Document Type : Original Article


1 Department of Nursing, Faculty of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran

2 Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran


BACKGROUND: Nurses in their workplace, for a variety of reasons, always face moral distress that
is an underlying issue in the nursing profession, which can lead to problems such as reduced quality
and quantity of care and sleep disorder. Besides, given the increased privatization of hospitals, this
study aimed to explore the association between nurses’ moral distress and sleep quality and its
comparison among nurses in private and public hospitals.
MATERIALS AND METHODS: This was a descriptive‑analytical study involving 150 nurses working
in Ilam Province hospitals. Sampling conducted using a multistage random sampling method. Data
were collected through the questionnaire of sociodemographic characteristics, the Corley’s Moral
Distress Scale, and the Pittsburgh Sleep Quality Index. Data were analyzed using SPSS software
version 22. Descriptive statistics such as frequency, mean, ANOVA, independent t‑test, multiple linear
regression, and Pearson correlation coefficient at the significant level of P < 0.05 were calculated.
RESULTS: The analysis revealed that moral distress was positively associated with sleep quality.
Furthermore, the scores of nurses’ moral distress and sleep quality were different in private and
public hospitals, so that the level of moral distress in the public hospital and sleep quality in the
private hospital was higher and lower, respectively, but the difference was not statistically significant.
Moreover, sleep quality, and the type of employment was the most important predicting variables of
moral stress (B = 1.86) and sleep quality (B = 2.39), respectively.
CONCLUSION: According to the study results, a positive and significant association was found
between moral distress and nurses’ sleep quality. It is recommended that appropriate strategies
and training program be formulated by the health‑care system to increase nurses’ ability to combat
moral distress adverse effects.


1. Dalvand S, Khodadadi B, Niksima SH, Ghanei Gheshlagh R,
Shirzadegan R. The relationship between moral sensitivity and its
dimensions with demographic characteristics of nurses in Shahid
Madani hospital of Khorramabad in 2017. Sci J Nurs Midwifery
Paramed Faculty 2017;3:38‑48.
2. Azarm A, Hasanlo M, Hojt Ansari M, Mohammadi F, Ebrahimi H,
Asghari Jafarabadi M. Moral distress and the nursing care quality:
A correlational study in teaching hospitals. Health Spiritual Med
Ethics 2017;4:38‑47.
3. Christodoulou‑Fella M, Middleton N, Papathanassoglou EDE,
Karanikola MNK. Exploration of the Association between
nurses’ moral distress and secondary traumatic stress syndrome:
Implications for patient safety in mental health services. Biomed
Res Int 2017;2017:1908712.
4. Sadeghi M, Ebrahimi H, Abbasi M. The relationship between
moral distress and burnout in clinical nurses in the Shahroud
city. Iran J Nurs Res 2016;11:78‑87.
5. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses
in a medical intensive care unit. Am J Crit Care 2005;14:523‑30.
6. Borhani F, Abbaszadeh A, Nakhaee N, Roshanzadeh M. The
relationship between moral distress, professional stress, and intent
to stay in the nursing profession. J Med Ethics Hist Med 2014;7:3.
7. Rahimi Golsefid S, Jan Mohamadi S, Seyd Fatemi N, Haghani H.
Effectiveness of end‑of‑life care education on the moral distress
of nurses in neonatal intensive care units. Iran J Pediatr Nurs
8. Ameri M, Mirhashemi B, Hosseini SS. Moral distress and
the contributing factors among nurses in different work
environments. J Nurs Midwifery Sci 2015;2:44‑9.
9. Amiri R, Gaeeni M, Ahmari H, Momenyan S. The Relationship
between moral reasoning and the caring behavior of nurses
in emergency departments of Qom, 2015. Iran J Emerg Care
10. Asayesh H, Mosavi M, Abdi M, Masoud MP, Jodaki K. The
relationship between futile care perception and moral distress
among intensive care unit nurses. J Med Ethics Hist Med 2018;11:2.
11. Borhani F, Abbaszadeh A, Nakhaee N, Roshanzadeh M. The
relationship between moral distress, professional stress, and
intent to stay in the nursing profession. J Med Ethics Hist Med
12. Abbaszadeh A, Nakhaei N, Borhani F, Roshanzadeh M. The
relationship between moral distress and retention in nurses
in Birjand teaching hospitals. Iran J Med Ethics Hist Med
13. Schluter J, Winch S, Holzhauser K, Henderson A. Nurses’ moral
sensitivity and hospital ethical climate: A literature review. Nurs
Ethics 2008;15:304‑21.
14. Gómez‑García T, Ruzafa‑Martínez M, Fuentelsaz‑Gallego C,
Madrid JA, Rol MA, Martínez‑Madrid MJ, et al. Nurses’ sleep
quality, work environment and quality of care in the Spanish
National Health System: Observational study among different
shifts. BMJ Open 2016;6:e012073.
15. McDowall K, Murphy E, Anderson K. The impact of shift work
on sleep quality among nurses. Occup Med (Lond) 2017;67:621‑5.
16. Ghanei R, Hemmati Maslakpak M, Rezaei K, Baghi V, Makki B.
Nursing students quality of sleep in dormitories of urmia
university of medical sciences. UNMF 2011;9(4):278‑82.
17. Babamiri M, Moeini B, Tahmasian H, Barati M, Roshanai G. The
study of sleep health education effect on sleep quality among
lorestan nursing personnel. J Ergon 2017;4:8‑13.
18. Kassani A, Niazi M, Menati R, Alimohamadi Y, Menati W.
Relationship between nurses’ depression and quality of life:
Applying path analysis model. Q J Nurs Manage 2014;3:61‑9.
19. Zamanian Z, Nikeghbal K, Khajehnasiri F. Influence of sleep
on quality of life among hospital nurses. Electron Physician
20. Jannati A, Dadgar E, Gholizadeh M, Alizadeh L, KHodayari M.
Identifying the main factors to choose public or private hospital
for health services in hospitals of Tabriz in 2010. Tolooebehdasht
21. Nekoeimoghadam M, Amiresmaili M, Izadi A. The competitive
analysis of the private hospital industry using porter’s competitive
diamond model: A case study in Kerman. J Qual Res Health Sci
22. Nogueira Lde S, Koike KM, Sardinha DS, Padilha KG,
de Sousa RM. Nursing workload in public and private intensive
care units. Rev Bras Ter Intensiva 2013;25:225‑32.
23. Habibi H, Mooghali A, Habibi F, Ahmadi M. Comparative study of the relationship between job satisfaction and burnout among
Nurses in Public and Private Hospitals in Shiraz City in 2012.
JHOSP 2015;14:119‑26.
24. Sharif zadeh F, Ghorbani Zadeh V, Mohammadi Mahmouei A.
The effect of work‑family conflict on intention to leave by job
burnout as a mediator; a comparative study between public and
private hospitals. MDRSJRNS 2013;3:21‑42.
25. Sadeghi A, Goharloo Arkawaz A, Cheraghi F, Moghimbeigi A.
Survey of nurses’ job satisfaction in educational and therapeutic
centers of Hamadan University of medical sciences. Avicenna J
Nurs Midwifery Care 2018;26:40‑8.
26. van der Doef M, Mbazzi FB, Verhoeven C. Job conditions, job
satisfaction, somatic complaints and burnout among East African
nurses. J Clin Nurs 2012;21:1763‑75.
27. Massoudi R, Aetemadifar S, Afzali SM, Khayri F,
Hassanpour Dehkordi A. The influential factors on burnout
among nurses working in private hospitals in Tehran. Iran J Nurs
Res 2008;3:47‑58.
28. Pires BS, Oliveira LZ, Siqueira CL, Feldman LB, Oliveira RA,
Gasparino RC. Nurse work environment: Comparison between
private and public hospitals. Einstein(Sao Paulo) 2018;16:eAO4322.
29. Jafari M, Habibi Houshmand B, Maher A. Relationship of
occupational stress and quality of work life with turnover
intention among the nurses of public and private hospitals in
selected cities of Guilan Province, Iran, in 2016. J Health Res
Community 2017;3:12‑24.
30. Corley MC, Minick P, Elswick RK, Jacobs M. Nurse moral distress
and ethical work environment. Nurs Ethics 2005;12:381‑90.
31. Mealer M, Moss M. Moral distress in ICU nurses. Intensive Care
Med 2016;42:1615‑7.
32. Silén M, Svantesson M, Kjellström S, Sidenvall B, Christensson L.
Moral distress and ethical climate in a Swedish nursing context:
Perceptions and instrument usability. J Clin Nurs 2011;20:3483‑93.
33. Abbaszade A, Borhani F, Kalantari S. Moral distress of nurses
in health centers in the city of Bam in 2011. Med Ethics J
34. Beikrnoradi A, Rabiee S, Khatiban M, Cheraghi MA. Nurses
distress in intensive care unit: A survey in teaching hospitals.
J Med Ethics Hist Med 2012;5:58‑69.
35. Mardani Hamooleh M, Iranshahi M, Seyedfatemi N, Haghani H.
An evaluation of moral distress levels among the nursing staff
of Malayer hospitals: A cross‑sectional study. J Med Ethics Hist
Med 2016;9:42‑53.
36. Khajeh Hosseini S, Sayadi A, Mobini Lotfabad M, Heidari S. Sleep
quality among shift‑working nurses in the hospitals of Rafsanjan
city, Iran, in 2018. Health Dev J 2019;8:141‑51.
37. Bahri N, Moshki M, Mogharab M. The survey of sleep quality and
its relationship to mental health of hospital nurses. Iran Occup
Health 2014;11:97‑104.
38. Mikaeili N, Mehri S, Ghaseminejad M, Molavi P. The relationship
of morningness‑eveningness with sleep quality and professional
motivation in nurses. J Health Care 2017;18:316‑25.
39. Roodbandi ASJ, Feyzi V, Khanjani N, Moghadam SR, Bafghi MS,
Moghadasi M, et al. Sleep quality and sleepiness: A comparison
between nurses with and without shift work, and university
employees. Int J Occup Hyg 2016;8:230‑6.
40. Bozorg Sohrabi F, Suleimani A, Habibi MR, Emami Zidi A,
Sadat Nejad Georgia H, Hassanzadeh Kabi F. Sleep quality of
nurses working in ICUs of Mazandaran province hospitals and
related factors: Across‑sectional study. J Health Breeze 2014;2:18‑23.
41. Salehi K, Alhani F, Mahmoudifar Y, Rouhi N. Quality of sleep
and related factors among Imam Khomeini hospital staff nurses.
Iran J Nurs 2010;23:18‑25.
42. Kaliyaperumal D, Elango Y, Alagesan M, Santhanakrishanan I.
Effects of sleep deprivation on the cognitive performance of nurses
working in shift. J Clin Diagn Res 2017;11:CC01‑3.
43. Chien PL, Su HF, Hsieh PC, Siao RY, Ling PY, Jou HJ. Sleep
quality among female hospital staff nurses. Sleep Disord
44. Palhares Vde C, Corrente JE, Matsubara BB. Association between
sleep quality and quality of life in nursing professionals working
rotating shifts. Rev Saude Publica 2014;48:594‑601.
45. Yilmaz D, Tanrikulu F, Dikmen Y. Research on sleep quality and
the factors affecting the sleep quality of the nursing students. Curr
Health Sci J 2017;43:20‑4.
46. St‑Onge MP, Grandner MA, Brown D, Conroy MB, Jean‑Louis G,
Coons M, et al. Sleep duration and quality: Impact on lifestyle
behaviors and cardiometabolic health: A scientific statement from
the American Heart Association. Circulation 2016;134:e367‑86.
47. Akbari V, Hajian A, Mirhashemi M. Evaluating of sleep quality in
shift‑work nurses. Iran J Sleep Disored Ther 2016;5:225.
48. Darami Z, Nouri AA, Molavi H. Relationship of Perceived
Organizational Support and Corporate Culture with
Organizational Commitment among Nurses in Private and
Public Hospitals; 2013.
49. Samaha E, Lal S, Samaha N, Wyndham J. Psychological, lifestyle
and coping contributors to chronic fatigue in shift‐worker nurses.
J Adv Nurs 2007;59:221‑32.
50. Shamshri M, Moshki M, Mogharab M. The survey of sleep quality
and its relationship to mental health of hospital nurses. Iran Occup
Health J 2014;11:96‑104.
51. Ahmadabadi A, Tavousi SH, Sedaghat A, Sardar Antighechi F,
Khadem Rezaiyan M. Sleep quality in nurses of Burn ward
compared to other clinical wards. Iran Occup Health 2018;15:26‑33.
52. Park E, Lee HY, Park CS. Association between sleep quality and
nurse productivity among Korean clinical nurses. J Nurs Manag
53. Corley MC, Elswick RK, Gorman M, Clor T. Development and
evaluation of a moral distress scale. J Adv Nurs 2001;33:250‑6.
54. Aloba OO, Adewuya AO, Ola BA, Mapayi BM. Validity of the
Pittsburgh Sleep Quality Index (PSQI) among Nigerian university
students. Sleep Med 2007;8:266‑70.
55. Hosseini F, Fasihi Harandi T, Kazemi M, Rezaeian M, Hosseini R.
The relationship between sleep quality and general health of
nurses in Rafsanjan university of medical sciences in 2012.
J Rafsanjan Univer Med Sci 2013;12:843‑54.
56. Jalali K, Tabari‑Khomeiran R, Asgari F, Sedghi‑Sabet M,
Kazemnejad E. Moral distress and related factors among
emergency department nurses. Health 2019;1:3.
57. Shafiei A, Ravanipour M, Yazdankhahfard M, Mirzaei K. The
relationship between moral distress and burnout among nurses
of Shahid Ganji Hospital, Borazjan in 1394. Nurs Vulnerable J
58. Fernandez‑Parsons R, Rodriguez L, Goyal D. Moral distress in
emergency nurses. J Emerg Nurs 2013;39:547‑52.
59. Ebrahimi H, Kazemi A, Asghari Jafarabadi M, Azarm A.
Moral distress in nurses working in educational hospitals of
Northwest Medical Universities of Iran. Iran J Med Ethics Hist
Med 2013;6:80‑8.
60. Ohnishi K, Ohgushi Y, Nakano M, Fujii H, Tanaka H, Kitaoka K,
et al. Moral distress experienced by psychiatric nurses in Japan.
Nurs Ethics 2010;17:726‑40.
61. Shafipour V, Esmaeili R, Heidari MR, Aghaei N, Saadatmehr SR,
Sanagoo A. Investigating the level of moral distress and its related
factors among nurses in mazandaran burn center. J Mazandaran
Univer Med Sci 2015;25:58‑67.
62. Bahri N, Shamshri M, Moshki M, Mogharab M. The survey of
sleep quality and its relationship to mental health of hospital
nurses. Iran Occup Health 2014;11:97‑104.
63. Ansari H, Noroozi M, Rezaei F, Barkhordar N. Assessment of sleep
pattern among hospitals’ nurses of Zahedan University of Medical
Sciences in 2011. J Rafsanjan Univer Med Sci 2015;13:1021‑32.