The Impact of Moral Distress on Nurses Work Alienation in Third Grade Class-A Hospital in Wuhan ()
1. Introduction
Work alienation refers to a negative workplace phenomenon where an individual experiences psychological detachment from their environment, thereby impeding the establishment of an emotional connection with the organization. This results in a superficial engagement with work, manifested through psychological and behavioral states such as feelings of helplessness, powerlessness, and meaninglessness [1]. Research suggests that work alienation exerts adverse effects on employees, including reduced efficiency, diminished work autonomy, and limited participation in decision-making processes [2]. Moral distress is defined as the psychological anguish and/or imbalance experienced by an individual when they are unable to carry out what they perceive as the ethically correct course of action due to internal or external constraints [3]. In clinical practice, nurses often face significant psychological stress arising from role discrepancies among healthcare providers, medical disputes, nurse-patient conflicts, and ethical dilemmas, which adversely impact their mental and physical well-being and foster a detached and negative attitude toward their nursing duties [4] [5]. Current domestic research on factors influencing work alienation among nurses predominantly focuses on objective individual characteristics such as age, professional title, years of experience, and organizational performance, while empirical investigations into psychological aspects—such as moral distress—remain scarce. This study aims to investigate the current status of moral distress and work alienation among clinical nurses in tertiary hospitals, analyze the relationship between these two constructs, and provide a theoretical basis for nursing researchers and administrators to develop targeted organizational interventions aimed at mitigating work alienation among nurses.
2. Material and Methods
2.1. Participants
From April to December 2025, nurses working in the internal medicine, surgery, emergency, obstetrics and gynecology, pediatrics, and intensive care units of three Class-A Grade-III general hospitals in Wuhan were conveniently selected as the research subjects. The inclusion criteria for the research subjects were as follows: 1) having obtained a nurse practice certificate and being officially registered; 2) having continuously worked in the current department for more than one year; 3) voluntarily participating in this research. According to Kendall’s principle for sample size calculation, the sample size should be 5 to 10 times the number of questionnaire items [6]. In this study, there were 34 items. Considering the potential loss of samples, the sample size was increased by 20% on this basis. The sample size calculation formula is N = [34 × 10 × (1 + 20%)] = 408. Therefore, the sample size of this study should be at least 408, and ultimately, 842 nurses participated in this study.
2.2. Instruments
The socio-demographic data questionnaire for the study participants was designed by the researchers and included variables such as gender, age, marital status, work experience, employment type, educational background, professional title, position, and department affiliation.
The Nurse Moral Distress Scale (MDS), revised by Hamric [7] based on the Moral Distress Scale developed by Corley et al. [8], is primarily employed to assess the moral dilemmas encountered by nurses in clinical practice. The scale comprises four dimensions—value conflicts, failure to uphold patients’ best interests, individual responsibility, and infringement of patients interests—with a total of 22 items. Each item includes two components: Moral Distress Frequency (MDF) and Moral Distress Intensity (MDI). MDF indicates the frequency of occurrence of moral distress among nurses, while MDI reflects the degree of distress caused by such dilemmas. Both MDF and MDI are rated on a 5-point scale ranging from 0 to 4. For MDF, a score of 0 denotes “never occurs”, and 4 indicates “very frequently”, with progressive gradation in between. For MDI, 0 represents “no distress”, and 4 signifies “severe distress”, also following a progressive scale. The score for each item is calculated as the product of its MDF and MDI ratings, and the total scale score is the sum of all item scores, ranging from 0 to 352. Higher total scores indicate more severe moral distress, Scores above 265, between 177 and 264, between 89 and 176, and 88 or below are respectively classified into four grades: extremely severe, severe, moderate, and mild. The MDS was translated into Chinese by domestic scholars such as Sun Xia et al. [9]. Their study demonstrated that the Chinese version of the Nurse Moral Distress Scale achieved a Cronbach’s α coefficient of 0.879.
The Nursing Work Alienation Scale, developed by Ren Xiaojing [5], was utilized in this study. It comprises three dimensions: powerlessness, helplessness, and meaninglessness, with four items in each dimension, resulting in a total of 12 items. Each item is scored on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), where higher scores indicate a greater degree of work alienation among nurses, Scores were categorized into three levels: ≤20, 21 to 40, and >41 are respectively classified as mild, moderate, and severe levels. The Cronbach’s alpha coefficient for the scale is 0.89.
2.3. Methods
Using a convenience sampling method, potential participants names and units were obtained from personnel departments at the three hospitals which the school has a relationship. Individual departments at each hospital, including nursing and other departments, were contacted to schedule dates for administering the survey. The questionnaires were then distributed to participants with a cover page explaining the purposes and procedures of this study. All questionnaires were then collected by the researcher.
A total of 1000 questionnaires were distributed in this study, with 900 returned and 842 deemed valid, yielding an effective response rate of 94%.
2.4. Data Analysis
An Excel database was established and SPSS 22.0 software was used for statistical analysis, with double entry and checking of the data to ensure the correctness of the data. General socio-demographic data, the work alienation and scores of each dimension of clinical nurses were statistically described using, composition ratios; Single-factor analysis of work alienation employed a two-independent-samples t-test or analysis of variance; The correlation between moral dilemmas and work alienation utilized Pearson correlation analysis with the level of statistical significance set at P = 0.05.
3. Results
3.1. Participant Demographics
Among the 842 study participants, 43 were male (5.1%) and 800 were female (95%). The age range was 20 to 52 years, with a mean age of 31.07 ± 6.37 years. In terms of initial educational attainment, 386 participants (45.8%) held an associate degree, while 456 (54.2%) had a bachelor’s degree or higher. Regarding the highest education level, 418 participants (49.6%) had an associate degree, and 424 (50.4%) had a bachelor’s degree or above. Marital status distribution indicated that 256 participants (30.4%) were unmarried and 586 (69.6%) were married. Employment status showed that 274 participants (32.5%) held permanent positions, whereas 568 (67.5%) were employed under agency or contract arrangements. Other general characteristics are presented in Table 1.
Table 1. Participant demographics (N = 842).
Variables |
n |
% |
work alienation of the nurses () |
t/F |
P |
Departments |
|
|
|
9.004 |
<0.001 |
Emergency Medicine |
133 |
15.8 |
33.93 ± 9.28 |
|
|
Internal Medicine |
225 |
26.7 |
28.93 ± 7.54 |
|
|
Surgery |
207 |
24.6 |
28.84 ± 9.54 |
|
|
Obstetrics and Gynecology, Pediatrics |
185 |
21.9 |
29.26 ± 10.73 |
|
|
ICU |
92 |
10.9 |
34.84 ± 7.69 |
|
|
Title |
|
|
|
9.670 |
<0.001 |
Nurse |
234 |
27.7 |
26.02 ± 7.61 |
|
|
Nurse practitioner |
362 |
49.8 |
31.74 ± 8.82 |
|
|
Supervisor nurse practitioner |
211 |
25.1 |
33.14 ± 10.47 |
|
|
Deputy chief nursing officer and above |
35 |
4.2 |
26.60 ± 8.93 |
|
|
Position |
|
|
|
19.791 |
<0.001 |
Staff |
804 |
95.5 |
34.61 ± 9.08 |
|
|
Manager |
38 |
4.5 |
25.39 ± 9.64 |
|
|
Salary |
|
|
|
5.386 |
0.006 |
3000 - 5000 |
46 |
5.5 |
29.39 ± 7.99 |
|
|
5000 - 7000 |
251 |
29.8 |
31.23 ± 8.88 |
|
|
7000 - 9000 |
263 |
31.2 |
32.18 ± 8.27 |
|
|
>9000 |
281 |
33.4 |
27.14 ± 8.87 |
|
|
Years of nursing experience |
|
|
|
3.797 |
0.054 |
1 - 2 |
68 |
8.1 |
28.25 ± 8.82 |
|
|
3 - 5 |
359 |
42.6 |
29.02 ± 9.37 |
|
|
6 - 10 |
254 |
30.2 |
30.90 ± 8.73 |
|
|
>10 |
161 |
19.1 |
30.80 ± 9.60 |
|
|
Note: P < 0.05.
3.2. The Moral Distress of the Nurses Score
The total score for nurses ethical dilemmas was (48.31 ± 24.14) points, with scores for each dimension as follows: Individual Responsibility dimension (13.75 ± 10.98), Failure to Uphold Patient’s Best Interests (12.57 ± 7.72), and Harm to Patients Interests (4.09 ± 3.61).
3.3. The Work Alienation of the Nurses Score
The total score for nurses job alienation was (30.18 ± 9.24) points, with the following scores for each dimension: helplessness (11.77 ± 3.66) points, helplessness (8.99 ± 3.46) points, meaninglessness (9.41 ± 3.65) points.
3.4. Comparison of Work Alienation among Nurses with Different Demographic Characteristics
The results indicate that the total scores for nurses job alienation differ significantly across different positions, professional titles, departments (P < 0.05), as shown in Table 1.
3.5. Correlation Analysis Between Nurses Ethical Dilemmas and Job Alienation
Pearson correlation analysis revealed that the total score for nurses ethical dilemmas was positively correlated with the total score for work alienation and its respective dimension scores, as shown in Table 2.
Table 2. Correlation between work alienation and moral distress of nurses (r value).
Variables |
Feeling of helplessness |
Feeling of
helpless |
Feeling of
helpless |
Total score of
work alienation |
Individual responsibility |
0.390** |
0.395** |
0.389** |
0.457** |
Value Conflict |
0.273** |
0.296** |
0.254** |
0.319** |
harm the interests of patients |
0.308** |
0.359** |
0.337** |
0.390** |
Failure to uphold the patient’s best interests |
0.277** |
0.278** |
0.275** |
0.323** |
Total Score of Moral Dilemma |
0.385** |
0.405** |
0.385** |
0.457** |
**: P < 0.01.
4. Discussion
The findings of this study indicate that the ethical dilemmas experienced by nurses are at a mild level, consistent with the survey results of Yao Xiuyu [10] among nurses in Beijing’s tertiary hospitals. Although the level of ethical dilemmas experienced by clinical nurses is relatively low, the resulting ethical harm and negative impacts on nurses should not be overlooked. International research indicates that nurses experiencing ethical dilemmas may exhibit various psychological stress responses, such as guilt, frustration, helplessness, and diminished self-worth [11], accompanied by physiological reactions including headaches, palpitations, diarrhea, and sleep disturbances [12]. When confronting ethical dilemmas, nurses often resort to strategies like reducing patient interactions or diminishing humanistic care approaches to alleviate the distress caused by these dilemmas [13]. Such negative coping mechanisms can lead to poor communication between nurses and patients, potentially disrupting nursing order and ultimately compromising the quality of care.
Meanwhile, moral dilemma scores varied across different departments, with particularly pronounced differences among nurses in intensive care units, emergency departments, and psychiatric wards. Within these clinical settings, nurses commonly identified the value conflict dimension as the primary source of moral dilemmas. This aligns with the highest-scoring dimension in this study:value conflict (13.75 ± 10.98), which is consistent with the findings that physicians prioritize treatment outcomes and patient safety when making treatment decisions for critically ill patients. In contrast, nurses, while considering treatment outcomes, also emphasize enhancing patients quality of life during care delivery. Consequently, value conflicts often arise between physicians and nurses during treatment decision-making, causing distress for nurses [14]-[16]. During treatment, nurses should actively communicate with physicians regarding medical decisions to mitigate value conflicts arising from differing perspectives. This was also validated in the finding of Ding Ruixin [17] study on palliative care for terminally ill patients. Nurses often face insufficient professional knowledge reserves and inadequate experience in grief counseling, which constitutes a source of ethical dilemmas in the individual responsibility dimension. In this dimension, the study scored (12.57 ± 7.72), ranking as the second largest source of ethical dilemmas. Zhang Xinrui [18] research pointed out that Nurses in neonatal ICUs perceive excessive medical interventions and disproportionate use of new technologies as sub optimal choices for infants, representing the most common cause of ethical dilemmas. This also reflects conflicts between nurses professional responsibilities and the rights of the infants.
The results of this study indicate that nurses job alienation scores averaged (30.18 ± 9.24), reflecting a moderate level. This finding is consistent with Zhang Liping survey of nurses in tertiary hospitals [19]. Univariate analysis revealed that position, professional titles, and department are demographic factors influencing nurses job alienation, aligning with the findings of Chen Tao et al. [20]. Analyzing the reasons, the survey research revealed a significant correlation between work experience and job alienation. Compared to nurses in higher positions, those in lower positions, due to shorter tenure, lack sufficient clinical experience and interpersonal skills. When facing conflicts with colleagues, patients, or families, they may be less capable of rapidly adapting to the demands of complex healthcare environments using relevant knowledge, attitudes, and skills [21]. In contrast, senior nurses enjoy broader opportunities to demonstrate their talents and engage in work. As part of the hospital management team, senior nurses can realize their self-worth through clinical work, leading to higher job motivation. They are more willing to maintain high enthusiasm and exert extra effort to ensure the smooth completion of tasks.
The results of this study show that junior nurses without positions or part-time jobs in tertiary hospitals have a stronger sense of job alienation, which is similar to the findings of Wang Qian et al. [22]. Nurses who undertake department management, teaching or quality control, in addition to their regular work, are responsible for training new nurses in the department or evaluating the quality of nursing work. They need to constantly learn and improve themselves, and enhance their comprehensive abilities. Therefore, they have a higher sense of professional value and achievement than other nurses [23], and their sense of job alienation is relatively weak. Nursing managers should encourage junior nurses in the department to actively participate in department management, quality control or teaching, and attend relevant activities organized by the nursing association on time, to enhance their sense of responsibility and value, and indirectly reduce the level of job alienation. Furthermore, clinical departments such as emergency rooms and intensive care units operate in demanding medical environments characterized by fast-paced workflows, heavy workloads, and high risks compared to general wards. The specific nursing pressures inherent in such medical settings exert greater negative impacts on nurses.
5. Conclusion
This study indicates that clinical nurses ethical dilemmas are positively correlated with their job alienation, meaning that the higher the level of ethical dilemmas experienced by nurses, the higher their level of job alienation. Weber et al. [24] found that an individual’s sense of responsibility and professional ethics are closely linked to job alienation. Nurses encounter ethical dilemmas in clinical practice, such as failing to protect patient interests or providing ineffective care. Perceiving a significant gap between actual clinical care situations and their expectations reduces nurses professional identification with the nursing profession [25]. Furthermore, after experiencing moral injury, nurses may adopt passive coping strategies to avoid dilemmas. Such behaviors lead to psychological detachment and behavioral alienation from clinical nursing work, resulting in low job commitment. In severe cases, nurses may even consider leaving the nursing profession. Therefore, it is essential to address the moral struggles encountered by clinical nurses and their psychological impact, reduce psychological and behavioral barriers to nursing work, and lower job alienation.
The findings of this study confirm the positive impact of nurses ethical dilemmas on their job alienation. This suggests that hospital administrators should enhance relevant knowledge training by incorporating ethical and legal education into both pre-service training and ongoing continuing education. Addressing nurses confusion regarding clinical ethical issues and reducing the harm caused by ethical dilemmas can alleviate their job alienation, increase their professional identity and job satisfaction, ultimately leading to improved nursing quality.
6. Limitations of the Study
This study only investigated the current situation of moral distress and work alienation of clinical nurses in the tertiary hospitals in Wuhan region, and did not investigate other regions, sub-hospitals, and other health care providers due to the limitation of human and material resources, suggesting that future studies could investigate other health care institutions such as nursing homes and community health centers.