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Background The COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19. Methods An extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19. Results Three hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. “Inadequate emotional support for patients and their families” was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect,  ethical awareness and support. “Culture of not avoiding end-of-life-decisions” and “Self-reflective and empowering leadership” received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses ( p  < 0.001) and intensivists ( p  < 0.05) compared to one year prior. Conclusion Levels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care.

Background Commentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units (ICUs). Our aim was twofold: (1) to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and (2) determine the association between the ethical climate, moral distress, and intention to leave. Methods We performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire (EDMCQ) and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave. Results Nurses perceived the ethical climate for decision-making as less favorable than physicians ( p  < 0.05). They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/Pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units (3.54 ± 0.66 vs. 3.43 ± 0.81 vs. 3.30 ± 0.69; respectively; both p  ≤ 0.05) and also demonstrated lower moral distress scores (both p  < 0.05) and lower “intention to leave” scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated (r = −0.58, p  < 0.001); moral distress and \"intention to leave\" was positively correlated (r = 0.52, p  < 0.001); and ethical climate and “intention to leave” were negatively correlated (r = −0.50, p  < 0.001). Conclusions Significant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care.

Background The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. Methods A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. Results All 178 respondents (response rate: 25–32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to ‘team cooperation’, ‘team solidarity’ and ‘work ethic’. Lessons learned were mostly related to ‘quality of care’ and ‘professional qualities’. Conclusions Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals’ dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. Trial registration The trial was registered on The Netherlands Trial Register, number NL9177.

Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians’ involvement in patients’ end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19’s catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians’ demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents’ demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during “peak-Covid,” and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53–7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18–0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22–0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.

Background Although research plays a critical role during emerging pandemics such as COVID-19, clinical care and public health priorities may be in tension with research priorities at times. This study aimed to better understand the on-the-ground realities and experiences of those who worked at the intersections of research and clinical care early in the COVID-19 pandemic to clarify the ethical dimensions of pandemic research and the support needs of those involved. The research question guiding this inquiry was: What were healthcare and research personnel’s moral experiences of engaging with COVID-19 research during the first wave of the pandemic? Methods This Interpretive Description study included 26 semi-structured telephone or virtual interviews with healthcare and research personnel conducted between May and September 2020 to explore their moral experiences related to involvement in COVID-19 research. Data were analyzed inductively using constant comparative techniques. Results The overarching theme characterizing participants’ moral experiences was trying to do right by their patients in the midst of the storm. Five sub-themes included: (1) striving for evidence-based practice in the absence of evidence, (2) struggling to balance speed, ethical standards, and rigour, (3) advocating for patients in the rush to develop COVID-19 evidence, (4) bearing the burdens and risks of conducting COVID-19 research, and (5) feeling part of something bigger. Conclusions Study findings raise questions regarding what it means to be a good physician, nurse, or healthcare professional in the absence of evidence and amidst pressures to generate it quickly. Clinical trial number Not applicable.

Purpose Moral disengagement can lead to anti-social behaviour by employees in business. In the healthcare field, moral disengagement can lead nurses to make unethical decisions and behaviours that can harm patient well-being. Therefore, this paper will examine the factors influencing moral disengagement among ICU nurses with the aim of contributing to the reduction of the level of moral disengagement among nurses. Methods Between January 2024 and January 2025, ICU nurses from second-level and above general hospitals in Henan and Hubei, China, were selected as survey respondents. The questionnaire survey was conducted using a general information questionnaire, a moral disengagement scale, a moral resilience scale, and a moral disengagement energy scale, and multiple linear stepwise regression was used to analyze the influencing factors of ICU nurses' moral disengagement. Results 305 ICU nurses scored (91.40 ± 34.37) on the Moral Disengagement Scale. The multiple linear stepwise regression analysis results showed that years of working experience, whether or not they had received ethics training(16.219 p  < 0.001), ears of experience (-7.673, p  = 0.018), moral resilience(-18.452, p  < 0.001), and moral distress (5.523, p  < 0.001) were the influencing factors of moral disengagement among ICU nurses ( p  < 0.05). The adjusted R2 = 0.499,which explains 49.9% of the total variation, suggests that the model explains the influences of moral disengagement well. Conclusion The moral disengagement of ICU nurses is moderately high, and individualized interventions can be carried out for high-risk groups to reduce this level and improve ethical decision-making to protect patient's rights and interests.

Background Providing palliative care at the end of life (EOL) in intensive care units (ICUs) seems to be modified during the COVID-19 pandemic with potential burden of moral distress to health care providers (HCPs). We seek to assess the practice of EOL care during the COVID-19 pandemic in ICUs in the Czech Republic focusing on the level of moral distress and its possible modifiable factors. Methods Between 16 June 2021 and 16 September 2021, a national, cross-sectional study in intensive care units (ICUs) in Czech Republic was performed. All physicians and nurses working in ICUs during the COVID-19 pandemic were included in the study. For questionnaire development ACADEMY and CHERRIES guide and checklist were used. A multivariate logistic regression model was used to analyse possible modifiable factors of moral distress. Results In total, 313 HCPs (14.5% out of all HCPs who opened the questionnaire) fully completed the survey. Results showed that 51.8% ( n  = 162) of respondents were exposed to moral distress during the COVID-19 pandemic. 63.1% ( n  = 113) of nurses and 71.6% of ( n  = 96) physicians had experience with the perception of inappropriate care. If inappropriate care was perceived, a higher chance for the occurrence of moral distress for HCPs (OR, 1.854; CI, 1.057–3.252; p  = 0.0312) was found. When patients died with dignity, the chance for moral distress was lower (OR, 0.235; CI, 0.128–0.430; p  < 0.001). The three most often reported differences in palliative care practice during pandemic were health system congestion, personnel factors, and characteristics of COVID-19 infection. Conclusions HCPs working at ICUs experienced significant moral distress during the COVID-19 pandemic in the Czech Republic. The major sources were perceiving inappropriate care and dying of patients without dignity. Improvement of the decision-making process and communication at the end of life could lead to a better ethical and safety climate. Trial registration : NCT04910243 . Graphical abstract

The practice of palliative care and hospice is filled with overt and sometimes covert ethical challenges. These challenges are addressed by leading international palliative care and hospice scholars under three main domains: care delivery systems; addressing the many dimensions of suffering; and difficult decisions near the end of life.

Background Moral distress, or the inability to carry out what one believes to be ethically appropriate because of constraints or barriers, is understudied in obstetrics and gynecology. We sought to characterize moral distress among Maternal-Fetal Medicine (MFM) fellows using a standardized survey. Methods We disseminated a national anonymized survey study of MFM fellows electronically regarding moral distress using a validated questionnaire with supplemental questions pertaining to specific challenges within MFM clinical care. Multivariable linear regression modeling was used to examine the association between abortion restrictions, maternal mortality, and moral distress, controlling for demographic variables. Thematic analysis was performed for the free text responses elaborating upon moral distress and grouped by thematic elements. We hypothesized that training in states with more abortion restrictions and higher maternal mortality would be associated with higher moral distress scores. Results Among 245 total responses (61% response rate), 177 complete responses (44% complete response rate) were included for analysis. Most of our respondents identified as female (78.5%), White (71.8%), and training in urban programs (83.1%). 37.9% of respondents reported training in the Northeast, with the remainder of respondents evenly distributed across the United States. The mean score for the validated questions was 85.9  ±  48.8, with female gender identity associated with higher measures of moral distress on the validated portion of the questionnaire as compared to male gender identity (90.1  ±  49.2 vs. 70.4  ±  44.7, p  < 0.05), whereas more advanced training was associated with higher measures of moral distress on the supplemental questions as compared to those less advanced in training (20.9  ±  11.8 vs. 28.5  ±  15.9 vs. 25.9  ±  15.6 for PGY-5 vs. PGY-6 vs. PGY-7 and PGY-8 combined, respectively, p  < 0.05). After adjustment, higher measure of moral distress on the validated questionnaire was associated with training in states designated “Abortion restrictive” as compared to “Abortion most protective” (beta estimate 27.80 and p  < 0.01). Of 34 free responses, 65% referred to limitations on abortion access and reproductive justice as causes of significant moral distress. Conclusion MFM fellows who identify as female reported higher measures of moral distress, as well as those training in states with more abortion restrictions. Among free text respondents, abortion restrictions underlie a significant proportion of moral distress.