In
the
12
interviews
with
nurses
working
in
NICUs,
the
average
age
of
the
subjects
was
equal
to
33.5
years.
Of
the
nurses
studied,
10
had
bachelor’s
degree
in
nursing
and
2
had
a
master’s
degree
in
nursing.
Seven
were
single
and
five
were
married.
Moreover,
the
average
work
experience
of
the
nurses
was
9
years
and
average
work
experience
of
nurses
in
NICU
was
6
years,
which
is
shown
in
Table
1
.
As
shown
in
Table
2)
moral
challenges
have
three
themes:
“the
challenge
of
proper
care
with
love,”
“the
challenge
of
understanding
and
proper
dealing
with
families
of
newborns,”
and
“the
challenge
of
professional
skills
and
nursing
ethics.”
The
challenge
of
proper
care
with
love
is
composed
of
two
categories
of
proper
care
for
the
newborn
and
care
with
love.
The
challenge
of
understanding
and
proper
dealing
with
families
of
newborns
is
composed
of
two
categories
of
understanding
and
sympathy
for
the
families
of
the
newborns
and
conflict
in
dealing
with
newborns’
families
consists
of
four
sub-categories.
Moreover,
based
on
the
analysis
conducted,
the
challenge
of
professional
and
moral
skills
of
nurses,
as
the
third
moral
challenge
of
the
nurses,
is
composed
of
two
categories
of
nursing
skills
and
nurses’
moral
features
with
four
sub-categories.
Click
here
for
Table
1:
Distribution
of
demographic
characteristics
of
nurses
Click
here
for
Table
2:
Moral
challenges
1.
The
challenges
of
proper
care
with
love
The
first
theme
from
the
above
study
is
“The
challenge
of
proper
care
with
love”
that
is
composed
of
two
Categories:
“proper
care
of
the
newborn”
and
“taking
care
with
love.”
In
general,
this
theme
includes
issues
such
as
the
importance
of
a
commitment
to
revive
the
newborn,
lack
of
resources
and
equipment
in
failure
to
care
for
newborn,
attention
to
medical
relief
of
the
newborn,
good
sense
of
the
nurse
in
working
with
newborns,
and
challenges
such
as
knowing
the
newborn
like
one’s
own
newborn.
1.1.
Proper
care
of
the
newborn
The
category
is
composed
of
three
sub-Categories:
the
challenge
of
proper
care
of
the
newborn,
the
challenge
of
defects
in
care
of
the
newborn,
and
attention
to
relieving
pain
of
the
newborn.
According
to
nurses,
proper
nursing
care,
attention
to
relieving
the
newborn’s
pain,
and
defects
in
taking
care
of
were
the
main
challenges.
Nurses
were
sensitive
to
infant
care,
or
in
other
words,
infant
care
was
highly
sensitive.
One
of
the
participants
(nurse
#
2)
stated:
“Massaging
the
newborn
or
lubricating
the
skin
is
not
ordered
by
the
doctor,
but
we
occasionally
do
it
when
we
see
kid’s
skin
is
dry:
for
example,
we
wash
the
newborn
when
he
is
hospitalized
for
a
long
time
and
has
dirty
odor,
or
we
wash,
dry,
and
place
them
in
their
place
if
they
do
not
have
IV.
We
do
things
of
this
kind,
even
though
they
might
not
be
in
our
job
description.
However,
we
do
them
because
they
are
important
for
the
newborn.”
Another
participant
(nurse
#
12)
about
relieving
the
pain
of
the
newborn
stated:
Usually,
when
a
newborn
has
pain,
I
do
some
things
to
relieve
him,
for
example,
I
swaddle
them
or
put
some
mellitus
to
their
mouth,
and
for
the
ones
who
are
under
the
device
and
have
pain,
we
ask
the
doctor
to
order
fentanyl
or
phenobarbital
to
relieve
them.”
Experiences
stated
by
the
participants
show
that
caring
for
newborns
always
needs
accuracy
and
high
sensitivity
and
this
creates
challenges
related
to
care
for
newborns.
On
the
other
hand,
it
is
necessary
to
pay
special
attention
to
relieve
newborn
pain.
1.2.
Care
with
love
This
category
is
composed
of
two
sub-Categories
of
the
challenge
of
affectionate
behavior
with
love
in
working
with
newborns
and
having
attachment
and
dependency
to
newborn.
In
general,
the
nurses
stated
that,
it
is
necessary
to
feel
good
and
have
loved
while
caring
for
the
newborns,
and
some
believed
that,
one
should
consider
the
newborn
as
own
child.
One
of
the
participants
(Nurse
#
7)
stated:
“Some
say
that
working
with
newborns
is
hard
but
it
is
not
difficult
for
me,
so
I
would
love
to
work
with
interest,
although
sometimes
working
pressure
is
so
high
and
we
do
not
even
have
a
second
opportunity
to
sit
down.
Working
in
ICUs
is
generally
difficult,
but
I
love
it.
If
I
have
a
break
for
some
days
I
miss
my
job.”
One
of
the
participants
(Nurse
#
1)
stated:
You
have
to
be
very
gentle
with
the
newborn.
You
should
think
of
it
as
your
own
kid.
You
should
give
its
milk
on
time,
you
should
not
let
its
blood
sugar
drop,
do
not
let
pressure
drop,
skin
care
especially
for
premature
infants,
they
should
not
be
exposed
to
light,
we
usually
make
here
dark
because
when
the
lamps
are
on
they
get
shocked
and
jump
up
and
it
makes
us
sad.
Nurses
in
NICUs
considered
the
infant
like
their
own
child
and
after
some
time
working
with
them,
they
became
dependent
on
them
that
challenges
their
taking
care
of
newborns.
One
of
the
participants
(Nurse
#
2)
in
this
regard
stated:
For
about
one
month,
it
was
difficult
to
work
with
them,
but
later,
it
became
normal,
so
that
if
I
am
on
break
for
some
days
I
call
and
ask
how
the
newborns
are
in
the
unit
(with
a
smile).
I
love
working
with
newborns
with
all
its
difficulties.
This
is
so
that
if
in
rotation,
they
send
me
to
work
somewhere
else
I
resign;
I
just
can
work
with
newborns.
2.
The
challenge
to
understand
and
deal
properly
with
families
of
newborns:
The
second
theme
of
moral
challenges
of
nurses
is
the
challenge
of
understanding
and
dealing
properly
with
families
of
newborns.
The
theme
is
composed
of
two
categories
of
the
conflict
in
dealing
with
newborns’
families
understanding
and
empathizing
with
the
family
of
the
newborn.
2.1.
Having
contradiction
in
dealing
with
the
newborn’s
family
Nurses
felt
bad
in
dealing
badly
with
the
newborn’s
family
and
had
even
a
sense
of
guilt.
They
have
sometimes
challenged
due
to
dealing
with
unenforceable
requests
from
the
family
of
the
newborn,
but
they
knew
that
they
should
have
proper
treatment
with
their
families.
One
of
the
participants
(nurse
#
5)
stated:
It
rarely
happens
that
I
might
even
disagree
with
many
of
the
things
that
mothers
do,
but
I
tell
them
that
as
here
NICU
and
infection
control
is
very
important
and
they
should
not
bring
anything
from
outside.
We
sometimes
even
ask
the
mothers
to
be
with
the
newborn
or
if
they
want
to
give
something
to
the
newborn,
we
oppose
even
if
they
insist
we
do
not
let
them.
It
rarely
happens
that
they
bring
something
and
ask
us
to
give
it
to
the
newborn
even
when
they
know
we
do
not
lie
,
but
again
we
explain
so
that
they
are
convinced
that
it
is
for
their
own
benefit.
However,
if
they
are
not
convinced
at
all,
we
ask
them
to
put
it
in
the
closet
or
near
the
newborn
but
not
touch
the
newborn.
One
of
the
participants
(nurse
#
11)
stated:
I
feel
sad
myself,
but
I
tell
them
not
to
be
upset
with
me.
However,
it
is
not
correct
you
cannot
give
them
anything
even
a
drop
of
water.
You
cannot
do
it
to
yourself.
If
you
want
the
health
of
your
newborn,
this
is
what
you
should
do.
Now,
she
has
to
decide
whether
to
listen
or
not.
I
have
seen
some
mothers
that
in
a
hidden
way….
For
example,
you
say
your
newborn
cannot
drink
milk,
but
when
they
see
another
mother
is
feeding
the
newborn,
they
go
and
do
it
in
a
hidden
way.
Moreover,
when
you
say
why?
She
says
because
she
did,
and
when
you
explain,
they
are
convinced.
One
of
the
participants
(nurse
#
8)
stated:
See,
for
example
some
people
bring
Zamzam
water.
The
truth
is
that
we
oppose
that,
because
it
is
a
newborn
anyway,
you
cannot
give
anything
you
do
not
know
what
it
is,
and
we
do
not
accept
responsibility.
Some
bring
Koran
and
prayer
and
put
them
over
their
head.
Some
of
our
colleagues
say
take
them
away
we
do
not
let
you
put
them
here.
However,
I
myself
say
there
is
no
problem.
Put
it
near
his
sheet
so
that
it
is
not
around
because
we
want
to
change
the
sheets
and
do
other
things,
but
placed
over
the
sheet
there
is
no
problem.
2.2.
Understanding
and
Empathy
for
the
families
of
newborns
Nurses
believed
that
the
family
and
the
conditions
of
the
infant
should
be
understood,
but
due
to
the
crowding
of
the
unit
and
inconsistency
of
newborns’
status
and
the
number
of
nurses,
sometimes
they
could
not
establish
proper
communication
with
the
family.
The
nurses
liked
to
give
the
newborn’s
good
news
of
recovery
and
have
a
good
treatment
with
the
family,
but
sometimes
the
newborn’s
condition
did
not
improve
and
it
was
a
challenge
to
the
nurses.
One
of
the
participants
(nurse
#
4)
stated:
Well,
since
I
am
myself
an
emotional
person
and
I
have
a
small
kid,
I
sympathise
with
the
families.
Well,
when
someone
is
sick
and
in
the
hospital
yard,
there
is
a
lot
of
stress
on
it.
Now,
imagine
a
mother
that
after
birth
is
in
the
hospital
instead
of
house
for
one
or
two
months,
you
know
what
feeling
she
gets.
Instead
of
going
home
and
being
cared
for,
you
have
to
stay
in
the
hospital.
This
is
no
good
feeling.
One
of
the
participants
(nurse
#
8)
stated:
It
happens
that
for
example,
a
mother
says
something
that
is
difficult
to
accept,
but
I
myself
control
myself
as
far
as
possible.
I
may
get
sad
but
I
do
not
want
to
make
the
mother
sad.
This
is
my
behavior;
I
try
not
to
make
mothers
sad
even
if
I
am
myself
because
their
condition
is
special.
3.
Challenges
of
professional
skills
and
nursing
morals:
This
theme
is
composed
of
two
categories
of
professional
skills
of
nurses
and
nursing
moral
properties
with
four
sub-categories.
Participants
in
this
study
believed
that
nurses
need
knowledge
and
experience
to
work
with
the
newborn.
Moreover,
they
believed
that
each
of
these
skills
(knowledge
and
experience)
alone
cannot
guarantee
the
success
of
nurses
in
neonatal
care,
and
moral
principles
should
be
considered.
3.1.
Professional
nursing
skills
This
category
is
composed
of
two
sub-categories:
the
challenge
of
having
experience
and
expertise
in
working
with
newborns
and
the
importance
of
accuracy
and
speed
in
working
with
newborns.
Participants
believed
that
working
with
newborns
primarily
requires
high
precision
in
the
care
of
the
newborn
and
then
having
a
high
speed
in
dealing
with
this
sensitive
segment.
On
the
other
hand,
newborn
care
requires
knowledge,
experience,
and
work
experience
in
working
with
children.
One
of
the
participants
(nurse
#
6)
stated:
Having
knowledge
and
experience
are
both
important.
We
have
colleagues
who
are
masters
of
neonatal
intensive
care
and
some
others
like
Ms.….with
experience
and
good
knowledge
and
it
rarely
happens
that
someone
is
like
this,
for
example,
our
experienced
veterans
only
have
15
years
of
work.
I
can
surely
say
that
many
of
our
nurses
do
not
have
enough
experience.
I
mean
they
do
something
routine
for
15
or
20
years
and
their
experience
is
just
the
years
they
have
done
something.
But
there
was
a
nurse
who
was
very
knowledgeable
and
she
studies
a
lot.
She
loves
to
learn
and
train
new
things,
and
we
have
the
ones
with
high
degrees
but
not
enough
experience,
so
both
knowledge
and
experience
are
important.
One
of
the
participants
(nurse
#
1)
stated:
“I
think
a
man
should
be
calm
and
sedate
to
work
with
the
newborn
and
for
reducing
challenges,
accuracy
should
go
up.
Accuracy
should
go
higher,
and
you
should
think
the
newborn
is
your
own.
This
newborn
you
are
working
with
needs
love
and
your
accuracy
should
be
fairly
good.”
One
of
the
participants
(nurse
#
1)
stated:
“Speed
of
a
nurse
working
in
NICU
is
very
important
because,
for
example,
a
moment
of
ignorance
leads
to
hypoxia
of
the
newborn
and
finds
thousands
complications.”
3.2.
Moral
characteristics
of
a
nurse
This
class
is
composed
of
two
sub-categories:
conscience
in
taking
care
of
newborns
feeling
guilty
while
doing
a
painful
procedure
for
the
newborn.
Results
showed
that
the
participants
believed
that
their
conscience
in
infant
care
is
of
paramount
importance.
One
of
the
participants
(nurse
#
3)
stated:
Infant
nurse
should
have
good
conscience,
be
caring
and
compassionate
as
features
that
all
nurses
have
plus
the
features
nurses
working
in
NICU
have.
One
of
the
participants
(nurse
#
12)
stated:
“There
are
many
times
that
things
depend
on
your
own
conscience,
for
example,
to
change
the
newborns’
position
once
or
ten
times
in
your
shift,
many
places’
symptoms
show
what
you
have
done?
But
not
in
many
places,
sensitivity
of
newborns
are
high
because
a
newborn
is
an
oppressed
defenseless
creature
and
our
conscience
is
so
much
involved
in
working
with
newborns.”
Participants
believed
that
while
performing
painful
procedures
for
infants
and
unintentional
injuries,
they
severely
feel
guilty.
One
of
the
participants
(nurse
#
2)
stated:
Yes,
well
while
venepuncture
and
blood
sampling
I
try
once
or
eventually
twice
if
not
possible,
I
call
a
more
experienced
colleague,
because
I
really
take
punishment
with
a
newborn
suffering.
As
participants’
statements
showed,
nurses
in
the
care
of
newborns
in
NICU
face
many
challenges
and
to
improve
the
quality
of
care
of
the
newborn
and
reduce
the
potential
distress
of
nurses
in
the
above
units,
special
attention
should
be
paid
to
these
challenges.
The
findings
of
this
study
showed
that
nurses
in
NICU
are
faced
with
different
moral
challenges.
These
moral
challenges
are
in
three
categories:
the
challenge
of
proper
care
with
love,
challenge
of
understanding
and
dealing
properly
with
newborns’
families,
and
challenge
of
professional
and
moral
skills
of
nurses.
The
first
theme
of
the
above
study
was
“the
challenge
of
proper
care
with
love,”
which
is
composed
of
two
categories:
“proper
care
of
the
newborn”
and
“taking
care
with
love.”
Nurses
see
newborn
care
as
very
sensitive
and
emphasize
that
proper
care
of
the
newborn
should
be
done
and
any
nursing
care
for
newborn
should
be
done
with
love
and
if
proper
care
was
not
done
with
love,
they
were
morally
challenged.
Impairment
in
nursing
care
of
the
newborn
due
to
nursing
labor
shortages
and
lack
of
resources
and
equipment
impairment
is
a
factor
contributing
to
newborn
care
defect,
which
is
one
of
the
most
frequent
challenges
in
the
care
of
newborns.
In
one
study,
it
was
cited
that
nurses
of
infant
care
unit
have
high
levels
of
moral
distress
during
treatment
and
loss
of
newborn.
This
distress
worsens
when
nurses
feel
the
care
provided
for
the
newborn
has
not
been
the
best
care.
Providing
palliative
care
at
the
end
of
life
may
reduce
some
of
this
distress.
There
are
a
few
barriers
to
palliative
care.
The
first
obstacle
is
lack
of
NICU
staff
training
in
the
correct
definition
and
use
of
comfort
care
at
end
of
life.
The
existence
of
a
palliative
care
program
is
essential
because
it
leads
to
kind
communication
with
family
and
reduction
of
moral
distress
for
nurses
and
providing
quality
care
for
newborns
(12).
In
a
study
in
the
field
of
life
dilemmas
and
moral
distress
in
care
system,
it
mentioned
that
many
moral
dilemmas
could
be
because
of
shortage
of
nurses’
time.
Nurses
noted
that
while
they
want
to
devote
more
time
to
patients,
they
do
not
have
enough
time
to
do
it.
On
the
other
hand,
the
work
of
nurses
is
so
much
(3).
In
this
study,
when
caring
for
infants,
nurses
had
good
feelings
and
cared
for
the
newborns
with
love.
They
preferred
working
in
the
neonatal
unit
to
other
units,
and
although
most
of
the
participants
were
single
and
thus
had
no
newborns,
they
were
interested
in
taking
care
of
infants.
However,
in
several
studies,
it
is
suggested
that
moral
distress
may
have
negative
effects
on
job
satisfaction
and
lead
to
job
burnout
and
intention
to
leave
the
job
by
the
treatment
team
(2,
3)
and
nurses
working
in
intensive
care
units
have
moderate
to
severe
levels
of
moral
distress
(1).
In
the
present
study,
despite
the
moral
challenges,
nurses
did
care
of
the
newborn
with
love.
A
basic
premise
is
that
health-staff
preserve
work
values
and
when
faced
with
moral
dilemmas
try
to
solve
them
(3).
The
second
theme
of
moral
challenges
of
nurses
is
the
challenge
of
understanding
and
proper
dealing
with
the
family
of
the
infant.
This
theme
includes
two
categories:
conflict
in
how
to
deal
with
the
family
of
the
newborn
and
understanding
with
newborn
family.
This
challenge
means
that
nurses
feel
bad
about
dealing
badly
with
families
in
coping
with
the
demands
of
the
family
of
the
newborns,
which
were
contrary
to
the
newborn’s
health
and
caused
challenged
the
nurses
and
they
believed
that
the
family
of
the
newborn
should
be
dealt
with
appropriately.
The
existence
of
these
challenges
in
nurses
studied
showed
to
what
extent
they
try
to
act
Patients’
Bill
of
Rights.
In
the
study
by
Cavaliere,
one
of
the
moral
distresses
faced
by
nurses
in
NICU
was
continuing
infant
treatment
at
the
request
of
the
family
even
when
not
in
favor
of
newborn
(9).
NICU
is
an
environment
with
a
lot
of
moral
challenges
and
the
issues
related
to
resuscitation
and
treatment
of
very
premature
newborns.
The
philosophy
of
care
of
such
infants
is
different
in
different
countries
among
physicians
and
medical
centers
and
can
cause
challenges
in
the
care
of
newborns
(13).
In
the
study
by
Brosig,
parents
referred
to
the
importance
of
care
of
the
employees
of
them
such
as
taking
care
of
their
newborns
(14).
Relationship
with
empathy
can
be
pivotal
for
effective
communication
between
nurse,
newborn,
and
his
family
(15).
The
findings
of
the
present
study
are
in
line
with
the
findings
of
these
studies.
The
third
theme
of
our
research
was
professional
and
moral
skills
of
nurses.
This
theme
includes
has
two
categories
of
professional
skills
and
moral
skills
of
the
nurses.
These
challenges
show
that
nurses
in
this
study
believed
that
to
work
with
newborns,
nurses
need
enough
knowledge
and
experience.
This
is
while
they
believe
that
each
of
these
skills
(knowledge
and
experience)
alone
cannot
guarantee
success
of
nurse
in
dealing
with
and
caring
for
the
newborns.
Moreover,
according
to
the
nurses,
fear
and
stress
at
the
beginning
of
working
with
newborns
has
always
been
there,
but
with
the
passage
of
time,
one
can
gain
the
skills
and
experience
of
working
with
newborns
and
with
greater
work
experience,
one
can
be
more
compatible
with
the
environment.
However,
seeing
the
agony
of
a
newborn
when
performing
invasive
procedures
and
lack
of
palliative
care
guide
of
nurses
in
terms
of
whether
what
they
do
is
correct
or
not
is
a
challenge.
In
a
study
conducted
on
the
moral
challenges
experienced
in
providing
nursing
care
at
the
end
of
life
in
nursing
homes
in
Norway,
the
lack
of
competence
in
the
care
of
the
patient
has
been
referred
to
as
one
of
the
moral
challenges.
Unnecessary
medical
orders
for
testing
and
treating
in
newborn,
such
as
increasing
the
dose
of
a
sedative
by
doctors
for
fear
of
death
of
the
newborn,
not
relieving
the
suffering
of
newborns,
preparing
a
child
dependent
on
ventilator
for
placing
gastrostomy
tube,
extensive
measures
to
save
the
patient
while
only
prolonging
death,
prescriptions
for
unnecessary
tests,
and
treatment
for
a
terminally
ill
child
were
of
the
moral
challenges
reported
in
a
study
(9).
In
the
study
by
Elpern
et
al.
conducted
on
28
nurses
working
in
intensive
care
units,
the
results
showed
that
nurses
often
experience
moral
distress.
The
greatest
source
of
moral
distress
among
nurses
was
providing
aggressive
care
for
patients
in
whom
they
did
not
expect
recovery
was
regarded
as
futile
care.
Moral
distress
was
associated
with
years
of
experience
in
nursing.
Nurses
argued
that
moral
distress
could
have
negative
effects
on
job
satisfaction,
psychological
and
physical
well-being,
body
image
of
self,
and
spirituality.
The
nurses
who
worked
in
intensive
care
units
had
moderate
to
severe
levels
of
moral
distress.
Situations
with
the
greatest
distress
were
when
life
was
long,
or
at
the
time
of
aggressive
actions
(1).
As
the
results
of
various
studies
show,
moral
challenges
of
nurses
are
different
in
the
care
of
patients
in
different
situations.
It
should
be
noted
that
most
cases
referred
to
in
research
were
obtained
through
quantitative
research,
but
the
results
of
the
present
study
have
been
achieved
through
qualitative
method,
so
it
is
recommended
that
in
studying
moral
challenges,
NICUs
must
be
considered.
Results
of
this
study
showed
that
nurses
working
in
NICUs
face
challenges
in
the
care
of
newborns.
Overall,
the
challenge
of
defects
in
newborn
care
were
due
to
nursing
workforce
shortage,
lack
of
facilities
and
equipment,
caring
for
newborns
with
love,
good
feeling
of
nurse
in
working
with
newborns,
the
importance
of
empathy
with
the
newborn
mother
and
family,
the
challenge
of
coping
with
the
request
of
the
family
of
the
newborn
while
in
violation
of
infant
health,
the
importance
of
conscientiousness
in
caring
for
newborn,
and
creating
feeling
of
guilt
in
the
nurse
when
performing
painful
procedures
for
the
newborn
are
the
most
important
moral
challenges
nurses
face
in
the
face
of
newborns
admitted
to
the
intensive
care
unit.
In
general,
it
can
be
concluded
some
of
the
challenges
mentioned
like
“moral
characteristics
of
nursing”
can
be
associated
with
individual
and
professional
features
of
the
nurse
and
others
like
“the
challenge
of
defects
due
to
labor
shortages
in
nursing
care”
or
“lack
of
resources
and
equipment
in
impairment
for
infant
care,”
which
implicitly
affect
performance
in
nurses,
are
beyond
the
control
of
nurses.
Challenges
such
as
“challenge
of
understanding
and
proper
dealing
with
family
of
the
newborn”
are
due
to
the
lack
of
attention
to
family-centered
care.
Thus,
we
suggest
that
special
attention
should
be
paid
to
moral
challenges
faced
by
nurses
in
order
to
prevent
moral
distress
by
taking
into
account
the
appropriate
educational
program,
change
of
attitudes
of
nurses,
providing
facilities
and
equipment
needed,
and
emphasis
on
family-centered
care
facilities
and
equipment.
Limitations
of
the
study
One
limitation
of
this
study
is
conducting
the
research
in
a
particular
area.
Another
limitation
is
all
participants
were
female.
Acknowledgments
The
researchers
thank
the
respected
authorities
of
Islamic
Azad
University
of
Isfahan
(Khorasgan)
and
specialty
and
subspecialty
officials
of
Al-Zahra
hospital,
Isfahan
and
all
nurses
who
participated
to
achieve
the
objectives
of
this
study.
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