Moral caring competency and moral distress among Ghanaian nurses in adult care settings: A descriptive-correlational study


moral caring competency
moral distress
moral dilemmas
patient care
descriptive-correlational study

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Antwi, R. S., & Galanza, J. (2024). Moral caring competency and moral distress among Ghanaian nurses in adult care settings: A descriptive-correlational study. Belitung Nursing Journal, 10(2), 134–142.
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Accepted for publication: 2024-02-17
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Background: Nurses in adult care settings frequently encounter moral distress due to the daily ethical obligations they must fulfill. In contrast to other healthcare professionals, nurses often grapple with a heightened frequency of moral dilemmas, resulting in increased moral distress.

Objective: This study aimed to explore the levels and relationship between moral caring competency and moral distress among Ghanaian nurses in adult care settings.

Methods: This quantitative study utilized a descriptive-correlational design. A multistage sampling was used to select three public hospitals. Simple random sampling was used to recruit 231 nurses from the three public hospitals. Data were collected from June to July 2023 using validated questionnaires. The study utilized frequency and percentages, mean and standard deviation, and Spearman’s Correlation.

Results: The nurses had a low level of moral caring competency (M = 2.18, SD = 0.340). The composite moral distress score was 227.31, indicating a high level of moral distress among the nurses. Furthermore, there was a moderate, negative significant relationship between moral caring competency and moral distress (rs= -.474, N = 231, p <0.001). 

Conclusions: Nurses in public hospitals had limited personal cognitive, affective, and psychomotor abilities to address patient moral issues. The nurses also experience significant moral distress when delivering patient care. Furthermore, to decrease the level of moral distress, moral caring competency should be strengthened among nurses. Therefore, it is recommended that nurse administrators provide adequate organizational support and implement continuous moral training to improve nurses’ moral caring competency and mitigate their moral distress. Healthcare policymakers are encouraged to develop or refine policies to navigate moral dilemmas and reduce moral distress among nurses. Future studies employing qualitative designs can explore the influence of culture on moral caring competency within the Ghanaian setting.


Copyright (c) 2024 Rachel Serwaah Antwi, Jefferson Galanza

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Declaration of Conflicting Interest

The authors have declared no conflict of interest in this study.


The authors acknowledge and express gratitude to the School of Advanced Studies nursing faculty of Saint Louis University, Philippines. The authors also thank the research assistants and all study participants.

Authors’ Contributions

RA and JG made substantial contributions to conceptualizing the topic area, literature review, data collection and interpretations, revisions, and preparation of the final version. RA and JG approve of the final version to be published. RA and JG agree to be accountable for all aspects of the work.

Data Availability

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Declaration of Use of AI in Scientific Writing

There is nothing to disclose.


Aboud, M., Bukini, D., Waddell, R., Peterson, L., Joseph, R., Morris, B. M., Shayo, J., Williams, K., Merz, J. F., & Ulrich, C. M. (2014). Do Tanzanian hospitals need healthcare ethics committees. South African Journal of Bioethics and Law 11(2), 75-79.

Addo, B., Amoah, H. A., Eshun, S. A., & Ocran, H. N. (2020). Moral distress among midwives working in the labour ward of a hospital in Ghana. European Journal of Midwifery, 4, 24.

Adhikari, S., Paudel, K., Aro, A. R., Adhikari, T. B., Adhikari, B., & Mishra, S. R. (2016). Knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses from a resource poor setting, Nepal. BMC Medical Ethics, 17, 68.

Afoko, V., Hewison, A., Neilson, S., & Newham, R. (2022). Moral distress experienced by neonatal intensive and paediatric care nurses in Northern Ghana: A qualitative study. Journal of Research in N ursing, 27(6), 519-529.

Ahenkan, A., Afari, M. B., & Buabeng, T. (2018). Ethical dilemma of health professionals in Ghana: Experiences of doctors and nurses at the Korle-Bu Teaching Hospital. African Journal of Management Research, 25, 29-44.

Ale, A., Subba, R., Ghimire, A., & Nepal, S. (2022). Moral distress among nurses working in a teaching hospital. MedS Alliance Journal of Medicine and Medical Sciences, 2(3), 57-62.

Alimoradi, Z., Jafari, E., Lin, C.-Y., Rajabi, R., Marznaki, Z. H., Soodmand, M., Potenza, M. N., & Pakpour, A. H. (2023). Estimation of moral distress among nurses: A systematic review and meta-analysis. Nursing Ethics, 30(3), 334-357.

Andersson, H., Svensson, A., Frank, C., Rantala, A., Holmberg, M., & Bremer, A. (2022). Ethics education to support ethical competence learning in healthcare: An integrative systematic review. BMC Medical Ethics, 23(1), 1-26.

Asahara, K., Ono, W., Kobayashi, M., Omori, J., & Todome, H. (2013). Development and psychometric evaluation of the moral competence scale for home care nurses in Japan. Journal of Nursing Measurement, 21(1), 43-54.

Asare, P., Ansah, E. W., & Sambah, F. (2022). Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana. PloS One, 17(2), e0263557.

Atashzadeh-Shoorideh, F., Tayyar-Iravanlou, F., Chashmi, Z. A., Abdi, F., & Cisic, R. S. (2021). Factors affecting moral distress in nurses working in intensive care units: A systematic review. Clinical Ethics, 16(1), 25-36.

Bah, H. T., & Sey-Sawo, J. (2018). Teaching and practicing nursing code of ethics and values in the Gambia. International Journal of Africa Nursing Sciences, 9, 68-72.

Barchi, F., Kasimatis Singleton, M., Magama, M., & Shaibu, S. (2014). Building locally relevant ethics curricula for nursing education in Botswana. International Nursing Review, 61(4), 491-498.

Bayat, M., Shahriari, M., & Keshvari, M. (2019). The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. Journal of Medical Ethics and History of Medicine, 12, 8.

Berhie, A. Y., Tezera, Z. B., & Azagew, A. W. (2020). Moral distress and its associated factors among nurses in northwest amhara regional state referral hospitals, Northwest Ethiopia. Psychology Research and Behavior Management, 13, 161-167.

Boafo, I. M. (2016). “… they think we are conversing, so we don’t care about them…” Examining the causes of workplace violence against nurses in Ghana. BMC Nursing, 15, 68.

Cerit, B., & Dinç, L. (2013). Ethical decision-making and professional behaviour among nurses: A correlational study. Nursing Ethics, 20(2), 200-212.

Clark, P., Crawford, T. N., Hulse, B., & Polivka, B. J. (2021). Resilience, moral distress, and workplace engagement in emergency department nurses. Western Journal of Nursing Research, 43(5), 442-451.

Corley, M. C., Elswick, R. K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33(2), 250-256.

Davis, S., Schrader, V., & Belcheir, M. J. (2012). Influencers of ethical beliefs and the impact on moral distress and conscientious objection. Nursing Ethics, 19(6), 738-749.

Donkor, N. T., & Andrews, L. D. (2011). Ethics, culture and nursing practice in Ghana. International Nursing Review, 58(1), 109-114.

Elewa, A. H. (2020). Ethical climate, ethical behavior and professional values as perceived by staff nurses at two different hospitals. The Malaysian Journal of Nursing (MJN), 12(2), 125-136.

Giannetta, N., Sergi, R., Villa, G., Pennestrì, F., Sala, R., Mordacci, R., & Manara, D. F. (2021). Levels of moral distress among health care professionals working in hospital and community settings: A cross sectional study. Healthcare, 9, 1673.

Giorgini, V., Mecca, J. T., Gibson, C., Medeiros, K., Mumford, M. D., Connelly, S., & Devenport, L. D. (2015). Researcher perceptions of ethical guidelines and codes of conduct. Accountability in Research, 22(3), 123-138.

Haile, T. G. (2022). Factors associated with nursing code of ethics practice in Gurage Zone, SNNPR, Ethiopia, 2022. Nursing: Research and Reviews, 12, 135-145.

Hamric, A. B., Borchers, C. T., & Epstein, E. G. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1-9.

Hariharan, S., Jonnalagadda, R., Walrond, E., & Moseley, H. (2006). Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados. BMC Medical Ethics, 7, 7.

Hoglund, A. T., Eriksson, S., & Helgesson, G. (2010). The role of guidelines in ethical competence-building: perceptions among research nurses and physicians. Clinical Ethics, 5(2), 95-102.

Hoskins, K., Grady, C., & Ulrich, C. M. (2018). Ethics education in nursing: Instruction for future generations of nurses. OJIN: The Online Journal of Issues in Nursing, 23(1), 1-4.

Joseph, S., Tunio, H. K., Shahzad, S., Abbass, E., & Nangrejo, R. (2022). Moral distress among nurses in developing countries of Asia: A systematic review. Journal of Liaquat University of Medical & Health Sciences, 21(04), 238-244.

Kalvemark Sporrong, S. (2007). Ethical competence and moral distress in the health care sector: A prospective evaluation of ethics rounds [PhD Dissertation, Acta Universitatis Upsaliensis]. Sweden.

Koskenvuori, J., Stolt, M., Suhonen, R., & Leino‐Kilpi, H. (2019). Healthcare professionals’ ethical competence: A scoping review. Nursing Open, 6(1), 5-17.

Kwamie, A., Asiamah, M., Schaaf, M., & Agyepong, I. A. (2017). Postings and transfers in the Ghanaian health system: A study of health workforce governance. International Journal for Equity in Health, 16, 85.

Maluwa, V., Mwalabu, G., & Msiska, G. (2021). Factors that influence ethical competence among nurses in health facilities in Malawi. Malawi Medical Journal, 33(Postgraduate Supplementary Iss), 40-45.

Miljeteig, I., Defaye, F., Desalegn, D., & Danis, M. (2019). Clinical ethics dilemmas in a low-income setting-a national survey among physicians in Ethiopia. BMC Medical Ethics, 20(1), 1-13.

Momennasab, M., Ghanbari, M., & Rivaz, M. (2021). Improving nurses’ knowledge, attitude, and performance in relation to ethical codes through group reflection strategy. BMC Nursing, 20, 222.

Moodley, K., Kabanda, S. M., Soldaat, L., Kleinsmidt, A., Obasa, A. E., & Kling, S. (2020). Clinical ethics committees in Africa: Lost in the shadow of RECs/IRBs? BMC Medical Ethics, 21, 115.

Nikbakht Nasrabadi, A., Wibisono, A. H., Allen, K.-A., Yaghoobzadeh, A., & Bit-Lian, Y. (2021). Exploring the experiences of nurses’ moral distress in long-term care of older adults: A phenomenological study. BMC Nursing, 20(1), 156.

Nyante, G., Andoh, C., & Bello, A. (2020). Patterns of ethical issues and decision-making challenges in clinical practice among Ghanaian physiotherapists. Ghana Medical Journal, 54(3), 179-185.

Oelhafen, S., & Cignacco, E. (2020). Moral distress and moral competences in midwifery: A latent variable approach. Journal of Health Psychology, 25(13-14), 2340-2351.

Opoku, D. A., Ayisi-Boateng, N. K., Osarfo, J., Sulemana, A., Mohammed, A., Spangenberg, K., Awini, A. B., & Edusei, A. K. (2022). Attrition of nursing professionals in Ghana: An effect of burnout on intention to quit. Nursing Research and Practice, 2022, 3100344.

Oulton, J. A. (2000). ICN’s Code of Ethics for Nurses: Serving nurses and nursing care world-wide. International Nursing Review, 47(3), 137-141.

Park, M., Jeon, S. H., Hong, H.-J., & Cho, S.-H. (2014). A comparison of ethical issues in nursing practice across nursing units. Nursing Ethics, 21(5), 594-607.

Pathman, D. E., Sonis, J., Rauner, T. E., Alton, K., Headlee, A. S., & Harrison, J. N. (2022). Moral distress among clinicians working in US safety net practices during the COVID-19 pandemic: A mixed methods study. BMJ Open, 12(8).

Prompahakul, C., Keim-Malpass, J., LeBaron, V., Yan, G., & Epstein, E. G. (2021). Moral distress among nurses: A mixed-methods study. Nursing Ethics, 28(7-8), 1165-1182.

Quek, C. W. N., Ong, R. R. S., Wong, R. S. M., Chan, S. W. K., Chok, A. K.-L., Shen, G. S., Teo, A. Y. T., Panda, A., Burla, N., & Wong, Y. A. (2022). Systematic scoping review on moral distress among physicians. BMJ Open, 12(9), e064029.

Ramathuba, D. U., & Ndou, H. (2020). Ethical conflicts experienced by intensive care unit health professionals in a regional hospital, Limpopo province, South Africa. Health SA Gesondheid, 25, a1183.

Rosa, D., Bonetti, L., Villa, G., Allieri, S., Baldrighi, R., Elisei, R. F., Ripa, P., Giannetta, N., Amigoni, C., & Manara, D. F. (2022). Moral distress of intensive care nurses: A phenomenological qualitative study two years after the first wave of the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 19(22), 15057.

Salari, N., Shohaimi, S., Khaledi-Paveh, B., Kazeminia, M., Bazrafshan, M.-R., & Mohammadi, M. (2022). The severity of moral distress in nurses: A systematic review and meta-analysis. Philosophy, Ethics, and Humanities in Medicine, 17(1), 1-14.

Sedaghati, A., Assarroudi, A., Akrami, R., & Rad, M. (2020). Moral distress and its influential factors in the nurses of the nursing homes in khorasan provinces in 2019: A descriptive-correlational study. Iranian Journal of Nursing and Midwifery Research, 25(4), 319-324.

Siaw-Frimpong, M., Touray, S., & Sefa, N. (2021). Capacity of intensive care units in Ghana. Journal of Critical Care, 61, 76-81.

Sirilla, J., Thompson, K., Yamokoski, T., Risser, M. D., & Chipps, E. (2017). Moral distress in nurses providing direct patient care at an academic medical center. Worldviews on Evidence‐Based Nursing, 14(2), 128-135.

Talebian, F., Hosseinnataj, A., & Yaghoubi, T. (2022). The relationship between resilience and moral distress among Iranian critical care nurses: A cross-sectional correlational study. Ethiopian Journal of Health Sciences, 32(2), 405-444.

Tia, M. B., Aziato, L., & Dzansi, G. (2022). Exploring Ghanaian nurses knowledge and application of bio-ethical principles in postoperative pain management. PloS One, 17(10), e0276422.

Ulrich, C. M., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010). Everyday ethics: Ethical issues and stress in nursing practice. Journal of Advanced Nursing, 66(11), 2510-2519.

Ulrich, C. M., Zhou, Q. P., Hanlon, A., Danis, M., & Grady, C. (2014). The impact of ethics and work-related factors on nurse practitioners’ and physician assistants’ views on quality of primary healthcare in the United States. Applied Nursing Research, 27(3), 152-156.

Water, T., Rasmussen, S., Neufeld, M., Gerrard, D., & Ford, K. (2017). Nursing’s duty of care: From legal obligation to moral commitment. Nursing Praxis in Aotearoa New Zealand, 33(3), 7-20.

Wright, F., Cohen, S., & Caroselli, C. (1997). Diverse decisions: How culture affects ethical decision making. Critical Care Nursing Clinics of North America, 9(1), 63-74.

Zagenhagen, K., & Van Rensburg, G. (2018). The influence of rankism on the ethical competence of student nurses in a military context. Scientia Militaria: South African Journal of Military Studies, 46(2), 95-107.

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