This quantitative pilot study used a novel survey tool (Appendix). The tool was designed by a two-member research team to be quickly and easily filled, and thus had only four research questions and two socio-demographic items. The first question of this survey represented four small case studies about four different patients with one similarity: the need for a heart transplant. All of them were critically ill, and the study participant must decide which one should receive that organ. The idea of choosing only one patient was based on a Canadian scenario wherein the number of persons waiting for an organ transplant is much higher than the number of organs available for transplantation.

The tool was distributed to all 134 undergraduate nursing students who were attending classes in a mandatory nursing research course at the Nursing School of the University of Alberta. A total of 104 (77.6%) filled and returned it after a verbal introduction to the study by the first investigator and the provision of a written information letter. This study was approved in advance by the Research Ethics Committee at the University of Alberta.

All potential participants were asked to anonymously complete the survey. Instead of a signed consent form being obtained from each participant, the Research Ethics Committee determined that all those who completed and returned the questionnaire would be providing implied consent.

The data were collected between November 1 and December 6, 2016. All data were entered into a spreadsheet, and all entries were checked by the two researchers for accuracy prior to analysis. This paper reports the findings of the quantitative data analysis.

The Statistical Package for the Social Sciences (SPSS, version 23; IBM Corporation, Armonk, NY) was used for quantitative data analysis. Descriptive statistics were utilized to describe the sample. The chi-squared (χ²) test was subsequently used to examine categorical variables, while continuous variable data were analyzed using ANOVA and the Pearson Product Moment correlational test. These tests were performed to ascertain if moral distress was experienced in scenarios involving the availability of only one heart for transplantation to four individuals, as well as to determine if moral distress’ intensity varied according to age and gender.

The participants were asked to opt between four different persons and decide which one would get the one available heart for transplantation and thus life-saving purposes. As shown in the attached tool, a short description of each patient was provided to enable this decision-making process.

Among the 104 participants, 80.8% (n=84) chose to give the heart to Meredith. Meredith was the youngest person; she was 47 years old, widowed, and a mother of two children. She had already received a liver transplant due to liver failure from past intravenous drug use. The second most commonly chosen patient was Paul (17.3%; n=18), who was a divorced 67-year-old professor who needed a replacement heart after developing an infection that suddenly caused him heart failure. Paul lives with his 15-year-old son. The third but much less commonly chosen option was Brad (1.9%; n=2), a 57-year-old homeless person who had no next of kin and required a heart transplant due to untreated high blood pressure. No participant chose Susan, the oldest person. Susan was a 77-year-old retired truck driver who lives with her husband, has grandchildren, and has had many heart attacks.

Some differences in choices among the 104 students according to gender were noted. The male participants only chose two of the four options, with this most often being Meredith (72.2%), followed by Paul (27.8%). The female participants chose three of the four options, although 82.6% chose Meredith, followed by Paul (15.1%) and Brad (2.3%). Despite these differences, no correlation between gender and decision was found (chi-squared=1.994, df+2, p=.369). Similarly, no difference was identified regarding age.

All participants were asked to explain why they chose one over the others, and then report how they felt about their decision. Some degree of moral distress was reported. The median and mode moral distress scores were 7 on a scale from 0 indicating no moral distress, “not upset,” up to 10, the maximum score pointing to “very upset.” The mean score of 6.1 also indicates a common overall level of significant moral distress, as 1–5 scores would indicate only mild moral distress. However, it is worth noting that 39.4% (n=41) reported a 0–5 level of moral distress, while 60.6% (n=63) reported a 6–10 level of moral distress, indicating quite significant moral distress over this hypothetical situation.

Some differences in the level of reported moral distress according to gender and age were noted. A significant difference (T=2.036, p=0.48) was found between the male mean score of 5.06 and the female mean score of 6.28, with females thus more morally distressed in general, as most chose 8, 9 or 10 as scores. Age differences in moral distress scoring were also shown to be significant by the Pearson correlation test (R=220, p=025). Younger students scored higher on the moral distress scale compared to older students.

Correspondence: João Paulo Victorino – Av. dos Bandeirantes, 3.900 CEP 14040-902. Ribeirão Preto/SP, Brasil.