THE RELATIONSHIP BETWEEN MORAL DISTRESS WITH LEVEL OF BURNOUT ON NURSES IN INTENSIVE CARE ROOM AT THE DR. SOEBANDI HOSPITAL JEMBER

Moral distress is psychological disequilibrium and negative feelings that results from recognizing an ethically appropriate action, yet not taking it because of such barriers. Caused by increased workload of nurses in the intensive care room, resulting burnout that affects nurses, patients and health care providers. This study aimed to analyze the relationship between moral distress and the level of burnout in intensive care room nurses at the dr. Soebandi Hospital Jember. This study used a quantitative descriptive observational analytic with the approach cross sectional design selected 47 nurses as respondents used total sampling. Data collected by Measure of Moral Distress Scale - Healthcare Professionals and Maslach Burnout Inventory. The results revealed that most respondents experienced low moral distress (85.1%) and low burnout (61.7%). The bivariate analysis showed with spearman test that p-value was < 0.001 (alfa = 0.05; r = 0.531). There was a relationship between moral distress and the level of burnout with moderate and positive relationship strength. A healthy work environment plays an important role in the low level of moral distress and burnout, if there are staff skilled in communication, good collaboration between people or professions, effective decision making, proper staffing, recognition and leadership.

burnout intensive care moral distress nurses the United Kingdom, 7.02% of nurses reported leaving their jobs, 25.73% of nurses had considered leaving their jobs and 16.37% of nurses were considering leaving their jobs because moral distress.
Moral distress occurs when nurses know the actions that are morally right but cannot do so resulting in workloads on ICU nurses that were initially high will increase (Oh and Gastmans, 2015).The state of moral distress will cause a nurse to feel more tired both physically and emotionally so that the level of empathy for patients and families decreases which impact on the quality of services provided (Savel and Munro, 2015).Moral distress causes physical and psychological pressure on nurses in intensive care rooms to be higher and higher than before, which leads to burnout for nurses in intensive care.This can lead to an increase in turnover in taking actions that endanger patients and nurses, a decrease in the quality of care services, and can even lead to a decrease in reputation or accreditation from hospitals due to a decrease in the level of patient and family satisfaction.
According to Rushton et al., (2015), burnout includes emotional exhaustion, depersonalization and attainment of nurses' self achievement which this causes a decrease in health, an increase in nurse turnover and a decrease in patient satisfaction.In addition, other contributors that cause burnout are distress due to frequent nurses dealing with death, not having enough preparation to meet the emotional and spiritual needs of clients, and other staff support that is inadequate (Rushton et al., 2015).If burnout occurs due to moral distress, it is necessary to create a good work environment to reduce the possibility of moral distress and burnout, as well as providing support and trust from all staff in the care team to increase self-confidence and avoid the causes of moral distress and burnout.

METHODS
This research was conducted in the hospital area of dr.Soebandi Jember in December 2019-January 2020.This study used descriptive observational analytic methods through a cross sectional approach.This aimed to analyze the relationship between the two variables where the data is taken in one meeting with the respondent without any intervention.Respondents will be asked to fill in the questionnaire provided in accordance with their conditions.This study uses a total sampling technique with a sample of 47 intensive care nurses.Variable moral distress was measured with a questionnaire measure of moral distress scale -healthcare professionals (MMD-HP), while job burnout variables measured by maslach burnout inventory (MBI).The MMD-HP questionnaire was declared valid on 27 statement items with r count > 0.444 and declared reliable with a Cronbach alpha value of 0.949.The MBI questionnaire was declared valid on 22 statement items with r count > 0.444 and declared reliable with a Cronbach alpha value of 0.929.Data were analyzed with the spearman rank test to determine the relationship, the closeness of the relationship and the direction of the relationship between the two variables.This study was tested ethically by the Medical Research Ethics Commission of the Faculty of Dentistry University of Jember with number of ethic 631/UN25.8/KEPK/DL/2019and there were no ethical problems.

RESULTS
Univariate analysis results related to respondent characteristics, moral distress and work fatigue.
Respondent characteristics related to age, gender, length of work and nurse's last education.While the results of bivariate analysis are the correlation between moral distress variables and the level of burnout.
In table 1 explains that the median age of nurses working in the intensive care room of dr.Soebandi Hospital Jember is 35 years old with the youngest age is 24 years old and the oldest is 51 years old.It is known that there are 17 male nurses or 36.2% and 30 female nurses or 63.8%.This explains that the number of intensive care nurses who are female is greater than male nurses.In total, the length of work of 47 nurses in the intensive care unit has lasted more than 6 months (> 6 months) (100%), with the most number of nurses having graduated from Diploma 3 with 37 nurses (78.7%).
In table 2 explained that intensive care nurses who experienced low moral distress as many as 40 people (85.1%), which was as medium moral distress 7 (14.9%).Overall 47 nurses (100.0%) in the intensive care unit said they had never considered or left their clinical position due to moral distress and no left their clinical position due to moral distress and noone was considering leaving their current clinical position due to moral distress.
In table 3 explains that intensive care room nurses experience low burnout are 29 people or 61.7% and moderate burnout as many as 18 people or 38.3%.Based on table 3 it is known that there are no nurses who experience severe levels of burnout.
In table 4 describes the distribution of indicators fatigue in nurses working in intensive care with the highest value on the distribution of personal accomplishment indicators, followed indicator of emotional exhaustion and depersonalization.Indicator of personal accomplishment gets a median value of 26.00 with a minimum value of 13 and a maximum of 48.This shows the level of self-achievement of nurses is This shows the level of self-achievement of nurses is higher than the level of emotional exhaustion and depersonalization of nurses, so this causes the level of burnout in intensive care nurses is low.
Based on the results in table 5 be explained there is a relationship between moral distress to the level of burnout in nurses intensive care with a value of p < 0.001 (alfa = 0.05), in which the strength of the relationship between moral distress and moderate levels of burnout with correlation coefficient value is 0.531 and has a positive relationship direction (+) which means that the greater the value of moral distress to nurses, the greater the value of burnout in intensive care nurses.

Characteristic of Respondents
The results showed that the median age of intensive care unit nurses at dr. Soebandi Hospital Jember is 35 years old, which means that most respondents in category of early adulthood.And the most educational background of nurses from Diploma 3. Researchers assume that at this stage of early adulthood is a time when a person has high productivity because he is aware of the responsibilities that must be assumed.If the nurse's education level is good, it will be beneficial for the nurse herself to continue to grow.The results showed that all nurses had been working for more than 6 months in the intensive care room of dr.Soebandi Hospital Jember.This is in line with research Hiler et al., (2018) who conducted a similar study obtained data that intensive care nurses had worked for 1-10 years as many as 67% of nurses and who had worked for more than 10 years as many as 32% nurses.Nurses assume that the longer the nurse works in a unit, the nurse can adjust and adapt to the work environment.

Moral Distress
Based on the results of the study showed that nurses in the intensive care room experienced the most low moral distress (85.1%) and the rest experienced moderate moral distress (14.9%).This is not in line with the study of Hiler et al., (2018) who reported that the frequency and intensity of moral distress among nurses was at a high level, especially if the nurses considered the treatment provided was of no use.
Nurses who experience moral distress can use many coping strategies such as seeking social information and emotional support from others and carrying out planned problem solving (Forozeiya et al., 2019).Another factor is the work environment.A healthy work environment is a professional practice environment where communication, collaboration and leadership are good so that job satisfaction of nurses increases (McAndrew et al., 2011).Leadership in nursing is an important component in building and maintaining a healthy work environment, where leaders must be able to help deal with problems that occur both in teams and individuals effectively (McAndrew et al., 2011).Researchers assume from a healthy work environment to give good consideration to nurses in dealing with perceived problems such as patients, family, or coworkers that cause moral distress, so nurses are able to reduce and manage moral distress to a mild level.
Another thing that causes nurses' moral distress tends to be mild due to good spiritual well-being.Individuals with good spiritual well-being can find purpose and meaning in their lives so that they can recover themselves from existing stress (Sung, 2009).Researchers assume that with good spiritual wellbeing, it can reduce distress, so that not only physical health is considered but mental health is also needed.

Burnout
Based on the results of the study showed the frequency of nurses in the intensive care room most experienced low level of burnout (61.7%) and the rest experienced moderate level of burnout (38.3%).This is not in line with previous research.Kim and Yeom (2018) revealed that based on the experience of intensive care nurses as a whole experienced severe burnout.Researchers assume that there are differences related to factors that cause burnout.
The things that cause the low level of burnout in nurses intensive care room include good relations with teammates as well as professional interprofession and working hours management so that a healthy environment and work situation reduces the level of burnout in nurses.This is consistent with the research of Kim et al., (2019), the important role of a healthy work environment, especially good collaboration between members of the interprofessional health team, the recognition or appreciation and the existence of good management in primary care settings can reduce burnout in nurses.According to Nguyen et al., (2018), many solutions or interventions that might be effectively implemented to prevent burnout such as increasing the number of nurses, appropriate work schedules, minimizing favoritism by leaders, fairness and respecting nurse performance.Another thing that can affect the tendency of the low level of burnout of nurses in the intensive care room of dr.Soebandi Hospital Jember are teamwork and social interaction in it.The quality of social interaction in the workplace is good when problem solving is good, mutual support, the closeness and capacity to work as a team (Maslach and Leiter, 2008).Researchers assume that the existence of social interaction and good team work reduces the workload on nurses so that the level of burnout will decrease.

Relationship of Moral Distress with the Level of Burnout
The results of this study are in line with research by Neumann et al., (2017) show that there is a relationship between moral distress and work fa-tigue experienced by health professionals including nurses.Nurses who have experienced moral distress are more likely nurses will experience burnout where the consequences of burnout experienced not only affect the physical health, mental and welfare of nurses, but also will have an impact on health care institutions (Pastores, 2016).A healthy work environment plays an important role in the low level of moral distress and burnout (Kim et al., 2019).There are six important standards for creating a healthy work environment according to the American Association of Critical-Care Nurses (AACN) in Ulrich et al., (2014) include communication skills, collaboration, effective decision making, proper staffing, authentic recognition and leadership.
Emotional exhaustion can result from excessive workloads or individual personal conflicts with their work.In addition, poor interpersonal relationships and management systems that lack participation from nurses in making policies and decisions also become a source of emotional exhaustion that leads to burnout.So it is necessary to have a strategy to promote nurse autonomy in making decisions and recognition of nurses to avoid job dissatisfaction, burnout and neglect of the nursing profession (Dalmolin et al., 2012).
The majority of nurses in the intensive care room of dr.Soebandi Hospital Jember experienced low level of moral distress with low burnout.This shows that the possibility in the intensive care room of dr.Soebandi Hospital Jember has a healthy work environment so the level of moral distress and burnout in nurses tends to be mild.If the low level of moral distress on nurses, researchers assume that nurses have adapted to the work environment, the demands of existing work and have coping alternatives in dealing with work problems, so the level of burnout in nurses tends to be lowand nurses can optimize nursing care that can be given to patients in the intensive care room.

CONCLUSION
The most moral distress that occurred in the respondents in this study was in the low category by 81.5% and the moderate category by 14.9%.Most of the burnout that occurred in the respondents in this study was in the low level of 61.7% and in the moderate level of 38.3%.There is a relationship between moral distress with the level of burnout with the strength of a moderate relationship and the direction of a positive relationship, so that with the presence of moral distress can increase burnout in the intensive care room nurses in dr.Soebandi Hospital Jember.So that a healthy work environment can reduce moral distress and burnout, which includes good communication skills by staff, good collaboration between individuals and professions, effective decision making, recognition, proper staffing and good leadership.Because low moral distress balanced with low levels of burnout, will have a positive impact on nurses, patients and health care institutions.

Table 1 .
The Frequency Distribution Characteristics of an Intensive Care Nurse Respondents by Age, Gender, Lenghth of Work and the Latest Education (N = 47)

Table 2 .
The Frequency Distribution of Moral Distress in the Intensive Care Nurses (N = 47)

Table 3 .
The Frequency Distribution of Burnout in Nurses Intensive Care (N = 47)

Table 4 .
Distribution Indicator of Burnout in Nurses Intensive Care (N = 47)

Table 5 .
Bivariate Analysis between Moral Distress with Burnout in Intensive Care Nurses (N = 47)