Moral Distress and Ethical Climate Among Japanese Intensive Care Unit Nurses

Review of the Literature

Methods

Measurement Scales

In addition to the primary measurement scales summarized in Table 1, demographic data were collected, including sex, age, nursing and ICU experience, and professional certifications. Moral distress was measured using the Japanese version of the Moral Distress Scale-Revised (JMDS-R), which was developed for nurses in acute care hospitals in Japan, and which has demonstrated adequate validity and reliability (Hamric et al., 2012; Ishihara et al., 2018). The JMDS-R comprises 14 items across three subscales and captures both, frequency and intensity of morally distressing situations. Each item’s level score was calculated by multiplying frequency and intensity ratings, with higher scores indicating greater moral distress. Permission for use of the scale was obtained from the developers.

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Table 1.

Scales Used in This Study

Scale	Key characteristics	Reliability/source
JMDS-R	14 items across three subscales: Lack of respect for patient dignity; Collaboration with difficulty in quality assurance; Tacit approval of unethical behavior. Frequency and intensity are each rated from 0 to 4; item level = frequency × intensity. Total score range: 0–224.	Cronbach’s α = 0.86 Ishihara et al. (2018)
J-HECS	18 items across five subscales: Collaboration with fellow nurses; Support from trusted managers; Organizational support through clear hospital philosophy; Utilization of resources for patient care; Trust and collaboration from physicians. Items are rated on a five-point Likert scale. Total score range: 18–90.	Cronbach’s α = 0.94 Inagaki et al. (2020)

Ethical Climate

The ethical climate was measured using the Japanese Hospital Ethical Climate Survey (J-HECS), a culturally adapted version of Olson’s HECS for Japanese healthcare settings (Inagaki et al., 2020; Olson, 1998). The J-HECS comprises 18 items across five subscales and uses a five-point Likert response format, with higher total scores indicating a more positive ethical climate. Permission for its use was obtained from the developers.

Results

Participant Attributes

As shown in Table 2, of the 168 valid respondents, 77.9% were women, with approximately 70% being in their 20s (35.1%) or 30s (33.3%). A significant proportion (78.6%) had 1–4 years (41.1%) or 5–10 years (37.5%) of ICU experience. Specialized certifications (certified/specialized nurses) were held by 17.3% of the respondents.

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Table 2.

Basic Attributes (N = 168)

Basic attributes	Details	n	%
Sex	Female	131	77.9
	Male	35	20.8
	No response	2	1.2
Age	20–29 years	59	35.1
	30–39 years	56	33.3
	40–49 years	42	25.0
	50 years or older	11	6.5
Years of experience	1–4 years	46	27.4
	5–10 years	32	19.0
	11–15 years	34	20.2
	≥ 16 years	56	33.3
Years of intensive care unit experience	1–4 years	69	41.1
	5–10 years	63	37.5
	11–15 years	18	10.7
	≥ 16 years	18	10.7
Highest educational level attained	Diploma (vocational)	68	40.5
	Associate degree	20	11.9
	Bachelor’s degree	52	31.0
	Master’s degree	17	10.1
	Other	11	6.5
Specialized certification	Yes	29	17.3
	No	139	82.7
Type of employment	Full-time employment	164	97.6
	Non-regular employment	4	2.4
Position	Staff nurse	139	82.7
	Manager	29	17.3
Intensive care unit characteristics	Intensive care unit	130	77.4
	Coronary care unit	18	10.7
	Pediatric intensive care unit	10	6.0
	Stroke care unit	4	2.4
	Other	6	3.6
COVID-19 patient admission	Yes	95	56.5
	No	73	43.5

Moral Distress

The mean JMDS-R score was 44.63 (SD = 31.83), indicating a moderate level of moral distress. Among the subscales, “Lack of Respect for Patient Dignity” registered the highest level of distress (M = 17.15, SD = 11.78; Table 3).

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Table 3.

Mean Scores and Standard Deviations for Moral Distress (JMDS-R) and Ethical Climate (J-HECS) Subscales

Scale	Subscale	Mean	SD
JMDS-R	Lack of respect for patient dignity	17.15	11.78
	Collaboration with difficulty in quality assurance	14.67	13.99
	Tacit approval of unethical behavior	6.77	8.12
	JMDS-R Total	44.63	31.83
J-HECS	Collaboration with nursing colleagues	14.39	3.15
	Support from reliable supervisors	10.61	3.17
	Organizational support through clear philosophy	11.46	3.25
	Access to resources for patient care	9.18	2.24
	Trust and collaboration with physicians	11.10	3.09
	J-HECS Total	56.74	12.13

Correlation Between Moral Distress and Ethical Climate Subscales

A significant negative correlation was observed between moral distress related to “collaboration with difficulty in quality assurance” and the ethical climate subscale “organizational support through clear hospital philosophy” (r = −0.42, p < .001; Table 4).

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Table 4.

Correlations Between Moral Distress (JMDS-R Level Subscales) and Ethical Climate (J-HECS Subscales)

JMDS-R subscales	Collaboration with nursing colleagues	Support from reliable supervisors	Organizational support through clear philosophy	Access to resources for patient care	Trust and collaboration with physicians
Lack of respect for patient dignity	-0.02 (p = .782)	-0.11 (p = .150)	-0.18 (p = .018)	-0.18 (p = .020)	-0.11 (p = .153)
Collaboration with difficulty in quality assurance	-0.32 (p < .001)	-0.28 (p < .001)	-0.42 (p < .001)	-0.28 (p < .001)	-0.19 (p = .016)
Tacit approval of unethical behavior	-0.21 (p = .006)	-0.29 (p < .001)	-0.31 (p < .001)	-0.19 (p = .013)	-0.13 (p = .104)

Each cell presents correlation coefficients (r values) with their corresponding p-values.

Qualitative Survey Findings: Complementing Quantitative Findings

Table 5 summarizes the semi-structured interviews conducted with 11 participants. Content analysis revealed key themes that complemented and elaborated on the quantitative findings (see Table 6 for the key themes, descriptions, and representative quotes).

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Table 5.

Overview of Interview Participants (N = 11)

ID	Years of nursing experience	Years of ICU experience	Highest educational level attained	Specialized certification	COVID-19 patient admission
A	14	11	Graduate school	CCNS	Yes
B	19	10	Vocational school	Certified in specified medical acts	Yes
C	6	6	University	None	Yes
D	7	7	University	None	Yes
E	10	8	Graduate school	CCNS	Yes
F	8	8	University	None	No
G	17	12	Graduate school	CCNS	No
H	9	2	University	None	No
I	6	6	University	None	Yes
J	18	4	Vocational school	None	No
K	8	4	Vocational school	None	Yes

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Table 6.

Key Themes Identified in the Qualitative Analysis, Description, and Representative Quotes

Key themes	Description	Representative quotes
Theme 1: Ethical dilemmas and a sense of powerlessness in end-of-life care	Moral distress associated with the perceived futility of life-prolonging interventions for terminally ill patients and the difficulty of deciding when to discontinue such interventions	“Despite the evident end-of-life status, no one decides to discontinue treatment; we just continue interventions day after day. It is distressing for the patients, their family members, and us” (Participant G)
Theme 2: Collaborative challenges and concerns about quality of care	Moral distress stemming from concerns about declining quality of care due to collaboration with inexperienced staff and inadequate communication with physicians	“Currently, about half of the ICU staff are transfers…with no emergency or ICU experience” (Participant E)
		“When a complication occurs that a physician anticipated but we did not, they ask, ‘Why didn’t you catch that?’ which leaves us feeling our nursing care isn’t valued.” (Participant G)
Theme 3: Perceived challenges in organizational culture and ethical climate	The perception that physician-centered decision-making and ambiguous organizational policies are undermining the ethical climate	“Nurses’ opinions are often overruled by a single word from physicians, and adequate communication with physicians is impossible.”
		“Hospital policies are ambiguous, leaving the frontline staff struggling to adapt to constantly changing directives.” (Participant I)
Theme 4: Risk of care routinization and diminished ethical sensitivity	The risk that the routinization of nursing duties may blunt ethical sensitivity and lead to the neglect of individual patient circumstances	“Morning care is provided uniformly without adequate consideration of individual patient circumstances” (Participant H)
		“There are many tasks beyond core nursing duties, leaving us overwhelmed with clerical work” (Participant C)

Discussion

This study employed a mixed-methods design to comprehensively examine moral distress among ICU nurses in Japan and its relationship with the ethical climate. The main findings were: (1) moral distress among Japanese ICU nurses is particularly pronounced in end-of-life care and tends to intensify with accumulated years of experience; and (2) a positive ethical climate—particularly “organizational support through a clear hospital philosophy”—was negatively associated with distress arising from “collaboration with difficulty in quality assurance.” These findings should be interpreted in the context of the unique Japanese healthcare culture. In the Japanese context, the cultural value of “wa” (harmony) can discourage open disagreement and the expression of ethically justified concerns, particularly within hierarchical physician–nurse relationships. Repeated suppression of such concerns may prevent ethical issues from being resolved and thereby contribute to the accumulation of moral residue over time. Together, the qualitative themes help explain the quantitative patterns: Theme 1 clarified why end-of-life care emerged as the most salient source of moral distress; Theme 2 illuminated distress related to collaboration with difficulty in quality assurance; Theme 3 explained why limited organizational support and physician-centered decision-making contributed to a poorer ethical climate; and Theme 4 further suggested that routinized practice may suppress ethical sensitivity and reinforce these difficulties. The qualitative themes related to end-of-life care—including “sense of powerlessness due to continuation of futile treatment,” “disagreements with patients’ family members,” and “dissatisfaction with physician-centered decision-making”—elaborated the contexts in which moral distress was most acutely experienced. The present study suggests that some features of the Japanese cultural context—such as reluctance to make explicit end-of-life decisions, social pressure to prioritize family wishes, and organizational cultures marked by deference to physician authority—may further exacerbate moral distress (Freidson, 2017; Ruhnke et al., 2000). This finding aligns with that of Ruhnke et al., who revealed in their Japan–US comparison that, in Japan, the wishes of patients’ family members are prioritized over the patients’ own wishes in treatment-related decisions, and physician authority tends to be relatively strong (Ruhnke et al., 2000). The situations described in the qualitative data—such as “no one makes the decision to discontinue treatment; interventions simply continue”—likely reflect a complex interplay of cultural norms that prioritize contextual factors and interpersonal relationships over individual patient autonomy. This indicates that, although moral distress is a cross-cultural phenomenon, its manifestations and intensity are shaped by each society’s unique sociocultural landscape. Izumi et al. emphasized the importance of delivering high-quality nursing care to patients with advanced diseases (Izumi et al., 2010). In this study, ICU nurses’ end-of-life distress stemmed from their ethical aspirations to provide dignified care—an aspiration impeded by cultural and organizational constraints.

The finding that nurses with more years of ICU experience reported higher moral distress can be theoretically explained through Epstein and Hamric’s concepts of moral residue and the crescendo effect—the idea that unresolved ethical conflicts accumulate internally and intensify over time, as similar situations recur (Epstein & Hamric, 2009). This aligns with Dodek et al.’s international research findings linking years of professional ICU experience with higher moral distress (Dodek et al., 2016). However, our qualitative data also suggest that Japanese organizational culture, with its emphasis on seniority and group harmony (“wa”), may inhibit less experienced nurses from voicing their ethical concerns. If they do voice these concerns, they are unlikely to receive organizational support (e.g., “nurses’ opinions are overruled by a single word from a physician”). In such an environment, unresolved ethical conflicts may accumulate more severely, suggesting that veteran nurses not only encounter more distressing situations but also bear a heavier burden of unresolved issues. A systematic review by Lamoureux et al. on psychiatric nurses highlighted that chronic moral distress exacerbates burnout, depersonalization, cynicism, and decreased job satisfaction (Lamoureux et al., 2024). These findings underscore the possibility that accumulated experience might not necessarily translate into reduced distress or improved coping skills; instead, it may amplify feelings of helplessness and resignation.

These findings reflect broader international concerns that task overload, routinization, hierarchical communication, and pandemic-related pressures can impair ethical sensitivity and intensify ICU nurses’ moral distress (Donkers et al., 2021; Silverman et al., 2022).

Together, these studies support our interpretation that routinized care practices and a lack of ethical dialogue reflect not merely individual issues but broader systemic and cultural factors, highlighting the need for organizational and structural responses (Donkers et al., 2021; Silverman et al., 2022). Prior work has noted how hierarchical decision-making and ambiguous institutional policies can undermine nurses’ moral agency; our findings align with these observations and extend them to ICU contexts in Japan.

One of the key findings of the present study was the significant negative correlation between “organizational support through clear hospital philosophy” (an aspect of the ethical climate) and moral distress related to “collaboration with difficulty in quality assurance.” Studies have demonstrated a strong association between perceived organizational support and reduced moral distress among nurses (Robaee et al., 2018), reinforcing the importance of clear organizational philosophy and support structures. This suggests that when hospital philosophy and ethical guidelines are clearly and tangibly reflected in multidisciplinary decision-making, resource allocation, and staff education, nurses’ recognition of this as organizational support may reduce the distress arising from team conflicts and competency differences that affect care quality. This emphasis on clear organizational direction and robust support systems is central to fostering a culture of patient safety. Fujii et al. (2021) found that Japanese hospitals scored poorly on the continuous improvement mindset dimension of their patient safety culture. The low ratings for “organizational support through a clear hospital philosophy” may reflect that nurses perceive a lack of sustained, organization-wide commitment to ethical practice and care quality improvement (Fujii et al., 2021). A positive ethical climate may enhance psychological safety and promote constructive communication, contributing to the improvement of patient safety culture. Therefore, fostering such a climate is crucial not only for reducing moral distress but also for broader organizational improvement.

In recent years, there has been increasing recognition of the importance of measuring and researching moral distress among Japanese healthcare professionals. In addition to the JMDS-R used in this study, new instruments are being developed and adopted to more comprehensively capture contemporary aspects of moral distress—such as excessive documentation tasks and administrative directives that undermine care quality (Ishihara et al., 2018). The Japanese version of the Measure of Moral Distress for Healthcare Professionals (MMD-HP), originally developed by Epstein et al. (2019), was validated by Fujii et al. (2021). These advancements will deepen our understanding of the multifaceted dimensions of moral distress in Japanese clinical settings and pave the way for developing targeted interventions. The findings of this study are consistent with domestic research trends. Pandemic-specific conditions likely amplified several mechanisms identified in our data. Visitor restrictions complicated end-of-life communication and may have increased perceptions of futility, while staffing shortages and the redeployment of inexperienced staff strained collaboration, thereby intensifying moral distress in high-acuity settings. These pandemic-related dynamics may have particularly influenced three key findings of the present study. First, the high moral distress scores in end-of-life care situations may reflect not only longstanding cultural constraints, but also pandemic-specific barriers to family-centered communication, such as restricted visitation policies that prevented nurses from facilitating meaningful conversations between patients and families. Second, the relatively low scores for “organizational support through a clear hospital philosophy” may have been further depressed by the institutional ambiguity and rapid policy changes that were characteristic of the early pandemic period, when institutional guidance was frequently inconsistent or absent. Third, the positive association between ICU experience and moral distress may have been amplified under pandemic conditions, as experienced nurses—bearing greater clinical responsibility and a heavier accumulated moral residue—faced unprecedented ethical demands with inadequate systemic support. Therefore, while the patterns observed in this study likely reflect the underlying structural and cultural features of Japanese ICU nursing, the absolute levels of moral distress as well as ethical climate scores should be interpreted with consideration of the extraordinary circumstances during the pandemic period. As such, replication under non-pandemic conditions is warranted.

Drawing on the present study’s quantitative survey findings—specifically the correlation between ethical climate and moral distress—as well as qualitative insights from nurses’ lived experiences and organizational requests, we propose the following concrete measures to mitigate moral distress among ICU nurses.

Medical facilities should implement clear ethical guidelines for end-of-life care and establish regular multidisciplinary ethics conferences to review individual cases and support decision-making, thereby reducing nurses’ sense of powerlessness. These conferences should be institutionalized to empower nurses to participate as colleagues whose opinions are respected, with training focused on facilitative skills and psychological safety. Ethical leadership development programs should be offered to leaders across medical disciplines to foster heightened ethical sensitivity throughout the organization. Finally, institutions should expand nurses’ discretionary authority in care provision and promote more active nurse participation in treatment decision-making to prevent the routinization of care.

The implementation of these recommendations may face barriers such as the existing organizational culture, hierarchy, and constraints on time and human resources. Key factors for successful implementation include commitment from leadership, continuous interdisciplinary dialogue, mutual understanding, and sharing specific success stories.

Conclusion

Japanese ICU nurses experience moderate levels of moral distress, particularly in end-of-life care, and a positive ethical climate correlates with lower levels of moral distress. These findings underscore the necessity of improving the ethical climate in medical facilities, with careful consideration of organizational and cultural contexts. Establishing an organization-wide support system is crucial. This includes promoting multidisciplinary collaboration, supporting ethical decision-making, ensuring psychological safety, strengthening leadership among managers, and providing continuous ethics education.

This study reaffirms that moral distress in Japanese ICUs is an organizational rather than an individual issue. It provides foundational data for future research on nursing ethics and clinical practice.

Future research should explore the development and evaluation of interventions tailored to improving the ethical climate in the ICU, such as structured ethical decision-making systems, ethics consultation services, and simulation-based ethics training. Additionally, longitudinal studies are needed to examine how changes in organizational policies and leadership practices influence moral distress over time. Cross-cultural comparative studies can reveal both universal and culture-specific factors that shape ICU nurses’ moral distress across diverse healthcare systems.

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Supplemental Material