as a result of the socio-cultural influences on the women in the research area. Controlling the other variables, job satisfaction were the only factor showed significant association with high level of moral distress. Nurses who were not satisfied in their job were nearly eight times more likely to have high moral distress compared to nurses who were satisfied [AOR = 7.67, 95% CI: 3.075, 19.121]. This is in line with studies done in USA ( 21 ), Philippines ( 22 ), south west Iran ( 23 ), south eastern united states ( 24 ), and Netherland ( 25 ) respectively. This might be due to not being satisfied in their job will lead to sadness and discouragement which finally end up in conflict of an individual’s views or inner moral standards and his /her environment. After controlling for all other variables, the working environment remained the significant variable of environmental factors. The study found that nurses working in an unfavorable working environment were four times more likely to have high moral distress than their counterparts or nurses working in a favorable working environment [AO = 4.069, 95% CI:1.915, 8.648]. This study's findings are similar to those of research conducted in Iran ( 26 ), Canada ( 3 ), Virginia ( 27 ), the south-eastern United States ( 24 ), and Jimma ( 8 ). This might be due to a lack of managerial ability, unhealthy relationship with other professionals, or a reduction in the quality of nursing care. Furthermore, unfavorable working conditions induce moral distress and burnout. This also in turn affects patient centered care, health team communication, patient’s family, community, and health institution. Strengths and Limitations of the study Strength of the study Using moral distress revised scale (MDS-R) It was tried to cover the different demographic and social-economic, personal and environmental factors that were supposed to determine moral distress Limitations of the study Recall bias may occurred Being a cross sectional study design Respondents difference in perception and knowledge on the definition of moral distress, some personal and environmental factors The research was limited to the public hospitals. Thus, the finding did not generalize for health centers Conclusion and Recommendations Conclusion From this study we concluded that three fourth of nurse have experienced high level of moral distress. The major predictors of moral distress among nurses were sex, job satisfaction, working environment. Recommendation Based on the study's findings, the following recommendations are given to reduce the proportion of moral distress among nurses. According to this study, public hospital administrators and managers should priorities the prevention and reduction of moral distress among nurses. Arsi zone public hospitals should priorities female nurses, improve working conditions, and increase job satisfaction; and plan training and workshops to provide educational programs and emotional support in order to identify and reduce the variables that contribute to the development of moral distress. We also urge that the Ethiopian Nursing Association undertake initiatives to decrease nurses' moral suffering. In reaction to the challenge, the AAU School of Nursing and Midwifery should strengthen its ethical education approaches. By using this finding as a base line data and limitation of this study as gap we also recommend researchers to conduct mixed type of research and identify the root cause of this problem. Declarations Acknowledgements Our heartfelt gratitude goes to Addis Ababa University for the provision of financial support for this project. We would also like to thank hospital administrators, data collectors, and all study participants for their valuable contributions to this research. Authors' Contributions Lemma Desalegn (LD) conceived and designed the study, led data collection, analysis, and manuscript writing. Debela Gala (DG) contributed to the study design, data interpretation, and manuscript revision. Abdisa Boka (AB) supported data analysis and critically reviewed the manuscript. All authors read and approved the final version of the manuscript. Funding This study was granted by Addis Ababa University, College of Health Sciences. Availability of Data and Materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Ethics Approval and Consent to Participate Ethical clearance was obtained from the Institutional Review Board (IRB) of Addis Ababa University, College of Health Sciences (Approval No: 14/SNM/15). A formal letter of cooperation was also secured from the West Arsi Zone Health Office and the respective public hospitals. Written informed consent was obtained from each study participant after explaining the purpose of the study, and participation was voluntary. Confidentiality and anonymity were maintained throughout the study by removing personal identifiers. This study was conducted in accordance with the Declaration of Helsinki. Consent for Publication Not applicable. Competing Interests The author declares that there is no conflict of interest. References Morley G, Ives J, Bradbury-Jones C, Irvine F. What is ‘moral distress’? A narrative synthesis of the literature. Nurs Ethics. 2019;26(3):646–62. Morley G. What is moral distress in nursing? How, can and should we respond to it? 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University","correspondingAuthor":false,"prefix":"","firstName":"Debela","middleName":"","lastName":"Gala²","suffix":""},{"id":521727965,"identity":"4bd14c4b-571f-4e84-bacc-2846ad633b82","order_by":2,"name":"Abdisa Boka²","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Abdisa","middleName":"","lastName":"Boka²","suffix":""}],"badges":[],"createdAt":"2025-08-18 10:23:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7398556/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7398556/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92437614,"identity":"839bb5d2-d08c-4b4f-ac37-04419dc81ee6","added_by":"auto","created_at":"2025-09-29 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17:39:54","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":102201,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7398556/v1/ed6354bcce538a94d625de38.html"},{"id":92437608,"identity":"bf60fb89-c674-4c71-99aa-c0b72d18ac43","added_by":"auto","created_at":"2025-09-29 17:31:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18984,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of moral distress among nurses working in West Arsi Zone public hospitals, south-east Ethiopia, March 2023 (n = 349).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7398556/v1/d8353151112ed23eb933dc72.png"},{"id":92438558,"identity":"9ad4838f-b63e-46c4-8505-2001ad60a440","added_by":"auto","created_at":"2025-09-29 17:47:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":998316,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7398556/v1/7f581d1c-7786-485a-90c0-2e072b653081.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Moral Distress and Associated Factors among Nurses Working in Public Hospitals in West Arsi Zone, Ethiopia, 2023","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMoral distress is a psychological response that occurs when an individual is aware of the ethically appropriate action to take but feels powerless to act due to institutional or systemic constraints. First introduced by Jameton in 1984, moral distress has become a widely recognized challenge in healthcare, particularly for nurses who provide frontline care but often have limited decision-making authority (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNurses are especially vulnerable to moral distress because of their continuous and close contact with patients, the hierarchical nature of healthcare systems, and conflicting demands between professional ethics and institutional policies. Repeated exposure to morally distressing situations can erode a nurse\u0026rsquo;s sense of professional integrity and contribute to emotional exhaustion, reduced job satisfaction, and compromised quality of patient care(\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGlobally, several studies have highlighted the widespread nature of moral distress among nurses. In high-income countries such as the United States, Canada, Australia, and Saudi Arabia, prevalence rates of moral distress among nurses have ranged from 72% to over 90%(\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Factors associated with moral distress include inadequate staffing, poor organizational support, lack of autonomy, and ethical conflicts with colleagues or management [8\u0026ndash;10].\u003c/p\u003e\u003cp\u003eIn low-income countries, however, moral distress is less well studied, and much of the available evidence comes from isolated hospital units such as emergency departments or intensive care settings. In Ethiopia, few studies have explored the magnitude of moral distress across general hospital settings or examined the broader institutional and environmental factors that may contribute to it [11\u0026ndash;12].\u003c/p\u003e\u003cp\u003eGiven the increasing burden on nurses in Ethiopia\u0026rsquo;s public healthcare system often characterized by high patient loads, resource limitations, and systemic inefficiencies understanding moral distress in this context is critical. Identifying the contributing factors will inform institutional policies, enhance job satisfaction, and improve patient care.\u003c/p\u003e\u003cp\u003eThis study, therefore, aims to assess the prevalence and associated factors of moral distress among nurses working in public hospitals in the West Arsi Zone of southeast Ethiopia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003e An institutional-based cross-sectional study was conducted from February 13 to March 2, 2023, in four public hospitals of the West Arsi Zone, located in the Oromia Regional State, southeast Ethiopia. The selected hospitals included Shashemene Referral Hospital, Dodola General Hospital, Melka Oda General Hospital, and Loke Primary Hospital. These hospitals provide services to a large population in both urban and rural communities.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Population and Eligibility Criteria\u003c/h3\u003e\n\u003cp\u003eThe source population comprised all nurses working in the public hospitals of the West Arsi Zone. Nurses who had been actively employed for at least one month were eligible to participate in the study. Nurses providing unpaid (volunteer) services were excluded.\u003c/p\u003e\n\u003ch3\u003eSample Size Determination and Sampling Procedure\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated using a single population proportion formula, assuming a 70.16% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) prevalence of moral distress from a previous study conducted in Jimma, Ethiopia, with a 5% margin of error and 95% confidence level. After adding a 10% non-response rate, the final sample size was 354 nurses.\u003c/p\u003e\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" width=\"142\" height=\"42\"\u003e\u003c/p\u003e\u003cp\u003eWhere n\u0026thinsp;=\u0026thinsp;the required sample size.\u003c/p\u003e\u003cp\u003eZ\u0026thinsp;=\u0026thinsp;the standard score corresponding to the 95% CI and was equal to 1.96.\u003c/p\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;the proportion of moral distress, which was assumed to be 70.16%.\u003c/p\u003e\u003cp\u003ed\u0026thinsp;=\u0026thinsp;level of precision (margin of error), which was taken at 5%.\u003c/p\u003e\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" width=\"351\" height=\"35\"\u003e\u003c/p\u003e\u003cp\u003eBy adding 10% non-response rate, 322\u0026thinsp;+\u0026thinsp;32\u0026thinsp;=\u0026thinsp;354.\u003c/p\u003e\u003cp\u003eFour hospitals were selected randomly from the eight public hospitals in the zone. Proportional allocation was applied based on the number of nurses at each hospital. Participants were selected using a simple random sampling (lottery) method from nursing staff lists obtained from the human resource departments.\u003c/p\u003e\n\u003ch3\u003eData Collection Tools and Procedures\u003c/h3\u003e\n\u003cp\u003eData were collected using a structured, self-administered questionnaire composed of four sections: Socio-demographic characteristics (9 items), Moral Distress Scale\u0026ndash;Revised (MDS-R) (9 items), Environmental factors (21 items covering working environment and perceived organizational support), and Personal factors (17 items covering job satisfaction, autonomy, and professional commitment) (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eEach item was measured on a 4-point Likert scale. The MDS-R tool and other items were adapted from validated instruments and previous literature. The questionnaire was initially developed in English and pretested among 5% of the sample (18 nurses) at Gambo Hospital to ensure clarity, consistency, and reliability. Six trained BSc nurses collected the data under supervision from an MSc nursing graduate. Supervisors monitored the process daily for completeness and consistency.\u003c/p\u003e\n\u003ch3\u003eVariables of the Study\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDependent variable:\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMoral distress (categorized as high or low based on the mean score of the MDS-R items)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIndependent variables:\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSocio-demographic factors: age, sex, marital status, educational level, monthly income, work experience, unit of assignment, and job position.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePersonal factors: job satisfaction, autonomy, professional commitment\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEnvironmental factors: working environment, perceived organizational support\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eOperational Definitions\u003c/h3\u003e\n\u003cp\u003e\u003cb\u003eMoral distress\u003c/b\u003e is a sort of psychological distress caused by moral restrictions or conflicts. Nine items were used to gauge how morally distressed the subject was. Low moral distress was defined as falling below the mean, and high moral discomfort was defined as exceeding the mean(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eWorking environment\u003c/strong\u003e\u003cp\u003ea place where nurses collaborated therapeutically with different specialists Based on the mean score of the participants' responses, it was determined that a working environment was not conducive if it was less than the mean score and a conducive working environment if it was greater than or equal to the mean score (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePerception of organizational support\u003c/strong\u003e\u003cp\u003eThis describes how the nurses felt about the organizational support they got while working in the hospital. According to the participants' responses' mean score, it was deemed to have poor perception if the participant received a score below the mean and good perception if the participant had a score above or equal to the mean (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eJob satisfaction\u003c/b\u003e is viewed as a grouping of emotions related to a professional setting, or simply how the nurses feel about their work. It was deemed not satisfied for scores below the mean and satisfied for scores higher than or equal to the mean based on the mean score of the participants' responses (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eProfessional autonomy\u003c/b\u003e is the nurse's discretion or authority to choose in a clinical setting. It was deemed autonomous for responses that were greater than or equal to the mean score, and not autonomous for responses that were less than the mean score (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eProfessional commitment\u003c/b\u003e refers to the internal attitude that nurses have toward their jobs. According to the participants' responses, it was deemed committed for scores greater than or equal to the mean and not committed for scores lower than the mean (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData Processing and Analysis\u003c/h2\u003e\u003cp\u003eThe collected data were checked for completeness and consistency, then coded and entered into EpiData version 3.1 and exported to SPSS version 26 for analysis. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize the data. Bivariate logistic regression was performed to identify candidate variables (p\u0026thinsp;\u0026lt;\u0026thinsp;0.25) for the multivariable model. Multivariable logistic regression analysis was then used to determine independent predictors of moral distress. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were calculated, and statistical significance was declared at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003e Ethical clearance was obtained from the Institutional Review Board (IRB) of Addis Ababa University, College of Health Sciences (protocol No.14/SNM/15). Official permission was secured from the Oromia Health Bureau and the respective hospital administrations. Written informed consent was obtained from each participant prior to data collection. Confidentiality and anonymity were ensured by using coded identifiers and secure data handling. Participation was voluntary, and nurses were informed of their right to withdraw at any point.\u003c/p\u003e\u003c/div\u003e"},{"header":"Result","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003eSociodemographic characteristics of study respondents\u003c/h2\u003e\u003cp\u003eA total of 349 participants were enrolled in this study with a response rate of 98.5%. The mean and SD age of the respondents was 31.92\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0 years with the majority of them 276(76.5%) were 18\u0026ndash;35 years of age. Among all of the participants, 194(55.6%) of them were females. The majority of the respondents were Oromo 303(86.8%) and almost half of the participants were Muslims 175(50.1%). Out of 349 participants, 293(84.0%) hold a bachelor of degree in nursing profession. The mean and SD year of experience was 7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9. Among 349 participants, 275(78.8%) of them have 0\u0026ndash;10 years of professional experience. The majority of the respondents 249(71.3%) were senior in their position. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic characteristics of nurses working in West Arsi Zone public hospitals, south-east Ethiopia, March 2023 (n\u0026thinsp;=\u0026thinsp;349).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercent (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e267\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u0026ndash;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEthnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOromo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e303\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAmhara\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTigre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eReligion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrthodox\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuslim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProtestant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidowhood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003eWorking unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical ward\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSurgical ward\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmergency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePaediatrics ward\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGynaecology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eEducational status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDegree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e293\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e84.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMsc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMonthly income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4605-7162.2 ETB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e219\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7162.3-11305 ETB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eExperiences(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ePosition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJunior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e249\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNurse manager\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e*(Sidama and Wolaita), ** (Adventist and wakefata)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eLevel of Moral Distress\u003c/h2\u003e\u003cp\u003eOut of 349 participants, 255 (73.1%) and 94 (26.9%) reported high and low levels of moral distress, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The respondents' mean and standard deviation for moral distress was 22.8\u0026thinsp;+\u0026thinsp;10.8.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003ePersonal and environmental Factors\u003c/h2\u003e\u003cp\u003eOut of 349 participants 208 (59.6%) not satisfied in their job. Similarly, from 349 participants of this research around 185(53.0%) of them are not autonomous in practicing their profession. One hundred seventy (48.7%) of the 349 participants worked in an unfavorable environment. According to their assessment of organizational support, 206 (59.0%) nurses had a negative perception towards their organization. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePersonal and environmental factors of nurses working in West Arsi Zone public hospitals, south-east Ethiopia, March 2023 (n\u0026thinsp;=\u0026thinsp;349).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercent (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eJob\u003c/p\u003e\u003cp\u003eSatisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAutonomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot autonomous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAutonomous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eProfessional commitment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommitted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot committed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWorking environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot conducive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConducive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e179\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePerception of organizational support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor perception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e143\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood perception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e206\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with moral distress among nurses\u003c/h2\u003e\u003cp\u003eIn, bivariate analysis socio demographic characteristics (sex, working unit, monthly salary and years of experience), personal factors (job satisfaction, autonomy, and professional commitment), and Organizational factor (working environment) were had p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.25 and candidate for the multivariable logistic regression analysis. In, multivariable logistic regression analysis sex, job satisfaction and working environment were associated with moral distress among nurses.\u003c/p\u003e\u003cp\u003eAccording to this study the nurses who were male were 54% [AOR (95% CI)], [0.46 (0.274\u0026ndash;0.914)] and (P\u0026thinsp;=\u0026thinsp;.023\u003cb\u003e)\u003c/b\u003e less likely to develop high level of moral distress compared to female. The nurses who were not satisfied 8 times [AOR (95% CI)], [7.668(3.075, 19.121)] and (P\u0026thinsp;=\u0026thinsp;.000\u003cb\u003e)\u003c/b\u003e more likely to develop high level of moral distress compared with satisfied ones. The nurses who were worked in not conducive environment were 4 times [AOR (95% CI)], [4.069(1.915, 8.648)] and (P\u0026thinsp;=\u0026thinsp;.023\u003cb\u003e)\u003c/b\u003e more likely to have high level of moral distress. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with moral distress among Nurses working in West Arsi zone public hospitals, south east Ethiopia, March, 2023 (n\u0026thinsp;=\u0026thinsp;349).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eMoral distress\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCOR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAOR\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.46 (0.28, 0.74)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.5 (0.27, 0.91)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003eWorking unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical ward\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.48 (0.19, 1.20) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.54 (0.18, 1.64)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSurgical ward\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.45 (0.18, 1.12) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.36 (0.12, 1.06)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmergency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.05 (0.38, 2.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.99 (0.30, 3.30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.83 (0.24, 2.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.55 (0.12, 2.50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePediatrics ward\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.49 (0.19, 1.27) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.46 (0.15, 1.44)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGynecology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.37 (0.14, 0.97) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.41 (0.13, 1.29)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.34 (0.41, 4.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.76 (0.19, 3.03)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMonthly salary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4605-7162.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e168\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.63 (1.01, 2.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.59 (0.75, 4.00)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7162.2-11305\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eYears of experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e200\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.52 (0.61, 3.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.74 (0.21, 2.59)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.13 (0.71, 6.36) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.72 (0.45, 6.58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eJob satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e134\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.76 (6.13, 30.89)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e7.67 (3.08, 19.12)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAutonomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot autonomous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.78 (1.10, 2.87)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.16 (0.62, 2.15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAutonomous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eProfessional commitment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot committed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.89 (1.16, 3.09)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.76 (0.39, 1.47)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommitted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWorking environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot conducive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.98 (5.28, 18.89)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e4.07 (1.92, 8.65)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConducive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePerception of organizational support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor perception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.48 (3.43, 12.23)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.78 (0.77, 4.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood perception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e*Adjusted odd ration at (95%) of CI with p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were statistical significance.\u003c/p\u003e\u003cp\u003eAOR: Adjusted odd ratio, COR: Crude odd ratio\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study we have found the level of moral distress and associated factors among nurses working in Arsi zone public hospitals. This cross sectional study involved 349 nurses from eight working units. The analysis of this study suggested that almost three fourth (73.1%) of the study participants experienced high level of moral distress.\u003c/p\u003e\u003cp\u003eThe magnitude of higher moral distress in this study is in line with study conducted in Australia (72%) and Jimma (70.16%) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This might be due to similarity in study design, number of sample size, method of data collection and tool used to assess the level of moral distress. The result of current study was higher than studies conducted in Saudi Arabia (33.8%), Brazil (41.5%), and Iran (24.3%)(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The difference could be attributed to study setting, socio-economic difference, working environment, work load, and technological advancement.\u003c/p\u003e\u003cp\u003eBut, it is relatively low compared to studies done in America (80%) and northern part of Ethiopia (83.7%) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The discrepancy could be due to difference in socio demographic, culture, basic environmental, personal characteristics of the respondents and tools used to measure the level of moral distress.\u003c/p\u003e\u003cp\u003eThe study also demonstrated from sociodemographic factors sex of the nurses showed significant association. Comparing female nurses to male nurses while controlling for all other factors, female nurses reported higher levels of moral distress, which is supported by research\u0026rsquo;s from Iran (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and the USA (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This could be due to women are more morally sensitive than men and experience guilt when they know the correct thing to do but are unable to carry it out because of differing environmental and personal restrictions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, this finding contradict with the studies done in Ethiopia (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This could be as a result of the socio-cultural influences on the women in the research area.\u003c/p\u003e\u003cp\u003eControlling the other variables, job satisfaction were the only factor showed significant association with high level of moral distress. Nurses who were not satisfied in their job were nearly eight times more likely to have high moral distress compared to nurses who were satisfied [AOR\u0026thinsp;=\u0026thinsp;7.67, 95% CI: 3.075, 19.121]. This is in line with studies done in USA (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), Philippines (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), south west Iran (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), south eastern united states (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), and Netherland (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) respectively. This might be due to not being satisfied in their job will lead to sadness and discouragement which finally end up in conflict of an individual\u0026rsquo;s views or inner moral standards and his /her environment.\u003c/p\u003e\u003cp\u003eAfter controlling for all other variables, the working environment remained the significant variable of environmental factors. The study found that nurses working in an unfavorable working environment were four times more likely to have high moral distress than their counterparts or nurses working in a favorable working environment [AO\u0026thinsp;=\u0026thinsp;4.069, 95% CI:1.915, 8.648]. This study's findings are similar to those of research conducted in Iran (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), Canada (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), Virginia (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), the south-eastern United States (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), and Jimma (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This might be due to a lack of managerial ability, unhealthy relationship with other professionals, or a reduction in the quality of nursing care. Furthermore, unfavorable working conditions induce moral distress and burnout. This also in turn affects patient centered care, health team communication, patient\u0026rsquo;s family, community, and health institution.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations of the study\u003c/h2\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003ch2\u003eStrength of the study\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eUsing moral distress revised scale (MDS-R)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIt was tried to cover the different demographic and social-economic, personal and environmental factors that were supposed to determine moral distress\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eLimitations of the study\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eRecall bias may occurred\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBeing a cross sectional study design\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eRespondents difference in perception and knowledge on the definition of moral distress, some personal and environmental factors\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe research was limited to the public hospitals. Thus, the finding did not generalize for health centers\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion and Recommendations","content":"\u003ch3\u003eConclusion\u003c/h3\u003e\n\u003cp\u003eFrom this study we concluded that three fourth of nurse have experienced high level of moral distress. The major predictors of moral distress among nurses were sex, job satisfaction, working environment.\u003c/p\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eRecommendation\u003c/h2\u003e\u003cp\u003eBased on the study's findings, the following recommendations are given to reduce the proportion of moral distress among nurses.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAccording to this study, public hospital administrators and managers should priorities the prevention and reduction of moral distress among nurses.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eArsi zone public hospitals should priorities female nurses, improve working conditions, and increase job satisfaction; and plan training and workshops to provide educational programs and emotional support in order to identify and reduce the variables that contribute to the development of moral distress.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWe also urge that the Ethiopian Nursing Association undertake initiatives to decrease nurses' moral suffering.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIn reaction to the challenge, the AAU School of Nursing and Midwifery should strengthen its ethical education approaches.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBy using this finding as a base line data and limitation of this study as gap we also recommend researchers to conduct mixed type of research and identify the root cause of this problem.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eOur heartfelt gratitude goes to Addis Ababa University for the provision of financial support for this project. We would also like to thank hospital administrators, data collectors, and all study participants for their valuable contributions to this research.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; Contributions\u003c/p\u003e\n\u003cp\u003eLemma Desalegn (LD) conceived and designed the study, led data collection, analysis, and manuscript writing. Debela Gala (DG) contributed to the study design, data interpretation, and manuscript revision. Abdisa Boka (AB) supported data analysis and critically reviewed the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was granted by Addis Ababa University, College of Health Sciences.\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eEthics Approval and Consent to Participate\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the Institutional Review Board (IRB) of Addis Ababa University, College of Health Sciences (Approval No: 14/SNM/15). A formal letter of cooperation was also secured from the West Arsi Zone Health Office and the respective public hospitals. Written informed consent was obtained from each study participant after explaining the purpose of the study, and participation was voluntary. Confidentiality and anonymity were maintained throughout the study by removing personal identifiers. This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for Publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eThe author declares that there is no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMorley G, Ives J, Bradbury-Jones C, Irvine F. What is \u0026lsquo;moral distress\u0026rsquo;? A narrative synthesis of the literature. Nurs Ethics. 2019;26(3):646\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorley G. What is moral distress in nursing? How, can and should we respond to it? J Clin Nurs. 2018;27(19\u0026ndash;20):3443\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAustin W. 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J Nurs Care Qual. 2022;37(1):28\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Moral distress, Nurses, Public hospitals, Job satisfaction, working environment, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-7398556/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7398556/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003e Moral distress is a psychological response experienced by nurses when they are prevented from acting according to their ethical beliefs due to internal or institutional constraints. Although moral distress is widely studied in high-income countries, limited evidence exists regarding its prevalence and associated factors in low-resource settings such as Ethiopia.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo assess the prevalence and associated factors of moral distress among nurses working in public hospitals of the West Arsi Zone, southeast Ethiopia, in 2023.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eAn institutional-based cross-sectional study was conducted from February 13 to March 2, 2023, among 349 nurses randomly selected from four public hospitals. Data were collected using a structured, self-administered questionnaire incorporating the Moral Distress Scale\u0026ndash;Revised (MDS-R) and tools assessing personal and environmental factors. Data were analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with high levels of moral distress. Statistical significance was determined at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 with 95% confidence intervals (CI).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf the 349 respondents (98.5% response rate), 73.1% reported high moral distress. Male nurses were less likely to report high distress compared to females [AOR\u0026thinsp;=\u0026thinsp;0.46; 95% CI: 0.27, 0.91]. Nurses who were dissatisfied with their jobs had nearly eight times greater odds of experiencing high moral distress [AOR\u0026thinsp;=\u0026thinsp;7.67; 95% CI: 3.08, 19.12]. Similarly, nurses working in unfavorable environments had significantly higher odds of moral distress [AOR\u0026thinsp;=\u0026thinsp;4.07; 95% CI: 1.92, 8.65].\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eMoral distress among nurses in West Arsi Zone public hospitals is alarmingly high. Key contributing factors include female gender, job dissatisfaction, and an unfavorable working environment. Interventions focusing on improving job satisfaction and working conditions are urgently recommended.\u003c/p\u003e","manuscriptTitle":"Moral Distress and Associated Factors among Nurses Working in Public Hospitals in West Arsi Zone, Ethiopia, 2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-29 17:31:49","doi":"10.21203/rs.3.rs-7398556/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-06T22:21:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T20:04:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166767997544898751048930265738378001082","date":"2025-10-05T19:19:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-03T21:29:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255410090599762706742810474844111543701","date":"2025-09-30T13:34:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T13:20:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237335810992436907915465867899320385016","date":"2025-09-20T16:58:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44215999431835406096242664385634087158","date":"2025-09-18T11:21:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141364062630511084202068805529793362196","date":"2025-09-18T10:56:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-18T10:17:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-22T09:19:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-22T06:25:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-22T06:24:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-08-18T10:07:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"28833d37-04ed-45aa-9c7c-d9403f1fa217","owner":[],"postedDate":"September 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T17:31:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-29 17:31:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7398556","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7398556","identity":"rs-7398556","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}