Intensive care units (ICUs) are highly specialized facilities where advanced and technologically sophisticated medical care is provided. Despite that, caring for critically ill patients is a stressful and emotionally demanding job due to high patient morbidity and mortality, regular confrontations with ethical challenges, and a tension-charged atmosphere.1–4 Sometimes, healthcare professionals (HCPs) may feel helpless, unable to provide care according to their own belief system, and therefore prone to develop moral distress (MD).2,4,5

MD has been described as a challenge that arises when one knows the right thing to do, medically or ethically, but institutional and/or external constraints make it nearly impossible to pursue the right course of action.5 Particularly in ICU, MD occur when HCPs have frequent exposure to patient care situations and/or to professional environments where they believe they are doing something ethically wrong, but they lack the ability to change the situation.3,4,6,7

Originally studied in nurses, this phenomenon is now understood to be a serious problem generalizable to other disciplines at hospitals, threatening the integrity of HCPs and healthcare systems as well.3,4,6,8 In fact, it compromises care both at a personal (as a root cause of burnout and employee attrition) and at a system (decreased quality of care) level.9

Valid and reliable instruments to measure MD are needed to explore its impact in order to develop effective interventions.10 Furthermore, conditions and factors that contribute to increase MD should be studied at local level as socio-demographic and health system characteristics are heterogeneous between countries.

The Moral Distress Scale (MDS) was the first available measure of MD.11,12 Afterwards, the MDS was shortened and revised to be applicable to all HCPs, the MDS-Revised (MDS-R).4,9,13–15 Recent studies have revealed additional root causes of MD not captured by the MDS-R.8,10,16 In this sense, Epstein et al.17 carried out a comprehensive review about MD and developed and validated the Measure of Moral Distress for Healthcare Professionals (MMD-HP – Supplemental electronic material 1). It captures the five key components of MD: complicity in wrongdoing, lack of voice, wrongdoing associated with professional (not personal) values, repeated experiences, and three levels of root causes (patient, unit, system). In addition, the six versions of the MDS-R were condensed into one standard instrument, so it can be usable by all HCPs in adult and pediatric critical care settings.

To our knowledge, no prior studies have evaluated MD among Spanish-speaking HCPs. Therefore, after having tested the reliability and validity of the Spanish version of the MMD-HP (MMD-HP-SPA),18 the aims of this study are to measure MD levels in Spanish ICU HCPs, and to explore the potential relationship between MD, demographic factors, and ICU ethical climate.

We conducted a cross-sectional study in all Spanish ICUs. The study population included HCPs directly involved in critically ill patient care. We developed a 55-item questionnaire that included work-related and socio-demographic characteristics, the MMD-HP-SPA to investigate MD, and the Spanish shortened version of Olson's Hospital Ethical Climate Scale (HECS)13,19 to assess workplace ethical climate. Prior to use, a structured 10-step translation process was followed18 adhering to the international principles of good practice20 for translation and cultural adaptation of patient-reported outcomes. The questionnaire was electronically distributed via the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Galician Society of Intensive and Critical Care Medicine and Coronary Units (SOGAMIUC), the Spanish Society of Intensive Care Nursing and Coronary Units (SEEIUC), and the Spanish Society of Paediatric Intensive Care (SECIP) mailing lists. Participation was on a voluntary anonymous basis. Information on the study was included in a cover letter accompanying each survey; informed consent was assumed by return of completed survey. Data collection took place between October and December 2019. The study was conducted in accordance with the 2013 amended Declaration of Helsinki. The local Research Ethics Committee approved the study (ref. CAEIG 2019/471).

A total of 1065 HCPs completed the questionnaire, 608 nurses (57.1%) and 457 physicians (42.9%). Participants’ sociodemographic characteristics are reported in Table 1.

In the past decades, numerous treatments and technological advances have resulted in improved ICU survival, but interventions to improve patient and family-centered care have not kept pace.22–24 In addition, these advances have sometimes led to futile aggressive treatments. The feeling of inappropriateness about some aspects of critical care can further development of MD among ICU staff.9 Previous research in different health sectors found that this feeling has negative consequences for HCPs, teams and health systems.3,8,25

In view of the above, it is crucial to have valid and reliable tools to explore the causes of MD among HCPs in order to design effective interventions.10 After a comprehensive review, Epstein et al.17 developed the newest instrument for measuring MD. The MMD-HP captures the five key components of MD: complicity in wrongdoing, lack of voice, wrongdoing associated with professional (not personal) values, repeated experiences, and three levels of root causes (patient, unit, system). In order to use this tool to assess MD among HCPs working in ICU in Spain, we translated and validated the MMD-HP-SPA.18 Our findings show that the MMD-HP-SPA is a valid and reliable instrument to measure MD among Spanish critical care staff. In consequence, we consider that this tool can be used in future studies on MD to be performed both in Spanish and Latin-American ICUs.

In this study, MD was present in all HCPs groups (median MMD-HP-SPA score of 68). Although previous studies expressed MMD-HP scores in means and the comparison between means and medians is not advisable, our MMD-HP-SPA scores are relatively lower than those reported in the previous studies that used the MMD-HP questionnaire, both conducted in North America.17,26 This difference may reflect the specifics of ICU environment, the hospitals organization, or the type of healthcare system. In Spain most ICUs are part of public hospitals, many of them affiliated to Universities, with complex and hierarchical structures.

Our results are somewhat inconsistent with previously reported data when assessing the differences between nurses and intensivists. We have observed that MD was higher for physicians than nurses. On the contrary, in most previous studies using the MDS-R4,9,14 and the MMD-HP,17 MD was higher for nurses than physicians. This phenomenon has been thought to be due to nurses’ consistent presence at the bedside, where many patient-level root causes occur.4,6,9,10,27 In looking at the responses to the MMD-HP-SPA items in our study, we noted an interesting pattern emerging. Our results indicate that system-level root causes, particularly those related to patient's suffering due to lack of provider continuity and to be required to care for more patients than one can safely care for, are among the most morally distressing for all HCPs, especially physicians. In addition, three of the top-ranked root causes, excessive documentation, lack of resources, and lack of administrative action, were newly added to the MMD-HP17 and are related also to system-level problems. Epstein et al.17 already noted a smaller difference in MD levels than was expected using the new MMD-HP. They suggested that with the addition of new items related to system-level root causes this questionnaire may apply more broadly to all HCPs, not only those at the bedside. Accordingly, our findings highlight the substantial contribution of system-level root causes to MD. Thus, they must be taken into account when designing specific interventions to different professional groups.

MD has several potential negative consequences. One of the most studied is the association between MD and the propensity to leave a position. It is relevant that nearly half of intensivists (40.7%) and nurses (48.4%) considered to leave or left their job in the past because of MD. Additionally, almost 40% of participants are currently thinking about leaving their position. Our results are slightly higher than those from recent studies in critical care settings from the US17 and Canada,26 where 20% and 13.8% of participants were currently considering leaving their position, respectively. Also, Druwé et al.,8 in a study with emergency medicine physicians from 24 different countries, found that 33.8% of participants were thinking of leaving their position due to MD. To leave a job when working in ICU is a matter of concern, since HCPs working experience in the ICU is essential to manage both standard and complex patients. MD may accelerate the staff turnover and may be associated with suboptimal quality of care.6,10,28 Despite the significant difference in MD levels between physicians and nurses in our study, it should be noted that the prevalence of intention to leave a position is quite similar between groups. This fact could be attributed to the differences in specialization in critical care between nurses and physicians. In Spain, Intensive Care Medicine is a primary specialty for physicians, whereas Critical Care Nursing is not recognized as a nursing specialty. This situation allows nurses to find other alternative jobs easily.

We have observed that both extremes in age (young and senior HCPs) report higher MD levels. Accordingly, some previous studies have reported higher MD levels with increasing years of experience.4 By contrast, Austin et al.29 did not correlate the number of years working in health care to higher MD. They suggested that it may be due to conditioning to the workplace environment over time or feeling more content the closer one gets to retirement. We consider that MD in junior staff might be related to lack of experience and, in some cases, to premature burnout. In the case of mean age HCPs, those with MD could be more prone to quit their job and therefore this age category become less represented in MD surveys.

In line with other authors, we consider that there is a clear need to design and implement strategies to reduce and prevent MD and other contributors to burnout.25,29,30 The first step should be to acknowledge the problem and measure its impact,17,26 this is a pending task in Spain yet. Targeting high-risk areas or groups may yield substantial benefit. Units and teams may differ in which root causes are most problematic.17,31 Some authors have proposed to counteract MD and its burnout consequences by enhancing the ethical climate in ICUs.32 It was suggested that this could avoid disrupting the continuity of care due to increased absenteeism.9 In this sense, a good ethical climate may be essential.13,19 In our study, HECS scores were inversely correlated with MMD-HP-SPA scores, which supports the validity of the Spanish version of the MMD-HP.

In the current situation, we consider that future studies should be carry out to explore the impact of COVID-19 pandemic on MD among ICU HCPs. Also, to study the complex dynamic interplay between associated factors, considering a range of baseline and time-varying potential confounders, in order to try to answer the causal questions and to obtain clue to counteract the MD problem.

Our study has some limitations to be considered. First, our results reflect subjective perceptions of participants. These perceptions could differ from the entire contacted population of HCPs. Second, we have no information about the exact number of HCPs who received the questionnaire to calculate the response rates across centres so the findings may be biased and difficult to generalize. Third, we lack detailed information on potentially relevant characteristics of participants (psychological trait, level of knowledge and experience, participation in ethics or quality-of-care committees, etc.). Finally, the study design precludes conclusions about causal associations between MD, ethical climate perception and the analyzed factors.

The MMD-HP-SPA is a valid and reliable instrument to assess specific MD root causes that can be used as a diagnostic tool to target interventions for particular units, teams, and professionals. In the study sample, Spanish intensivists report higher MD than nurses. Strategies are needed and should be implemented in order to mitigate MD and prevent burnout in HCPs. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

ERR, MCI, PVB, and MMR wrote and prepared the manuscript. AEG and ABH performed statistical analysis. MSRC and ARN supervised and approved the final version of the manuscript.

The local Research Ethics Committee approved the study (ref. CAEIG 2019/471). Participation was on a voluntary anonymous basis and informed consent was assumed by return of completed survey.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors have no conflict of interest to declare regarding this article.