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Perceived organizational support and moral distress among nurses



Moral distress is prevalent in the health care environment at different levels. Nurses in all roles and positions are exposed to ethically challenging conditions. Development of supportive climates in organizations may drive nurses towards coping moral distress and other related factors. This study aimed at determining the level of perceived organizational support and moral distress among nurses and investigating the relationship between the two variables.


This was a correlational-descriptive study. A total of 120 nurses were selected using random quota sampling method. A demographic questionnaire, Survey of Perceived Organizational Support, and Moral Distress Scale were used to collect the data which were analyzed using descriptive and analytical tests in SPSS20.


The mean perceived organizational support was low (2.63 ± 0.79). The mean moral distress was 2.19 ± 0.58, which shows a high level of moral distress. Moreover, Statistical analysis showed no significant relationship between perceived organizational support and moral distress (r = 0.01, p = 0.86).


Given the low level of perceived organizational support and high moral distress among nurses in this study, it is necessary to provide a supportive environment in hospitals and to consider strategies for diminishing moral distress.

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Moral distress is a common problem among the professionals employed in health care settings [1]. It occurs when the individuals feel that they cannot act according to the pivotal values and duties or when the measures taken to achieve the intended results fail to succeed so that the totality of individual’s ethical principles is seriously endangered [2]. In other words, moral distress can be considered as the stress tolerated by professionals at a time when, despite an awareness of the right performance, they cannot achieve the correct performance due to some barriers [1, 3,4,5]. Moral distress has been described as a major problem in the nursing profession [5, 6].

The particular characteristics of nursing and the different work cultures generated in different health care institutions expose nurses to a higher risk of moral distress than other professionals [7]. Moral distress has undesirable outcomes for both nurses and patients, and can have direct and indirect effects on nurses. Physical disorders such as nightmares, headache and anxiety and a dysfunctional personal life have been reported among nurses at risk for moral distress [8].

Moreover, feeling of anger, failure, sin, and disability are among the consequences of moral distress. Some studies have demonstrated that moral distress is correlated with personnel burnout, deteriorated team work, reduced quality of care, and challenges related to patient safety [2, 9, 10]. It will further lead to occupational stress and turnover [11].

Various factors contribute to moral distress in nurses among them are invasive procedures on patients with incurable diseases, orders for unnecessary tests or examinations, insufficient and inefficient treatment by colleagues, lack of balance in power among the health specialists, and lack of organizational support [12].

When exposed to stressful environments and high job demands, the employees need the financial and spiritual support of their organization. Perceived organizational support is a condition based on how much the organization considers employees’ values and needs [13]. Organizational support is one of the important indices of nursing work environment [14], and can be considered an influential moral factor [15].

Additionally, one aspect of ethical competency of nurse leaders is their supportive behavior [14]. The leaders’ supportive behavior will be compensated for by the followers’ proper compliance. The organization is less likely to face a situation in which the staff’s behavior disturbs the leader’s or group’s work [14, 16,17,18,19,20]. This perception of level of organizational support especially about ethical practice is a vital element of the constraints upon nurses’ actions [21].

Perceived organizational support reduces stressors in the workplace and is potentially involved in dealing with work-related fatigue, excitement, and depression [22]. Supportive occupational environments are the most important factor in creating job satisfaction for nurses that influences positively the patients’ treatment, absorption and maintenance of manpower in the organization. A climate with high levels of support diminishes occupational tension and maintains the nurses in the organization [23].

Moreover, some studies have revealed that perceived organizational support is negatively correlated with work absenteeism [24], and intent to turnover [25], while it is positively correlated with award expectation, role of performance and social behavior, preventive and civil behaviors [26], and also organizational commitment and subsequently self-competency [27]. Nurse leaders’ supportive behavior plays a key role in productivity and promoting nurses’ professional performance [20, 28].

Iran is a developing country located in the south-west of Asia with a population of about 80,000,000 people. The nursing manpower at different levels is estimated to be about 150,000. As it is the case in many other developing countries, nurses in Iran encounter many challenges such as long working hours, changing work shifts, limited vacation, abundant occupational wants and wishes, unsatisfactory payment or salary, and inappropriate behavior towards some patients or their families [29, 30]. These challenges often result from deficient techniques of manpower management in hospitals [30], shortage of manpower, job dissatisfaction, nurses’ low social status, absence of a satisfactory student acceptance system at the universities, and shortage of ethics course in the nursing curriculum [31,32,33,34,35,36], leading to increased workload, fostered medical and nursing errors, and subsequently, moral distress in nurses [36].

There are some controversies about the level of moral distress among Iranian nurses [37,38,39,40]. A review of literature related to the two variables “perceived organizational support” and “moral distress” indicated that the investigation of these two variables has been very limited on Iranian nurses. Furthermore, no comprehensive study has been found on determining the correlation between “perceived organizational support” and “moral distress” among Iranian nurses. Development of supportive organizations may lead nurses to better cope with moral distress and other problems such as job dissatisfaction [5, 21, 41,42,43].


The purpose of this research was to determine the level of perceived organizational support and moral distress among nurses and to investigate the relationship between these two variables.


Research design

This correlational descriptive study used random quota sampling to select the participants. First, considering the distribution of hospitals affiliated to Shahid Beheshti University of Medical Sciences in different regions of Tehran (north, south, east, west and center), one hospital was randomly selected from each region and the required number of nurses was selected from each hospital in proportion to the total number of nurses working in it. Considering the number of hospitals surveyed, 120 questionnaires were distributed among all the qualified nurses selected from the morning, evening, and night shifts using random sampling.

The sample size was calculated by the following formula to explore correlation between moral distress and perceived organizational support.

$$ N={\left[\frac{Z_{\alpha }+{Z}_{\beta }}{c}\right]}^2+3 $$

Where N is the desired sample size, Z α is the standard normal score of 95% of confidence interval = 1.96, Z β = statistical power at 90%, which is 1.28 and c = 0/5 × Ln[(1 + r)(1 − r)] with being the correlation coefficient, which is 0.3 according to a study by Jay Maningo-Salinas [15].

Considering a participant attrition of 10%, 120 nurses were selected for the study. However, 110 completed questionnaires were analyzed. The study inclusion criteria consisted of having a bachelor’s degree or higher in nursing and at least 1 year of work experience.

Data collection tools

In this study, a demographic questionnaire, Eiesenberger’s Survey of Perceived Organizational Support (SPOS), and nurses’ Moral Distress Scale (MDS) were used to collect the data.

Demographic information questionnaire

The demographic questionnaire examined participants’ demographic data including age, gender, marital status, level of education, work experience, work shifts, and history of attendance in ethics workshops.

Survey of Perceived Organizational Support

The 8-item SPOS was developed by Eisenberger et al. [13]. Each item in this survey is scored based on a 7-point Likert scale from strongly disagree (zero) to strongly agree (six). The range of scores in each item varies from zero to six while on a total scale is zero to 48. A higher score indicates more perceived organizational support. This scale is a unidimensional measure and has been widely used in research studies. Evidence of its validity and reliability has been reported in numerous studies [44,45,46]. The Cronbach’s alpha coefficient of perceived organizational support was calculated as 0.74 in this study.

Moral distress scale

The nurses’ MDS is a native scale developed by Atashzadeh-Shoorideh et al. [40]. It contains 30 items in three dimensions, namely “inappropriate competencies and responsibilities”, “errors”, and “not respecting the ethical principles”. All the items in this scale are scored based on a 5-point Likert scale from 0 (not at all) to 4 (very much). The score of moral distress is then calculated as the mean of the total score of the items. The score of moral distress obtained is then classified into four categories: 0–1 is low, 1.01–2 is moderate, 2.01–3 is high, and 3.01–4 is very high moral distress. The Cronbach’s alpha coefficient for the “Moral Distress Scale” and all of its dimensions designed by Atashzadeh-Shoorideh et al. was calculated in this study as 0.77.

Data collection

The participants were oriented on how to answer the questionnaires and were informed about the voluntary nature of participation in the study. The questionnaires were distributed among nurses working in different shifts and were collected within 2 days.

Data analysis

The collected data was analyzed via SPSS 20 using the descriptive statistics of data as absolute and relative frequency report, and inferential statistics as a determination of correlation between the variables under study via Pearson product moment correlation coefficient.


The study participants consisted of 110 nurses with a mean age of 34.1 ± 7.4 years and a mean work experience of 9.6 ± 6.5 years, 90% of them were female, 55.5% were married and 95.5% held a bachelor’s degree in nursing. The majority of the nurses (48.2%) were working in rotating shifts. The majority (51.8%) had not attended ethics workshops in the past (Table 1).

Table 1 Sociodemographic characteristics of study participant

As shown in Table 2, the mean perceived organizational support was low (2.63 ± 0.79) and the mean moral distress was high (2.19 ± 0.58). The highest mean of moral distress pertained to the dimension of errors (2.43 ± 0.65).No relationships were observed between perceived organizational support and moral distress (p = 0.86) or its dimensions (p > 0.05); (Table 3).

Table 2 Mean and standard deviation of perceived organizational support, moral distress, and the associated dimensions
Table 3 Correlation between perceived organizational support and moral distress and its dimensions

There was a statistically significant relationship between moral distress and work shifts. Also, relationship between the dimension of errors and work shifts was statistically significant. The significance level set for the work shift test was p = 0.04 for moral distress and p = 0.00 for the dimension of errors. A significant relationship was also observed between the inappropriate competencies and responsibilities dimension of moral distress and work experience (p = 0.04) as shown in Table 4.

Table 4 Correlation between organizational support and moral distress and its dimensions with Sociodemographic characteristics


This study was conducted to determine the level of perceived organizational support and moral distress among nurses and to investigate the relationship between these two variables.

The results revealed low perceived organizational support in the nurses, this finding supports the results of previous studies. In a study by Kwak conducted on nurses in South Korea, organizational support was investigated using corrected nursing work index with a rate assessed as falling in the low limits [47]. Another study carried out on nurses in Italy reported the mean score of perceived organizational support as 2.26 ± 0.78 which is lower than the central point value reported by Eisenberger et al.’s scale [48]. This is inconsistent with other studies that reported moderate perceived organizational support [15, 29]. Jay Maningo-Salinas investigated the perceived organizational support level among oncology nurses using Eisenberg et al.’s scale and reported it at the moderate level of 3.70 ± 0.86.16. Moreover, the study by Gorji et al. reported the perceived organizational support among the emergency room nurses as moderate [29].

The dissimilarity of results between these studies and the present one may be due to the differences in the instruments used, the research populations, the climate of the organization and how their respective managers managed the research populations. The lack of a supportive environment in hospitals may cause further moral and work conflicts, job dissatisfaction, and reduced employees’ trust in the organization [48].

The current study reported the intensity of moral distress as high among the nurses, which is consistent with the results obtained by Woods et al. conducted on nurses in New Zealand [49]. Also, Cummings found that the prevalence of moral distress was high among nurses and proposed this phenomenon as responsible for nurses’ turnover rates [50].

Moral distress has been reported as moderate in some studies [37,38,39, 53], while it is reported to be lower than moderate in a number of other studies [51, 52]. A study on Swedish nurses elucidated the point that moral distress was at the low range [54]. Additionally, the studies carried out in America reported the nurses’ moral distress scores at rather low levels [5, 55]. Another study undertaken in Turkey showed that nurses had low-level moral distress [1], a finding which is inconsistent with our results.

This inconsistency may be attributed to differences in organizational, cultural, educational, geographical, and individual factors and beliefs. For instance, mention can be made of the existence of the required standards of care in hospitals, level of knowledge and awareness, high participation of the health staff, and ethical traits of the participants. Also, it may be speculated that the extreme differences in moral distress between this study and other endeavors may be attributed to variations in the study population and measurement instruments used in the present study. The scale used in this study to measure moral distress includes three dimensions while the moral distress instrument used in other studies has been one-dimensional with some items not appropriately working in the Iranian context. For example, the item of “discharge a patient when he has reached the maximum length of stay based on diagnostic related grouping although he has many teaching needs” in Corley Moral Distress Scale isn’t appropriate in Iranian nurses. Comparing the findings of this research with other studies has shown that moral distress for most nurses is moderate to high.

In this study, the highest level of moral distress pertained to the dimension of “errors”, while the lowest level belonged to the aspect of “not respecting ethical principles”. In numerous studies, the most common causes of moral distress among nurses have been reported to be working with incompetent staff [1, 40, 49, 56], useless care [1, 40], and inappropriate intra-team relations [1, 49]. On the basis of the results of these studies, high level of distress in the dimension of “errors” seems to be logical compared to other dimensions.

The results of this study showed no statistically significant relationships between perceived organizational support and moral distress and any of its’ dimensions, A study by Maningo-Salinas, conducted on oncology nurses, expunged upon the correlation between moral distress and inclination for turnover and also determined the mediating effect of perceived organizational support on these two variables. Their findings suggested that perceived organizational support does not mediate the correlation between moral distress and inclination for turnover and that the interaction between moral distress and perceived organizational support was not statistically significant [15]. They point out no statistically significant relationship, this possibility suggests that Eisenberg’s perceived organizational support scale may not be the best instrument for measuring perceived organizational support among the nurses. Hence, it is necessary to carry out a more comprehensive study regarding the use of a perceived organizational support tool in nursing [15].

Of course, several studies have reported the effect of ethical work climate on moral distress. The ethical climate does not often lead to personnel’s’ perceived organizational support. The reason for this can be the creation of a work environment which is reliable in the organization [57]. Fogel showed that ethical climate agents have a moderating effect on the moral distress, turnover, poor patient care, and justice subjects [58]. In the study by Fogel, the relations between managers and Fnurses induced significant effects on ethical work climate [58]. This, in turn, affects moral distress. Silen’s study showed that ethical climate is an important factor in nurses’ work setting [54]. But in some articles, it has been indicated that a negative relationship exists between ethical climate and moral distress [50,51,52,53, 59].

In the current study, perceived organizational support was not significantly correlated with any of the demographic variables examined, while a significant relationship was observed between the inappropriate competencies and responsibilities dimension of moral distress and the variable of work experience. The present study found a statistically significant relationship between total moral distress and the dimension of errors and work shifts. This is inconsistent with the results obtained by Atashzadeh-Shoorideh et al. [40]. The inconsistency between the findings of the present study and the study of Atashzadeh-Shoorideh et al. may be due to the differences in the research setting and work environment, which may have led to lower rates of error and moral distress in the nurses examined by Atashzadeh-Shoorideh et al. [40].

The limitations of this research are the descriptive design and data collection with a questionnaire and reliance on self-report data. As a result, some people may refuse to provide real responses and give unrealistic responses. A further limitation is the potential impact of confounding factors such as high occupancy, fatigue, and lack of readiness of nurses to complete the questionnaire. This study used a cross-sectional design. For this reason, it makes the conclusion about cause-effect relations difficult. Therefore, a closer examination can be done by conducting in-depth and longitudinal studies. A further limitation of this research was the selection of nurses from just one city. With the implementation of national and international studies, the possibility of generalizing these findings will increase.


The results of this study showed that the level of perceived organizational support was low in nurses and moral distress was high. Therefore, it is necessary to provide a supportive environment in hospitals and to consider strategies for diminishing moral distress.

Also, the findings indicated that there was no significant correlation between perceived organizational support and moral distress. These results are not consistent with the findings of other studies on moral distress. It is recommended that a similar study be carried out with other measurement scales of organizational support and the results be compared and contrasted with our findings.



Intensive Care Unit


Moral Distress Scale


Registered Nurse


Survey of Perceived Organizational Support


  1. 1.

    Karagozoglu S, Yildirim G, Ozden D, Çınar Z. Moral distress in Turkish intensive care nurses. Nurs Ethics. 2017;24(2):209–24.

    PubMed  Article  Google Scholar 

  2. 2.

    Wallis L. Moral distress in nursing. AJN Am J Nurs. 2015;115(3):19–20.

    PubMed  Article  Google Scholar 

  3. 3.

    Johnstone M-J, Hutchinson A. “Moral distress”–time to abandon a flawed nursing construct? Nurs Ethics. 2015;22(1):5–14.

    PubMed  Article  Google Scholar 

  4. 4.

    McCarthy J, Gastmans C. Moral distress: a review of the argument-based nursing ethics literature. Nurs Ethics. 2015;22(1):131–52.

    PubMed  Article  Google Scholar 

  5. 5.

    Corley MC, Minick P, Elswick RK, Jacobs M. Nurse moral distress and ethical work environment. Nurs Ethics. 2005;12(4):381–90.

    PubMed  Article  Google Scholar 

  6. 6.

    Gallagher A. Moral distress and moral courage in everyday nursing practice. Online J Issues Nurs. 2011;16(2):1–8.

    Google Scholar 

  7. 7.

    Hamric AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Prim Res. 2012;3(2):1–9.

    Article  Google Scholar 

  8. 8.

    Lazzarin M, Biondi A, Di Mauro S. Moral distress in nurses in oncology and haematology units. Nurs Ethics. 2012;19(2):183–95.

    PubMed  Article  Google Scholar 

  9. 9.

    Rodney PA. What we know about moral distress. AJN Am J Nurs. 2017;117(2):S7–10.

    PubMed  Article  Google Scholar 

  10. 10.

    Burston AS, Tuckett AG. Moral distress in nursing: contributing factors, outcomes and interventions. Nurs Ethics. 2013;20(3):312–24.

    PubMed  Article  Google Scholar 

  11. 11.

    Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. J Adv Nurs. 2001;33(2):250–6.

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    McCarthy J, Deady R. Moral distress reconsidered. Nurs Ethics. 2008;15(2):254–62.

    PubMed  Article  Google Scholar 

  13. 13.

    Eisenberger R, Jones JR, Aselage J, Sucharski IL. Perceived organizational support. J Appl Psychol. 1986;71(3):500–7.

    Article  Google Scholar 

  14. 14.

    Barkhordari-Sharifabad M, Ashktorab T, Atashzadeh-Shoorideh F. Ethical competency of nurse leaders A qualitative study. Nurs Ethics. 2016; Epub ahead of print 14 Jun 2016. DOI:

  15. 15.

    Maningo-Salinas MJ. Relationship between moral distress, perceived organizational support and intent to turnover among oncology nurses. Minneapolis, MN: Capella University; 2010.

  16. 16.

    Den Hartog DN, De Hoogh AHB. Empowering behaviour and leader fairness and integrity: studying perceptions of ethical leader behaviour from a levels-of-analysis perspective. Eur J Work Organ Psychol. 2009;18(2):199–230.

    Article  Google Scholar 

  17. 17.

    Mayer DM, Kuenzi M, Greenbaum R, Bardes M, Salvador RB. How low does ethical leadership flow? Test of a trickle-down model. Organ Behav Hum Decis Process. 2009;108:1–13.

    Article  Google Scholar 

  18. 18.

    Neubert MJ, Carlson DS, Kacmar KM, Roberts JA, Chonko LB. The virtuous influence of ethical leadership behavior: evidence from the field. J Bus Ethics. 2009;90(2):157–70.

    Article  Google Scholar 

  19. 19.

    Resick CJ, Hanges PJ, Dickson MW, Mitchelson JK. A cross-cultural examination of the endorsement of ethical leadership. J Bus Ethics. 2006;63(4):345–59.

    Article  Google Scholar 

  20. 20.

    Barkhordari-Sharifabad M, Ashktorab T, Atashzadeh-Shoorideh F. Ethical leadership outcomes in nursing: A qualitative study. Nurs Ethics. 2017; Epub ahead of print 18 Jan 2017. doi:

  21. 21.

    Erlen JA. Moral distress: a pervasive problem. Orthop Nurs. 2001;20(2):76–80.

    CAS  PubMed  Article  Google Scholar 

  22. 22.

    Liu L, Hu S, Wang L, Sui G, Ma L. Positive resources for combating depressive symptoms among Chinese male correctional officers: perceived organizational support and psychological capital. BMC Psychiatry. 2013;13:89.

    PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    AbuAlRub RF. Job stress, job performance, and social support among hospital nurses. J Nurs Scholarsh. 2004;36(1):73–8.

    PubMed  Article  Google Scholar 

  24. 24.

    Adebayo SO, Nwabuoku UC. Conscientiousness and perceived organizational support as predictors of employee absenteeism. Park J Soc Sci. 2008;5(4):363–7.

    Google Scholar 

  25. 25.

    Tumwesigye G. The relationship between perceived organisational support and turnover intentions in a developing country: the mediating role of organisational commitment. African J Bus Manag. 2010;4(6):942–52.

    Google Scholar 

  26. 26.

    Uymaz AO. Prosocial organizational behavior: is it a personal trait or an organizational one. Eur J Bus Manag. 2014;6(2):124–9.

    Google Scholar 

  27. 27.

    Battistelli A, Galletta M, Vandenberghe C, Odoardi C. Perceived organisational support, organisational commitment and self-competence among nurses: a study in two Italian hospitals. J Nurs Manag. 2016;24(1):E44–53.

    PubMed  Article  Google Scholar 

  28. 28.

    Dehghan Nayeri N, Nazari AA, Salsali M, Ahmadi F, Adib HM. Iranian staff nurses’ views of their productivity and management factors improving and impeding it: a qualitative study. Nurs Health Sci. 2006;8(1):51–6.

    PubMed  Article  Google Scholar 

  29. 29.

    Gorji HA, Etemadi M, Hoseini F. Perceived organizational support and job involvement in the Iranian health care system: a case study of emergency room nurses in general hospitals. J Educ Health Promot. 2014;3:58.

    PubMed  PubMed Central  Google Scholar 

  30. 30.

    Sabokroo M, Kalhorian R, Kamjoo Z, Taleghani G. Work-family conflict: the role of organizational support on intention to leave the job (case study of Tehran hospital nurses). J Public Manag. 2011;3(6):111–26.

    Google Scholar 

  31. 31.

    Shahriari M, Mohammadi E, Abbaszadeh A, Bahrami M, Fooladi MM. Perceived ethical values by Iranian nurses. Nurs Ethics. 2011;19(1):30–44.

    PubMed  Article  Google Scholar 

  32. 32.

    Esmaelzadeh F, Abbaszadeh A, Borhani F, Peyrovi H. Ethical sensitivity in nursing ethical leadership: a content analysis of Iranian nurses experiences. Open Nurs J. 2017;11:1–13.

    PubMed  PubMed Central  Article  Google Scholar 

  33. 33.

    Atashzadeh-Shorideh F, Ashktorab T, Yaghmaei F. Iranian intensive care unit nurses’ moral distress a content analysis. Nurs Ethics. 2012;19(4):464–78.

    PubMed  Article  Google Scholar 

  34. 34.

    Farsi Z, Dehghan Nayeri N, Negarandeh R, Broomand S. Nursing profession in Iran: an overview of opportunities and challenges. Japan J Nurs Sci 2010;7(1):9–18.

  35. 35.

    Sadeghi A, Goharloo Arkawaz A, Cheraghi F, Moghimbeigi A. Relationship between head nurses’ servant leadership style and nurses' job satisfaction. Q J Nurs Manag. 2015;4(1):28–38.

    Google Scholar 

  36. 36.

    Cheraghi MA, Salsali M, Safari M. Ambiguity in knowledge transfer: the role of theory-practice gap. Iran J Nurs Midwifery Res. 2010;15(4):155–66.

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Poladi F, Atashzadeh-Shoorideh F, Abaaszade A, Moslemi A. The correlation between moral distress and burnout in nurses working in educational hospitals of Shahid Beheshti University of Medical Sciences during 2013. Iran J Med Ethics Hist Med. 2015;8(4):37–45.

    Google Scholar 

  38. 38.

    Joolaee S, Jalili H, Rafiee F, Haggani H. The relationship between nurses’ perception of moral distress and ethical environment in Tehran University of Medical Sciences. Iran J Med Ethics Hist Med. 2011;4(4):56–66.

    Google Scholar 

  39. 39.

    Ameri M, SafaviBayat Z, Ashktorab T, Kavoosi A. Atefeh Vaezi. Moral distress: evaluating nurses’ experiences. Iran J Med Ethics Hist Med. 2013;6(1):64–73.

    Google Scholar 

  40. 40.

    Atashzadeh-Shoorideh F, Ashktorab T, Yaghmaei F, Alavi MH. Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nurs Ethics. 2015;22(1):64–76.

    Article  Google Scholar 

  41. 41.

    Cassells JM, Silva MC, Chop RM. Administrative strategies to support staff nurses as moral agents in clinical practice. Nursingconnections. 1990;3(4):31–7.

    CAS  PubMed  Google Scholar 

  42. 42.

    Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics. 2002;9(6):636–50.

    PubMed  Article  Google Scholar 

  43. 43.

    Olson LL. Ethical climate as the context for nursing retention. J Illinois Nurs. 2002;99(6):3–7.

    Google Scholar 

  44. 44.

    Lee J, Peccei R. Discriminant validity and interaction between perceived organizational support and perceptions of organizational politics: a temporal analysis. J Occup Organ Psychol. 2011;84(4):686–702.

    Article  Google Scholar 

  45. 45.

    Francis CA. The mediating force of “face” supervisor character and status related to perceived organizational support and work outcomes. J Leadersh Organ Stud. 2012;19(1):58–67.

    Article  Google Scholar 

  46. 46.

    Gillet N, Colombat P, Michinov E, Pronost A, Fouquereau E. Procedural justice, supervisor autonomy support, work satisfaction, organizational identification and job performance: the mediating role of need satisfaction and perceived organizational support. J Adv Nurs. 2013;69(11):2560–71.

    PubMed  Google Scholar 

  47. 47.

    Kwak C, Chung BY, Xu Y, Eun-Jung C. Relationship of job satisfaction with perceived organizational support and quality of care among south Korean nurses: a questionnaire survey. Int J Nurs Stud. 2010;47(10):1292–8.

    PubMed  Article  Google Scholar 

  48. 48.

    Bobbio A, Bellan M, Manganelli AM. Empowering leadership, perceived organizational support, trust, and job burnout for nurses: a study in an Italian general hospital. Health Care Manag Rev. 2012;37(1):77–87.

    Article  Google Scholar 

  49. 49.

    Woods M, Rodgers V, Towers A, La Grow S. Researching moral distress among New Zealand nurses: a national survey. Nurs Ethics. 2015;22(1):117–30.

    PubMed  Article  Google Scholar 

  50. 50.

    Cummings CL. The effect of moral distress on nursing retention in the acute care setting. Jacksonville, FL:University of North Florida; 2009.

  51. 51.

    Maiden JM. A quantitative and qualitative inquiry into moral distress, compassion fatigue, and medication error in critical care nurses. San Diego, CA: University of San Diego; 2008.

  52. 52.

    Fernandez-Parsons R, Rodriguez L, Goyal D. Moral distress in emergency nurses. J Emerg Nurs. 2013;39(6):547–52.

    PubMed  Article  Google Scholar 

  53. 53.

    Pauly B, Varcoe C, Storch J, Newton L. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics. 2009;16(5):561–73.

    PubMed  Article  Google Scholar 

  54. 54.

    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(23–24):3483–93.

    PubMed  Article  Google Scholar 

  55. 55.

    O’Connell CB. Gender and the experience of moral distress in critical care nurses. Nurs Ethics. 2015;22(1):32–42.

    PubMed  Article  Google Scholar 

  56. 56.

    Vaziri MH, Merghati-Khoei E, Tabatabaei S. Moral distress among Iranian nurses. Iran J Psychiatry. 2015;10(1):32–6.

    PubMed  PubMed Central  Google Scholar 

  57. 57.

    Valentine S, Greller MM, Richtermeyer SB. Employee job response as a function of ethical context and perceived organization support. J Bus Res. 2006;59(5):582–8.

    Article  Google Scholar 

  58. 58.

    Fogel KM. The relationships of moral distress, ethical climate, and intent to turnover among critical care nurses. Chicago, IL: The University of Chicago; 2007.

  59. 59.

    Mathumbu D, Dodd N. Perceived organisational support, work engagement and organisational citizenship behaviour of nurses at Victoria Hospital. Aust J Psychol. 2013;4(2):87–93.

    Google Scholar 

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The authors would like to express their gratitude to all the hospitals affiliated to the Ministry of Health and its medical sciences universities, to all the participating nurses and finally to Dr. Eisenberger for allowing us to use the Survey of Perceived organizational support.


This research project was funded by Shahid Beheshti University of Medical Sciences in Tehran, Iran (Project code: 7582). Shahid Beheshti University of Medical Sciences had no part in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Availability of data and materials

Sharing the data is not possible due to an agreement with the participants on the confidentiality of the data.

Author information




All authors (NR, FA, TA, AB and MB) have participated in the conception and design of the study. NR contributed the data collection and prepared the first draft of the manuscript. FA and TA critically revised and checked closely the proposal, the analysis and interpretation of the data and design the article. AB carried out the analysis, interpretation of the data and drafting the manuscript. MB has been involved in revising the manuscript critically. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Foroozan Atashzadeh-Shoorideh.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (No. 1394.255). The questionnaires were distributed among the participants after obtaining legal permissions from the authorities and ensuring compliance with ethical issues. Before commencing the study, written consent was provided by all participants. Permissions to use the SPOS and the MDS were obtained from instruments developers.

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The authors declare that they have no competing interests.

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Robaee, N., Atashzadeh-Shoorideh, F., Ashktorab, T. et al. Perceived organizational support and moral distress among nurses. BMC Nurs 17, 2 (2018).

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  • Ethics
  • Morals
  • Perceived organizational support
  • Moral distress
  • Nurses