Article Data

  • Views 3509
  • Dowloads 299


Open Access

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 Vol.17,Issue 4,July 2021 pp.192-202

Submitted: 21 March 2021 Accepted: 12 May 2021

Published: 08 July 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

Cite and Share

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. 17(4);192-202.


[1] Nejadsarvari N, Abbasi M, Borhani F, Ebrahimi A, Rasooli H, Kalantar Motamedi MH, et al. Relationship of moral sensitivity and distress among physicians. Trauma Monthly. 2015; 20: e26075.

[2] Fourie C. Who Is Experiencing What Kind of Moral Distress? Distinc-tions for Moving from a Narrow to a Broad Definition of Moral Distress. AMA Journal of Ethics. 2017; 19: 578–584.

[3] Fourie C. Moral Distress and Moral Conflict in Clinical Ethics. Bioethics. 2015; 29: 91–97.

[4] Henrich NJ, Dodek PM, Alden L, Keenan SP, Reynolds S, Rodney P. Causes of moral distress in the intensive care unit: a qualitative study. Journal of Critical Care. 2016; 35: 57–62.

[5] Atashzadeh Shorideh F, Ashktorab T, Yaghmaei F. Iranian intensive care unit nurses’ moral distress: a content analysis. Nursing Ethics. 2012; 19: 464–478.

[6] Dudzinski DM. Navigating moral distress using the moral distress map. Journal of Medical Ethics. 2016; 42: 321–324.

[7] Wiegand DL, Funk M. Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics. 2012; 19: 479–487.

[8] Hamric AB, Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Critical Care Medicine. 2007; 35: 422–429.

[9] Alborzi J, Sabeti F, Baraz S, Miladinia M, Saidkhani V, Sharhani A. Investigating of moral distress and attitude to euthanasia in the intensive care unit nurses. International Journal of Pediatrics. 2018; 6: 8475–8482.

[10] Karanikola MNK, Albarran JW, Drigo E, Giannakopoulou M, Kalafati M, Mpouzika M, et al. Moral distress, autonomy and nurse-physician collaboration among intensive care unit nurses in Italy. Journal of Nursing Management. 2014; 22: 472–484.

[11] Papathanassoglou EDE, Karanikola MNK, Kalafati M, Giannakopoulou M, Lemonidou C, Albarran JW. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. American Journal of Critical Care. 2012; 21: e41–e52.

[12] Mohammadi S, Talebi F, Borhani F, Roshanzadeh M. Moral distress and attitude to euthanasia: A correlation study in nurses. Medical Ethics Journal. 2014; 8: 28.

[13] Van Wijmen MPS, Rurup ML, Pasman HRW, Kaspers PJ, Onwuteaka-Philipsen BD. Advance directives in the Netherlands: an empirical contribution to the exploration of a cross-cultural perspective on advance directives. Bioethics. 2010; 24: 118–126.

[14] Borhani F, Abbaszadeh A, Mohamadi E, Ghasemi E, Hoseinabad-Farahani MJ. Moral sensitivity and moral distress in Iranian critical care nurses. Nursing Ethics. 2017; 24: 474–482.

[15] Mealer M, Moss M. Moral distress in ICU nurses. Intensive Care Medicine. 2016; 42: 1615–1617.

[16] McCarthy J, Gastmans C. Moral distress: a review of the argument-based nursing ethics literature. Nursing Ethics. 2015; 22: 131–152.

[17] Bruce CR, Miller SM, Zimmerman JL. A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics. Critical Care Medicine. 2015; 43: 823–831.

[18] Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies that Evaluate Health Care Interventions: Explanation and Elaboration. Annals of Internal Medicine. 2009; 6: e1000100.

[19] Herzog R, Álvarez-Pasquin MJ, Díaz C, Del Barrio JL, Estrada JM, Gil Á. Are healthcare workers’ intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review. BMC Public Health. 2013; 13: 154.

[20] Ghozy S, Dung NM, Morra ME, Morsy S, Elsayed GG, Tran L, et al. Efficacy of kinesio taping in treatment of shoulder pain and disability: a systematic review and meta-analysis of randomised controlled trials. Physiotherapy. 2020; 107: 176–188.

[21] Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560. doi:10.1136/bmj.327.7414.557

[22] Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L. Comparison of two methods to detect publication bias in meta-analysis. The Journal of the American Medical Association. 2006; 295: 676–680.

[23] Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. British Medical Journal. 1997; 315: 629–634.

[24] El-Qushayri AE, Ghozy S, Abbas AS, Dibas M, Dahy A, Mahmoud AR, et al. Hyperimmunoglobulin therapy for the prevention and treatment of congenital cytomegalovirus: a systematic review and meta-analysis. Expert Review of Anti-Infective Therapy. 2020; 19: 661–669.

[25] Borhani F, Saleh ZN, Loghmani L, Rasouli M, Nasiri M. Moral distress and compassion fatigue in nurses of neonatal intensive care unit. Electronic Journal of General Medicine. 2019; 16: 4.

[26] Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care. 2005; 14: 523–530.

[27] Altaker KW, Howie-Esquivel J, Cataldo JK. Relationships among Palliative Care, Ethical Climate, Empowerment, and Moral Distress in Intensive Care Unit Nurses. American Journal of Critical Care. 2018; 27: 295–302.

[28] Cavaliere TA, Daly B, Dowling D, Montgomery K. Moral distress in neonatal intensive care unit RNs. Advances in Neonatal Care. 2010; 10: 145–156.

[29] De Boer JC, Van Rosmalen J, Bakker AB, Van Dijk M. Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurements. Nursing in Critical Care. 2016; 21: 19–27.

[30] Dodek PM, Norena M, Ayas N, Wong H. Moral distress is associated with general workplace distress in intensive care unit personnel. Journal of Critical Care. 2019; 50: 122–125.

[31] Dryden-Palmer K, Moore G, McNeil C, Larson CP, Tomlinson G, Roumeliotis N, et al. Moral Distress of Clinicians in Canadian Pediatric and Neonatal ICUs. Pediatric Critical Care Medicine. 2020; 21: 314–323.

[32] Ganz FD, Raanan O, Khalaila R, Bennaroch K, Scherman S, Bruttin M, et al. Moral distress and structural empowerment among a national sample of Israeli intensive care nurses. Journal of Advanced Nursing. 2013; 69: 415–424.

[33] Lamiani G, Ciconali M, Argentero P, Vegni E. Clinicians’ moral distress and family satisfaction in the intensive care unit. Journal of Health Psychology. 2020; 25: 1894–1904.

[34] Larson CP, Dryden-Palmer KD, Gibbons C, Parshuram CS. Moral Distress in PICU and Neonatal ICU Practitioners: a cross-sectional evaluation. Pediatric Critical Care Medicine. 2017; 18: e318–e326.

[35] Sannino P, Giannì ML, Carini M, Madeo M, Lusignani M, Bezze E, et al. Moral Distress in the Pediatric Intensive Care Unit: an Italian Study. Frontiers in Pediatrics. 2019; 7: 338.

[36] DeKeyser Ganz F, Berkovitz K. Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. Journal of Advanced Nursing. 2012; 68: 1516–1525.

[37] Saleh ZN, Loghmani L, Rasouli M, Nasiri M, Borhani F. Moral distress and compassion fatigue in nurses of neonatal intensive care unit. Electronic Journal of General Medicine. 2019; 16: em116.

[38] Epstein EG, Whitehead PB, Prompahakul C, Thacker LR, Hamric AB. Enhancing Understanding of Moral Distress: the Measure of Moral Distress for Health Care Professionals. AJOB Empirical Bioethics. 2019; 10: 113–124.

[39] Lin T, Lin H, Cheng S, Wu L, Ou-Yang M. Work stress, occupational burnout and depression levels: a clinical study of paediatric intensive care unit nurses in Taiwan. Journal of Clinical Nursing. 2016; 25: 1120–1130.

[40] Henrich NJ, Dodek PM, Alden L, Keenan SP, Reynolds S, Rodney P. Causes of moral distress in the intensive care unit: a qualitative study. Journal of Critical Care. 2016; 35: 57–62.

[41] Lamiani G, Borghi L, Argentero P. When healthcare professionals cannot do the right thing: a systematic review of moral distress and its correlates. Journal of Health Psychology. 2017; 22: 51–67.

[42] Dodek PM, Wong H, Norena M, Ayas N, Reynolds SC, Keenan SP, et al. Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. Journal of Critical Care. 2016; 31: 178–182.

[43] Neumann JL, Davis L, Jernigan C. Methods to Address Moral Distress Experienced by Stem Cell Transplantation Nurses and Build Resiliency. Biology of Blood and Marrow Transplantation. 2018; 24: S117–S118.

[44] Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral Distress among Healthcare Professionals: Report of an Institution-Wide Survey. Journal of Nursing Scholarship. 2015; 47: 117–125.

[45] Wiegand DL, Funk M. Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics. 2012; 19: 479–487.

[46] Nuttgens S, Chang J. Moral Distress within the Supervisory Relationship: Implications for Practice and Research. Counselor Education and Supervision. 2013; 52: 284–296.

[47] Carroll KW, Mollen CJ, Aldridge S, Hexem KR, Feudtner C. Influences on Decision Making Identified by Parents of Children Receiving Pediatric Palliative Care. AJOB Primary Research. 2012; 3: 1–7.

[48] Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. Journal of Nursing Scholarship. 2015; 47: 117–125.

[49] Colville GA, Dawson D, Rabinthiran S, Chaudry-Daley Z, Perkins-Porras L. A survey of moral distress in staff working in intensive care in the UK. Journal of the Intensive Care Society. 2019; 20: 196–203.

[50] O’Connell CB. Gender and the experience of moral distress in critical care nurses. Nursing Ethics. 2015; 22: 32–42.

[51] Førde R, Aasland OG. Moral distress among Norwegian doctors. Journal of Medical Ethics. 2008; 34: 521–525.

[52] Green CA, Pope CR. Gender, psychosocial factors and the use of medical services: a longitudinal analysis. Social Science & Medicine. 1999; 48: 1363–1372.

[53] Abbasi M, Nejadsarvari N, Kiani M, Borhani F, Bazmi S, Nazari Tavaokkoli S, et al. Moral distress in physicians practicing in hospitals affiliated to medical sciences universities. Iranian Red Crescent Medical Journal. 2014; 16: e18797.

[54] Hlubocky FJ, Rose M, Epstein RM. Mastering Resilience in Oncology: Learn to Thrive in the Face of Burnout. American Society of Clinical Oncology Educational Book. American Society of Clinical Oncology Annual Meeting. 2017; 37: 771–781.

[55] Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. Journal of Clinical Oncology.2012; 30: 1235–1241.

[56] Hlubocky FJ, Taylor LP, Marron JM, Spence RA, McGinnis MM, Brown RF, et al. A Call to Action: Ethics Committee Roundtable Recommendations for Addressing Burnout and Moral Distress in Oncology. JCO Oncology Practice. 2020; 16: 191–199.

[57] Musto LC, Rodney PA, Vanderheide R. Toward interventions to address moral distress: navigating structure and agency. Nursing Ethics. 2015; 22: 91–102.

[58] Wocial L, Ackerman V, Leland B, Benneyworth B, Patel V, Tong Y, et al. Pediatric Ethics and Communication Excellence (PEACE) Rounds: Decreasing Moral Distress and Patient Length of Stay in the PICU. HEC Forum. 2017; 29: 75–91.

[59] Perni S. Moral distress: A call to action. AMA Journal of Ethics. 2017; 19: 533–536.

[60] Disch J. Rethinking Mentoring. Critical Care Medicine. 2018; 46: 437–441.

[61] Hamric AB, Epstein EG. A Health System-wide Moral Distress Consultation Service: Development and Evaluation. HEC Forum. 2017; 29: 127–143.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 1.0 (2022) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time