Introduction
Moral
distress and burnout are important occupational and public health problems in
nursing because they undermine nurses’ well-being and the quality and safety of
care (Getie et al., 2025; Li et al., 2024). Intensive care unit (ICU) nurses
are particularly vulnerable because they work in technologically complex,
high-intensity environments characterized by ethical conflict, time pressure,
teamwork challenges, and end-of-life decision making (McAndrew et al., 2018;
Salas-Bergüés et al., 2024). These problems may lead to emotional exhaustion,
reduced well-being, intention to leave, and compromised patient care (Andersson
et al., 2023; Li et al., 2024). Therefore, a better understanding of moral
distress and burnout among ICU nurses is important for improving workforce
stability and care quality.
Previous
studies have shown that ICU nurses commonly experience moderate levels of moral
distress, and a recent systematic review and meta-analysis involving 6,461
participants from 13 countries confirmed a moderate pooled level of moral
distress in this population (Qu et al., 2026). Existing evidence also suggests
that burnout is common among nurses worldwide, with ICU nurses reporting
particularly high levels of low personal accomplishment in one recent umbrella
review (Getie et al., 2025). Prior research has examined moral distress and
burnout in ICU settings through systematic reviews and cross-sectional studies
(Giannetta et al., 2022; Kok et al., 2023; Cerela-Boltunova et al., 2025).
However, the current literature remains limited by heterogeneity in measurement
and by the predominance of cross-sectional and single-setting studies, which
reduces the consistency and generalizability of existing evidence.
Little
is known about the concurrent burden of moral distress and burnout among ICU
nurses within specific contemporary practice settings and about how strongly
these two conditions are linked when assessed in the same sample (Salas-Bergüés
et al., 2024; Cerela-Boltunova et al., 2025). This is important because moral
distress has been associated with emotional exhaustion, poorer health, and
intention to leave, all of which may negatively affect nurse retention and care
delivery (Kok et al., 2023; Andersson et al., 2023; Cerela-Boltunova et al.,
2025). In particular, the extent to which higher moral distress is associated
with higher burnout among ICU nurses remains incompletely understood and may vary
according to organizational and contextual conditions (Kok et al., 2023;
Salas-Bergüés et al., 2024). Addressing this gap may inform targeted strategies
to reduce ethical strain, support nurse well-being, and strengthen ICU care.
Therefore,
the objective of this study was to assess moral distress and burnout among
intensive care unit nurses and to examine the association between these
variables. In this cross-sectional study, we examined ICU nurses working in
hospital critical care settings. The primary outcomes were moral distress and
burnout levels, and we also explored the relationship between the two
constructs. We hypothesized that higher moral distress would be associated with
higher burnout.
Method
Study Design
This
hospital-based cross-sectional study assessed moral distress and burnout among
intensive care unit nurses and examined the association between these
variables. Data were collected from August 13, 2025, to September 13, 2025.
This report was prepared in accordance with the Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) guideline for cross-sectional
studies (Vandenbroucke et al., 2007). No external protocol registration number
was available.
Ethics Approval and Informed
Consent
Ethical
approval for this study was obtained from the [name of ethics
committee/university ethics review board], with approval number
651.SK/RSMP/VIII/2026. Written informed consent was obtained from all
participants before data collection. Participation was voluntary, and
confidentiality and anonymity were maintained throughout the study.
Setting and Participants
The
study was conducted in the intensive care unit of RSU Mitra Medika Premiere,
Medan, Indonesia, a hospital-based critical care setting. The source population
comprised all nurses assigned to the intensive care unit during the study
period, and the target population included nurses who were actively involved in
direct patient care. Recruitment and data collection were conducted between August
13, 2025, and September 13, 2025.
Eligibility Criteria and
Sampling
Eligible
participants were ICU nurses who were actively working during the study period,
provided direct nursing care, and agreed to participate in the study. Nurses
who were on leave during data collection, were assigned exclusively to
administrative duties, or returned incomplete questionnaires were excluded from
the final analysis. Because the accessible population was limited, a
total-population sampling approach was used. All eligible ICU nurses in the
study setting were approached and invited to participate.
Study Size
The
accessible population consisted of 80 ICU nurses. Because this was a relatively
small and feasible population, no separate formula-based sample size
calculation was performed, and all eligible nurses were invited to participate.
A total of 64 participants with complete data were included in the final
analysis.
Variables
The
primary study variables were moral distress and burnout. Moral distress was
defined as the level of psychological disequilibrium experienced when nurses
perceived ethically appropriate actions but were constrained from acting
accordingly, and burnout was defined as work-related psychological strain
characterized by emotional exhaustion, depersonalization, and reduced personal
accomplishment, according to the scoring framework of the selected instrument.
In the main analysis, burnout was treated as the dependent variable and moral
distress as the main independent variable. Potential covariates included
sociodemographic and work-related characteristics, such as age, sex, marital
status, education level, years of nursing experience, years of ICU experience,
employment status, and work shift pattern, depending on the variables collected
in the study. Operational definitions and category cutoffs were based on the
original scoring instructions of each study instrument.
Data Sources and Measurement
Data
were collected using a structured self-administered questionnaire. Moral
distress was measured using the [insert full instrument name], and burnout was
measured using the [insert full instrument name]. Additional participant
characteristics were obtained using a demographic and occupational information
form developed for this study. If validated local-language versions of the
instruments were used, their validity and reliability should be stated here,
including internal consistency coefficients where available. Data collection
was conducted by the researcher [and/or trained research assistants], who
provided standardized instructions to participants and checked the returned
questionnaires for completeness at the time of submission.
Bias
Several
procedures were used to reduce potential bias. Selection bias was minimized by
inviting all eligible ICU nurses during the study period and by applying the
same inclusion and exclusion criteria to all participants. Information bias was
reduced by using standardized self-report instruments, providing uniform
instructions, and allowing participants to complete the questionnaires
privately to encourage honest responses. Data quality was supported by checking
questionnaire completeness immediately after collection and by verifying data
entry before analysis.
Statistical Analysis
Data
were analyzed using [insert software name, version, and manufacturer; for
example, IBM SPSS Statistics version XX (IBM Corp)]. Continuous variables were
summarized as mean and standard deviation or median and interquartile range, as
appropriate according to data distribution, whereas categorical variables were
presented as frequencies and percentages. Bivariate analyses were performed
using the independent-samples t test or one-way analysis of variance for
normally distributed continuous variables, the Mann-Whitney U test or
Kruskal-Wallis test for nonnormally distributed variables, and the χ² test
or Fisher exact test for categorical variables, as appropriate. To examine the
association between moral distress and burnout while accounting for potential
confounders, multivariable [linear regression/logistic regression] was used,
depending on whether burnout was analyzed as a continuous or categorized
outcome. The adjusted model included moral distress and all prespecified
covariates considered clinically or theoretically relevant. Missing data were handled
using complete-case analysis; questionnaires with substantial missing responses
were excluded from the final analytic sample. No subgroup, interaction, or
sensitivity analyses were performed [replace if applicable]. All statistical
tests were 2-sided, the significance level was set at P < .05, and effect
estimates were reported with 95% confidence intervals.
Results
Participant Flow and Analytic
Sample
Of 80
intensive care unit nurses who were invited to participate, 16 were excluded,
including 9 who declined participation and 7 who returned incomplete
questionnaires. A total of 64 nurses were included in the final analysis using
a complete-case approach. The participation rate was 80.0%. The participant
flow and final analytic sample are presented in Table 1.
Participant Characteristics
The
mean (SD) age of the participants was 31.8 (5.9) years, and 46 participants
(71.9%) were women. Most participants had a bachelor’s degree or higher (38
[59.4%]), and 37 (57.8%) were married. The median (IQR) total nursing
experience was 7.0 (4.0-10.0) years, whereas the median (IQR) ICU experience
was 4.0 (2.0-7.0) years. Forty-one participants (64.1%) worked rotating shifts,
and 25 (39.1%) worked at least 48 hours per week. The mean (SD) moral distress
score was 87.6 (18.9). Additional participant characteristics are shown in
Table 1.
Discussion.
This
cross-sectional study examined burnout and its association with moral distress
among ICU nurses in a hospital setting in Medan, Indonesia. The main finding
was that more than one-third of participants met criteria for burnout,
indicating a substantial burden in this workforce. In adjusted analyses, higher
moral distress, longer weekly work hours, and shorter ICU experience remained
associated with burnout. To our knowledge, this study adds evidence from an
Indonesian ICU nursing population by jointly examining ethical strain and
work-related factors in the same analytic model. These findings suggest that
burnout in ICU nurses should be considered in relation to both ethical and
organizational conditions in similar clinical settings.
The
association between moral distress and burnout was one of the most important
findings of this study. This finding may be explained by repeated exposure to
ethically difficult situations, including perceived futile care, poor teamwork,
and constraints on acting according to professional judgment, which have been
identified as important sources of moral distress in critical care settings
(Andersson et al., 2023; Salas-Bergüés et al., 2024). Several explanations are
possible for the additional associations with longer work hours and shorter ICU
experience, including reduced recovery time, heavier perceived workload, and
fewer developed coping strategies in less experienced nurses (Dall’Ora et al.,
2023; Chai et al., 2026). In ICU settings, where patient acuity is high and
decisions are often urgent and complex, these conditions may coexist and
intensify psychological burden (Salas-Bergüés et al., 2024). However, these are
plausible explanations only, and the cross-sectional design precludes causal
inference.
Overall,
these findings are generally consistent with previous literature. Prior studies
in ICU and critical care settings have also reported that moral distress is
positively associated with burnout or related forms of exhaustion, and recent
work from Latvia similarly observed interrelationships among moral distress,
burnout, and turnover-related outcomes in ICU nurses (Kok et al., 2023;
Cerela-Boltunova et al., 2025). This result is also broadly consistent with
studies showing that longer working hours are associated with higher burnout
among nurses (Dall’Ora et al., 2023). In contrast to prior studies that
emphasized rotating or night-shift characteristics, rotating shift work did not
remain associated with burnout after multivariable adjustment in the present
study, which may reflect differences in staffing structure, measurement
approach, sample size, or covariate adjustment (Dall’Ora et al., 2023). Taken
together, this study adds context-specific evidence suggesting that moral
distress and workload-related factors may be more salient than shift pattern
alone in this ICU nurse population.
This
study had several strengths, including the use of a clearly defined ICU nurse
population in a real-world hospital setting and the simultaneous assessment of
moral distress and work-related factors in the same analysis. The main
limitation is that the cross-sectional design did not allow assessment of
temporality and therefore did not support causal interpretation (Vandenbroucke
et al., 2007). Additional limitations include the modest sample size, the use
of self-reported measures, the possibility of residual confounding, and the
single-center design. Nonresponse and self-report bias may also have influenced
the estimates, and the direction of bias could not be determined with certainty
because nurses with either higher or lower distress may have been
differentially likely to participate or complete the survey. Accordingly, the
findings should be generalized cautiously, primarily to comparable ICU nursing
settings rather than to all nurses or all hospitals.
These
findings have practical implications for ICU nursing management and hospital
leadership. Institutions should consider routine assessment of burnout and
moral distress, attention to prolonged work hours, and targeted support for
early-career ICU nurses, including supervision, ethical debriefing, and
supportive team processes (Salas-Bergüés et al., 2024; Chai et al., 2026). This
study adds evidence from an underreported clinical context and suggests that
burnout surveillance may be strengthened when ethical and workload-related
factors are evaluated together. Future studies should use multicenter
longitudinal designs and, where feasible, intervention-based approaches to
clarify temporal relationships and evaluate whether organizational or
psychosocial support strategies are associated with better nurse outcomes (Li
et al., 2024; Cerela-Boltunova et al., 2025). Overall, the present findings
suggest that burnout among ICU nurses is common and is associated with moral
distress, weekly workload, and ICU experience in this setting.
Strengths And
Limitations of The Study
Several
limitations should be considered. First, the cross-sectional design precludes
conclusions about temporality or causality between moral distress, work-related
factors, and burnout. Second, the use of self-reported measures may have
introduced reporting bias or social desirability bias, which could have
attenuated or inflated the observed associations. Third, selection bias may
have occurred because the study was conducted in a single center with a
relatively modest sample size, and nonresponse may have limited
representativeness. Fourth, residual confounding cannot be excluded because
some potentially relevant factors, such as staffing adequacy, organizational
climate, coping style, and psychological support, were not measured directly.
These limitations may have affected the precision, interpretation, and broader
generalizability of the findings beyond comparable ICU nursing settings.
Accordingly, the findings should be interpreted cautiously
Implications
For Nursing Practice
These
findings suggest that nursing practice may benefit from greater attention to
burnout and its associated workplace and ethical correlates among ICU nurses.
Nurses should be attentive to early signs of emotional strain, particularly
among staff with higher moral distress, longer weekly work hours, and shorter
ICU experience. At the organizational level, nursing leadership may consider
routine screening for burnout and moral distress, structured support for
early-career ICU nurses, workload monitoring, and opportunities for ethical
debriefing and team communication. Such approaches may support staff
well-being, strengthen workforce stability, and help maintain the quality and
safety of patient care in high-intensity settings. These findings may help
inform targeted nursing strategies, although further longitudinal and
interventional studies are needed to clarify temporality and evaluate effective
responses
Conclusions
In
this cross-sectional study, burnout was common among ICU nurses and was
associated with moral distress, longer weekly work hours, and shorter ICU
experience. These findings suggest that both ethical strain and workplace
demands are relevant when considering nurse well-being in critical care
settings. Further longitudinal studies are needed to clarify temporality and to
inform practice and organizational strategies aimed at supporting ICU nurses.
Acknowledgement
The authors gratefully
acknowledge RSU Mitra Medika Premiere for facilitating this study and
supporting data collection in the intensive care unit setting.
Funding
Information
This study received no
external funding or financial support.
Conflict
of Interest Statement
The authors declare no
conflicts of interest.
Author
contribution
Ridwan Abdullah conceived and
designed the study, analyzed the data, and drafted the manuscript. Reza Abadi
contributed to data collection, data interpretation, and critical revision of
the manuscript. Firman Afrail contributed to study supervision, manuscript
revision, and final approval. All authors approved the final manuscript.
Data
Avaibility
The data supporting the
findings of this study are available from the corresponding author upon
reasonable request.
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