Data Gathering

RESEARCH INSTRUMENT WITH INFORMED CONSENT FORM
I understand that I am being asked to participate in a research study in Midsayap, North

Cotabato. This research study will assess the interrelationship between profile, moral distress,
and professional autonomy among staff nurses in hospitals in Midsayap for the second quarter of
2023.
If I agree to participate in the study, I will be made to answer a questionnaire for approximately
15 – 30 minutes about my profile and my perceptions on moral distress and professional
autonomy. The filling-out of the questionnaire will take place in an area most convenient to the
respondent. No identifying information will be included after answering the questionnaire. I
understand I will not receive any monetary consideration for participating in the study. There are
no risks associated with the study.
I realize that I may not participate in the study if I am younger than 18 years of age or I cannot
read and write.
I realize that the knowledge gained from this study may help either the me or other nurses of
Midsayap, Northern Cotabato to know more about organizational commitment.
I realize that my participation in this study is entirely voluntary, and I may withdraw from the
study at any time I wish. If I decide to discontinue my participation in this study, I will continue
to be treated in the usual and customary fashion.
I understand that all the data will be kept confidential. However, this information may be used in
publication or presentations.
I understand that if I sustain injuries from my participation in this research project. I will not be
automatically compensated by the hospital. If I need to, I can contact UV-REC office at 416-
8607 or 0943-533049 or email at rec@uv.edu.ph, anytime during the study.
The study has been explained to me, I have read and understand the consent forms, all of my
questions have been answered and I agree to participate, I understand that I will be given a copy
of the signed consent form.
________________________________
Signature of Respondent and Date
Witness
________________________________ ________________________________
Signature of Researcher and Date Signature of Witness and Date
I. PROFILE
Age: ____________________ (years)
Sex: Male Female
Highest Educational Attainment:
College Degree Holder With Master’s Degree Units
With Master’s Degree With Doctoral Units
With Doctoral Degree
Number of Years in the Nursing Profession: _______________ (years)
Type of Institution:
Private Public
PART II. MORAL DISTRESS
Instructions: The following statements present everyday situations associated with care of
patients and their family. Please indicate to what extent the situation makes you experience
stress of conscience? (1 - not at all 6 - to a very large extent). In case you have not experienced
such situations, mark the answer ‘‘irrelevant.’’
Not Very
at large
all extent
Statements 1 2 3 4 5 6 irrelevant
Time
1. I do not have enough time to provide

the patient with the care she/he deserves
2. I was forced to keep a patient, who

needed a treatment, waiting, due to lack
of time
3. I did not give the patient a sufﬁcient

attention due to lack of time
Resources
1. I pondered whether to tell the patient

(who did not have the means) that he can
purchase an expensive medication not
included in the ‘‘medication basket’’
2. I was forced to invade the patient’s

privacy due to inadequate conditions
(e.g., a patient in a corridor)
3. I was obliged to respond to the patient,

who deserved a treatment but did not get
it
4. I was forced to move a patient to an

unsuitable department instead of
providing her/him an appropriate
treatment in my department
Relationships
1. I was forced to treat the patient

according to the physician’s directions
against my conscience
2. I pondered what to do while witnessing

deﬁcient treatment provided by another
nurse or a physician
3. I was forced to ignore the patient’s

questions because the physician was
supposed to address them
4. I was forced to ignore the patient’s

family questions because the physician
was supposed to address them
PART III. PROFESSIONAL AUTONOMY
Instructions: Please answer each items using the following scales:
1 as nurses have no authority nor accountability

2 as nurses assume authority and accountability when asked
3 as nurses share authority and accountability with others
4 as nurses consult with others and participate in-group decisions
5 as nurses have full independent authority and accountability.
Statements 1 2 3 4 5
Patient Care Decisions
1. Serve as patient advocate
2. Question physician orders
3. Teach about patient medication
4. Consult with MD and other professionals
5. Prevent skin breakdown
6. Teach self-care activities
7. Discuss alternatives with physician
8. Prevent patient falls
9. Teach heath care promotion activities
10. Refuse to carry out physician’s orders
11. Decide time to administer care
12. Plan care with patient
13. Advance PRN orders
14. Refer to other healthcare professionals
15. Make decision for pain management
16. Handle individual patient’s complaints
17. Develop patient education material

18. Handle physician complaints
19. Inform patient of surgery risks
20. Order diagnostic test
21. Determine day of discharge
Unit Operation Decisions
1. Arrange for trading hours
2. Decide own break and lunch time
3. Make patient assignments
4. Serve on department committees
5. Present unit in service
6.Determine delivery of care method
7. Implement new ideas
8. Schedule own hours
9. Develop unit goals
10 Develop and revise unit procedures
11. Develop and revise standards of care
12. Develop and revise unit policies
13. Initiate research activities
14. Determine quality assurance indicators
15. Choose new equipment and supplies
16. Determine staff meeting agendas
17. Develop peer review evaluation
18. Staff nurse job description
19. Interview and select new staff
20. Identify causes for unit budget variance

21. Plan yearly unit budget

Data Gathering

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RESEARCH INSTRUMENT WITH INFORMED CONSENT FORM

I understand that I am being asked to participate in a research study in Midsayap, North

Age: ____________________ (years)

Sex: Male Female

Highest Educational Attainment:

College Degree Holder With Master’s Degree Units

With Master’s Degree With Doctoral Units

With Doctoral Degree

Number of Years in the Nursing Profession: _______________ (years)

PART II. MORAL DISTRESS

1. I do not have enough time to provide

2. I was forced to keep a patient, who

3. I did not give the patient a sufﬁcient

1. I pondered whether to tell the patient

2. I was forced to invade the patient’s

3. I was obliged to respond to the patient,

4. I was forced to move a patient to an

1. I was forced to treat the patient

2. I pondered what to do while witnessing

3. I was forced to ignore the patient’s

4. I was forced to ignore the patient’s

Instructions: Please answer each items using the following scales:

1 as nurses have no authority nor accountability

Patient Care Decisions

1. Serve as patient advocate

2. Question physician orders

3. Teach about patient medication

4. Consult with MD and other professionals

5. Prevent skin breakdown

6. Teach self-care activities

7. Discuss alternatives with physician

8. Prevent patient falls

9. Teach heath care promotion activities

10. Refuse to carry out physician’s orders

11. Decide time to administer care

12. Plan care with patient

13. Advance PRN orders

14. Refer to other healthcare professionals

15. Make decision for pain management

16. Handle individual patient’s complaints

17. Develop patient education material

19. Inform patient of surgery risks

20. Order diagnostic test

21. Determine day of discharge

Unit Operation Decisions

1. Arrange for trading hours

2. Decide own break and lunch time

3. Make patient assignments

4. Serve on department committees

5. Present unit in service

6.Determine delivery of care method

7. Implement new ideas

8. Schedule own hours

9. Develop unit goals

10 Develop and revise unit procedures

11. Develop and revise standards of care

12. Develop and revise unit policies

13. Initiate research activities

14. Determine quality assurance indicators