Prevalence and determinants of moral distress among nurses in public hospitals of Wolaita Zone, South Ethiopia: a mixed-methods study

Moral distress is a distinct psychological phenomenon where nurses identify the ethically correct course of action but are constrained from implementing it due to institutional, systemic, or policy barriers. In Ethiopia, nurses may face unique cultural and societal expectations that conflict with their ethical principles. This study aimed to assess the prevalence and determinants of moral distress among nurses in the Wolaita Zone. A facility-based explanatory sequential mixed-methods study (cross-sectional quantitative and phenomenological qualitative) was conducted among 459 nurses selected via simple random sampling in August 2023. Quantitative data were collected using a self-administered questionnaire, and qualitative data through in-depth interviews. Data were analyzed using SPSS v26 (quantitative) and OpenCode v3.4 (thematic qualitative). Multivariable logistic regression (Adjusted Odds Ratio [AOR], 95% CI, p < 0.05) identified factors associated with moral distress. Among the 459 nurses, 64.1% experienced moral distress. Key factors included older age groups (30–39 years: AOR = 4.93; 95% CI: 2.27–10.68; >40 years: AOR = 36.08; 95% CI: 12.72–102.38), being a senior clinical nurse (AOR = 8.88; 95% CI: 3.89–20.29), having 5–10 years of service (AOR = 4.20; 95% CI: 1.83–9.62), holding a diploma (AOR = 2.33; 95% CI: 1.28–4.24), lack of organizational commitment (AOR = 2.49; 95% CI: 1.48–7.93), job dissatisfaction (AOR = 3.67; 95% CI: 1.72–8.95), and a non-conducive work environment (AOR = 3.08; 95% CI: 1.37–6.93). Qualitative findings highlighted moral triggers (e.g., inadequate staffing, resource shortages), personal outcomes (physical pain, emotional irritation), coping mechanisms (reporting, peer sharing, spiritual practices), and recommendations for systemic improvements including professional development and improved resource allocation. A high prevalence of moral distress exists among nurses in the Wolaita Zone. Older age, diploma-level education, lack of organizational commitment, job dissatisfaction, and poor work environments are key determinants. Hospital administration should prioritize improving resource allocation, staffing levels, organizational commitment, and administrative leadership to mitigate moral distress and enhance ethical care provision.