Moral Distress among Thai Nurses: A Mixed Methods Study

Background: Moral distress is a common experience among nurses and can lead to frustration, withdrawal from patient care, and leaving a position or even the nursing profession. The Measure of Moral Distress – Healthcare Professionals (MMD-HP) is a newly updated moral distress scale and is recommended to be used cross culturally. This is the first study using the MMD-HP in Thailand.

Purpose: This dissertation study had 2 main aims: 1) to test the psychometric properties of the Thai version MMD-HP, and 2) to describe the phenomenon of moral distress among Thai nurses, including investigation of the relationships between moral distress and selected demographic and practice factors, and identification of predictors of moral distress.

Methods: A convergent parallel mixed-methods design was employed. The MMD-HP was translated into Thai language using the modified Brislin’s (1970) cross-cultural instrument translation method. All questionnaires were distributed electronically to the target participants at 2 large tertiary care institutions in a Southern province in Thailand. The completed returned surveys (462) were analyzed using parametric statistics (e.g. mean, standard deviation, independent sample T-test, one-way ANOVA, and hierarchical multiple regression). Twenty nurses who completed the survey were interviewed and the interview data were analyzed using thematic analysis. The findings from both components were integrated. Of the 462 returned surveys, 448 cases maintained the statistical assumptions for factor analysis and were used to test the construct of the MMD-HP through exploratory factor analysis.

Results: A three-factor solution was accepted and named as system-level, team-level, and patient/family-level root causes of moral distress. Internal consistency of the overall MMD-HP was 0.94 and 0.897, 0.896, and 0.849 for system-level, team-level, and patient/family-level, respectively. The top seven ranked causes of moral were related to system-level root causes and end-of-life care situations. Work unit (acute care, critical care), considering leaving position, and number of moral distress episodes in the past year were significant predictors of moral distress. The interview data demonstrated 3 main themes: (1) powerlessness (at patients/family-, team-, and organizational level), (2) end-of-life issues, and (3) poor team function (poor communication and collaboration, incompetence healthcare providers, and inappropriate behavior of colleagues), and enrich the quantitative findings, especially as related to the top 7 causes of moral distress.

Discussion: The MMD-HP is a multi-dimensional scale to measure moral distress. Thai version MMD-HP is a reliable, valid, and useful tool to measure moral distress among nurses in the Thai context. The most problematic causes of moral distress for Thai nurses are similar to those among nurses in western cultures although there are unique components that require additional exploration. Interventions to mitigate moral distress also need to be developed and tested.