Saudi Critical Care Journal

: 2023  |  Volume : 7  |  Issue : 1  |  Page : 8--14

The presence of moral distress among critical care nurses in Saudi Arabia

Jennifer de Beer1, Dalia Sunari1, Seema Nasser2, Zahra Alnasser2, Hawazen Rawas3, Hend Alnajjar3,  
1 King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
2 College of Nursing, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center; Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
3 College of Nursing, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center; Ministry of the National Guard - Health Affairs, Jeddah, Saudi Arabia

Correspondence Address:
Jennifer de Beer
King Faisal Specialist Hospital and Research Center, Jeddah
Saudi Arabia


Background: Moral distress (MD) was first defined as a situation in which one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. This can be even more challenging within the critical care context as critical the care context imposes physical, emotional, and cognitive stressors on critical care nurses. Methodology: A descriptive quantitative approach was followed, and the critical care units of two tertiary hospitals in two provinces in Saudi Arabia were included in the study, yielding a cluster sample size of 361 critical care nurses. Data were collected using the MD Scale-Revised, for which reliability and validity have been established. Results: The mean total MD experienced by respondents was 77.15 ± 58.32, representing a low level of MD. The statement that nurses indicated as causing the most distress was “follow the family's wishes to continue life support even though I believe it is not in the best interest of the patient” with 5.98 ± 5.04. Furthermore, 17.5% (n = 63) of nurses had considered leaving their positions because of MD. MD was the highest in the Emergency department with 102.12 ± 70.59; as experience increased by 1 year, the MD score increased by 11.56. Conclusion: When dealing with issues related to futile care, critical care nurses experience MD. Therefore, future research is required to develop appropriate interventions with which to address critical care-related MD.

How to cite this article:
de Beer J, Sunari D, Nasser S, Alnasser Z, Rawas H, Alnajjar H. The presence of moral distress among critical care nurses in Saudi Arabia.Saudi Crit Care J 2023;7:8-14

How to cite this URL:
de Beer J, Sunari D, Nasser S, Alnasser Z, Rawas H, Alnajjar H. The presence of moral distress among critical care nurses in Saudi Arabia. Saudi Crit Care J [serial online] 2023 [cited 2023 Jun 4 ];7:8-14
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Research on moral distress (MD) has grown exponentially since the introduction of this term in the 1990s and more recently due to the COVID-19 pandemic. Despite this, there is an ongoing debate regarding the nature scope, and relevance of MD. There is also a debate regarding conceptual clarity and what it means to express MD.[1] In addition, there is still a vast amount that is not known about MD, particularly interventions with which to address MD effectively. Thus, a key step for the future is to develop a deeper understanding of relational practices related to MD[2] and pay more attention to prevention strategies, and the reduction of factors leading to distress.[3] However, despite the ongoing scholarly debate, MD is of growing importance in the nursing profession, greatly affecting the career and quality of life of nurses.[4]

MD was first defined in 1984 as a situation in which “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”[5] A recent definition of MD is “a situation where nurses feel they know the right thing to do,” but system structures or personal limitations make it nearly impossible to pursue the right course of action. MD can lead to negative consequences such as feelings of anger, frustration, and guilt, but it can also be a catalyst for self-reflection, growth, and advocacy.[6] Furthermore, due to the COVID-19 pandemic, the concept of moral injury is discussed in the literature. This term refers to “a concept described in the military context, is a more extreme form of moral suffering that occurs in situations where personal integrity is violated.” This injury is recognized retrospectively after an actual conscience violation has occurred and can remain an unresolved moral injury or feelings of MD.[7]

Internal factors such as a lack of knowledge and fear, as well as external factors such as team conflicts, system characteristics, power dynamics, and unequal hierarchies within the institution, can lead to MD.[8] However, the most cited factor appears to be resource allocation (human and material), particularly if staff believe that safe staffing and/or necessary treatment and equipment are unavailable,[9] especially during the COVID-19 pandemic.[10],[11] In addition, the COVID-19 pandemic led to a specific type of COVID-19 MD, in which health-care professionals were distressed by allowing patients to die alone.[11] Although morally distressing situations are unpredictable, MD is more likely to occur when one is faced with decisions concerning unnecessary pain and suffering on the part of the patient, medically prolonging life, the objectification of patients, limited resources, constraints on health policy, and inter-professional relationships.[8],[12],[13]

MD can affect nurses both physically and psychologically. Psychological symptoms include anger, fear, frustration, depression, misery, decreased self-esteem, loss of integrity, powerlessness, and feeling constrained.[1],[13] Physical symptoms include heart palpitations, migraines, loss of appetite, and nausea.[14],[15] This has negative consequences in terms of job satisfaction, recruitment, and retention.[16] In addition, there is a negative consequence for patient care because a health-care system is unable to function effectively with morally distressed health-care providers. This can lead to a lack of support for patients and family members who are expected to make decisions in ethically challenging situations.[17]

This can be even more challenging within the critical care context as the critical care context imposes physical, emotional, and cognitive stressors on critical care nurses.[18] Patients admitted to critical care tend to be physiologically unstable, requiring constant cardiac and respiratory monitoring and continuous adjustments of treatment, which, in turn, requires critical care nurses to be skilled at interpreting, integrating, and responding to a variety of types of information.[19],[20] Thus, the work in critical care units do not happen linearly; rather, it is remade every day, alive in action, and integrated with the use of various technologies.[21] In addition, critical care nurses are responsible for making decisions regarding life and death and may experience frequent MD while making these ethical decisions.[13],[22] Ethical issues include end-of-life decisions (e.g., dying with dignity), the recognition of the right to privacy, engaging the family in decision-making, assigning/taking on responsibilities within the health-care team, and health-care access.[23]

The literature on MD over the last 10–20 years has been conducted primarily in Western countries, such as Australia, Canada, and Europe; therefore, the conclusion on MD experienced by nurses was predominately drawn from studies performed in Western settings. “Given the significance of cultural differences, health-care technology, and the nurse density between Western and non-Western countries, the results of previous reviews would limit to represent the experience of MD in non-Western nurses.”[24] To date, there are only two documented studies of MD in Saudi Arabia.[25],[26] It is within this backdrop that the researchers aimed to investigate this phenomenon within a Saudi Arabian critical care context.


Study design and setting

A descriptive quantitative approach was used. The study was conducted in the Jeddah and Riyadh provinces of Saudi Arabia at the National Guard Health Affairs Hospital. National Guard Health Affairs – Jeddah is a 746-bed military hospital located in the Western Region of Saudi Arabia, which consists of 10 critical care units and 277 beds. National Guard Health Affairs – Riyadh is a 1225-bed military hospital in the Eastern region of Saudi Arabia, and it consists of 14 critical care units and 779 beds. Care is primarily provided to National Guard soldiers and their families.


Based on a cluster approach and population of 1056 on a margin of error of 5%, a confidence level of 95%, and a response distribution rate of 50%, the sample size was calculated to be a total of 282 CCNs; however, to compensate for incomplete questionnaires, oversampling using 30% was included, resulting in a total of 370 questionnaires being distributed. Ultimately, this study had a sample size of 361. The final sample of 361 included 97 participants from Jeddah and 264 from Riyadh.

Data collection

Appointments were made with the unit managers of each unit before data collection commenced. Once this was established, the questionnaires were given to potential respondents by the researchers. The researchers handed questionnaires to all nurses available in units at the time of data collection. All nurses were targeted, taking into consideration those who were on annual leave. A letter was attached to the questionnaire explaining the purpose of the study and stating that permission had been obtained from management, which has approved the study at the respective hospitals, as well as providing the contact details of the researchers. Furthermore, attached to the letter was a sealable envelope with instructions to ensure that the completed questionnaires remained confidential while waiting to be collected by the researcher. Due to the busy nature of critical care units, the questionnaires were collected a day after it was handed out, to allow the nurses time to complete them. The questionnaire used was the MD Scale-Revised (MDS-R), Nurse Adult Questionnaire. This questionnaire measures an individual's perceptions of clinical situations based on the intensity of MD and the encountered situations.[27] The adult version can be used with nurses, doctors, and other health-care professionals. The tool is Likert in nature and includes a frequency range from 0 (never) to 4 (very frequently) and an intensity range from 0 (none) to 4 (great extent). The questionnaire included 21 items. The MDS-R allows for separate analysis of intensity and frequency but also allows for a composite score for each item (frequency multiplied by intensity). The composite score thus ranges from 0 to 16 for each item and 0 to 336 total for the 21-item scale. The tool has existing reliability, which is indicated by a Cronbach's alpha of 0.89.[27] Furthermore, Sporrong et al.[28] reported that the intensity scale has a Cronbach's alpha of 0.98 and the frequency scale has a Cronbach's alpha of 0.90. The reliability coefficient for the 21-item used in this study had a Cronbach's alpha of 0.93. The validity of the MDS-R tool is 100%.[29]

Ethical considerations

Data collection commenced after the necessary ethical approval was obtained (Institutional Review Board number: RJ 19073-J from the King Abdullah International Medical Research Center, Jeddah, Saudi Arabia. Confidentiality was maintained by restricting the collected data to only the researchers. In addition, no identifying information of the respondents was collected – respondents were given an anonymous unique serial number. Verbal informed consent was obtained from participants.

Data analysis

The Statistical Package for the Social Sciences, Version 26 (IBM Corp., Armonk, N.Y., USA), was used for descriptive and inferential statistics, included one-way ANOVA, independent t-test, and linear regression was used.


The number of respondents who partook in this study was 361, with a response rate of 97.5% of the proposed sample number. Of those, 38.8% (140) of the participant had missing data. The data was found to be not missing completely at random (MCAR), as the Little's MCAR Test was significant (P = 0.000). However, from the data entry observation of the display of the questionnaire, it is believed to be missing at random (MAR). The maximum percentage of missing data among a variable was 17.5%. Therefore, the multiple imputations method was used to replace the missing data as it could preserve the variance structure maintaining the SD to an acceptable level.


The total number of respondents who partook in this study was 361, yielding a response rate of 97.5%. Of the respondents, 26.9% (n = 97) were from Jeddah and 73.1% (264) were from Riyadh. There were 82% of females (n = 296) and 17.5% of males (n = 63) with a mean age of 33.78 years. Most respondents, 36.8% (n = 133), had between 0 and 5 years of experience with only 5% (n = 18), having more than 20 years of experience. The majority of respondents, 46.3% (n = 167), were from the Philippines, and 74.2% (268) of respondents had a bachelor's degree in nursing. Most of the respondents, 58.7% (n = 212), worked in the adult critical care context, with the highest response rate being observed for the Emergency critical care context, at 25.48% (n = 92).

Frequency and distribution of moral distress

The mean of total MD experienced by respondents was 77.15 ± 58.32, which represents a low level of MD. The statements that the nurses indicated as causing the most distress were “follow the family's wishes to continue life support even though I believe it is not in the best interest of the patient” at 5.98 ± 5.04; “initiate extensive life-saving actions when I think they only prolong death” at 5.59 ± 4.85; and “continue to participate in care for a hopelessly ill person who is being sustained on a ventilator when no one will decide to withdraw support” at 5.25 ± 4.87. The lowest scoring statement was “follow the physician's request not to discuss the patient's prognosis with the patient or family” at 1.67 ± 2.86 [Table 1]. A total of 17.5% (n = 63) considered leaving their positions because of MD while 48.5% (n = 175) did not consider quitting their position because of MD, as illustrated in [Table 2].{Table 1}{Table 2}

The mean and standard deviation varied between critical care units. Nurses working in the Emergency department had the highest level of MD at 102.12 ± 70.59, while nurses who worked in the Neonatal Intensive Care units had the lowest levels of MD at 45.67 ± 44.63 [Table 3]. Using one-way ANOVA, we found a significant, moderate effect on the part of a unit on levels of MD, F (4, 227; 356) = 8.50; 8.72; 8.36; 7.80; 8.95; 8.70), P < 0.001, ω = 0.115; 0.079; 0.075; 070; 0.081; 0.079. The post hoc test showed that there is a significant mean difference between the Emergency department and the pediatric intensive care unit (P = 0.005), as well as the Neonatal Intensive Care unit (P > 0.001). There was also a significant mean difference between intensive care units and the Neonatal Intensive Care unit (P > 0.001) [Table 4].{Table 3}{Table 4}

In addition, using an independent t-test to assess the mean difference in MD scores between different regions showed a nonsignificant statistical difference between Jeddah (M = 79.57) and Riyadh (M = 77.78) in terms of mean MD score with t (18,252) = 0.264, P = 0.791. Multiple regression was conducted to determine the best linear combination of gender, age, unit, years of experience, and nationality with which to predict MD levels. This combination of variables significantly predicted stress scores, with an F-statistic of 6.22; 8.26; 7.99; 7.57; 8.72; 8.60, P < 0.001. Based on R2 = 0.13; 0.10; 0.10; 0.10; 0.11; 0.11, around 10 to 13% of the variance in the MD score is predicted by gender, age, unit, years of experience, and nationality. Considering each predictor, gender, t (355) = 0.047, P = 0.962; age, t (355) = −1.47, P = 0143; and nationality, t (355) = 46, P = 0.643, is not a significant predictor of MD score while the working unit, t (355) = −4.98, P < 0.001; and years of experience, t (355) = 2.98, P = 0.003, are significant predictors of MD score [Table 4]. For years of experience: b = 11.56, as experience increases by 1 year, the MD score increased by 11.56 units if the effect of other variables was held constant.


The findings of this study highlight the fact that the MD experienced by critical care nurses within the study setting was low, with a mean score of 77.15 ± 58.32; however, the study findings also show that the items related to futile care led the highest level of MD. The item related to the highest level of MD was “follow the family's wishes to continue life support even though I believe it is not in the best interest of the patient.” Futile medical care is care that does not benefit the patient and as a result intensive care unit staff experience MD when they perceive care as futile.[29],[30],[31],[32],[33] Futile medical care is among the five main issues regarding MD,[34] and moral burnout. In addition, nurses experience with futile care increases with increasing years of working in critical care units, the diagnosis of futile situations by nurses will increase over time.[29],[30],[31],[35],[36]

Furthermore, a large portion of the respondents in this study was of the Islamic religion and culture. Islamic patients, families, and health-care professionals who carry their values and beliefs into the clinical setting may seek to negotiate health-care pathways based on their religious values and, at the same time, abide by the conventions, professional standards, and expectations of clinical care. Thus, when negotiating clinical care goals at the end-of-life, and when making decisions about withholding or withdrawing life-sustaining care, clinicians, patients, and families may consider the ethical guidelines sourced within their faith.[37] According to Bone, Rackow, Weg et al,[38] negotiating end-of-life care and making collaborative decisions about the withholding and/or withdrawal of life-sustaining treatment may require the consideration of the faith commitments of patients, families, and health-care staff.

Nurses working in the Emergency department had the highest level of MD with 102.12 ± 70.59, while nurses who worked in the Neonatal Intensive Care units had the lowest levels of MD. According to the literature, Emergency department nurses experience MD more strongly than other nurses.[39],[40] This may be attributed to the fact that the Emergency department is a specialty area that caters to patients of all ages who present with a broad spectrum of complaints. Unlike other specialty areas, there are no restrictions or limitations placed on the type of patient that registers and is treated in the Emergency department. This results in nurses working in Emergency departments preparing to care for myriad conditions simultaneously, often without warning. Many health-care professionals have reported that the Emergency department is the most stressful environment in hospitals.[41]

Finally, this study found that as the years of experience among nurses increased, so did MD. That is, as experience increased by 1 year, the MD score increased by 11.56 units. Dodek et al.[42] reported that MD was higher among intensive care nurses than among other health-care professionals except for physicians. MD was greater with increased years of experience among nurses. Berhie et al.[43] found that nurses with 11–20 years of experience were two times more likely to experience MD than nurses who had 0 to 10 of experience. Years of experience as a nurse and having a greater responsibility in a nursing role (rather than being a staff nurse) were positively correlated with MD by other authors.[30],[42],[44],[45]

Limitations and recommendations

This study was conducted only in two settings in Saudi Arabia, even though the sample size included in the study was sufficient to generalize the findings to the critical care area. The study only included 26.9% of nurses in these two settings. The researchers recommend a larger scale study involving more settings including private hospital settings within Saudi Arabia, other health-care professionals, and the Corley Scale. Qualitative studies should be planned to allow researchers to collect experiences directly from health-care professionals. Further research should investigate the role of Islam as a religion and culture on MD scores.


Critical care nurses when dealing with issues related to futile care experience MD. Therefore, future research must develop appropriate interventions with which to address critical care-related MD.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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