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Moral distress among health care workers in the intensive care unit; a systematic review and meta-analysis

  • Rakan M. AlQahtani1
  • Abdalrhman Al Saadon1
  • Mohammed Ibrahim Alarifi1
  • Ruaim Muaygil2
  • Yasmeen Khalaf Maan Altaymani1
  • Mohamed Abdelwahab Mohamed Elsaid1
  • Fahad Alsohime3
  • Mohamad-Hani Temsah3
  • Khaldoon Aljerian4

1Department of Critical Care Medicine, College of Medicine, King Saud University, 12372 Riyadh, Saudi Arabia

2Department of Medical Education, College of Medicine, King Saud University, 12372 Riyadh, Saudi Arabia

3Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, 12372 Riyadh, Saudi Arabia

4Forensic Medicine Unit, Department of Pathology, College of Medicine, King Saud University, 12372 Riyadh, Saudi Arabia

DOI: 10.22514/sv.2021.101

Submitted: 21 March 2021 Accepted: 12 May 2021

Online publish date: 09 June 2021

*Corresponding Author(s): Rakan M. AlQahtani E-mail:


Background: The effect of moral distress among healthcare providers is significant on disease morbidity, especially within the intensive care unit (ICU). In this systematic review and meta-analysis, we aimed to gather all evidence regarding moral distress frequency and severity/intensity among ICU health care providers.

Methods: We conducted a systematic search to gather all relevant studies from six databases, followed by a manual search of references. Fourteen studies consisting of 5905 participants were included in the final moral distress scale analyses.

Results: Overall, there was moderate moral distress severity/intensity among all participants (Mean = 27.79; 95% confidence interval (CI) = 7.40–64.18). On further stratification of the results according to countries, Canada (Mean = 91.99; 95% CI = 80.10–105.65) and USA (Mean = 52.54; 95% CI = 44.78–61.64) showed the highest distress scores, followed by Iran (Mean = 21.20; 95% CI = 7.21–62.30) and Italy (Mean = 3.42; 95% CI = 3.15–3.72). Studies conducted in high income-earning countries reported more severity/intensity (Mean = 22.65; 95% CI = 6.58–78.02) compared to those in the upper-middle income-earning ones (Mean = 18.89; 95% CI = 2.80–127.34). There was significant heterogeneity among the included studies, which could not be explained by the difference in scales, country of the participants, or the female proportion. Moreover, there was a moderate frequency of moral distress (Mean = 46.83; 95% CI = 8.34–262.87), which was found to be much higher (Mean = 87.94; 95% CI = 83.55–92.57), in performing analysis.

Conclusion: Moral distress is a major problem in the ICU setting, in terms of both severity/intensity and frequency. Future large-scale studies are required, through a unified framework, to develop appropriate interventions to address ICU-related moral distress.


Moral distress; Intensive care unit; Health care worker; Meta-analysis

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Rakan M. AlQahtani,Abdalrhman Al Saadon,Mohammed Ibrahim Alarifi,Ruaim Muaygil,Yasmeen Khalaf Maan Altaymani,Mohamed Abdelwahab Mohamed Elsaid,Fahad Alsohime,Mohamad-Hani Temsah,Khaldoon Aljerian. Moral distress among health care workers in the intensive care unit; a systematic review and meta-analysis. Signa Vitae. 2021.doi:10.22514/sv.2021.101.


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