Paediatric intensive care units (PICUs) are highly specialised workplaces that support children with critical illnesses and their caregivers. Advances in paediatric critical care have significantly improved survival among critically ill children, although this improvement has also led to higher rates of morbidity, more disabilities, and longer hospital stays.1 2 3 4 5 These changes have resulted in potentially conflicting views regarding expectations and treatment goals among healthcare workers and patients’ families, increasing the incidence of moral distress among healthcare workers.6

Moral distress is a term that refers to experiences of frustration and failure arising from healthcare workers’ attempts to fulfil their moral obligations to patients, families, and the public.7 8 In an intensive care setting, healthcare workers frequently encounter ethical issues. Moral distress arises when a healthcare worker has determined the right course of action but cannot follow it because of internal or external constraints (eg, limited resources, institutional policies, or family preferences).9 Moral distress has been identified among healthcare workers in both adult ICUs and PICUs.10 11 It is associated with greater experience and lower staff retention.12

Depression and stress-related symptoms are common in healthcare workers, particularly among ICU staff.13 14 Studies have shown that these symptoms can ultimately impair patient care quality.15 16 Thus far, most literature regarding moral distress has been published in Western countries; the concept of moral distress is not well-known outside of the Western world.17 To our knowledge, there have been few analyses of moral distress and psychological status among healthcare workers in non-Western PICUs. Factors that can influence the level and type of moral distress include cultural backgrounds; beliefs of the patient, their family, and the clinical team; and differences among healthcare systems. Hong Kong is a multicultural city influenced by both Eastern and Western cultures; challenges in this setting may be unique. This study assessed moral distress prevalence and psychological status among PICU healthcare workers in Hong Kong.

This prospective single-centre cross-sectional study was conducted from June to July 2020 in the six-bed tertiary PICU of the Hong Kong Children’s Hospital (HKCH), which began operation at the end of March 2019. The HKCH is the only dedicated paediatric oncology centre in the region, and most PICU admissions (54%) during the study period involved patients with cancer.

Study participants were healthcare workers involved in direct clinical care within the HKCH PICU, including doctors, nurses, and allied health professionals (ie, physiotherapists, occupational therapists, speech therapists, pharmacists, and dietitians). Healthcare workers were excluded if they had <3 months of critical care experience in the PICU or were temporarily on leave from the PICU during the study period. The survey was distributed to all eligible healthcare workers in the HKCH PICU during working hours within the study period.

The survey included two validated instruments (Revised Moral Distress Scale [MDS-R] Paediatric Version and Depression Anxiety and Stress Scale–21 items [DASS-21]) to measure levels of moral stress, depression, anxiety, and stress in all participants.18 19 The participants’ demographic details were also collected. The survey explored job-quitting intentions related to moral distress or other reasons. It was piloted with two HKCH PICU staff members; questions were refined based on feedback from them. The final survey was paper-based. An email was sent to all participants before study commencement with information regarding the aim and details of the study. The survey was distributed by hand, and all copies were collected in a sealed box after completion. To ensure anonymity, the survey did not contain any identifiers.

Moral distress, the main outcome of the study, was measured using the validated paediatric version of the MDS-R (online supplementary Appendix 1).18 It consists of 21 items describing predetermined potentially morally distressing situations. There are five predetermined categories of situations: end-of-life care and quality of life, poor communication, staffing and material resources, hierarchies of decision making, and witnessing unethical behaviour. Each item on the MDS-R is scored according to the frequency and intensity that a healthcare worker experienced, using a Likert scale that ranges from 0 to 4. If a specific situation has never been experienced, participants are asked to indicate how disturbing the situation would be if they encountered it in their workplace. The frequency and intensity scores are then multiplied to produce an overall score for each item. The total moral distress score is the sum of the 21 overall scores for each item, ranging from 0 to 336. The English version of this instrument was used.

Psychological status was assessed using the DASS-21 (online supplementary Appendix 2).19 It is a set of three self-reporting subscales that measure participants’ emotional states: depression, anxiety, and stress. Each scale contains seven items for each emotional state. Each item is scored on a four-point Likert scale ranging from 0 (‘Did not apply to me at all’) to 3 (‘Applied to me very much or most of the time’). The total score for each emotional state is the sum of the subscale scores multiplied by 2. Depression, anxiety, or stress was considered present if the relevant scores exceeded the normal cut-off. The emotional state was categorised as mild, moderate, severe, or extremely severe, based on published cut-offs. The English and Chinese versions of this instrument were used; both language versions have been validated.19 20

Outcome measures were demographic data and the levels of moral distress, depression, anxiety, and stress. Data were expressed using median (interquartile range [IQR]) for continuous variables and count (percentage) for categorical variables. Results of the MDS-R and DASS-21 were compared among doctors, nurses, and allied health professionals using the Chi squared test, Kruskal-Wallis test, or Cohen’s d. Correlations between participant variables and outcome measures were evaluated using Spearman’s rank correlation coefficient. P values <0.05 were considered statistically significant. Statistical analysis was performed using SPSS (Windows version 26.0; IBM Corp, Armonk [NY], United States).

In total, 46 of 56 healthcare workers in the PICU completed the survey; the response rate was 82%. On one survey, the moral distress section was incomplete; that survey was excluded from the analysis of moral distress.

Most participants were women (n=36, 78%) and were aged ≥30 years (n=35, 76%). More than half of the participants were nurses (n=26, 57%). Approximately half of the participants (n=24, 52%) had >5 years of PICU experience. Detailed participant characteristics are presented in Table 1.

The median MDS-R score was 71 (IQR=34-115). There was a significant difference in MDS-R score among the three professions (P<0.001). Doctors and nurses had significantly higher MDS-R scores, compared with allied health professionals (P<0.05). Nurses had the highest median MDS-R score (102, IQR=71-126), whereas allied health professionals had the lowest (20, IQR=6-39). There were no significant differences in MDS-R score according to sex, age, or duration of PICU experience (Table 1).

Among the 21 items on the MDS-R, the most morally distressing item was related to end-of-life care and quality of life: ‘Honour the family’s wishes to continue life support even though I believe it is not in the child’s best interest’. This item also scored highest in frequency and intensity among the 21 items. All three groups of health professionals ranked this item as the most morally distressing situation in the clinical setting. The second most morally distressing item was also related to end-of-life care and quality of life: ‘Initiate extensive life-saving actions when I think they only prolong death’. This item also consistently scored high in frequency and intensity (Table 2). Situations involving poor communication constituted the remaining three most morally distressing items in this study. The top five most morally distressing items, as well as the top five items with the highest frequency and intensity, are presented in Table 2.

A higher MDS-R moral distress score was associated with the intention to quit. Healthcare workers who intended to quit their jobs had significantly higher moral distress scores (P<0.05). A higher moral distress score was also associated with higher DASS-21 depression factor (r=0.445; P<0.05) and anxiety factor scores (r=0.417; P<0.05). Nurses who had worked for a greater number of years in the PICU also experienced higher moral distress (r=0.512; P<0.05). Twenty-eight percent of all participants and 35% of nurses reported they intended to quit their jobs because of moral distress.

The median depression, anxiety, and stress scores were 11 (IQR=0.5-18), 8 (IQR=3-145), and 30 (IQR=21-38), respectively; these scores corresponded to mild depression, mild anxiety, and severe stress. Among the three groups, nurses had the highest median anxiety (11, IQR=6-16) and stress scores (20, IQR=12-26) [Fig]; these scores corresponded to mild depression, moderate anxiety, and moderate stress. Participants with significantly higher depression and anxiety (both P<0.05) scores also intended to quit their jobs. There was no significant difference in stress score between participants who did and did not intend to quit their jobs (P=0.434).

In this study, various levels of moral distress were present in all three groups of PICU healthcare workers. There was a significant difference in MDS-R scores among the three professions, and nurses had the highest median MDS-R score. This finding is contrary to the results of previous PICU studies, which showed that moral distress did not differ among various healthcare workers.21 22 The literature suggests that nurses exhibit higher moral distress scores because they often have less autonomy concerning options in situations that involve moral dilemmas, and they are required to implement care plans with which they do not agree.23 24 25 26 Studies of PICU healthcare workers’ behaviours in ethical and morally distressing dilemmas have shown that 48% of PICU nurses reported needing to perform actions that violated their conscience. These results reflect the culture and hierarchies of power in the PICU.23 26 27 Moreover, nurses are the frontline workers who directly experience the impacts of clinical decisions on patients and their families.26 28 In newly established PICUs, decreased self-confidence or increased fear in a new working environment, combined with an uncertain ethical climate, unclear team dynamics, and less decision-making autonomy regarding care plans, can cause nurses to perceive less moral agency (ie, ability to act morally and change a situation).22 24 25 26 29 30 31 A reduced sense of moral agency can result in moral distress, which may be more apparent in newly established PICUs.29 31

We note that moral distress scores among nurses in the present study are among the highest in published studies of PICU healthcare workers (Table 3). In addition to the aforementioned lack of clarity in working environment and team dynamics, the diverse levels of experience among nurses might have also contributed to their high moral distress scores. In the present study, 54% of nurses had <3 years of PICU experience, whereas 39% of nurses had >10 years of PICU experience. These proportions of nurses with extensive and minimal experience were both larger than the proportions reported in previous PICU studies.32 33 The presence of such a large number of inexperienced junior nurses in the PICU may place additional stress on more experienced nurses. Indeed, survey items related to staffing (item 17 ‘Work with nurses or other care providers who are less competent than the child’s care requires’ and item 21 ‘Work with levels of care provider staffing that I consider unsafe’ in the MDS-R) were ranked by nurses as the seventh and eighth most morally distressing items; these rankings were higher than in other professions.

The PICU case mix might also contribute to moral distress. The majority of PICU admissions during the study period involved patients with cancer, who had considerably higher mortality rates; care for such patients frequently involved end-of-life and palliative care issues.34 35 In a study of nurses’ experiences while caring for dying children, Davies et al36 found that when nurses recognise a child’s death is inevitable, they often have to manage conflicting obligations: follow the doctor’s treatment orders and allow the child to die without unnecessary pain. These disparate treatment goals for critically ill children with terminal cancer can exacerbate moral distress.36 37 In a comparison of moral distress scores among various paediatric disciplines (eg, general care and surgical service), Trotochaud et al21 found that healthcare workers in haematology/oncology areas experienced the second highest amount of moral distress on the list, second to healthcare workers in PICUs. Moreover, the proportion of patients with cancer in our PICU is much higher than the proportions in previous PICU studies.38 39 Therefore, it is entirely understandable that moral distress in our PICU was particularly high among nurses.

The present study revealed a positive correlation between years of PICU experience and moral distress scores among nurses, consistent with previous results concerning healthcare workers in PICUs and adult ICUs.12 26 This correlation may be related to effective utilisation of clinical knowledge and experience, along with greater awareness concerning the impacts of potentially inappropriate treatment plans on patients.40 Conversely, a study by Larson et al26 revealed a negative correlation between moral distress scores and years of experience among doctors in the PICU. However, the present study showed no correlation between moral distress scores and years of experience among doctors. This finding might be attributed to the small number of doctors involved, which was insufficient to demonstrate an association.

Moral distress is often associated with the intention to quit a job.41 42 43 44 The results of the study were consistent with previous findings. Studies by Sannino et al11 and Trotochaud et al21 showed that 10.3% to 25% of PICU nurses intended to quit their jobs because of moral distress. The proportion of nurses in our study who intended to quit their job because of moral distress (34.6%) was higher than the proportions in previous PICU studies,11 21 which could be explained by their high moral distress scores. However, further studies are needed to determine the impact of moral distress alone on a healthcare worker’s intention to quit their job, compared with other possible distressing factors (eg, working hours and promotional opportunities) that can have a synergistic effect on the decision to quit.

To our knowledge, this is the first study of moral distress among healthcare workers in an East Asian PICU. The results of this study provide insights concerning the broader understanding of moral distress in newly established PICUs. The high response rate also suggests strong participation and indicates that the study sample is representative of healthcare workers in our PICU.

However, the results of this study should be interpreted with the following caveats. First, this was a single-centre study with a relatively small sample size, which limits the generalisability of the findings. The small sample size also hindered further evaluation of identifiable demographic factors, such as education level and whether participants had any children; another study indicated that such factors may be associated with moral distress.11 Moreover, the small sample size precluded subgroup analysis. Second, this study was susceptible to ‘survivorship’ bias because the sample did not include PICU staff who already quit their jobs, including some who quit because of moral distress. Third, considering the cross-sectional nature of this study, causal relationships among various factors could not be established. For example, although participants with higher depression and anxiety scores reported a stronger intention to quit their jobs, we could not determine whether these participants reported more psychological symptoms because of their intention to quit, or if their intention to quit led to more psychological symptoms. Larger multicentre studies are needed to further explore moral distress among healthcare workers in Hong Kong PICUs. As our unit expands to a 16-bed PICU and a five-bed high-dependency unit, a longitudinal study will also enhance the broader understanding of moral distress dynamics in a developing PICU, as well as the efficacies of various strategies to address moral distress.

Considering the results of this study, moral distress should be regarded as a key area for service improvement. The high levels of moral distress experienced by nurses, as well as the substantial moral distress in relation to end-of-life care, suggest that coping strategies should target nurses and focus on end-of-life education. These coping strategies are urgently needed to improve staff retention and quality of care; they can be implemented at the individual, organisational, and administrative levels.20

At the individual level, ethics education is essential for improvements in coping capacity and sense of moral agency, which can reduce the levels of moral distress.22 45 Education can be provided through interactive workshops or self-guided programmes.41 Prentice et al42 suggested that education should focus on improving knowledge regarding patient outcomes, the degree of uncertainty in specific situations, and appropriate pain control. Instead of emphasising ethical dilemmas and underlying principles, education should highlight communication skills, clarify values, and enhance the overall understanding of the healthcare system to address potential environmental conflicts.31 This approach can ultimately increase staff confidence (ie, moral courage) in constructively communicating their concerns.42 Screening tools for various emotional states, such as the DASS-21, should also be included to help individuals gain better awareness of their own psychological well-being and seek professional help if necessary. Additionally, these tools can be used to monitor emotions that might cause moral distress.

At the organisational level, efforts should be made to promote intra- and interdisciplinary communication. Poor communication, one of the five most morally distressing items, can lead to diminished quality of care, reduced job satisfaction, and poor patient outcomes.46 Ethics rounds, formal and informal discussions, and debriefing sessions regarding morally distressing cases could improve interdisciplinary communication.22 These initiatives can help promote better mutual understanding of viewpoints across disciplines and individuals.22 Participation in these events may also allow nurses to feel more empowered and experience a greater sense of decision-making autonomy.43 Finally, the establishment of formal ethical consultation services may provide support and clarification with respect to ethical dilemmas.44

At the administrative level, administrators should recognise that it is acceptable for staff to perceive moral distress; this perception is a sign of humanity and an affirmation of moral values.44 Improvements in clinical environments (eg, reduction of staff shortages, promotion of intra- and interdisciplinary collaboration, and encouragement of a safe and supported ethical climate) can help decrease moral distress.47 These measures include providing respectful feedback to staff, empowering staff to voice perceptions and emotions, and making difficult decisions in a timely manner after open discussion.48

This study revealed significant differences in moral distress among doctors, nurses, and allied health professionals in a newly established PICU in Hong Kong. Nurses had the highest moral distress scores among the three groups of PICU healthcare workers in this study and among published studies involving PICU nurses. Most areas of moral distress were related to end-of-life care and poor communication. Higher moral distress was also associated with greater depression, anxiety, and intention to quit. There is an urgent need for interventions to help healthcare workers cope with moral distress and create a more sustainable working environment.

Concept or design: WL Cheung, KL Hon, KKY Leung, WF Hui.
Acquisition of data: WL Cheung, KL Hon, KKY Leung, WF Hui.
Analysis or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

As an editor of the journal, KL Hon was not involved in the review process. Other authors have disclosed no conflicts of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This research was approved by the Hong Kong Children’s Hospital Research Ethics Committee (Ref No.: HKCH-REC-2020-008) and was conducted in accordance with the Declaration of Helsinki and International Conference on Harmonisation Good Clinical Practice Guideline. All participants provided informed consent to take part in the research.

1. Jones S, Rantell K, Stevens K, et al. Outcome at 6 months after admission for pediatric intensive care: a report of a national study of pediatric intensive care units in the United Kingdom. Pediatrics 2006;118:2101-8. Crossref

2. Cremer R, Leclerc F, Lacroix J, Ploin D; GFRUP/RMEF Chronic Diseases in PICU Study Group. Children with chronic conditions in pediatric intensive care units located in predominantly French-speaking regions: prevalence and implications on rehabilitation care need and utilization. Crit Care Med 2009;37:1456-62. Crossref

3. Namachivayam P, Shann F, Shekerdemian L, et al. Three decades of pediatric intensive care: who was admitted, what happened in intensive care, and what happened afterward. Pediatr Crit Care Med 2010;11:549-55. Crossref

4. Edwards JD, Houtrow AJ, Vasilevskis EE, et al. Chronic conditions among children admitted to U.S. pediatric intensive care units: their prevalence and impact on risk for mortality and prolonged length of stay. Crit Care Med 2012;40:2196-203. Crossref

5. Ebrahim S, Singh S, Hutchison JS, et al. Adaptive behavior, functional outcomes, and quality of life outcomes of children requiring urgent ICU admission. Pediatr Crit Care Med 2013;14:10-8. Crossref

6. Bruce CR, Miller SM, Zimmerman JL. A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics. Crit Care Med 2015;43:823-31. Crossref

7. Austin W. Moral distress and the contemporary plight of health professionals. HEC Forum 2012;24:27-38. Crossref

8. Jameton A. Nursing practice: the ethical issues. Englewood Cliffs (NJ): Prentice Hall Inc; 1984.

9. Garros D, Austin W, Carnevale FA. Moral distress in pediatric intensive care. JAMA Pediatr 2015;169:885-6. Crossref

10. Lusignani M, Giannì ML, Re LG, Buffon ML. Moral distress among nurses in medical, surgical and intensive-care units. J Nurs Manag 2017;25:477-85. Crossref

11. Sannino P, Giannì ML, Carini M, et al. Moral distress in the pediatric intensive care unit: an Italian study. Front Pediatr 2019;7:338. Crossref

12. Dodek PM, Wong H, Norena M, et al. Moral distress in intensive care unit professionals is associated with profession, age, and years of experience. J Crit Care 2016;31:178-82. Crossref

13. Ohayon MM, Priest RG, Guilleminault C, Caulet M. The prevalence of depressive disorders in the United Kingdom. Biol Psychiatry 1999;45:300-7.Crossref

14. de Vargas D, Dias AP. Depression prevalence in intensive care unit nursing workers: a study at hospitals in a northwestern city of São Paulo State. Rev Lat Am Enfermagem 2011;19:1114-21. Crossref

15. Poghosyan L, Clarke SP, Finlayson M, Aiken LH. Nurse burnout and quality of care: cross-national investigation in six countries. Res Nurs Health 2010;33:288-98. Crossref

16. Humphries N, Morgan K, Conry MC, McGowan Y, Montgomery A, McGee H. Quality of care and health professional burnout: narrative literature review. Int J Health Care Qual Assur 2014;27:293-307. Crossref

17. Prompahakul C, Epstein EG. Moral distress experienced by non-Western nurses: an integrative review. Nurs Ethics 2020;27:778-95. Crossref

18. Hamric AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Prim Res 2012;3:1-9. Crossref

19. Tran TD, Tran T, Fisher J. Validation of the Depression Anxiety Stress Scales (DASS) 21 as a screening instrument for depression and anxiety in a rural community-based cohort of northern Vietnamese women. BMC Psychiatry 2013;13:24. Crossref

20. Wang K, Shi HS, Geng FL, et al. Cross-cultural validation of the Depression Anxiety Stress Scale–21 in China. Psychol Assess 2016;28:e88-100. Crossref

21. Trotochaud K, Coleman JR, Krawiecki N, McCracken C. Moral distress in pediatric healthcare providers. J Pediatr Nurs 2015;30:908-14. Crossref

22. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate part II: neonatal and pediatric perspectives. Dimens Crit Care Nurs 2015;34:33-46. Crossref

23. Papathanassoglou ED, Karanikola MN, Kalafati M, Giannakopoulou M, Lemonidou C, Albarran JW. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. Am J Crit Care 2012;21:e41-52. Crossref

24. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002;9:636-50. Crossref

25. Wilkinson JM. Moral distress in nursing practice: experience and effect. Nurs Forum 1988;23:16-29. Crossref

26. Larson CP, Dryden-Palmer KD, Gibbons C, Parshuram CS. Moral distress in PICU and neonatal ICU practitioners: a cross-sectional evaluation. Pediatr Crit Care Med 2017;18:e318-26. Crossref

27. Solomon MZ, Sellers DE, Heller KS, et al. New and lingering controversies in pediatric end-of-life care. Pediatrics 2005;116:872-83. Crossref

28. Molloy J, Evans M, Coughlin K. Moral distress in the resuscitation of extremely premature infants. Nurs Ethics 2015;22:52-63. Crossref

29. McCarthy J, Gastmans C. Moral distress: a review of the argument-based nursing ethics literature. Nurs Ethics 2015;22:131-52. Crossref

30. LaSala CA, Bjarnson D. Creating workplace environments that support moral courage. Online J Issues Nurs 2010;15:Manuscript 4. Crossref

31. Epstein EG, Delgado S. Understanding and addressing moral distress. Online J Issues Nurs 2010;15:Manuscript 1. Crossref

32. Ahmed GE, Abosamra OM. Knowledge of pediatric critical care nurses regarding evidence based guidelines for prevention of ventilator associated pneumonia (VAP). J Educ Pract 2015;6:94-101.

33. Hickey PA, Pasquali SK, Gaynor JW, et al. Critical care nursing’s impact on pediatric patient outcomes. Ann Thorac Surg 2016;102:1375-80. Crossref

34. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S. Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 2003;21:1133-8. Crossref

35. Wösten-van Asperen RM, van Gestel JP, van Grotel M, et al. PICU mortality of children with cancer admitted to pediatric intensive care unit a systematic review and meta-analysis. Crit Rev Oncol Hematol 2019;142:153-63. Crossref

36. Davies B, Clarke D, Connaughty S, et al. Caring for dying children: nurses’ experiences. Pediatr Nurs 1996;22:500-7.

37. Johnston EE, Alvarez E, Saynina O, Sanders L, Bhatia S, Chamberlain LJ. Disparities in the intensity of end-of-life care for children with cancer. Pediatrics 2017;140:e20170671. Crossref

38. Demaret P, Pettersen G, Hubert P, Teira P, Emeriaud G. The critically-ill pediatric hemato-oncology patient: epidemiology, management, and strategy of transfer to the pediatric intensive care unit. Ann Intensive Care 2012;2:14. Crossref

39. Dalton HJ, Slonim AD, Pollack MM. Multicenter outcome of pediatric oncology patients requiring intensive care. Pediatr Hematol Oncol 2003;20:643-9. Crossref

40. Zhang W, Wu X, Zhan Y, Ci L, Sun C. Moral distress and its influencing factors: a cross-sectional study in China. Nurs Ethics 2018;25:470-80. Crossref

41. Beumer CM. Innovative solutions: the effect of a workshop on reducing the experience of moral distress in an intensive care unit setting. Dimens Crit Care Nurs 2008;27:263-7. Crossref

42. Prentice T, Janvier A, Gillam L, Davis PG. Moral distress within neonatal and paediatric intensive care units: a systematic review. Arch Dis Child 2016;101:701-8. Crossref

43. Browning AM. CNE article: moral distress and psychological empowerment in critical care nurses caring for adults at end of life. Am J Crit Care 2013;22:143-51. Crossref

44. Santos RP, Garros D, Carnevale F. Difficult decisions in pediatric practice and moral distress in the intensive care unit. Rev Bras Ter Intensiva 2018;30:226-32. Crossref

45. Burston AS, Tuckett AG. Moral distress in nursing: contributing factors, outcomes and interventions. Nurs Ethics 2013;20:312-24. Crossref

46. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh 2015;47:117-25. Crossref

47. Atabay G, Çangarli BG, Penbek Ş. Impact of ethical climate on moral distress revisited: multidimensional view. Nurs Ethics 2015;22:103-16. Crossref

48. Benoit DD, Jensen HI, Malmgren J, et al. Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA. Intensive Care Med 2018;44:1039-49. Crossref