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Background:
Moral distress is common among pediatric nurses. However, evidence on moral distress in this population from non-Western healthcare settings remains limited.
Objectives:
This study aimed to assess the level of moral distress among pediatric nurses in China and identify factors influencing moral distress in this population.
Methods:
A cross-sectional survey was conducted from June to August 2024. Using census sampling, all 29 tertiary A hospitals in Sichuan Province, China, concurrently operating the Pediatric Intensive Care Units (PICUs), Neonatal Intensive Care Units (NICUs), and general pediatric wards were selected. Questionnaire invitations were sent to registered pediatric nurses at these hospitals, and 1,292 nurses meeting the inclusion criteria participated. The valid response rate was 76.8%. Data were collected using a demographic questionnaire, the Revised Moral Distress Scale–Nurse Pediatric Version (MDNPV), the Hospital Ethical Climate Survey (HECS), and the Moral Sensitivity Questionnaire-Revised (MSQ-R). Data analysis employed the Wilcoxon Rank-Sum Test, Kruskal–Wallis H test, Spearman rank correlation, and multiple linear regression.
Findings:
The median total moral distress score was 64.00 (IQR: 36.00–84.00). Compared with nurses working in general pediatric units, PICUs and NICUs reported higher levels of moral distress (H = 30.828, P<0.01). Those with the title of charge nurse and above experienced higher levels of moral distress than nurses with lower titles (H = 17.620, P<0.01). Female nurses experienced more severe moral distress than male nurses(Z = 2.006, P<0.05). Multiple linear regression identified six independent predictors of moral distress: department, professional title, gender, hospital ethical climate, moral sensitivity, and nurse–physician collaboration, collectively accounting for 40.2% of the variance (R2 = 0.402, adjusted R2 = 0.398, P < 0.05).
Conclusion:
In our study, moral distress was prevalent among pediatric nurses in Sichuan Province, China. The levels of moral distress were associated with department, professional title, gender, hospital ethical climate, moral sensitivity, and nurse–physician collaboration.
IntroductionMoral distress was first introduced into nursing by Jameton (1984), who defined it as occurring “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.” (1) This phenomenon is prevalent across healthcare disciplines, with nurses experiencing the highest frequency and severity of moral distress (2, 3), particularly those working in intensive care and pediatric settings (4, 5). Repeated exposure to morally distressing situations alters the ease stage of moral reckoning among nurses, causing psychological and behavioral disturbances, and thereby requiring them to take a stand or give up (6). Orgambídez et al. (7) demonstrated that moral distress is strongly correlated to emotional exhaustion in healthcare professionals. Hancock et al. (8) found that the frequency of moral distress was negatively correlated with the level of nursing skills and the quality of nursing services. A study showed that moral distress was negatively correlated with nurses’ job satisfaction and work engagement and positively correlated with burnout and the intention to leave (9, 10). In response, the American Association of Critical-Care Nurses has identified moral distress as a “frequently overlooked problem” and introduced the standardized “4A” process (Ask, Affirm, Assess, and Act) for its management (11). Despite this recognition, it remains a persistent challenge in nursing practice worldwide, and continues to be a focus of growing academic investigation (12).
In pediatric settings, end-of-life and complex ethical issues are frequent. Children's physical and mental immaturity often limits their capacity to participate in healthcare decisions, making them dependent on legal guardians. The recurring challenge of aligning nursing interventions with the child's best interests leads to frequent and demanding ethical decisions (13). Available evidence underscores the global prevalence of this issue. In Canadian NICUs and PICUs, 8.3% of healthcare providers reported significant work-related moral distress (14). Australian studies revealed that 72% of NICU nurses experienced morally distressing events monthly (15), while 58% of NICU/PICU staff encountered moral distress, with nurses showing the highest levels (16). Similarly, 6% of staff at Nordic pediatric cancer centers considered leaving due to moral distress (17). These findings collectively highlight the critical need to address moral distress among pediatric nurses, particularly those in PICUs and NICUs.
Research on moral distress is increasing annually, with approximately 71% of studies focusing on nurses (3). However, a systematic review by Prompahakul & Epstein (18) of literature published between 1999 and 2019 revealed that of the identified studies on moral distress in nurses, 156 were conducted in Western regions such as North America, Canada, Europe, and Australia, while only 16 originated from non-Western countries, including those in the Middle East and Asia. This indicates a notable lack of data on moral distress among nurses in non-Western contexts. Among the limited studies from these regions, one investigation involving 465 nurses in Shandong Province, China, confirmed that Chinese clinical nurses also experience moral distress (19). However, pediatric nurses were not examined separately in that investigation. Therefore, the present study proposes that pediatric nurses in China experience moral distress, with levels varying by unit type and being more severe in PICUs and NICUs. To test this premise, we conducted a large-scale, multicenter cross-sectional survey of pediatric nurses at all tertiary hospitals in Sichuan Province that concurrently operate PICUs, NICUs, and general pediatric wards. This study aimed to: (1) assess the level of moral distress among pediatric nurses in Sichuan, China; and (2) identify factors influencing moral distress in this population, thereby providing an evidence base for developing tailored intervention strategies.
MethodsDesign and sampleThis observational cross-sectional study enrolled pediatric nurses from 29 Level A tertiary hospitals in Sichuan Province, located in western China, between June and August 2024. In China, hospitals are classified into three categories: primary, secondary, and tertiary. Each level is further subdivided into three grades—A, B, and C—based on the quality of medical care, medical education, and medical research provided. It is noteworthy that three level-A tertiary hospitals represent the highest tier in China and feature the most comprehensive range of departments. The aim was to investigate the level of moral distress among pediatric nurses in Sichuan Province, and we hope to compare differences across three pediatric departments: PICUs, NICUs, and general pediatric wards. To achieve this, we consulted data from the official website of the Sichuan Provincial Health Commission; there are 105 Class III Grade A hospitals in the province. We individually reviewed the official websites of each of the hospitals to verify whether it concurrently operated PICUs, NICUs, and general pediatric wards. Finally, 29 hospitals met the criteria. We next identified the number of registered nurses working in the relevant departments of these hospitals. For hospitals where this information was not publicly available online, the research project manager confirmed the nurse counts through direct consultation with the nursing departments during the formal data collection process. In total, 1,682 pediatric register nurses were identified as the target population.
The study applied inclusion and exclusion criteria for participant selection. The inclusion criteria were as follows: (1) full-time healthcare workers, (2) having at least one year of frontline clinical experience in pediatrics, and (3) providing informed consent and voluntarily agreeing to participate. The exclusion criteria included (1) nurses visiting from other hospitals for further education and (2) nurses temporarily absent from their positions during the study period due to illness or maternity leave.
An online survey platform was used to conduct the study (https://www.wjx.cn/), thereby minimizing privacy risks associated with paper-based questionnaires. The project manager contacted the nursing directors of the 29 participating hospitals via email to obtain institutional approval and requested permission to post recruitment notices and questionnaire links on the nursing departments’ online platforms. Following approval, text messages were sent to pediatric ward nurses to alert them to the recruitment notice. The online survey remained accessible for a 14-day period. Before completing the survey, each participant received 15–20 min of online training covering the study's purpose, content, procedure, and important considerations. The survey system was configured to prevent submission if any required information was omitted; participants were automatically redirected to incomplete sections, ensuring all items were filled out before final submission. In addition, backend settings restricted each IP address to a single response to prevent duplicate submissions. Two researchers monitored the incoming data in the backend, and data were exported after no new entries were recorded for one week. Two additional researchers reviewed the questionnaire responses for quality control, removing any that contained errors or contradictions. In addition, the authors adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting checklist for observational studies.
Sample size estimationIn regression analysis, the sample size should satisfy N ≥ 20 × m, where N represents the total sample size and m denotes the number of independent variables. This study included 33 independent variables, yielding a minimum sample size of 660. Accounting for an estimated 20% attrition rate, the target sample size was increased to at least 825 pediatric nurses.
Ethical considerationsThe study received approval from the Bioethics Committee of West China Hospital, Sichuan University (Approval No. 2021-1783) before commencement. All participants were informed about the study purpose, procedures, and methodology prior to participation. Questionnaires were administered only after participants provided fully informed consent. Participation was voluntary, and respondents could withdraw at any time without penalty. The survey was conducted anonymously, and all data were stored on an encrypted computer accessible exclusively to the research team.
MeasuresIn the preliminary phase of the study, the research team completed a systematic review of factors potentially influencing nurses’ moral distress. The selection of independent variables in this study was informed by the findings of the prior research.
For details on the prior research findings, see Additional file 1: Appendix 1.
Personal and professional characteristicsThis section comprises two parts: demographic characteristics and subjective perceptions of nursing care. Demographic characteristics included department (general pediatric ward, PICU, NICU), age (continuous), gender (male, female), education level (associate degree or below, bachelor's degree, master's degree or above), marital status (unmarried, married, divorced), number of children (none, one, two, three or more), years in practice (<5, 5–10, >10 years), professional title (primary title, middle title, vice-senior title and above), monthly income (from <4,000 RMB to >10,000 RMB, in four categories), and average number of night shifts per month (from 0 to >10, in four categories). Subjective perceptions were assessed using yes/no items covering adequacy of nurse staffing, job satisfaction, autonomy in decision-making, participation in hospital management, and ethics training.
Moral distressThe Revised Moral Distress Scale–Nurse Pediatric Version (MDNPV), developed by Hamric (20), was used in this study to assess moral distress among pediatric nurses. The Chinese version, translated and culturally adapted by Zhu in 2020 (21), consists of 21 items. Each item is rated on a 5-point Likert scale for frequency (0 = never to 4 = very frequently) and intensity (0 = none to 4 = great extent). The score for each item was calculated by multiplying the frequency and intensity ratings. The total MDNPV score, ranging from 0 to 336, was obtained by summing all item scores, with higher scores indicating greater moral distress. Two questions additionally elicited nurses’ intent to leave their clinical positions: “Have you ever left or considered leaving a clinical position due to moral distress?” and “Are you currently considering leaving your position due to moral distress?” The scale demonstrated good psychometric properties: the content validity index (S-CVI) was 0.90, split-half reliability was 0.87, and test-retest reliability was 0.91.
Hospital ethical climateThe Hospital Ethical Climate Survey (HECS) was developed by Olson in 1998 (22). It is applicable to nurses at the level of ethical climate in hospitals. The Chinese version of the scale was translated by Wang in 2018 (23). This 26-item instrument employs a 5-point Likert scale, with total scores ranging from 26 to 130. The scale includes the five dimensions of relationships with peers, patients, managers, the hospital, and physicians. Higher scores reflect a more positive ethical climate as perceived by nurses. The Chinese version demonstrated good psychometric properties: Cronbach's α was 0.915, test-retest reliability was 0.786, I-CVI values ranged from 0.83 to 1.00, and S-CVI was 0.89.
Moral sensitivityThe Moral Sensitivity Questionnaire-Revised (MSQ-R), developed by Lützén in 2006 (24), was used to assess moral sensitivity among pediatric nurses. The Chinese version of the scale (25) consists of nine items across two dimensions: moral responsibility and strength and sense of moral burden. Each item is rated on a 6-point Likert scale, yielding total scores from 9 to 54, with higher scores reflecting greater moral sensitivity. It demonstrated satisfactory internal consistency, with a Cronbach's α of 0.82 and item-total correlations ranging from 0.524 to 0.717. The questionnaire has been validated for use with Chinese nurses.
Nurse-physician collaborationThe Nurse-Physician Collaboration Scale (NPCS), developed by Ushiro in 2009 (26), was used to evaluate collaboration levels among pediatric nurses. The Chinese version, adapted by Chen in 2014 (27), contains 21 items rated on a 5-point Likert scale, with total scores ranging from 21 to 105. The scale includes the three dimensions of joint participation in the cure/care decision-making process, sharing of patient information, and cooperativeness. Higher scores reflect more positive perceptions of collaboration. The scale's validity and reliability are well established, with an S-CVI/Ave of 0.913, Cronbach's α of 0.946, Guttman's split-half coefficient of 0.881, and test-retest reliability of 0.713, supporting its use with Chinese nurses.
Preliminary surveyA pre-survey was conducted prior to the formal investigation to assess the reliability of the instruments. A convenience sample of 45 pediatric nurses who met the inclusion and exclusion criteria was recruited from the PICU of a tertiary Grade A general hospital in Chengdu, Sichuan Province. All scales demonstrated good reliability: Cronbach's α was 0.970 for the MDNPV, 0.969 for the HECS (with its five dimensions ranging from 0.759 to 0.918), 0.934 for the MSQ-R (with its two dimensions being 0.887 and 0.943), and 0.987 for the NPCS (with three dimension coefficients ranging from 0.940 to 0.983). These results supported the suitability of the questionnaire for use in the study.
Statistical analysesStatistical analyses were conducted using SPSS 25.0. Descriptive statistics, including frequencies, percentages, means, standard deviations, medians, and interquartile ranges, were computed to summarize the sample characteristics. Group differences in moral distress across demographic characteristics were examined using the Wilcoxon rank-sum test and the Kruskal–Wallis H test. Spearman's rank correlation was used to assess relationships among hospital ethical climate, nurse-physician collaboration, moral sensitivity, and moral distress. Multiple linear regression with a stepwise approach was employed to identify factors associated with moral distress, which served as the dependent variable. Independent variables included those with p < 0.1 in univariate analyses.
ResultsCharacteristics and univariate analysis of participantsA total of 1,292 nurses participated in the study, yielding a response rate of 76.8% (1,292/1,682). Among them, 98.92% were female, with the majority aged 30–39 years. Over two-thirds held a bachelor's degree. In terms of department, 45.59% worked in general pediatric wards, 17.72% in the PICU, and 36.69% in the NICU. Univariate analysis revealed that moral distress scores differed significantly (p < 0.05) by department, age, gender, marital status, number of children, years of service, job title, and several subjective perceptions, including adequacy of nurse staffing, job satisfaction, and autonomy in decision-making (Table 1).
CharacteristicsParticipants, n (%)Moral distress scoresCharacteristics and univariate analysis of the moral distress (n = 1,292).
Associate degree or below: requires three years of college education following high school graduation. IQR, interquartile range; CNY, Chinese Yuan; Z, Wilcoxon rank-sum test; H, Kruskal–Wallis H test.
Major study variables descriptions analysisTable 2 shows the descriptive statistics for the study variables. The median moral distress score among pediatric nurses was 64.00 (IQR: 36.00–84.00), with a mean of 69.71 (range: 16–304). Of the participants, 17 (1.32%) reported having left a healthcare setting due to moral distress, and 106 (8.20%) were considering leaving their clinical position for the same reason. The total scores for hospital ethical climate, moral sensitivity, and healthcare cooperation were 102.55 ± 16.12, 36.50 ± 12.33, and 84.01 ± 15.28, respectively.
VariablesScore rangeMean ± SD/ median (IQR)Moral distress0–33664.00 (36.00–84.00)Hospital ethical climate26–130102.55 ± 16.12 The relationships of peers4–2016.99 ± 2.58 The relationships of patients4–2016.51 ± 2.58 The relationships of managers6–3025.14 ± 4.38 The relationships of hospital6–3024.33 ± 4.24 The relationships of physicians6–3019.58 ± 3.62Moral sensitivity9–5436.50 ± 12.33 Moral responsibility and strength6–3621.28 ± 7.62 Sense of moral burden4–2415.22 ± 5.26Nurse-physician collaboration27–13584.01 ± 15.28 Joint participation in the cure/ care decision making process12–6039.84 ± 7.74 Sharing of patient information9–4532.30 ± 5.83 Cooperativeness6–3011.87 ± 2.46Total scores and scores of various dimensions for the study (n = 1,292).
Moral distress scores exhibited a non-normal distribution and are reported as median (interquartile range).
Correlation analysis between moral distress, hospital ethical climate, moral sensitivity, and nurse-physician collaboration among pediatric nursesSpearman’s correlation analysis revealed that lower moral distress was significantly associated with a more positive hospital ethical climate, higher moral sensitivity, and better nurse–physician collaboration (Table 3).
Variables12345678910111213141 moral distress12 Hospital ethical climate−0.358**13 The relationships of peers−0.324**0.890**14 The relationships of patients−0.353**0.895**0.822**15 The relationships of managers−0.356**0.934**0.858**0.807**16 The relationships of hospital−0.334**0.940**0.788**0.825**0.850**17 The relationships of physicians−0.319**0.897**0.738**0.750**0.777**0.840**18 Moral sensitivity−0.319**0.405**0.362**0.400**0.381**0.376**0.365**19 Moral responsibility and strength
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