Background/aims Invasive treatment without sufficient benefit induces doubts among nurses and physicians about ‘appropriateness of patient care’. Conflicting interpersonal moral convictions, may cause moral distress. Additional sources of moral distress are incompatible institutional requirements, workplace deficiencies and insufficient/unsafe levels of staffing. The associated declining self-respect, frustration, and guilt cause work-dissatisfaction, burnout, turnover, and consequently, diminished patient care. In this survey study, perceived appropriateness of care and levels of moral distress were evaluated across time. We also determined if respondents’ background predicted moral distress levels.

Methods After baseline assessment (background, moral distress, ethical climate), nurses and physicians of our level-III NICU evaluated day-levels of perceived appropriateness of care, the different aspects of moral distress, and ethical climate, at the end of five randomly selected shifts.

Results Response rate: nurses 87(77%)/physicians 30(91%). Moral distress (range 1–16) was low at baseline (M = 2.21; SD = 1.55), but significantly higher for nurses than for physicians (M = 2.40/SD = 1.68 vs M = 1.68/SD = 0.98; p = 0.01). Nurses were less likely to disagree with treatment than physicians (OR = 2.62, p = 0.02). Moral distress at day-level (range1–4) was very low (M = 0.08/SD = 0.21) and significantly depended on being religious (β= 0.16; 95% CI= 0.03 to 0.28) and perceived ‘overtreatment’ (β = 0.18; 95% CI= 0.07 to 0.30), contrary to ‘undertreatment’ (β = 0.17; 95% CI -0.63 to 0.29). Highest scores were observed for the following aspects of moral distress: provider (dis)continuity, communication about patient care, and (un)safe levels of staffing.

Conclusion In earlier studies, ‘expressing concerns’ and ‘facilitated ethics conversations’ proved to diminish moral distress. Possibly in our NICU the existence of structured-multi-disciplinary-medical-ethical-decision-making explains the (very)low levels of moral distress.