1. INTRODUCTION:

In the nursing practice environment where disease often preponderates, critical care nurses are affected by numerous facets, as they are exposed to a hefty array of stressors, which on a daily basis can put them in problematic circumstances and impose them to experience moral dilemmas, thus leading to moral distress⁽¹⁾. However, when an nurses develops the ability to feel, interpret, and express emotions correctly, adaptively, and follows accepted standard, he/she puts up actions that are morally inclined which means Emotional Intelligence (EI) leads to moral competence and enhance professional success and workforce work engagement^(2,3).

1.1 Conceptual framework:

The clinical, conceptual, and empirical literature hypothesis dynamic relationships between moral distress, emotional intelligence, and work engagement. Emotional intelligence is conceptualized as an independent variable that relates to work engagement and moral distress. The conceptual model for this study is developed by the researchers and depicted in Figure 1. It is based upon a review of linked literatures^(1-4).

Figure (1): Conceptual Model: Proposed Relationships among Moral Distress, Emotional Intelligence and Work Engagement.

1.1.1. Moral Distress:

Moral distress refers to aching feelings and psychological imprudence that arise when nurses are cognizant of the morally correct conduct to be followed, but are repelled to follow that course of deed because of hurdles such as the lack of time, unwillingness of overseers, the impeding structure of medical clout, institutional policies, or legal aspects^(5,6). Also, the American Nurse Association code of ethics (ANA) 2015 ⁽⁷⁾ depicts moral distress as the state of knowing the morally exact thing to do, but institutional, practical or social restrictions make undertaking the right thing closely unattainable; intimidate core tenets and moral impartiality.

Corley (2002)⁽⁸⁾ was one of the first researchers who examined moral distress amongst nurses in critical and intensive care nurses. He developed a theory of moral distress which is based on two grounds; 1) nursing is a moral profession, and 2) nurses are moral agents. When a nurse cannot enact moral agency, she/he becomes vulnerable to moral distress. Also, he specified that nursing was an intrinsically “moral endeavor”. As such, nurses were faced each day with conditions in which the right replies were not always clear or possible. In fact, not infrequently, nurses were obliged to make decisions in violation of their own senses of personal and professional morality and ethics either due to organizational pressures or other environmental circumstances and conditions.

In this sense, moral distress can derive from a variety of sources, including restricted resources, legislations, direct communication with patients, providing superfluous medical care, hospital procedures, more social plea, an affront to the independence of patients, relations between doctors and nurses, struggles with the wishes of the family, decisions on the release of patient’s information, and the incapacity to prevent the patient’s death^(8-13). However, not all theorists considered the practice of moral distress completely negative; Peter and Liaschenko (2004)⁽¹⁴⁾, and Hardingham (2004)⁽¹⁵⁾ suggested that some nurses find the experience of moral distress to be a positive catalyst for change and for understanding their own moral values, professional obligations as nurses, and moral commitments.

Several researchers (Corley, 2002; Elpern et al., 2005; Jay 2010)^(8,16,17) contended that intense and frequent or persistent exposure to moral distress and the resulting residue affect nurses’ physical, mental, spiritual, social relations, personal and professional aspect which include the development of emotional symptoms, such as foiling, unease, fury, and blame; as well as physical clues, such as shaking, sweating, headaches, diarrhea, and crying, with possible risks of stumpy self-esteem, harm of integrity and the inability to deliver patients with good care that causes job dissatisfaction, stress, quitting job, grief, shame, tiredness, insecurity, fear, depression in nurses and influences their performance that leads to nurses’ burnout and anticipated turnover. Numerous Studies indicate that higher levels of emotional intelligence (EI) could temper the negative effects of moral distress^(18-22).

1.1.2. Emotional Intelligence:

Mayer and Salovey (1997)⁽²³⁾ defined EI as the capability to perceive precisely, judge, and express emotions; the ability to access and/or engender feelings when they smooth thought; the ability to comprehend emotion and emotional knowledge; and the capacity to regulate emotions to promote emotional and intellectual progress. Wong and Law (2002)⁽²⁴⁾ defined EI as "a set of abilities that a person uses to understand, regulate, and make use of his or her own emotions". Murthy (2004)⁽²⁵⁾ added that "El is the ability to choose the right feelings appropriate to a given situation and the skill to communicate these feelings effectively. It is the emotional competency which includes awareness of our own emotions, ability to identify and empathize with others' feelings". In addition, Coleman (2008)⁽²⁶⁾ refers to it as "the capability of individuals to recognize their own, and other people's emotions, to distinguish between different feelings and tag them appropriately, to use emotional information to monitor thinking and behavior, and manage and/or fit emotions to adapt environment and achieve one's goals".

Wong and Law (2002)⁽²⁴⁾ classified EI into four dimensions: self-emotion appraisal, others emotion appraisal, use of emotion, and regulation of emotion. Self-emotion Appraisal (SEA) refers to an individual’s aptitude to understand his or her profound emotions and express them naturally. Most people with the ability to express themselves naturally sense and recognize their emotions better. Others- emotion Appraisal (OEA) focuses on an individual’s capability to perceive and understand the emotions of people. Consequently, be very sensitive to the emotions of others and predict the emotional responses of others. Use of Emotion (UOE) relates to an individual’s ability to make use of his or her emotions by guiding them toward productive activities and personal performance. In the light of this, the person who is able to maintain positive emotions most of the time is able to encourage him-or herself to do better. Regulation of emotion (ROE) means the ability of the person to manage his or her emotions, enabling a more rapid recovery from psychological mood swings- positive or negative. Consequently, enable the person to return quickly to a normal psychological state after rejoicing or experiencing distress, be less likely to lose his or her temper⁽²⁷⁾.

Bar-On et al. (2007)⁽²⁸⁾ clarified that EI helps individuals to manage emotions and communicate effectively, enhance decision making, be sufficiently optimistic, positive and self-motivated. Consequently, improve job satisfaction and performance. Emotional intelligent nurses are better equipped to be sensitive to the patients’ emotional needs; handle relationships with patients while maintaining a healing environment, provide excellent caring behavior^(29,30). Ciarrochi et al. (2001)⁽³¹⁾ hypothesized that individuals high in emotional intelligence may adapt well to stressful events and those with low emotional intelligence may adapt poorly, which would include responding with depression, hopelessness, and other negative behaviors. EI enables nurses to become aware of their expressed emotion and helps them work harmoniously through their views and feelings (Mayer & Salovey, 1997)⁽²³⁾.

Behind the emotional intelligence model is the theory that personal development will lead to professional success and boosted labor force engagement through building glad, self-confident and mature nurses. Aptitude to control one’s emotions and the capacity to positively manipulate other people’s emotions play a key role in nurses’ engagement⁽³²⁾.

1.1.3. Work Engagement:

Schaufeli et al. (2002)⁽³³⁾ define work engagement as “a positive, fulfilling, work-related state of mind that is characterized by vigor, dedication, and absorption”. It is characterized by high levels of energy at work, mental resilience while working, a willingness to invest effort in one’s work, persistence even in times of difficulty, a sense of enthusiasm, inspiration, pride, and challenge in regards tone’s work, and being deeply engrossed and fully concentrated in one’s work. Robinson et al. (2004) ⁽³⁴⁾ clarified work engagement as a positive attitude held by the nurses towards the organization and its value which means it is one step up from commitment. Gupta (2008)⁽³⁵⁾ concluded that it is only an ‘engaged nurses’ who is intellectually and emotionally bound with the organization, feels passionately about its goals and understands the values of organization. It represents a “motivational process that is driven by the availability of resources”. Both job resources, i.e., supervisory coaching, financial rewards, performance feedback, autonomy, career opportunities, etc., and personal resources, i.e., optimism, self‐efficacy, self‐esteem, etc., may engage employees in their work⁽³⁶⁾.

In this context, Schaufeli et al. (2002)⁽³³⁾ classified work engagement into three aspects; vigor, dedication, and absorption. Vigor is branded by high levels of power and mental resilience while working, the inclination to invest exertion in one’s work, and persistence even in the face of snags. Dedication refers to being powerfully involved in one's work and undergoing a sense of importance, eagerness, motivation, pride, and challenge. Absorption, is characterized by being completely concentrated and happily occupied in one’s work, whereby time passes rapidly and one has hitches with detaching oneself from work.

SIGNIFICANCE OF STUDY:

In health care environment, critical care nurses are experience a high degree of stress due to the demands of their environment, fast- paced, unpredictable clinical care, quick overturn in patients, the acute level of care required for their patients, aggressive treatment of patients fronting death, false examinations, incomplete and poor treatment by the staff, biased dissemination of power among colleagues, and deficiency of organizational support, hierarchical system in which nurse operate, budget deficits and most recently, the addition of technology requirements. Moreover, nurses are obligated by rules and regulation to provide care to every person, even when the acuity and bulk of patients is beyond the services capacity of any given emergency department. Within this context, maximum grade of moral distress can arise among nurses. As evidenced by researches^(36,37), greater that 50% critical care units and 65% of ICU nurses are reported experiencing moral distress. As a results moral distress cause nurses to act in a way opposing to their personal and professional values, leads to withdrawal and a flight response on the part of nurses to their work, nurses become apathetic leading to mistakes in the practical setting, quality of patient care is threatened as nurses avoid and not engaged in their work as a coping strategy for dealing with moral distress.

2. MATERIAL AND METHODS:

The aim of this study is to assess the relationship emotional intelligence, moral distress and work engagement. Methods: A descriptive correlational research design was used. Setting: the study was conducted in critical care units (n= 9 units) at three governmental hospitals namely; Alexandria University hospitals (n=5 units), University Students Hospital (n=2 units), and Smouha University Hospital (n=1 unit), which are considered as non for profit organizations with large bed capacity and admit similar types of patients who had slightly the same acuity level. Participants: A convenient sample was elicited including all nurses (N =250) who were working at previously mentioned settings and agreed to participate in this study. They were classified as; Alexandria University hospitals (n=179), University Students Hospital (n=46), and Smouha University Hospital (n=25).

Tools: three tools were used to collect the necessary data;

Tool (1): Moral Distress Scale Revised (MDS-R). It was developed by Karagozoglu et al. (2017)⁽⁴⁰⁾ to assess the frequency and intensity of moral distress suffered by critical care nurses working in a hospital. The original version of moral distress scale was developed by Corley (2001)⁽³⁸⁾ including 32 items and revised by Hamric et al. (2012)⁽³⁹⁾. MDS-R consists of 21 items, the scale has two parts: frequency and intensity. The responses were measured on five-part Likert scale in the frequency dimension from (0) never (4) very frequently and in the intensity dimension from (0) none to (4) great extent. Item scores of the MDS-R were obtained by multiplying the frequency score of each item (0–4) with the intensity score of each item (0–4). When calculating the score of an item in the scale, scores for frequency and intensity are multiplied with each other, and then one single score is obtained. The possible resulting score to be obtained from the 21 items will range between 0 and 336 the higher scores indicate that the level of distress is high. The mean percent score range from 0 - 33.3% indicates lower moral distress, 33.4 - 66.6 indicates moderate moral distress and 66.7 – 100% indicates higher moral distress.

Tool (2): Wong and Law Emotional Intelligence Scale (WLEIS): this tool was developed by Wong and Law (2002)⁽⁴¹⁾ and validated by Kong (2017)⁽⁴²⁾. It was used was used to assess traits emotional intelligence (TEI). It consists of 16 items classified into 4 dimensions self-emotion appraisal, others emotion appraisal, use of emotion, and regulation of emotion each one had 4 items. The responses were measured on a five point- likert scale ranging from (1) strongly disagree to (5) strongly agree. The overall scoring system ranging from 16 to 80; the higher score indicating higher emotional intelligence and vice versa. The mean percent score range from 0 - 33.3% indicates lower EI, (33.4 - 66.6) indicates moderate EI and (66.7–100%) indicates higher EI.

Tool (3): Utrecht Work Engagement Scale. This tool was developed by Schaufeli el al. (2002)⁽³³⁾ to assess nurses’ work engagement. It consists of 17 items classified into 3 dimensions; vigor (6 items), dedication (5 items), and absorption (6 items). The responses were measured on a 7-point likert scale ranging from (0) never to (7) always. The overall sore range from 0- 119; the higher score represent higher work engagement and vice versa. The mean percent score range from 0 - 33.3% indicates lower work engagement, (33.4 - 66.6) indicates moderate work engagement and (66.7 – 100%) indicates higher work engagement.

In addition, socio-demographic and work related data was developed by the researcher, related to age, gender, educational level, and years of experience.

Validity and reliability:

The study tools were translated into the Arabic language to suit the Egyptian culture and tested for content validity along with the fluency of the translation by five experts in the field of study Accordingly, some statements were modified for more clarity. The study tools were tested for internal reliability using Cronbach’s alpha correlation coefficient. The results proved that the three tools were reliable with a correlational coefficient a = 0.85, 0.88, and 0.86 for tool1, 2, 3 respectively, while the statistical significance level was set at p < 0.05. In addition, a pilot study was done on 25 nurses (10%) who were excluded from the study subjects to confirm the clarity and applicability of tools and estimate the time required to complete the study questionnaires. In the light of the findings of the pilot study, no changes occurred in the final tools.

Data collection:

Written consent was obtained from administrative authority in the identified setting to gather the required data. The questionnaires were handed out by the researchers to nurses who approved to participate in the study. Each nurse took about 15 minutes to complete the questionnaires after given the complete instruction. Data were collected from nurses after obtaining their approval using the questionnaires in 5 months.

Ethical considerations:

an assent was obtained from Ethics Committee at Faculty of Nursing, Alexandria University and hospital authorities to conduct the study. The researchers clarified the goal of the research to all participants. The privacy and confidentiality of data were maintained and assured by obtaining participants’ informed consent to participate in the research before data collection. The anonymity of participants was granted.

Statistical analysis:

Data were coded by the researchers and statistically analyzed using Statistical Package for the Social Science (SPSS) version 20. Cronbach’s alpha correlation coefficient was used to test study’s tools for internal reliability. Frequency and percentages were used for describing demographic and professional characteristics. Arithmetic mean and standard deviation (SD) were used as measures of central tendency and dispersion, respectively, for quantifying variables under the study. Pearson correlation coefficient analysis (r) was used to test the nature of the relationship between emotional intelligence, moral distress and work engagement. Regression analysis (R2) was run to test was run to test the predictive power of independent variables (emotional intelligence) on the dependent variables (moral distress and work engagement).

3. RESULTS:

Table 1 exhibits the distribution of the studied nurses according to socio demographic data. The majority of nurses (71.6) were working at Alexandria Main University Hospital, 10% of them working at Smouha University Hospital, and 18.4% working at University Students Hospital. Around below half of nurses (44.8%) of nurses in twenties of their age with mean age equal 32.22 ± 7.47. Also, the majority of nurses (87.6%) were female. Around more than two third of nurses (36.8%, 35.2%) were marries and single respectively. Higher than two third of nurses (73.2%) were professional. One third (33.6%) of nurses had lower than five years’ experience and the same percentage of them had from 5 to 10 years of experience.

Table (1): Distribution of the studied nurses according to socio demographic data (n = 250)

Demographic Characteristics	No.	%
Setting Alexandria Main University Hospital University Students Hospital Smouha University Hospital	179 46 25	71.6 18.4 10
Age (years)
20 – 30	112	44.8
31 – 40	94	37.6
41+	44	17.6
Min. – Max.	20.0 – 45.0
Mean ± SD.	32.22 ± 7.47
Sex
Male	31	12.4
Female	219	87.6
Marital status
Single	88	35.2
Married	92	36.8
Divorced	53	21.2
Widow	17	6.8
Educational qualification
Secondary technical diploma	77	30.8
Technical health institute	80	32.0
Professional nurse	93	37.2
Years of experience
Less than 5 years	84	33.6
From 5 to 10 years	84	33.6
More than 10 years	82	32.8

Table 2 Portrayed descriptive analysis of the studied nurses according to nurses’ perception of moral distress, work engagement, emotional intelligence and their sub-dimensions. The overall mean score % of nurses perception of emotional intelligence were low (24.36± 5.71) as well as represented in its sub dimensions. In addition to high mean score % (79.19±14.67) of morals distress as perceived by nurses which is represented in its intensity and frequency. On the other side, nurses perceived moderate mean score % (36.42±9.96) of work engagement represented in moderate mean score % (34.12±9.62, 41.58±17.68) of its dimensions in term of vigor and absorption respectively and low mean score % (32.98±13.22) in term of dedication.

Table (2): Descriptive analysis of the studied nurses according to nurses’ perception of moral distress, overall work engagement and its sub dimensions, overall emotional intelligence and its sub-dimensions (n = 250)

Variables	Total Score Mean ± SD.	Total Score Mean % Score
Overall Emotional intelligence	31.59 ± 3.65	24.36 ± 5.71
Self-emotion appraisal	8.40 ± 1.92	27.48 ± 11.99
Other emotion appraisal	8.18 ± 1.99	26.10 ± 12.45
Use of emotion	7.52 ± 1.68	22.03 ± 10.48
Regulation of emotion	7.50 ± 1.75	21.85 ± 10.91
Overall Moral Distress	133.0 ± 24.65	79.19 ± 14.67
Moral distress frequency	66.74 ± 12.32	79.45 ± 14.67
Moral distress intensity	66.30 ± 12.39	78.92 ± 14.75
Overall Work Engagement	24.76 ± 6.77	36.42 ± 9.96
Vigor	8.19 ± 2.31	34.12 ± 9.62
Dedication	6.60 ± 2.64	32.98 ± 13.22
Absorption	9.98 ± 4.24	41.58 ± 17.68

Note. SD: Standard Deviation

0-33.3% -----Indicates low mean score percent

33.4-66.6----Indicates moderate mean score percent

66.7–100%--Indicates high mean score percent

Table 3 and figure 2 presented the correlation between nurses’ perception of moral distress, work engagement, and emotional intelligence as well as their sub dimensions. As can be seen, there were a highly significant negative correlation between moral distress and overall emotional intelligence as well as its sub dimensions in tem of self-emotion appraisal, other emotion appraisal, use of emotion, and regulation of emotion where P <0.001. Also, there were a highly significant negative correlation between moral distress and overall work engagement and its sub dimension in term of vigor, dedication, and absorption where P <0.001. On the other hand, there were a highly significant positive correlation between overall emotional intelligence and work engagement as well as their sub dimensions where P <0.001.

Figure (2): Relationships among Moral Distress, Emotional Intelligence and Work Engagement

Table (3): Correlation between nurses’ perception of moral distress, work engagement, and emotional intelligence

Variables		Self-emotion appraisal	Other emotion appraisal	Use of emotion	Regulation of emotion	Overall emotional intelligence
Self-emotion appraisal	r	1.000	-0.026	0.015	0.060	0.546
Self-emotion appraisal	P		0.686	0.812	0.346	<0.001^*
Other emotion appraisal	r		1.000	-0.030	0.038	0.536
Other emotion appraisal	P			0.636	0.546	<0.001^*
Use of emotion	r			1.000	-0.089	0.408
Use of emotion	P				0.160	<0.001^*
Regulation of emotion	r				1.000	0.489
Regulation of emotion	P					<0.001^*
Overall EI	r					1.000
Overall EI	P
Moral distress frequency	r
Moral distress frequency	P
Moral distress intensity	r
Moral distress intensity	p
Overall moral distress	r
Overall moral distress	p
Vigor	r
Vigor	p
Dedication	r
Dedication	p
Absorption	r
Absorption	p
Overall work engagement	r
Overall work engagement	p

Continue Table

Moral distress frequency	Moral distress intensity	Overall moral distress	Vigor	Dedication	Absorption	Overall work engagement
-0.297	-0.284	-0.291	0.227	0.248	0.231	0.319
<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*
-0.344	-0.339	-0.342	0.222	0.175	0.223	0.284
<0.001^*	<0.001^*	<0.001^*	<0.001^*	0.005^*	<0.001^*	<0.001^*
-0.210	-0.215	-0.212	0.173	0.266	0.099	0.225
0.001^*	0.001^*	0.001^*	0.006^*	<0.001^*	0.120	<0.001^*
-0.256	-0.255	-0.256	0.225	0.197	0.133	0.237
<0.001^*	<0.001^*	<0.001^*	<0.001^*	0.002^*	0.036^*	<0.001^*
-0.561	-0.554	-0.559	0.427	0.442	0.351	0.538
<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*
1.000	0.991	0.998	-0.379	-0.448	-0.402	-0.556
	<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*
	1.000	0.998	-0.385	-0.449	-0.408	-0.562
		<0.001^*	<0.001^*	<0.001^*	<0.001^*	<0.001^*
		1.000	-0.383	-0.450	-0.406	-0.561
			<0.001^*	<0.001^*	<0.001^*	<0.001^*
			1.000	0.348	0.190	0.596
				<0.001^*	0.003^*	<0.001^*
				1.000	0.337	0.720
					<0.001^*	<0.001^*
					1.000	0.823
						<0.001^*
						1.000

r: Pearson coefficient

*: Statistically significant at p ≤ 0.05

Table (4): Relation between nurses’ perception of overall emotional intelligence, moral distress, work engagement and socio demographic data (n= 250)

Demographic Characteristics	Overall Emotional intelligence Mean % Score	Overall Moral Distress Mean % Score	Overall work engagement Mean % Score
Age
20 – 30	25.53 ± 6.20	78.52 ± 15.95	37.41 ± 10.40
31 – 40	23.37 ± 4.84	80.22 ± 13.14	34.54 ± 7.67
41+	23.51 ± 5.69	78.67 ± 14.58	37.90 ± 12.47
F (p)	4.367^* (0.014^*)	0.375(0.688)	2.746 (0.066)
Gender
Male	23.49 ± 4.57	77.55 ± 11.55	35.72 ± 7.51
Female	24.49 ± 5.85	79.42 ± 15.07	36.52 ± 10.27
t (p)	0.911(0.363)	0.662(0.509)	0.415(0.678)
Marital status
Single	24.96 ± 6.08	78.94 ± 15.61	37.20 ± 9.08
Married	24.97 ± 5.43	78.83 ± 14.75	36.84 ± 11.64
Divorced	23.23 ± 5.01	79.28 ± 13.35	34.46 ± 8.50
Widowed	21.51 ± 6.34	82.14 ± 14.15	36.16 ± 8.55
F (p)	2.841^* (0.038^*)	0.255(0.858)	0.922(0.431)
Educational qualification
Secondary technical diploma	24.17 ± 5.43	79.82 ± 14.75	37.24 ± 10.58
Technical health institute	24.57 ± 5.21	79.17 ± 13.49	35.28 ± 8.54
Professional nurse	24.78 ± 6.47	77.05 ± 15.23	37.59 ± 11.68
F (p)	0.274(0.844)	0.528(0.663)	0.829(0.479)
Years of experience
Less than 5 years	24.98 ± 6.16	79.12 ± 15.84	37.12 ± 9.26
From 5 to 10 years	24.63 ± 5.69	77.98 ± 15.16	35.52 ± 10.48
More than 10 years	23.46 ± 5.19	80.50 ± 12.89	36.62 ± 10.16
F (p)	1.625 (0.199)	0.611(0.544)	0.561(0.571)
Setting
Alexandria Main University Hospital	24.17 ± 5.80	79.29 ± 13.97	36.24 ± 9.59
University Students Hospital	24.11 ± 5.30	80.42 ± 15.28	35.29 ± 8.80
Smouha University Hospital	25.23 ± 5.80	77.72 ± 16.48	38.02 ± 11.99
F (p)	0.682 (0.506)	0.400 (0.671)	0.926 (0.397)

t: Student t-test F: F for ANOVA test

p: p value for association between different categories

*: Statistically significant at p ≤ 0.05

Table (4): Relation between nurses’ perception of overall emotional intelligence, moral distress, work engagement and socio demographic data (n= 250):

This table highlighted that a statistically significant difference was documented between overall emotional intelligence and socio demographic of nurses in term of age, marital status (F= 4.367, P= 0.014), (F=2.841, P =0.038) respectively. The highest mean score %was observed for those aging between 20 to 30 years old (25.53 ± 6.20). Also, the highest mean score % was observed for married and single nurses (24.97 ± 5.43, 24.96 ± 6.08) respectively. However, there was no statistical significant relation between nurses’ socio demographic and their perception of moral distress and work engagement

Table 5 and figure 3 reveals regression coefficient value between dimensions of emotional intelligence as independent variables and overall moral distress as a dependent variable where R2 = 0. 315. This means that approximately 3.1% of the explained variance of overall moral distress is accounted by emotional intelligence, and these later variables independently contribute significant prediction of overall moral distress where the model is significant (F = 28.189, p < 0.001). However, coefficients table of regression analysis has displayed that the contribution of use of emotion variable is relatively high (β =0.074, P<0.001), where increase in each degree of use of emotion tends to lower the level of moral distress by 0.337 units.

Table (5): Multivariate Linear regression analysis between different dimensions of emotional intelligence as independent variable toward moral distress

Emotional intelligence	B	Beta	t	p
Self-emotion appraisal	-0.345	0.065	5.315^*	<0.001^*
Other emotion appraisal	-0.409	0.062	6.554^*	<0.001^*
Use of emotion	-0.337	0.074	4.527^*	<0.001^*
Regulation of emotion	-0.333	0.072	4.651^*	<0.001^*
Overall Emotional intelligence	-1.437	-0.559	10.621^*	<0.001^*
R²= 0.315,F= 28.189,p<0.001^*

F,p: f and p values for the model R²: Coefficient of determination

B: Unstandardized Coefficients Beta: Standardized Coefficients

t: t-test of significance *: Statistically significant at p ≤ 0.05

Figure (3): Correlation between Overall Emotional intelligence and Moral Distress

Table 6 and figure 4 indicates regression coefficient value between dimensions of emotional intelligence as independent variables and overall work engagement as a dependent variable where R2 = 0.291. This means that approximately 2.9% of the explained variance of overall work engagement is accounted by emotional intelligence, and these later variables independently contribute significant prediction of overall work engagement where the model is significant (F = 25.122, p < 0.001). However, coefficients table of regression analysis has displayed that the contribution of use of emotion variable is relatively high (β =0.051, P<0.001), where increase in each degree of use of emotion tends to higher the level of work engagement by 0.237 units.

Table (6): Multivariate Linear regression analysis between different dimensions of emotional intelligence as independent variable toward work engagement

Emotional intelligence	B	Beta	t	P
Self-emotion appraisal	0.256	0.045	5.722^*	<0.001^*
Other emotion appraisal	0.232	0.043	5.390^*	<0.001^*
Use of emotion	0.237	0.051	4.607^*	<0.001^*
Regulation of emotion	0.209	0.049	4.231^*	<0.001^*
Overall Emotional intelligence	0.938	0.538	10.051^*	<0.001^*
R²= 0.291, F= 25.122,p<0.001^*

F,p: f and p values for the model R²: Coefficient of determination

B: Unstandardized Coefficients Beta: Standardized Coefficients

t: t-test of significance *: Statistically significant at p ≤

Figure (4): Correlation between Overall Emotional intelligence and Work Engagement

4. DISCUSSION:

Critical care unit (CCU) is a stressful environment due to high patient mortality and morbidity, daily confrontations with ethical dilemmas, and a tension-charged atmosphere⁽⁴³⁾. The CCU is an especially complex and difficult work environment for critical care nurses. Critical care nurses are recurrently exposed to work-related stresses, counting involvement in end-of-life discussions, extension of life with artificial support device, and the potential for delivering unfitting care⁽⁴⁴⁾. When confronted with these stressful situations, nurses may feel powerless, unable to provide care according to their own belief system, and therefore prone to develop moral distress⁽⁴⁵⁾. This goes in the same line of the result of present study as nurses’ perceived high mean of moral distress in the frequency and intensity. This is similar to Rushton et al. (2016)⁽⁴⁶⁾ and Moss et al. (2016)⁽⁴⁷⁾ who clarified that nurses are more prospective to develop moral distress due to the nurse’s perceived inability to make decisions and their feeling of being “voiceless” during morally complicated conversations. Also, Allen et al. (2013)⁽⁴⁸⁾ and (2016)⁽⁴⁹⁾ identified moral distress as existing among all nurses, and latest health care professionals. Likewise, Dodek et al. (2016)⁽⁵⁰⁾, concluded the similar results. Similarly, Colville et al. (2019)⁽⁵¹⁾declared that nurses perceived high frequency and intensity moral distress. On the other hand, Elpern et al. (2005)⁽¹⁶⁾ reported contradicted results since nurses in his study reported moderate moral distress in ICU.

Regarding work engagement, the result of the current study revealed that nurses are moderately engaged in their work with moderate mean given to vigor and absorption and low mean of dedication dimension. These results may be attributed to nurses’ perception of high moral distress they experienced in their work environment. In addition, ICU is considered a highly stressful environment. This is supported by Rushton et al. (2016) ⁽⁴⁶⁾, Epstein and Hamric (2009)⁽⁵²⁾ explained that, over time, reiterated contact to morally stressful events can cause more insistent feelings of powerlessness and render the nurse more possible to remove themselves from future discussions of morally stimulating situations. Long-term outcome of moral distress hurt the ability of a critical care nurse to provide accurate patient care, impact their ability to perform expected job responsibilities, and lessening their work engagement. Besides, Sierra et al. (2015)⁽⁵³⁾ proposed that positive work atmosphere and supportive organization are factors that encouraging works engagement. In addition Mahboubi et al. (2015)⁽⁵⁴⁾ found moderate work engagement in their study. While, this is contradicted with Abou Hashish el al. (2018)⁽⁵⁵⁾ nurses’ perception of overall work engagement was high represented by the highest mean for dedication followed by vigor and absorption dimensions.

Concerning emotional intelligence, the result of this study clarified that nurses’ perceived low mean percent score of emotional intelligence represented in its dimensions; Self-emotion appraisal, Other emotion appraisal, Use of emotion, and Regulation of emotion. This may be attributed to that all patients are critically ill and most of them during data collection are comatose which decrease the interactions with patients, families and colleagues, this interactions have an impact on developing their emotional intelligence as they fuel them with wide varieties of emotional experiences. Klem and Schechter (2008)⁽⁵⁶⁾ emphasized that there was significant positive relationship between emotional intelligence and psychological climate. This is contradicted with the study done by Allam (2018)⁽⁵⁷⁾which found that nurses’ perceived high mean percent score of total emotional intelligence and self-emotion appraisal. While, the lowest mean percent score was related to regulation of emotion. Also, Mahmoud (2013)⁽⁵⁸⁾ and Farghally (2013)⁽⁵⁹⁾ found that their study subjects perceived moderate level of emotional intelligence.

It is clear that, these results revealed a highly significant negative correlation between moral distress and work engagement as well as between moral distress and emotional intelligence. Alternatively, there was a highly significant positive correlation between emotional intelligence and work engagement. Also, the present study illustrated that, emotional intelligence as independent variable is a predicting for moral distress and work engagement as dependent variable. This is supported by Lawrence (2011)⁽⁶⁰⁾ who illustrated that there was a negative relationship between moral distress and work engagement. Frey et al. (2018)⁽⁶¹⁾, Codier el al. (2011)⁽⁶²⁾, Scruth el al. (2018)⁽⁶³⁾, Kaur el al. (2013)⁽⁶⁴⁾, Karimi et al. (2014)⁽⁶⁵⁾ indicated that higher levels of emotional intelligence (EI) could temper the negative effects of moral distress, Also, Pérez-Fuentes et al. (2018)⁽⁶⁶⁾, Shukla et al. (2013)⁽⁶⁷⁾clarified that there was a significant positive and moderate correlation between emotional intelligence and employee engagement.

It is surprising that, demographic characteristics had no impact on differentiating nurses’ perception of moral distress and work engagement. This may be related to that the fact that a stressful work environment not differentiate between nurses’ perception. This similar to the study done by Colville et al. (2019)⁽⁵¹⁾ who illustrated that socio-demographic factors are not strongly predictive of moral distress. However, this is contradicted with the study done by Dodek et al. (2016)⁽⁵⁰⁾ who concluded that age is inversely associated with moral distress and years of experience is directly associated with moral distress. Also, Matsumoto et al. (2010)⁽⁶⁸⁾, Kawauchi et al. (2011)⁽⁶⁹⁾, Fukuoka et al. (2013)⁽⁷⁰⁾, and Sato et al. (2014)⁽⁷¹⁾ clarified that work engagement in nurses has shown the relation towards age, marital status, years of experience, and employment/work status. Also, Pérez-Fuentes et al. (2018)⁽⁶⁶⁾ concluded that that there were significant differences in work engagement and socio-demographic variables which are sex, age, and number of children.

On the other side, it is noticed that there was a statistically significant difference was documented between overall emotional intelligence and socio demographic of nurses in term of age, marital status. The highest mean percent score was observed for those aging between 20 to 30 years old. Also, the highest mean percent score was observed for married and single nurses. These result similar to that conducted by Pérez-Fuentes et al. (2018)⁽⁶⁶⁾who concluded that that there were significant differences in EI and socio-demographic variables which are sex, age, and number of children. On the other hand, Van Dusseldorp et al. (2011)⁽⁷²⁾ illustrated that age was not associated with the emotional intelligence of nurses. Also, Kahraman and Hiçdurmaz (2016)⁽⁷³⁾found no significant differences between the emotional intelligence scores in nurses based on demographic variables such as age, sex, marital status, or having children. However, in terms of sex-related differences, several researchers Gerits et al. (2004) ⁽⁷⁴⁾, Van Dusseldorp et al. (2011)⁽⁷²⁾, Arteche et al. (2008) ⁽⁷⁵⁾, and Liébana et al. (2012)⁽⁷⁶⁾found a statistical significance difference between sex and EI. While, Azimi et al. (2010)⁽⁷⁷⁾declared that there was no significant relationship between sex and EI.

5. CONCLUSION AND RECOMMENDATIONS:

The main finding shows low level of emotional intelligence, high degree of moral distress, moderate work engagement among nurses. There is a highly statistical significant negative correlation between moral distress and overall emotional intelligence as well as its sub dimensions. Also, there is a highly statistical significant negative correlation between moral distress and overall work engagement and its sub dimension. In addition to, highly significant positive correlation between overall emotional intelligence and work engagement as well as their sub dimensions.

Based on the study findings, the following recommendations are suggested that focus on strategies to decrease moral distress and improve emotional intelligence among nurses which subsequently increase their work engagement:

· Provide positive, supportive and resourceful work environments, especially in terms of job autonomy, departmental resources and ethical committee.

· Providing a charge nurse to make rounds in critical care units and speaking with nurses to identify moral distress in the care of specific patients. This would allow the charge nurse to make patient assignments based on needed staff support, or the need to rotate the care of patients based on potential morally distressing situations.

· Nursing leaders must acknowledge the presence of situations that create moral distress among nurses and establish strategies to deal with these issues

· Practice storytelling and group meetings to share and argue ethical and clinical situations

· Suggestions include educators, social workers, executives, and chaplains lead debriefing sessions after difficult days or events, develop a patient/family task force or call families to come to talk to staff after discharge, boost social events within the unit and hospital, and address the systems issues in health care settings such as staffing, nurse-patient ratios ,role conflicts and management policies , double documentation, and supplies.

· Extra formal or informal forums may be intended to allow nurses to express feelings and encourage them to listen to patient’s and families’ views, however divergent, to hear the stakeholders and recognize their meaning in supporting the selections they make.

· Nurse administrators have to enhance the constructs of emotional intelligence in a training environment to better prepare managers/supervisors for their jobs and train them on unconditional acceptance of self and others

· Enrich a healthy work environment with open communications through conducting a schedule for staff meeting with their managers in order to improve the ability of the managers to consider others' emotions.

· Future studies are recommended to investigate moral distress with other variables such as resilience , Austerity ethical decision making , and institutional responsibility.

5. CONFLICT OF INTEREST:

The authors declare that there is no conflict of interest

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Received on 12.05.2020 Modified on 28.05.2020

Int. J. of Advances in Nur. Management. 2020; 8(3):237-248.

DOI: 10.5958/2454-2652.2020.00060.8