Introduction
Moral distress is a situation in which a nurse is challenged to make the right decision. This condition may be due to a lack of time and energy to do the job or conflict with organizational discipline [1, 2]. Some studies have shown that moral distress causes depression, anxiety, sleep disorders, and burnout in novice nurses [3, 5]. Research has shown that moral distress has unintended consequences for nurses, patients, and healthcare organizations [9]. The consequences of this phenomenon include insecurity in the workplace, increasing the length of hospital stay, and reducing the quality of patient care [6، 7، 9]. 
Problem-solving skills training has been proposed in the literature to reduce nurses’ moral distress [13, 14]. This method can emotionally and psychologically empower nurses [15, 16].
 Therefore, this study was conducted to determine the effect of problem-solving skills training on the moral distress of novice nurses.
Materials and Methods
 This clinical trial study was conducted on 70 novice nurses of Khorramabad Educational Hospital, Khorramabad City, Iran. The samples were selected by convenience sampling method and then assigned to the intervention (n=35) and control (n=35) groups using the block random sampling method. The inclusion criteria included work experience of fewer than 3 years, age between 23 and 27 years, with bachelor’s or master’s degree. The exclusion criteria included unwillingness to continue participation in the study, migration, and death. Data collection tools included a demographic information form and Corley’s moral distress questionnaire. The questionnaire has 21 items, which include two sections: recurrence and severity of moral stress. The validity and reliability of this questionnaire have been c in confirmed in various studies [18]. The educational content was held in six sessions: familiarity, problem definition, data collection, goal setting, possible solutions, decision-making, and evaluation [17]. Moral distress was assessed first at the beginning of the study and then at the end of the sessions, and the results before and after the intervention were compared between the two groups. Finally, the data were analyzed using SPSS software version 16. Then descriptive statistics (mean and standard deviation) and inferential statistics (the independent t test, paired t test, and the Pearson correlation tests) were used. 
Results
This study was performed on 70 novice nurses whom all had 1-3 years of experience in the hospital. In terms of mean age, the samples had a mean age of 25. Regarding education, 98.5% of the samples had a Bachelor’s degree, and 1.5% had a Master’s degree (Table 1).  


The statistical results of the Chi-square, Pearson, and Fisher exact tests showed no statistically significant difference between the control and intervention groups in terms of age, education level, and income level (P>0.05).
 Comparison of the mean scores of moral stress before and 3 months after the intervention using the paired t test, independent t test, and Chi-square showed a statistically significant difference in terms of improving problem-solving ability and reducing moral stress among the intervention group (P<0.05). While in the control group, no statistically significant difference was observed (P>0.05) (Table 2).


Comparison of moral stress scores of novice nurses between the two groups in terms of frequency before and after the intervention also demonstrated a statistically significant difference based on the intensity of moral distress between the intervention and control groups (P<0.05) (Table 3).


Discussion 
The study showed that novice nurses experience moral distress at the beginning of clinical practice. However, its intensity was moderate. This finding is consistent with the results of some studies. They showed that the severity and frequency of moral distress in the intensive care unit and emergency nurses were moderate [3, 6, 13]. However, two studies showed that the average moral distress in nurses was severe [1, 7]. Another study also reported low levels of moral distress in nurses [19]. This difference in the results of these studies can be due to differences in workload, work environment, and organizational rules and regulations. Another study showed that the intensity of moral distress in nurses was low [20]. A researcher stated that the ethical decisions of caregivers in intensive care units are influenced by their attachment to patients and are more emotional than rational. These researchers describe moral distress as an unexplained and hidden phenomenon that is not considered a fact [21]. In this study, no significant differences were found between the level of moral distress and with age, gender, and income level of the subjects. Nevertheless, a study showed that moral distress decreases with age in nurses [20].
The results of this study showed that the intervention and control groups at the beginning of the study did not have a significant difference in the intensity of moral distress. However, after providing problem-solving training in the intervention group, the intensity of moral distress significantly declined [23]. Finally, this study showed that applying problem-solving skills can decrease the moral distress of novice nurses in the clinical setting.
Using this method can reduce the moral stress in novice nurses, increase the quality of nursing care and provide better and more appropriate nursing care to patients.

Ethical Considerations
Compliance with ethical guidelines
This article has been approved by the Research Ethics Committee of Arak University of Medical Sciences with the code of ethics IR.ARAKMU.REC.1395.449. Also, its clinical trial code is IRCTID: IRCT2017042233569N1. All principles of the Declaration of Helsinki, including obtaining informed consent from the participants and confidentiality of their information, were observed.

Funding
This study is taken from Zainab Birvanvand's master's thesis in nursing and approved by Arak University of Medical Sciences, and the Research and Technology Vice-Chancellor of the University of Medical Sciences has provided all the funds needed for this research.

Authors' contributions
Accountability in all aspects of research and proposal writing: Zainab Birvanvand, Mahbobe Sajjadi and Majid Taheri; Searching for sources, registering the clinical trial and reading the draft of the article and its final correction: Mahbobe Sajjadi and Majid Taheri; Providing training and holding workshops, collecting information and writing the final thesis: Zainab Birvanvand; Study design: Mehbobe Sajjadi; Supervising the implementation of the thesis, consulting in holding workshop sessions, helping in data analysis, writing the draft of the article, reading the final article: Soheila Shamsikhani.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors express their gratitude to the Vice-Chancellor of Research and Technology of the University of Medical Sciences, honorable nurses and all the people who helped us to complete the study.

References

1. McAndrew NS, Leske J, Schroeter K. Moral distress in critical care nursing: The state of the science. Nurs Ethics. 2018; 25(5):552-70. [DOI:10.1177/0969733016664975] [PMID]
2. Oh Y, Gastmans C. Moral distress experienced by nurses: A quantitative literature review. Nurs Ethics. 2015; 22(1):15-31. [DOI:10.1177/0969733013502803] [PMID]
3. Abbaszadeh A, Nakhaei N, Borhani F, Roshanzadeh M. [The relationship between Moral distress and retention in nurses in Birjand teaching hospitals (Persian)]. Iran J Med Ethic Hist Med. 2013; 6(2):57-66. [Link]
4. Mirzazadeh G, Nourozi K, Fallahi-Khoshkenab M, Vaziri M, Kiany T. [Evaluating the effect of stressful incident debriefing on Moral distress of nurses (Persian)]. Iran J Rehabil Nurs. 2015; 2(1):1-11. [Link]
5. da Luz KR, Vargas MA, Schmidtt PH, Barlem EL, Tomaschewski-Barlem JG, da Rosa LM. Ethical problems experienced by oncology nurses. Rev Lat Am Enfermagem. 2015; 23(6):1187-94. [DOI:10.1590/0104-1169.0098.2665] [PMID] [PMCID]
6. Sadeghi M, Ebrahimi H, Abbasi M. [The relationship between Moral distress and burnout in clinical nurses in the Shahroud city (Persian)]. Iran J Nurs Res. 2016; 11(2):78-87. [Link]
7. Naboureh A, Imanipour M, Salehi T, Tabesh H. [The relationship between Moral distress and self-efficacy among nurses in critical care and emergency units in hospitals affiliated to Ahvaz Jundishapur university of medical sciences in 2015 (Persian)]. J Rafsanjan Univ Med Sci. 2015; 14(6):443-54. [Link]
8. Lluch-Canut T, Sequeira C, Falcó-Pegueroles A, Pinho JA, Rodrigues-Ferreira A, Olmos JG, et al. Ethical conflicts and their characteristics among critical care nurses. Nurs Ethics. 2020; 27(2):537-53. [DOI:10.1177/0969733019857785] [PMID]
9. Hussein R, Everett B, Ramjan LM, Hu W, Salamonson Y. New graduate nurses’ experiences in a clinical specialty: A follow up study of newcomer perceptions of transitional support. BMC Nurs. 2017:16(1):42. [DOI:10.1186/s12912-017-0236-0] [PMID] [PMCID]
10. Mohamadi J, Ghazanfari F, Azizi A. [The effectiveness of ethics training on nurses’ ethical distress (Persian)]. J Med Educ Dev. 2016; 8(20):99-105. [Link]
11. Rafii F, Sajadi Hezaveh M, Seyed Fatemi N, Rezaei M. [Concept analysis of social support of new graduate nurses in the workplace: A hybrid model (Persian)]. Iran J Nurs. 2014; 26(86):71-89. [Link]
12. Seyedfatemi N, Moshirabadi Z, Borimnejad L, Haghani H. [Relationship between problem solving and assertiveness skills among nursing students (Persian)]. Hayat. 2013; 19(3):70-81. [Link]
13. Shafipour V, Esmaeili R, Heidari M R, Aghaei N, Saadatmehr S R, Sanagoo A. Investigating the level of Moral distress and its related factors among nurses in Mazandaran Burn Center (Persian)]. J Mazandaran Univ Med Sci. 2015; 25(126):58-67. [Link]
14. Korkmaz S, Kazgan A, Çekiç S, Tartar AS, Balcı HN, Atmaca M. The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in covid-19 services. J Clin Neurosci. 2020; 80:131-6. [DOI:10.1016/j.jocn.2020.07.073] [PMID] [PMCID]
15. Abdollahi A, Talib MA, Yaacob SN, Ismail Z. [Problem-solving skills and hardiness as protective factors against stress in Iranian nurses (Persian)]. Issues Ment Health Nurs. 2014; 35(2):100-7. [DOI:10.3109/01612840.2013.843621] [PMID]
16. Aitamaa E, Suhonen R, Puukka P, Leino-Kilpi H. Ethical problems in nursing management - a cross-sectional survey about solving problems. BMC Health Serv Res. 2019; 19(1):417. [DOI:10.1186/s12913-019-4245-4] [PMID] [PMCID]
17. Ghavipanjeh S, Ebrahimi H, Barzanjeh Atri S, Pakpour V, Tarverdizadeh P. [Effect of problem-solving skills on depression scores in nursing and midwifery students (Persian)]. Hayat. 2014; 20(2):38-46. [Link]
18. Badolamenti S, Fida R, Biagioli V, Caruso R, Zaghini F, Sili A, et al. Modified Moral distress scale (MDS-11): Validation study among Italian nurses. Prof Inferm. 2017; 70(4):238-48.  [DOI:10.7429/pi.2017.704238] [PMID]
19. Fazljoo E, Borhani F, Abbaszadeh A, Razban F. [The relationship between nurses’ perceptions of Moral distress and the ethical climate in Shahid Sadoughi university of medical sciences of Yazd (Persian)]. Iran J Med Ethic Hist Med. 2014; 7(2):80-90. [Link]
20. Joolaee S, Jalili H R, Rafii F, Hajibabaee F, Haghani H. [Relationship between Moral distress and job satisfaction among nurses of Tehran university of medical sciences hospitals (Persian)]. Hayat. 2012; 18(1):42-51. [Link]
21. Ameri M, Safavibayatneed Z, Kavousi A. Moral distress of oncology nurses and Morally distressing situations in oncology units. Aust J Adv Nurs. 2016; 33(3):6-12. [Link]
22. Prompahakul C, Epstein EG. Moral distress experienced by non-Western nurses: An integrative review. Nurs Ethics. 2020; 27(3):778-95. [DOI:10.1177/0969733019880241] [PMID]
23. Shahbazi S, Hazrati M, Moattari M, Heidari M. [The effect of problem solving skills training on emotional intelligence of nursing students of Shiraz (2008) (Persian)]. Iran J Med Educ. 2012; 12(1):67-76. [Link]
24. Svantesson M, Silén M, James I. It’s not all about moral reasoning: Understanding the content of Moral case deliberation. Nurs Ethics. 2018; 25(2):212-29. [DOI:10.1177/0969733017700235] [PMID]