Frontline Ethical Burdens: A Mixed‑Methods Investigation of Moral Distress in Emergency Medical Services

Abstract

Prehospital emergency medical services (EMS) clinicians frequently operate under time and information constraints, requiring quick ethical decisions in rapidly changing clinical situations. Moral distress occurs when healthcare providers recognize the ethically correct action but face institutional, hierarchical, or resource-based barriers to its execution, leading to emotional conflict and potential burnout. Public health emergencies, such as the COVID-19 pandemic, can exacerbate these stressors. In this study, 104 Czech EMS professionals completed an adapted 16-item Moral Distress Scale-Revised (MDS-R) and shared open-ended descriptions of additional ethically distressing situations. Quantitative analysis explored relationships between MDS-R scores and demographic, occupational, and organizational factors, while reflexive thematic analysis identified recurring stressor themes. The average MDS-R score was 40.4 (SD 28.9; Cronbach’s α = 0.85). Younger practitioners (≤ 40 years) reported higher distress compared to older colleagues (> 40 years) (p = 0.014), and those with tertiary education scored higher than those with secondary education (p < 0.001). Subjective stress correlated with MDS-R scores (ρ = 0.32; p < 0.001). Scenario analysis revealed that breaches of professional respect, particularly physician-led disrespect, were key stressors. Thematic coding identified six interconnected domains, such as resource diversion, interpersonal toxicity, systemic handover failures, and role incongruence. The study suggests that integrating confidential ethics consultations, structured debriefings, and leadership-driven ethics training within EMS protocols can reduce barriers to ethical practice, alleviate distress, and enhance clinician resilience.