Moral Distress and Ethical Climate Among Japanese Intensive Care Unit Nurses

Abstract

Introduction: Moral distress among intensive care unit (ICU) nurses is a global concern that affects the quality of care and well-being. In Japan, how hierarchy and consensus culture shape nurses’ experiences and ethical perceptions remain underexplored. Objectives: This mixed-methods study explored moral distress, how Japanese ICU nurses perceive the ethical climate, and the interrelationship between the two. Methods: An explanatory sequential design was used. Phase one involved a web-based survey of 168 ICU nurses from 54 facilities, employing the revised Japanese versions of the Moral Distress Scale and the Hospital Ethical Climate Survey. Phase two comprised semi-structured interviews with 11 purposively selected nurses based on quantitative findings, followed by content analysis. Results: Quantitative analysis showed moderate moral distress, with the highest score for “lack of respect for patient dignity” and significant correlations with longer ICU experience. “Organizational support through clear hospital philosophy” received low ratings and was negatively correlated with distress arising from collaboration difficulties. Qualitative findings expanded on these results by identifying themes of powerlessness over futile treatment, communication challenges in multidisciplinary teams, and dissatisfaction with physician-centered decision-making. Conclusion: Japanese ICU nurses experienced moderate moral distress, with end-of-life care emerging as a salient context. The distress was associated with the ethical climate, particularly the lack of perceived organizational support. These findings emphasize the need to enhance organizational structures, clarify ethical principles, and foster open interprofessional communication. Future research should use longitudinal designs to examine the effects of structured interventions—such as ethical decision-making support systems—on reducing moral distress and improving the ethical climate in ICUs.