Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study

Moniek A. Donkers*, Vincent J. H. S. Gilissen, Math J. J. M. Candel, Nathalie M. van Dijk, Hans Kling, Ruth Heijnen-Panis, Elien Pragt, Iwan van der Horst, Sebastiaan A. Pronk, Walther N. K. A. van Mook

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


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.

Original languageEnglish
Article number73
Number of pages12
JournalBMC Medical Ethics
Issue number1
Publication statusPublished - 17 Jun 2021


  • Moral distress
  • Ethical climate
  • Intensive care medicine
  • Nurses
  • Intensivists
  • Doctors
  • COVID-19
  • Coronavirus
  • RISK


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