# Association Between Organizational Bullying, Moral Distress, and Disengagement Among Emergency Department Nurses in Ilam Hospitals: A Cross Sectional Study

## TL;DR

Emergency department nurses in Ilam, Iran, experience bullying linked to moral distress and unethical behavior, suggesting a need for organizational interventions.

## Contribution

This study establishes empirical links between organizational bullying, moral distress, and moral disengagement among emergency nurses in Ilam Province hospitals.

## Key findings

- Organizational bullying is moderately linked to moral distress (r = 0.1865) and moral disengagement (r = 0.2358).
- Moral distress has a strong direct association with moral disengagement (r = 0.6470).
- Bullying behaviors may exacerbate unethical actions by increasing moral disengagement among nurses.

## Abstract

It is widely accepted that emergency department is an inherently high-stress environment where organizational bullying is prevalent, potentially leading to psychological harm and ethical complications. Moral distress occurs when nurses feel unable to adequately resolve ethical challenges, while moral disengagement involves mental processes that rationalize or excuse unethical actions, thereby diminishing personal responsibility.

This descriptive-analytical study was carried out in 2024 across public and private hospitals in Ilam Province, a border region in western Iran. Ilam Province has a total of 11 hospitals, consisting of 9 public hospitals and 2 private hospitals. The study population comprised 266 nurses working in emergency departments, with the entire group selected via census sampling. The research instruments included the Einarsen Organizational Bullying Questionnaire, the Hamric Moral Distress Scale, and Fida's Moral Disengagement in Nursing instrument. Data were analyzed using SPSS version 25, examining the complex relationships among organizational bullying, moral distress, and moral disengagement. Model 4 of the PROCESS macro was employed to assess mediation effects. Descriptive statistics were calculated for all variables, and data normality was assessed using skewness and kurtosis values. To further explore the associations among the key variables, Pearson correlation coefficients were computed.

The nurses' mean ratings for organizational bullying, moral distress, and moral disengagement were 42 ± 14.5, 22.2 ± 12.8, and 39 ± 10.9, respectively. Statistical research found a moderate link between organizational bullying and moral suffering (p = 0.0112, r = 0.1865). Furthermore, a substantial and direct relationship was detected between moral discomfort and moral disengagement (p < 0.001, r = 0.6470). A positive and moderate connection was discovered between organizational bullying and moral disengagement (p=0.0006, r = 0.2358).

The findings of this study show that organizational bullying is strongly linked to moral anguish among emergency department nurses. Furthermore, moral distress has a significant and direct association with moral disengagement, suggesting that it may weaken ethical awareness and increase the likelihood of unethical behavior in the workplace. Furthermore, the considerable positive link between organizational bullying and moral disengagement suggests that increasing bullying behaviors may exacerbate moral disengagement among nurses. These findings highlight the necessity of adopting organizational measures to minimize bullying in healthcare settings while also improving nurses' psychological and ethical well-being. It is recommended that hospital administrators and health system policymakers develop and implement educational and supportive programs aimed at mitigating organizational bullying, bolstering moral resilience, and promoting the overall professional well-being of nurses.

The findings indicate that organizational bullying significantly influences moral distress and moral disengagement among nurses, highlighting the need for targeted management strategies. Nursing leaders should implement strict antibullying policies, foster ethical decision-making through training programs, and provide psychological support systems to reduce moral distress. Additionally, mentoring younger and less experienced nurses, particularly those in public hospitals and emergency departments, can help mitigate disengagement. Creating a culture of accountability, promoting ethical leadership, and ensuring open communication will enhance job satisfaction and improve patient care outcomes.