{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:54:56Z","timestamp":1790816096924,"version":"4.1.0"},"reference-count":36,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T00:00:00Z","timestamp":1771891200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"},{"start":{"date-parts":[[2026,3,11]],"date-time":"2026-03-11T00:00:00Z","timestamp":1773187200000},"content-version":"vor","delay-in-days":15,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"funder":[{"DOI":"10.13039\/501100004077","name":"Kocaeli \u00dcniversitesi","doi-asserted-by":"publisher","award":["Supported by the Kocaeli University Scientific Research Projects Coordination Unit (Project No: TDK-2022-2798)."],"award-info":[{"award-number":["Supported by the Kocaeli University Scientific Research Projects Coordination Unit (Project No: TDK-2022-2798)."]}],"id":[{"id":"10.13039\/501100004077","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sci Rep"],"DOI":"10.1038\/s41598-026-40282-3","type":"journal-article","created":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T09:25:37Z","timestamp":1771925137000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Moral distress of primary health care workers during the global pandemic"],"prefix":"10.1038","volume":"16","author":[{"given":"Meltem","family":"Do\u011fan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asl\u0131han","family":"Akp\u0131nar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,24]]},"reference":[{"key":"40282_CR1","unstructured":"WHO. Primary health care. World Health Organization. https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/primary-health-care (2023)."},{"key":"40282_CR2","unstructured":"Kurt \u00d6, \u015ea\u015fmaz T. The socialization of health services in Turkey: 1961\u20132003. Mersin Univ. Fac. Med. Lokman Hekim J. Hist. Med. Folk Med. 67\u201368, (2011)."},{"issue":"4","key":"40282_CR3","doi-asserted-by":"publisher","first-page":"163","DOI":"10.15511\/tjtfp.19.00463","volume":"10","author":"M \u00c7elik","year":"2019","unstructured":"\u00c7elik, M., Limnili, G. & G\u00fcldal, A. D. Evaluation of primary health care services. J. Turk. Fam. Physician 10(4), 163\u2013172 (2019).","journal-title":"J. Turk. Fam. Physician"},{"key":"40282_CR4","unstructured":"Official Gazette. Family Medicine Practice Regulation. Official Gazette. https:\/\/www.mevzuat.gov.tr\/mevzuat?MevzuatNo=17051&MevzuatTur=7&MevzuatTertip=5 (2013)."},{"issue":"1","key":"40282_CR5","first-page":"3","volume":"5","author":"A Akp\u0131nar","year":"2013","unstructured":"Akp\u0131nar, A., Alvur, T. M., Ersoy, N. & Topsever, P. D\u00fczce \u0130li Aile Hekimlerinin Ya\u015fad\u0131\u011f\u0131 Etik Sorunlara Dayanan Bir Etik E\u011fitim Program\u0131 \u00d6nerisi. Konuralp T\u0131p Dergisi. 5(1), 3\u201310 https:\/\/dergipark.org.tr\/tr\/pub\/ktd\/issue\/10301\/126374 (2013).","journal-title":"Konuralp T\u0131p Dergisi"},{"issue":"3","key":"40282_CR6","doi-asserted-by":"publisher","first-page":"102","DOI":"10.4103\/AJM.AJM_119_20","volume":"10","author":"H Chamsi-Pasha","year":"2020","unstructured":"Chamsi-Pasha, H., Chamsi-Pasha, M. & Albar, M. A. Ethical dilemmas in the era of COVID-19. Avicenna J. Med. 10(3), 102\u2013105 (2020).","journal-title":"Avicenna J. Med."},{"issue":"11","key":"40282_CR7","doi-asserted-by":"publisher","first-page":"471","DOI":"10.5435\/JAAOS-D-20-00371","volume":"28","author":"AM Dunham","year":"2020","unstructured":"Dunham, A. M., Rieder, T. N. & Humbyrd, C. J. A bioethical perspective for navigating moral dilemmas amidst the COVID-19 pandemic. J. Am. Acad. Orthop. Surg. 28(11), 471\u2013475 (2020).","journal-title":"J. Am. Acad. Orthop. Surg."},{"issue":"7","key":"40282_CR8","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1080\/15265161.2020.1764138","volume":"20","author":"AL McGuire","year":"2020","unstructured":"McGuire, A. L. et al. Ethical challenges arising in the COVID-19 pandemic: An overview from the association of bioethics program directors (ABPD) Task Force. Am. J. Bioeth. 20(7), 15\u201327 (2020).","journal-title":"Am. J. Bioeth."},{"key":"40282_CR9","doi-asserted-by":"publisher","DOI":"10.31744\/einstein_journal\/2020AE5775","volume":"18","author":"E Satomi","year":"2020","unstructured":"Satomi, E. et al. Fair allocation of scarce medical resources during COVID-19 pandemic: Ethical considerations. Einstein 18, eAE5778 (2020).","journal-title":"Einstein"},{"issue":"2","key":"40282_CR10","doi-asserted-by":"publisher","first-page":"348","DOI":"10.21763\/tjfmpc.853344","volume":"15","author":"S T\u00fcrkili","year":"2021","unstructured":"T\u00fcrkili, S., Uysal, Y., Tot, \u015e & Mert, E. Aile hekimlerinde korona vir\u00fcs salg\u0131n\u0131 nedeniyle ya\u015fan\u0131lan zorluklar, kayg\u0131 ve t\u00fckenmi\u015flik durumlar\u0131n\u0131n incelenmesi. Turkish Journal of Family Medicine and Primary Care. 15(2), 348\u2013356 https:\/\/doi.org\/10.21763\/tjfmpc.853344 (2021).","journal-title":"Turkish Journal of Family Medicine and Primary Care"},{"issue":"1","key":"40282_CR11","doi-asserted-by":"publisher","first-page":"22","DOI":"10.4103\/jfmpc.jfmpc_1653_20","volume":"10","author":"SJ Chandy","year":"2021","unstructured":"Chandy, S. J., Ranjalkar, J. & Chandy, S. S. Collateral effects and ethical challenges in healthcare due to COVID-19: A dire need to support healthcare workers and systems. J. Fam. Med. Prim. Care 10(1), 22\u201326 (2021).","journal-title":"J. Fam. Med. Prim. Care"},{"issue":"6","key":"40282_CR12","doi-asserted-by":"publisher","first-page":"617","DOI":"10.1001\/journalofethics.2017.19.6.mhst1-1706","volume":"19","author":"A Jameton","year":"2017","unstructured":"Jameton, A. What moral distress in nursing history could suggest about the future of health care. AMA J. Ethics 19(6), 617\u2013628 (2017).","journal-title":"AMA J. Ethics"},{"key":"40282_CR13","doi-asserted-by":"publisher","DOI":"10.1080\/20008066.2025.2512677","author":"ME Gustavsson","year":"2025","unstructured":"Gustavsson, M. E., Juth, N., von Schreeb, J. & Arnberg, F. K. Moral distress, moral residue, and associations with psychological distress: A cross-sectional study. Eur. J. Psychotraumatol. https:\/\/doi.org\/10.1080\/20008066.2025.2512677 (2025).","journal-title":"Eur. J. Psychotraumatol."},{"issue":"1","key":"40282_CR14","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1177\/0969733020981748","volume":"28","author":"I Miljeteig","year":"2021","unstructured":"Miljeteig, I. et al. Priority-setting dilemmas, moral distress, and support experienced by nurses and physicians in the early phase of the COVID-19 pandemic in Norway. Nurs. Ethics 28(1), 66\u201381 (2021).","journal-title":"Nurs. Ethics"},{"issue":"14","key":"40282_CR15","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph18147565","volume":"18","author":"N Giannetta","year":"2021","unstructured":"Giannetta, N. et al. Ethical problems and moral distress in primary care: A scoping review. Int. J. Environ. Res. Public Health 18(14), 7565. https:\/\/doi.org\/10.3390\/ijerph18147565 (2021).","journal-title":"Int. J. Environ. Res. Public Health"},{"key":"40282_CR16","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp.2023.0193","author":"ML Molinaro","year":"2023","unstructured":"Molinaro, M. L., Shen, K., Agarwal, G., Inglis, G. & Vanstone, M. Family physicians\u2019 moral distress when caring for patients experiencing social inequities: A critical narrative inquiry in primary care. Br. J. Gen. Pract. https:\/\/doi.org\/10.3399\/bjgp.2023.0193 (2023).","journal-title":"Br. J. Gen. Pract."},{"key":"40282_CR17","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijnurstu.2021.103984","volume":"121","author":"G Morley","year":"2021","unstructured":"Morley, G., Field, R., Horsburgh, C. C. & Burchill, C. Interventions to mitigate moral distress: A systematic review of the literature. Int. J. Nurs. Stud. 121, 103984. https:\/\/doi.org\/10.1016\/j.ijnurstu.2021.103984 (2021).","journal-title":"Int. J. Nurs. Stud."},{"issue":"3","key":"40282_CR18","doi-asserted-by":"publisher","first-page":"631","DOI":"10.31020\/mutftd.1468779","volume":"14","author":"M Do\u011fan","year":"2024","unstructured":"Do\u011fan, M., Balc\u0131, & S., Akp\u0131nar, A. Birinci Basamak Sa\u011fl\u0131k \u00c7al\u0131\u015fanlar\u0131 \u0130\u00e7in Ahlaki S\u0131k\u0131nt\u0131 \u00d6l\u00e7e\u011fi ve K\u0131salt\u0131lm\u0131\u015f Hastane Etik \u0130klim \u00d6l\u00e7e\u011fi\u2019nin T\u00fcrk\u00e7e Ge\u00e7erlik ve G\u00fcvenirlik \u00c7al\u0131\u015fmas\u0131. Lokman Hekim Dergisi. 14(3), 631\u2013637. https:\/\/doi.org\/10.31020\/mutftd.1468779 (2024).","journal-title":"Lokman Hekim Dergisi."},{"issue":"2","key":"40282_CR19","doi-asserted-by":"publisher","first-page":"113","DOI":"10.1080\/23294515.2019.1619351","volume":"10","author":"EG Epstein","year":"2019","unstructured":"Epstein, E. G., Whitehead, P. B., Prompahakul, C., Thacker, L. R. & Hamric, A. B. Enhancing understanding of moral distress: The Measure of moral distress for health care professionals. AJOB Empir. Bioeth. 10(2), 113\u2013124. https:\/\/doi.org\/10.1080\/23294515.2019.1619351 (2019).","journal-title":"AJOB Empir. Bioeth."},{"issue":"3","key":"40282_CR20","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1111\/j.1466-7657.1995.tb00735.x","volume":"42","author":"L Olson","year":"1995","unstructured":"Olson, L. Ethical climate in health care organizations. Int. Nurs. Rev. 42(3), 85\u201390. https:\/\/doi.org\/10.1111\/j.1466-7657.1995.tb00735.x (1995).","journal-title":"Int. Nurs. Rev."},{"issue":"2","key":"40282_CR21","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/21507716.2011.652337","volume":"3","author":"AB Hamric","year":"2012","unstructured":"Hamric, A. B., Borchers, C. T. & Epstein, E. G. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Prim. Res. 3(2), 1\u20139. https:\/\/doi.org\/10.1080\/21507716.2011.652337 (2012).","journal-title":"AJOB Primary Research"},{"issue":"1","key":"40282_CR22","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12910-024-01041-z","volume":"25","author":"E Girela-Lopez","year":"2024","unstructured":"Girela-Lopez, E. et al. Measuring moral distress in health professionals using the MMD-HP-SPA scale. BMC Med. Ethics 25(1), 1\u201312 (2024).","journal-title":"BMC Med. Ethics"},{"issue":"1","key":"40282_CR23","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12955-021-01855-7","volume":"19","author":"T Fujii","year":"2021","unstructured":"Fujii, T. et al. Translation and validation of the Japanese version of the measure of moral distress for healthcare professionals. Health Qual. Life Outcomes 19(1), 1\u201311. https:\/\/doi.org\/10.1186\/s12955-021-01855-7 (2021).","journal-title":"Health Qual. Life Outcomes"},{"issue":"1","key":"40282_CR24","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12910-023-01034-4","volume":"24","author":"C Fischer-Gr\u00f6nlund","year":"2023","unstructured":"Fischer-Gr\u00f6nlund, C., Br\u00e4nnstr\u00f6m, M. & Isaksson, U. Psychometric testing of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP). BMC Med. Ethics 24(1), 1\u201310. https:\/\/doi.org\/10.1186\/s12910-023-01034-4 (2023).","journal-title":"BMC Med. Ethics"},{"issue":"23","key":"40282_CR25","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph192315649","volume":"19","author":"E Girela","year":"2022","unstructured":"Girela, E. et al. Study of the psychometric properties of the Spanish version of the measure of moral distress for health care professionals (MMD-HP-SPA). Int. J. Environ. Res. Public Health 19(23), 15649. https:\/\/doi.org\/10.3390\/ijerph192315649 (2022).","journal-title":"Int. J. Environ. Res. Public Health"},{"issue":"24","key":"40282_CR26","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph182413367","volume":"18","author":"G Lamiani","year":"2021","unstructured":"Lamiani, G., Biscardi, D., Meyer, E. C., Giannini, A. & Vegni, E. Moral distress trajectories of physicians 1 year after the COVID-19 outbreak: A grounded theory study. Int. J. Environ. Res. Public Health 18(24), 13367. https:\/\/doi.org\/10.3390\/ijerph182413367 (2021).","journal-title":"Int. J. Environ. Res. Public Health"},{"issue":"4","key":"40282_CR27","doi-asserted-by":"publisher","first-page":"958","DOI":"10.52142\/omujecm.39.4.7","volume":"39","author":"KS K\u0131z\u0131ltepe","year":"2022","unstructured":"K\u0131z\u0131ltepe, K. S. & Kurtg\u00f6z, A. Understanding physicians\u2019 moral distress in the COVID-19 pandemic. J. Exp. Clin. Med. 39(4), 958\u2013965 (2022).","journal-title":"J. Exp. Clin. Med."},{"issue":"16","key":"40282_CR28","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph18168723","volume":"18","author":"N Smallwood","year":"2021","unstructured":"Smallwood, N., Pascoe, A., Karimi, L. & Willis, K. Moral distress and perceived community views are associated with mental health symptoms in frontline health workers during the COVID-19 pandemic. Int. J. Environ. Res. Public Health 18(16), 8723. https:\/\/doi.org\/10.3390\/ijerph18168723 (2021).","journal-title":"Int. J. Environ. Res. Public Health"},{"issue":"10","key":"40282_CR29","doi-asserted-by":"publisher","first-page":"1007","DOI":"10.1002\/da.23186","volume":"38","author":"SB Norman","year":"2021","unstructured":"Norman, S. B. et al. Moral distress in frontline healthcare workers in the initial epicenter of the COVID-19 pandemic in the United States: Relationship to PTSD symptoms, burnout, and psychosocial functioning. Depress. Anxiety 38(10), 1007\u20131017. https:\/\/doi.org\/10.1002\/da.23186 (2021).","journal-title":"Depress. Anxiety"},{"issue":"3","key":"40282_CR30","doi-asserted-by":"publisher","first-page":"799","DOI":"10.1111\/jan.15621","volume":"78","author":"ET Lake","year":"2022","unstructured":"Lake, E. T. et al. Hospital nurses\u2019 moral distress and mental health during COVID-19. J. Adv. Nurs. 78(3), 799\u2013809. https:\/\/doi.org\/10.1111\/jan.15621 (2022).","journal-title":"J. Adv. Nurs."},{"issue":"1","key":"40282_CR31","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12910-022-00775-y","volume":"23","author":"H Silverman","year":"2022","unstructured":"Silverman, H. et al. Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center. BMC Med. Ethics 23(1), 1\u201315. https:\/\/doi.org\/10.1186\/s12910-022-00775-y (2022).","journal-title":"BMC Med. Ethics"},{"key":"40282_CR32","unstructured":"Turkish Medical Association (TMA). TMA \u201cFamily Medicine Pandemic Survey\u201d results. Turkish Med. Assoc. https:\/\/www.ttb.org.tr\/haber_goster.php?Guid=d490f11a-fb24-11ea-abf2-539a0e741e38 (2020)."},{"key":"40282_CR33","unstructured":"G\u00fcler, S., Topuz, \u0130., & Ulusoy, F.  Covid-19 Pandemisinde Aile Sa\u011fl\u0131\u011f\u0131 Merkezi \u00c7al\u0131\u015fanlar\u0131n\u0131n Deneyimleri. Halk Sa\u011fl\u0131\u011f\u0131 Hem\u015fireli\u011fi Dergisi, 2(3), 143-151. https:\/\/izlik.org\/JA26BH95KH, (2020)."},{"issue":"7","key":"40282_CR34","doi-asserted-by":"publisher","first-page":"383","DOI":"10.1016\/j.medin.2022.03.009","volume":"46","author":"E Rodriguez","year":"2022","unstructured":"Rodriguez, E. et al. Moral distress among healthcare professionals working in intensive care units in Spain. Med. Intensiva 46(7), 383\u2013391. https:\/\/doi.org\/10.1016\/j.medin.2022.03.009 (2022).","journal-title":"Med. Intensiva"},{"issue":"4","key":"40282_CR35","doi-asserted-by":"publisher","first-page":"735","DOI":"10.1002\/pon.5006","volume":"28","author":"P Pergert","year":"2019","unstructured":"Pergert, P., Bartholdson, C. & af Sandeberg, M. The ethical climate in pediatric oncology: A national cross-sectional survey of health-care personnel. Psychooncology 28(4), 735\u2013741. https:\/\/doi.org\/10.1002\/pon.5006 (2019).","journal-title":"Psychooncology"},{"issue":"7","key":"40282_CR36","doi-asserted-by":"publisher","first-page":"1067","DOI":"10.1002\/pon.6148","volume":"32","author":"P Ventovaara","year":"2023","unstructured":"Ventovaara, P. et al. Moral distress and ethical climate in pediatric oncology care impact healthcare professionals\u2019 intentions to leave. Psychooncology 32(7), 1067\u20131075. https:\/\/doi.org\/10.1002\/pon.6148 (2023).","journal-title":"Psychooncology"}],"container-title":["Scientific Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41598-026-40282-3","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-026-40282-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41598-026-40282-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T08:38:22Z","timestamp":1782117502000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41598-026-40282-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,24]]},"references-count":36,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["40282"],"URL":"https:\/\/doi.org\/10.1038\/s41598-026-40282-3","relation":{},"ISSN":["2045-2322"],"issn-type":[{"value":"2045-2322","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,24]]},"assertion":[{"value":"18 February 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"11 February 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 February 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 June 2026","order":6,"name":"change_date","label":"Change Date","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Update","order":7,"name":"change_type","label":"Change Type","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The original online version of this Article was revised: The original version of this Article contained errors in References 5, 10, 18, 21 and 33. The correct References now accompany the original Article.","order":8,"name":"change_details","label":"Change Details","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}},{"value":"The study was conducted in accordance with the Helsinki Declaration. Ethical approval was obtained from the Non-Interventional Ethics Committee of Kocaeli University on 21\/10\/2021, with project number GOKAEK-2021\/18.15 (2021\/301). The consent was obtained from the participants.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}}],"article-number":"8698"}}