qualitative research moral distress

Advertisement

Empirical Research on Moral Distress: Issues, Challenges, and Opportunities

• Published: 04 April 2012
• Volume 24 , pages 39–49, ( 2012 )

Cite this article

• Ann B. Hamric 1  

5749 Accesses

147 Citations

Explore all metrics

Studying a concept as complex as moral distress is an ongoing challenge for those engaged in empirical ethics research. Qualitative studies of nurses have illuminated the experience of moral distress and widened the contours of the concept, particularly in the area of root causes. This work has led to the current understanding that moral distress can arise from clinical situations, factors internal to the individual professional, and factors present in unit cultures, the institution, and the larger health care environment. Corley et al. ( 2001 ) was the first to publish a quantitative measure of moral distress, and her scale has been adapted for use by others, including studies of other disciplines (Hamric and Blackhall 2007 ; Schwenzer and Wang 2006 ). Other scholars have proposed variations on Jameton’s core definition (Sporrong et al. 2006 , 2007 ), developing measures for related concepts such as moral sensitivity (Lutzen et al. 2006 ), ethics stress (Raines 2000 ), and stress of conscience (Glasberg et al. 2006 ). The lack of consistency and consensus on the definition of moral distress considerably complicates efforts to study it. Increased attention by researchers in disciplines other than nursing has taken different forms, some problematic. Cultural differences in the role of the nurse and understanding of actions that represent threats to moral integrity also challenge efforts to build a cohesive research-based understanding of the concept. In this paper, research efforts to date are reviewed. The importance of capturing root causes of moral distress in instruments, particularly those at unit and system levels, to allow for interventions to be appropriately targeted is highlighted. In addition, the issue of studying moral distress and interaction over time with moral residue is discussed. Promising recent work is described along with the potential these approaches open for research that can lead to interventions to decrease moral distress. Finally, opportunities for future research and study are identified, and recommendations for moving the research agenda forward are offered.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Similar content being viewed by others

Sources of Moral Distress

Evaluation of Interventions to Address Moral Distress: A Multi-method Approach

Rethinking moral distress: conceptual demands for a troubling phenomenon affecting health care professionals

Austin, W., Bergum, V., & Goldberg, L. (2003). Unable to answer the call of our patients: Mental health nurses’ experience of moral distress. Nursing Inquiry, 10 (3), 177–183.

Article   Google Scholar  

Austin, W., Lemermeyer, G., Goldberg, L., Bergum, V., & Johnson, M. S. (2005). Moral distress in healthcare practice: The situation of nurses. HEC Forum, 17 (1), 33–48.

Beumer, C. M. (2008). Innovative solutions: The effect of a workshop on reducing the experience of moral distress in an intensive care unit setting. Dimensions of Critical Care Nursing, 27 (6), 263–267.

Brazil, K., Kassalainen, S., Ploeg, J., & Marshall, D. (2010). Moral distress experienced by health care professionals who provide home-based palliative care. Social Science and Medicine, 71 (9), 1687–1691.

Cavaliere, T. A., Daly, B., Dowling, D., & Montgomery, K. (2010). Moral distress in neonatal intensive care unit RNs. Advances in Neonatal Care, 10 (3), 145–156.

Google Scholar  

Chen, P. (2009). When nurses and doctors can’t do the right thing, New York Times. http://www.nytimes.com/2009/02/06/health/05chen.html . Accessed 5 Feb 2009.

Corley, M. C. (1995). Moral distress of critical care nurses. American Journal of Critical Care, 4 (4), 280–285.

Corley, M. C., Elswick, R. K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33 (2), 250–256.

Corley, M. C., Minick, P., Elswick, R. K., & Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12 (4), 381–390.

Creswell, J. (2009). Research design: Qualitative, quantitative and mixed methods approaches (3rd ed.). Thousand Oaks: Sage Publications.

Eizenberg, M. M., Desivilya, H. S., & Hirschfeld, M. J. (2009). Moral distress questionnaire for clinical nurses: Instrument development. Journal of Advanced Nursing, 65 (4), 885–892.

Elpern, E. H., Covert, B., & Kleinpell, R. (2005). Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care, 14 (6), 523–530.

Epstein, E. G. (2008). End-of-life experiences of nurses and physicians in the newborn intensive care unit. Journal of Perinatology, 28 , 771–778.

Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20 (4), 330–342.

Erlen, J. A., & Frost, B. (1991). Nurses’ perceptions of powerlessness in influencing ethical decisions. Western Journal of Nursing Research, 13 , 397–407.

Ferrell, B. R. (2006). Understanding the moral distress of nurses witnessing medically futile care. Oncology Nursing Forum, 33 (5), 922–930.

Fry, S. T., Harvey, R. M., Hurley, A. C., & Foley, B. J. (2002). Development of a model of moral distress in military nursing. Nursing Ethics, 9 (4), 373–387.

Glasberg, A. L., Eriksson, S., Dahlqvist, V., Lindahl, E., Strandberg, G., Soderberg, A., et al. (2006). Development and initial validation of the stress of conscience questionnaire. Nursing Ethics, 13 (6), 633–648.

Gordon, E. J., & Hamric, A. B. (2006). The courage to stand up: The cultural politics of nurses’ access to ethics consultation. Journal of Clinical Ethics, 17 , 231–254.

Gutierrez, K. M. (2005). Critical care nurses’ perceptions of and responses to moral distress. Dimensions of Critical Care Nursing, 24 (5), 229–241.

Hamric, A. B., & Blackhall, L. J. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine, 35 (2), 422–429.

Hamric, A.B., Borchers, C.T., & Epstein, E.G. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research , 3 (2), 1–9.

Harrowing, J. N., & Mill, J. (2010). Moral distress among Ugandan nurses providing HIV care: A critical ethnography. International Journal of Nursing Studies, 47 , 723–731.

Hefferman, P., & Heilig, S. (1999). Giving “moral distress” a voice: Ethical concerns among neonatal intensive care unit personnel. Cambridge Quarterly of Healthcare Ethics, 8 (2), 173–178.

Jameton, A. (1984). Nursing practice: The ethical issues . Englewood Cliffs: Prentice-Hall.

Jameton, A. (1993). Dilemmas of moral distress: moral responsibility and nursing practice. AWHONN’s Clinical Issues in Perinatal Women’s Health Nursing, 4 , 542–551.

Kalvemark, S., Hoglund, A. T., Hansson, M. G., Westerholm, P., & Arnetz, B. (2004). Living with conflicts-ethical dilemmas and moral distress in the health care system. Social Science and Medicine, 58 (6), 1075–1084.

Lutzen, K., Dahlqvist, V., Eriksson, S., & Norberg, A. (2006). Developing the concept of moral sensitivity in health care practice. Nursing Ethics, 13 , 187–196.

Parker-Hope, T. (2009). Medicine and moral distress, New York Times . Anonymous quote posted February 5, 2009. http://well.blogs.nytimes.com/2009/02/05/medicine-and-moral-distress/ . Accessed 10 Feb 2009.

Pauly, B., Varcoe, C., Storch, J., & Newton, L. (2009). Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics, 16 (5), 561–573.

Pike, A. W. (1991). Moral outrage and moral discourse in nurse-physician collaboration. Journal of Professional Nursing, 7 (6), 351–362.

Raines, M. L. (2000). Ethical decision making in nurses. Relationships among moral reasoning, coping style, and ethics stress. JONA’s Healthcare Law Ethics Regulation, 2 , 29–41.

Rodney, P., Varcoe, C., Storch, J. L., McPherson, G., Mahoney, K., Brown, H., et al. (2002). Navigating towards a moral horizon: A multisite qualitative study of ethical practice in nursing. Canadian Journal of Nursing Research, 34 (3), 75–102.

Rogers, S., Babgi, A., & Gomez, C. (2008). Educational interventions in end-of-life care: Part I: An educational intervention responding to the moral distress of NICU nurses provided by an ethics consultation team. Advances in Neonatal Care, 8 (1), 56–65.

Schwenzer, K. J., & Wang, L. (2006). Assessing moral distress in respiratory care practitioners. Critical Care Medicine, 34 (12), 2967–2973.

Sporrong, S. K., Arnetz, B., Hansson, M. G., Westerholm, P., & Hoglund, A. T. (2007). Developing ethical competence in health care organizations. Nursing Ethics, 14 (6), 825–837.

Sporrong, S. K., Hoglund, A. T., & Arnetz, B. (2006). Measuring moral distress in pharmacy and clinical practice. Nursing Ethics, 13 (4), 416–427.

Ulrich, C., O’Donnell, P., Taylor, C., Farrar, A., Danis, M., & Grady, C. (2007). Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Social Science and Medicine, 65 , 1708–1719.

Varcoe, C., Hartrick, G., et al. (2004). Ethical practice in nursing: Working the in-betweens. Journal of Advanced Nursing, 45 (3), 316–325.

Webster, G., & Bayliss, F. (2000). Moral residue. In S. Rubin & L. Zoloth (Eds.), Margin of error: The ethics of mistakes in the practice of medicine . Hagerstown: University Publishing Group, Inc.

Wiggleton, C., Petrusa, E., Loomis, K., Tarpley, J., Tarpley, M., O’Gorman, M. L., et al. (2010). Medical students’ experiences of moral distress: Development of a web-based survey. Academic Medicine, 85 (1), 111–117.

Wilkinson, J. M. (1987/1988). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23 (1), 16–29.

Wocial, L. D., & Weaver, M. T. (in press). Development and psychometric testing of a new tool for detecting moral distress: The moral distress thermometer. Journal of Advanced Nursing , 53 .

Download references

Author information

Authors and affiliations.

School of Nursing, Virginia Commonwealth University, P.O. Box 980567, Richmond, VA, 23298-0567, USA

Ann B. Hamric

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Ann B. Hamric .

Rights and permissions

Reprints and permissions

About this article

Hamric, A.B. Empirical Research on Moral Distress: Issues, Challenges, and Opportunities. HEC Forum 24 , 39–49 (2012). https://doi.org/10.1007/s10730-012-9177-x

Download citation

Published : 04 April 2012

Issue Date : March 2012

DOI : https://doi.org/10.1007/s10730-012-9177-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Moral distress
• Empirical research
• Moral residue
• Moral distress scale
• Moral distress thermometer
• Find a journal
• Publish with us
• Track your research

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.10(9); 2023 Sep
• PMC10416007

Registered Nurses' and nursing students' perspectives on moral distress and its effects: A mixed‐methods systematic review and thematic synthesis

Tessa watts.

1 School of Healthcare Sciences, Cardiff University, Cardiff UK

Dean Whybrow

Eunice temeng, rachael hewitt, rachael pattinson, christine bundy, richard g. kyle.

2 Public Health Wales, Cardiff UK

3 Academy of Nursing, University of Exeter, Exeter UK

Bethan Jones

4 School of Health and Social Wellbeing, University of West of England, Bristol UK

Associated Data

Data available in article supplementary material.

To examine Registered Nurses (RNs') and nursing students' perspectives on factors contributing to moral distress and the effects on their health, well‐being and professional and career intentions.

Joanna Briggs Institute mixed‐methods systematic review and thematic synthesis. Registered in Prospero (Redacted).

Five databases were searched on 5 May 2021 for studies published in English since January 2010. Methodological quality assessment was conducted in parallel with data extraction.

Searches yielded 2343 hits. Seventy‐seven articles were included. Most were correlational design and used convenience sampling. Studies were mainly from North America and Asia and situated in intensive and critical care settings. There were common, consistent sources of moral distress across continents, specialities and settings. Factors related to perceived inability or failure to enact moral agency and responsibility in moral events at individual, team and structural levels generated distress. Moral distress had a negative effect on RNs health and psychological well‐being.

Patient or Public Contribution

No patient or public contribution to this systematic review.

1. BACKGROUND

Global concern about the complex phenomenon of moral distress within nursing has been expressed for almost four decades. Morally challenging situations are common in healthcare and moral distress is not unique to nursing. However, experiencing moral distress is known to have profound personal and professional effects on individuals. It undermines integrity, functional competency and negatively impacts mood and intentions to remain in the workforce (Colville et al.,  2019 ).

Initially coined by Jameton ( 1984 ), moral distress is an elusive concept which, in the context of nursing, evades conceptual clarity (Johnstone & Hutchinson, 2015 ; Pauly et al., 2012 ) and consensual definition (Deschenes et al., 2020 ; Morley et al.,  2019 ). Indeed, Morley et al. ( 2019 ) found 20 moral distress definitions and identified five moral distress subtypes: moral constraint, moral conflict, moral tension, moral uncertainty and moral dilemmas (Morley, Bradbury‐Jones, & Ives,  2020 ). For this review, moral distress was defined as an ‘umbrella concept that describes the psychological, emotional and physiological suffering that may be experienced when we act in ways that are inconsistent with deeply held ethical values, principles or moral commitments’ (McCarthy & Deady,  2008 , p. 1).

Nursing work is inherently demanding (Broetje et al.,  2020 ). Higher rates of mental ill‐health among nurses compared with the general working population have been identified (Kinman et al.,  2020 ; Martín‐Del‐Río et al.,  2018 ). The risk of psychological morbidity among nurses is well documented (Chana et al.,  2015 ; Chin et al.,  2019 ; House of Commons,  2021 ; Melnyk,  2020 ; Melnyk et al.,  2018 ). Evidence shows that nurses' stress is compounded by structural, organisational, workplace‐based challenges, including excessive and intensive workloads, staff shortages, difficult working conditions, shift work, incivility, team conflict, quality of leadership and management practices (Hartin et al.,  2018 , 2020 ; Lee & Kim,  2020 ; Tahghighi et al.,  2017 ). The cumulative effect of repeated exposure to workplace stressors impacts on mental health (Stelnicki & Carleton,  2021 ), influencing staff turnover and decisions to leave the profession (Nursing and Midwifery Council,  2020 ; Royal College of Nursing,  2019 ), thereby contributing to the global nursing workforce retention crisis. Sustaining and retaining a healthy, motivated and appropriately supported nursing workforce is central to high quality, safe and effective care which optimises patient outcomes, reduces ‘missed care’ and preventable mortality, and meets population health needs (Aiken et al.,  2014 ; Griffiths et al.,  2018 ).

Moral distress is a key determinant of nurses' poor psychological and physical health. However, despite the ubiquity of morally challenging experiences in nursing practice, the influencing factors and effects of moral distress among nurses are poorly understood. This hampers the provision of appropriate organisational support, especially in the context of SARS‐Cov‐2 recovery, and the development of accessible interventions to mitigate the psychological effects of moral distress. To support and retain a healthy nursing workforce and inform planning for future public health emergencies, including pandemics, learning from the existing literature on moral distress with Registered and student Nurses before the SARS‐CoV‐2 pandemic is essential. This mixed‐methods systematic review examines RNs' and nursing students' perspectives on factors contributing to moral distress and the effects on their health, well‐being and professional and career intentions by answering the following review questions:

• What factors contribute to moral distress among RNs and nursing students?
• Health and well‐being?
• Professional and career intentions?

The systematic review was informed by the Joanna Briggs Institute (JBI) mixed‐methods systematic reviews methodology (MMSR) (Lizarondo et al.,  2020 ) and registered in PROSPERO (CRD42021245362). The review is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) guidelines (Page et al.,  2021 ).

2.1. Inclusion and exclusion criteria

Primary qualitative, quantitative and mixed‐methods research studies which focused on moral distress in Registered Nurses (RNs), nursing associates/apprentices/students working in healthcare settings and were published in English were included. Non‐empirical, opinion pieces, theoretical and methodological articles, reviews and editorials were excluded. Research studies were excluded if they were based on secondary data analysis, conducted in neonatal and social care settings, reported on healthcare professionals' moral distress where data were pooled for analysis, or did not meet any of the four quality criteria during the quality appraisal process, as detailed below.

2.2. Search strategy, study selection and data extraction

The search strategy was developed and tested in collaboration with a specialist health service systematic review librarian (EG). On 5th May 2021, one reviewer (ET) systematically searched the electronic databases MEDLINE, PsycINFO (via OvidSp), CINAHL (via EBSCO host), Embase (via Elsevier) and the Web of Science for studies published in English since 2010. This review was commissioned in the early stages of the SARS‐CoV‐2 pandemic. Given our timescales, the decision to run the searches between 2010 and 2021 was pragmatic, and taken in consultation with information specialists to ensure relative stability in the healthcare context within which nurses were working and experiencing moral distress. A combination of Medical Subject Headings (MeSH) search terms was used including moral*, distress, suffering, injury, residue, psychological distress, nurse and nurses. To enhance the sensitivity and refine the searches, Boolean operators (OR and AND) were used. A detailed description of the search strategies used in each database is presented in the online supplementary material ( File S1 ). All hits were entered into EndNote and duplicates removed. Remaining hits were imported to Covidence SR management software. Additional duplicates were identified and removed.

All project team members were involved in the screening and selection process. Standardised systematic review methods (Centre for Reviews & Dissemination,  2009 ) were used. Firstly, two reviewers independently screened returned titles and abstracts, sifting these into a ‘yes’, ‘no’ or ‘maybe’ category. Where a definite decision based on title and abstract alone could not be made, the full text was retrieved and assessed. Secondly, full text of all potentially relevant abstracts were retrieved and independently assessed for inclusion by reviewers against the purposively designed eligibility criteria. Uncertainties for both first‐ and second‐level screening were resolved by the two reviewers. In the event of disagreement, an independent reviewer would arbitrate. However, arbitration was not required. Reasons for exclusion at full text review were recorded.

Data were extracted systematically using an adapted JBI mixed‐methods data extraction form and Covidence software. A second reviewer independently cross‐checked all data extraction forms for accuracy, integrity and completeness. To establish concordance, a third reviewer independently moderated a sample (10%) of extracted data. Extracted data included the author(s), year and country of publication, study aim and design, setting, number and characteristics of participants, approaches to sampling, data collection, analysis and quality appraisal outcome. In preparation for analysis and to facilitate the comparison and contrast of study findings systematically and coherently, for each study, a brief, textual, narrative summary reporting key findings relevant to the review questions was written.

2.3. Quality appraisal

Two reviewers independently assessed the quality of included studies using the Mixed Methods Appraisal Tool (MMAT) version 18 (Hong et al.,  2018 ). The MMAT was constructed specifically for quality appraisal in mixed studies reviews (Hong et al.,  2018 ; Pace et al.,  2012 ). Each study was assigned a score based on the number of criteria met (25%—one criterion met; 100%—all criteria met). Studies were excluded if they met none of the quality criteria.

2.4. Data analysis and synthesis

Findings from qualitative, quantitative and mixed‐methods studies were synthesised thematically to address the review questions. The textual narrative summaries created during data extraction were aggregated and checked (TW). Guided by Thomas and Harden's ( 2008 ) approach to thematic synthesis, two researchers (TW, BJ) read and reread the aggregated textual summaries and corresponding articles. Initial, descriptive inductive codes were generated independently. Patterns within and between the studies were identified and following consultation with other team members for rigour.

3.1. Search results and overview of studies selected

Figure  1 shows a PRISMA flow chart of search results. Following first‐ and second‐level screening, 77 articles (3.3%) were deemed suitable for inclusion.

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only. Adapted from: Page et al. ( 2021 ).

Seventy‐seven articles published between 2010 and 2021 were included: 42 quantitative, 29 qualitative and six mixed‐methods studies. A synopsis of study characteristics are provided in Tables  1 , ​ ,2, 2 , ​ ,3. 3 . Detailed summaries of these articles and the quality appraisal outcomes are provided in the online supplementary file ( File S2 ).

Synopsis of included quantitative studies.

Synopsis of included qualitative studies.

Synopsis of included mixed‐methods studies.

3.1.1. Study characteristics

All quantitative studies (Table  1 ) were cross‐sectional surveys and most used not only validated outcome measures, primarily Hamric et al.'s ( 2012 ) Moral Distress Scale‐Revised (MSD‐R) (n=), but also translated versions of the original English language MDS (Corley et al.,  2001 ) or the MDS‐R. Most qualitative studies ( n =  29) (Table  2 ) used a qualitative descriptive approach ( n =  18). Five studies used phenomenology, while other approaches included grounded theory ( n =  3), critical ethnography ( n =  1), narrative ( n =  1) and naturalistic enquiry ( n  = 1). A synopsis of mixed‐methods studies ( n  = 6) is presented in Table  3 .

3.1.2. Study populations

The majority of included studies ( n  = 77) were conducted in North America ( n  = 30): United States [ n  = 23] and Canada [ n  = 7]; Asia: ( n  = 26): Iran [ n  = 18]; China; Israel; Jordan; South Korea; Philippines; Taiwan [ n  = 2] and Thailand; Europe ( n  = 9): Norway; Sweden, Ireland; Italy [ n  = 3]; Cyprus; Germany and Lithuania. Other studies were from South America, specifically Brazil ( n  = 5); Africa ( n  = 5): Ethiopia; South Africa [ n  = 2]; Uganda and Malawi and Australasia: New Zealand [ n  = 2].

Most studies ( n  = 62) focused on moral distress among nurses in hospital settings specifically: intensive care ( n  = 14), critical care ( n  = 8), emergency departments ( n  = 7), haematology and oncology units ( n =  5) and psychiatric units ( n =  6). Six studies were conducted in universities with nursing students.

3.1.3. Study quality

Eight of the 29 qualitative studies (28%) and seven of the 42 quantitative studies (17%) fulfilled all four MMAT quality criteria. None of the mixed‐methods studies fulfilled all MMAT quality criteria.

3.1.4. Thematic synthesis

Moral distress was intrinsically connected to nurses and nursing students' perceived inability to act ethically, appropriately and simultaneously preserve the nursing identity and epistemology of person‐centred care and uphold core professional values, notably those relating to human dignity and advocacy (Alberto Fruet et al.,  2019 ; Caram et al.,  2019 ; Choe et al.,  2015 ; de Sousa Vilela et al.,  2021 ; Deady & McCarthy,  2010 ; Escolar Chua & Magpantay,  2019 ; Forozeiya et al.,  2019 ; Harrowing & Mill,  2010 ; Hsun‐Kuei et al.,  2018 ; Krautscheid et al.,  2017 ; Mehlis et al.,  2018 ; Prompahakul et al.,  2021 ; Ritchie et al.,  2018 ; Robinson & Stinson,  2016 ; Silverman et al.,  2021 ; Wojtowicz et al.,  2014 ; Wolf et al.,  2016 ). For the first review question, three synthesised findings reflected factors contributing to nurses' moral distress: ‘ What can we do? ’: the pervading influence of individuals' characteristics; ‘ Nobody listens to you ’: relational dynamics and practices within intra‐ and interprofessional teams and ‘ The system is broken ’: the effect of structural constraints.

3.2. Factors contributing to moral distress among nurses

3.2.1. ‘ what can we do ’: the pervading influence of individuals' characteristics.

A sense of powerlessness to intervene regarding care, treatment and decision‐making perceived as generating needless patient suffering and transgressing core professional values contributed to moral distress among RNs (Berhie et al.,  2020 ; Crespo Drago et al.,  2020 ; De Brasi et al.,  2021 ; Deady & McCarthy,  2010 ; Harrowing & Mill,  2010 ; Ko et al.,  2019 ; Langley et al.,  2015 ; Nikbakht Nasrabadi et al.,  2018 ; Prompahakul et al.,  2021 ; Sauerland et al.,  2014 ) and nursing students (Escolar Chua & Magpantay,  2019 ). This was invariably connected with interventions, treatment and care decisions perceived as futile (Asayesh et al.,  2018 ; Browning,  2013 ; Choe et al.,  2015 ; Ganz et al.,  2013 ; Dodek et al.,  2019 ; Dyo et al.,  2016 ; Emmamally & Chiyangwa,  2020 ; Hiler et al.,  2018 ; Hou et al.,  2021 ; Karanikola et al.,  2014 ; Ko et al.,  2019 ; Latimer et al.,  2021 ; Rezaee et al.,  2019 ; Robinson & Stinson,  2016 ; Silverman et al.,  2021 ; Wiegand & Funk,  2012 ; Wilson et al.,  2013 ), overly aggressive (Rezaee et al.,  2019 ; Wiegand & Funk,  2012 ) and inappropriate or unnecessary (Asgari et al.,  2019 ; Browning,  2013 ; Choe et al.,  2015 ; Christodoulou‐Fella et al.,  2017 ; De Brasi et al.,  2021 ; de Sousa Vilela et al.,  2021 ; Fernandez‐Parsons et al.,  2013 ; Forozeiya et al.,  2019 ; Ganz et al.,  2013 ; Ko et al.,  2019 ; Laurs et al.,  2020 ; Nikbakht Nasrabadi et al.,  2018 ; Silverman et al.,  2021 ) particularly, but not exclusively (de Sousa Vilela et al.,  2021 ; Deady & McCarthy,  2010 ; Rezaee et al.,  2019 ; Wojtowicz et al.,  2014 ), in the context of end‐of‐life care.

We're with the patients a lot more than the providers … we see the futility a lot of the times, because we're like there's no way this person is going to make it out of here at the end, but the surgeons when they came in for ECMO, they're like keep going, keep going, keep going, keep going, never stop. (Silverman et al.,  2021 , p. 1147: United States, acute care)

Findings are mixed regarding how perceived professional autonomy to enact moral agency when faced with moral problems in practice connected with experiencing moral distress (Caram et al.,  2019 ; Choe et al.,  2015 ; Christodoulou‐Fella et al.,  2017 ; Crespo Drago et al.,  2020 ; Dodek et al.,  2019 ; Karanikola et al.,  2014 ; Sarkoohijabalbarezi et al.,  2017 ; Yeganeh et al.,  2019 ). However, RNs' (Deady & McCarthy,  2010 ; Harorani et al.,  2019 ; Hsun‐Kuei et al.,  2018 ; Ko et al.,  2019 ; Pergert et al.,  2019 ; Sauerland et al.,  2014 ; Silverman et al.,  2021 ; Varcoe et al.,  2012 ) and nursing students' (Escolar Chua & Magpantay,  2019 ; Krautscheid et al.,  2017 ; Renno et al.,  2018 ) perceived lack of knowledge, self‐competence and confidence in their ability to articulate concerns and fulfil their perceived moral responsibilities in ethically challenging situations generated moral distress (Deady & McCarthy,  2010 ; Escolar Chua & Magpantay,  2019 ; Harorani et al.,  2019 ; Hsun‐Kuei et al.,  2018 ; Ko et al.,  2019 ; Krautscheid et al.,  2017 ; Pergert et al.,  2019 ; Renno et al.,  2018 ; Sauerland et al.,  2014 ; Silverman et al.,  2021 ; Varcoe et al.,  2012 ).

While studies suggested that perceptions of moral distress might be influenced by sociodemographic factors, findings are conflicting and consistent correlation lacking. Some studies found no statistically significant correlation between age and perceived moral distress (Bayat et al.,  2019 ; Dyo et al.,  2016 ; Evanovich Zavotsky & Chan,  2016 ; Karanikola et al.,  2014 ; Latimer et al.,  2021 ; Mehlis et al.,  2018 ; Prompahakul et al.,  2021 ; Wilson et al.,  2013 ). Others reported a significant, inverse correlation between age and moral distress (Abdolmaleki et al.,  2019 ; Borhani et al.,  2014 ; Christodoulou‐Fella et al.,  2017 ; Emmamally & Chiyangwa,  2020 ; Ganz et al.,  2013 ; Hamaideh,  2014 ; Hou et al.,  2021 ; Laurs et al.,  2020 ; Woods et al.,  2015 ). That is, younger nurses experienced greater moral distress. A positive correlation between age and perceived moral distress intensity has also been identified (Browning,  2013 ; Moaddaby et al.,  2021 ; O'Connell,  2015 ). Studies reporting the relationship between length of nursing service and perceived moral distress are inconsistent. Some studies (Alberto Fruet et al.,  2019 ; Berhie et al.,  2020 ; O'Connell,  2015 ) reported positive, occasionally significant (Alberto Fruet et al.,  2019 ; Berhie et al.,  2020 ) correlations. Others reported no statistically significant relationship (Bayat et al.,  2019 ; Dyo et al.,  2016 ; Emmamally & Chiyangwa,  2020 ; Evanovich Zavotsky & Chan,  2016 ; Karanikola et al.,  2014 ; Latimer et al.,  2021 ; Mehlis et al.,  2018 ; Prompahakul et al.,  2021 ; Wilson et al.,  2013 ). An inverse correlation was reported in four studies (Borhani et al.,  2014 ; Christodoulou‐Fella et al.,  2017 ; Hamaideh,  2014 ; Latimer et al.,  2021 ). Yet, the correlation was significant in just one study (Borhani et al.,  2014 ). Various studies indicated a relationship between gender and perceived moral distress and suggested male and female nurses experience different levels of moral distress (Berhie et al.,  2020 ; Borhani et al.,  2014 ; Christodoulou‐Fella et al.,  2017 ; Dyo et al.,  2016 ; Emmamally & Chiyangwa,  2020 ; Rathert et al.,  2016 ; Soleimani et al.,  2019 ).

3.2.2. ‘ Nobody listens ’: Relational dynamics and practices within intra and interprofessional teams

In morally challenging situations where patients' dignity, outcomes and optimal care were threatened and patient suffering occurred, colleagues' perceived ineptitude and unprofessional or unethical behaviours generated moral conflict. When unresolved, this contributed to moral distress among RNs (Asgari et al.,  2019 ; Atashzadeh Shorideh et al.,  2012 ; Choe et al.,  2015 ; Christodoulou‐Fella et al.,  2017 ; Emmamally & Chiyangwa,  2020 ; Hsun‐Kuei et al.,  2018 ; Fernandez‐Parsons et al.,  2013 ; Langley et al.,  2015 ; Maluwa et al.,  2012 ; Pergert et al.,  2019 ; Prompahakul et al.,  2021 ; Ritchie et al.,  2018 ; Robaee et al.,  2018 ; Sauerland et al.,  2014 ; Silverman et al.,  2021 ; Trautmann et al.,  2015 ; Varcoe et al.,  2012 ; Woods et al.,  2015 , Woods,  2020 ,) and nursing students (Escolar Chua & Magpantay,  2019 ; Krautscheid et al.,  2017 ; Reader,  2015 ; Renno et al.,  2018 ; Wojtowicz et al.,  2014 ).

Some spoke up, directly asserted their clinical expertise to colleagues or informed their managers (Hsun‐Kuei et al.,  2018 ; Nikbakht Nasrabadi et al.,  2018 ; Prestia et al.,  2017 ; Varcoe et al.,  2012 ). Others, however, seemingly remained silent. This was primarily on account of interprofessional team hierarchies, notably the perceived enduring power of the medical profession (Atashzadeh Shorideh et al.,  2012 ; Caram et al.,  2019 ; de Sousa Vilela et al.,  2021 ; Deady & McCarthy,  2010 ; Escolar Chua & Magpantay,  2019 ; Ko et al.,  2019 ; Langley et al.,  2015 ; Pavlish et al.,  2016 ; Renno et al.,  2018 ; Silverman et al.,  2021 ; Wolf et al.,  2016 ), encapsulated in the following data extract:

Physicians believed [sic] they are above us. They order for patients and they expect us to obey them and not tell them about wrong orders. We are obliged to carry out their orders without asking any question. (Atashzadeh Shorideh et al.,  2012 , p. 471: Iran, intensive care)

RNs and nursing students perceived that they were subordinate (Atashzadeh Shorideh et al.,  2012 ; Krautscheid et al.,  2017 ), powerless (Deady & McCarthy,  2010 ), invisible (de Sousa Vilela et al.,  2021 ) and their role, unique insights and contribution to care undervalued (Atashzadeh Shorideh et al.,  2012 ; Caram et al.,  2019 ; de Sousa Vilela et al.,  2021 ; Deady & McCarthy,  2010 ; Hsun‐Kuei et al.,  2018 ; Maluwa et al.,  2012 ; Ritchie et al.,  2018 ; Varcoe et al.,  2012 ; Wolf et al.,  2016 ).

The physician does not assess the patient, does not do a physical exam. The entire assessment of the patient is done by the nurses, it is the nurses who pass on the information. And even with our concern, they do not value our knowledge at all. (de Sousa Vilela et al.,  2021 , p. 5: Brazil, intensive care)

Fear of negative repercussions (Atashzadeh Shorideh et al.,  2012 ; Prompahakul et al.,  2021 ) and alienation (Deady & McCarthy,  2010 ), unsupportive, ineffective managers (Atashzadeh Shorideh et al.,  2012 ; Caram et al.,  2019 ; Hsun‐Kuei et al.,  2018 ; Langley et al.,  2015 ; Varcoe et al.,  2012 ; Wolf et al.,  2016 ; Woods,  2020 ) and a desire to avoid team conflict were reported.

We're trained to vocalize our concerns and ask the hard questions and debate, but we're reprimanded for that by our managers. (Ritchie et al.,  2018 , p. 104: Canada, Continuing care)

What stops me from acting was I am part of a team, which should be cohesive. (Deady & McCarthy,  2010 , p. 6: Ireland, Psychiatry)

RNs articulated that failing to speak up intensified their moral distress experience, particularly when care standards fell below their personal and professional practice standards, and they felt complicit in prolonging suffering (Deady & McCarthy,  2010 ). To mitigate moral distress in such circumstances, the importance of post‐incident team reflection was recognised (Deady & McCarthy,  2010 ). Yet, within and between teams, inadequate or insufficient communication, consultation and collaboration were identified as common problems compounding their moral distress (Atashzadeh Shorideh et al.,  2012 ; De Brasi et al.,  2021 ; de Sousa Vilela et al.,  2021 ; Langley et al.,  2015 ; Mehlis et al.,  2018 ; Pavlish et al.,  2016 ; Prompahakul et al.,  2021 ; Rezaee et al.,  2019 ; Ritchie et al.,  2018 ). Furthermore, RNs who reported poor team communication were almost five times more likely to experience moral distress compared with those experiencing good team communication (Berhie et al.,  2020 ).

3.2.3. ‘A slave to the system’: The effect of structural constraints

The organisational environment contributed to RNs' experiences of moral distress. Within complex organisations, they recognised their role as conductors of care (Caram et al.,  2019 ). However, there was scepticism that private sector, market‐driven institutional values and cultures privileged economic needs, managerialism, metrics and improving productivity over patients' needs and concerns.

It's all about the scores and the numbers. We're pulling them out of the rooms now and you're putting someone in the hallway who according to your policy should be on a monitor. (Wolf et al.,  2016 , p. 40: United States, emergency department)

Sometimes, a bed is free in the ICU, but if the patient depends on the public service, we pretend it is not free. I understand the economic aspect, because the institution needs money, but we [nurses] suffer because of it. (Caram et al.,  2019 , p. 6: Brazil, acute and intensive care)

Participants in one study (Choe et al.,  2015 ) described situations where the inability to pay medical bills and thereby contribute to the institution's income meant homeless patients were discharged or transferred. Ritchie et al. ( 2018 ) found that institutional policy prohibited overtime working. Participants perceived this constrained professional practice and, impacted negatively on patients when timely responses were crucial to optimising outcomes.

RNs articulated that organisational expectations, policies and mandates, particularly those regarding managing bureaucracy and the flow of information, disregarded their core professional beliefs and values and impeded the accomplishment of their idealised role as direct care givers:

We do a lot of bureaucratic work. So, it seems that I am a ‘secretary with a degree’. I do not want this. (Caram et al.,  2019 , p. 4: Brazil, acute and intensive care)

This is our…choice between good care and good documentation. You [can be] a really good nurse on paper or you can actually be a really good nurse, but you don't have time to be both. (Wolf et al.,  2016 , p. 41: United States, emergency department)

Nursing students reported that their practice experiences, including witnessing outdated best practice (Renno et al.,  2018 ) and being unsupported regarding their concerns did not live up to the view of nursing to which they were being socialised (Wojtowicz et al.,  2014 ), and contributed to moral distress.

Privileging routinised, task‐orientated approaches to care (Caram et al.,  2019 ; Choe et al.,  2015 ; Rezaee et al.,  2019 ; Silverman et al.,  2021 ; Varcoe et al.,  2012 ) in organisational environments of cost containment (Jansen et al.,  2020 ; Pergert et al.,  2019 ; Prestia et al.,  2017 ; Ritchie et al.,  2018 ), inadequate, unsafe nurse staffing ratios (Caram et al.,  2019 ; Choe et al.,  2015 ; Deady & McCarthy,  2010 ; Delfrate et al.,  2018 ; Forozeiya et al.,  2019 ; Hsun‐Kuei et al.,  2018 ; Jansen et al.,  2020 ; Maluwa et al.,  2012 ; Pergert et al.,  2019 ; Prestia et al.,  2017 ; Rezaee et al.,  2019 ; Silverman et al.,  2021 ; Varcoe et al.,  2012 ) and excessive, overwhelming workloads (Hsun‐Kuei et al.,  2018 ; Silverman et al.,  2021 ;Varcoe et al.,  2012 ; Wolf et al.,  2016 ), juxtaposed against high patient acuity and insufficient time correlated with reported perceptions of lower standards of care.

We usually have one or two patients max [ in the MICU ] And now, I have 6, 7, 8 patients, and they're all, like, most of them should be one‐to‐ones. (Silverman et al.,  2021 , p. 1150: United States, acute care)

There are many patients who need attention and you are all alone. There are a lot of activities to be carried out urgently but you find yourself not able to do them. As a result your patient suffers. (Maluwa et al.,  2012 , p. 199: Malawi, various settings)

Furthermore, reports of unreliable or insufficient essential equipment, for example, bed linen, personal protective equipment, thermometers, suction machines, catheters and medications, in low‐, middle‐ and high‐income countries, were documented (Atashzadeh Shorideh et al.,  2012 ; Deady & McCarthy,  2010 ; Harrowing & Mill,  2010 ; Maluwa et al.,  2012 ; Silverman et al.,  2021 ; Wolf et al.,  2016 ).

“The patient needed blood. There was a need to collect blood from a blood bank of another institution but there was no transport. Patient's condition deteriorated. I felt very bad.” (Maluwa et al.,  2012 , p. 200: Malawi, various settings)

Visible manifestations of the dominant organisational values and culture disrupted RNs' identity, generated moral conflict and moral tension and triggered moral distress (Choe et al.,  2015 ; Deady & McCarthy,  2010 ; Maluwa et al.,  2012 ; Prestia et al.,  2017 ; Ritchie et al.,  2018 ; Wolf et al.,  2016 ; Woods,  2020 ).

3.3. ‘I'm totally overwhelmed’: The effects of moral distress on nurses

The moral distress derived from RNs' perceived inability to act in accordance with core professional values and optimise timely, safe, effective high‐quality person‐centred holistic care generated adverse biopsychosocial sequalae. Furthermore, findings from numerous studies indicated how the experience of frequent and intense moral distress impacted negatively on their professional intentions. By way of contrast, there were no reports of the effects of moral distress on nursing students in the six studies retrieved.

Physical manifestations of moral distress among RNs were reported in studies from Iran (Fard et al.,  2020 ), Canada (Forozeiya et al.,  2019 ), Norway (Jansen et al.,  2020 ), USA (Prestia et al.,  2017 ; Sauerland et al.,  2014 ; Wilson et al.,  2013 ; Wolf et al.,  2016 ) and Uganda (Harrowing & Mill,  2010 ). Symptoms experienced included fatigue (Harrowing & Mill,  2010 ; Wolf et al.,  2016 ), insomnia (Fard et al.,  2020 ; Forozeiya et al.,  2019 ; Jansen et al.,  2020 ; Wilson et al.,  2013 ; Wolf et al.,  2016 ), hypertension (Jansen et al.,  2020 ; Wolf et al.,  2016 ) and appetite loss (Wolf et al.,  2016 ).

My body's given up on eating, like I long since have not been hungry anymore. Then at the end of the night, when I [urinate], it's orange, and I think, ‘Oh my God, my kidneys are going to shut down.’ What we're doing to our bodies to take care of other people's bodies. (Wolf et al.,  2016 , p. 43: United States, emergency department)

Moral residue, the enduring, cumulative effect of morally distressing situations (Stovall et al.,  2020 ), manifested in insomnia, cardiovascular, gastrointestinal and menstrual problems (Pavlish et al.,  2016 ), alopecia (Sauerland et al.,  2014 ) and activated exacerbations of physical and psychological illnesses (Pavlish et al.,  2016 ).

Psychological effects of RNs' moral distress were reported in studies from Brazil (de Sousa Vilela et al.,  2021 ), Canada (Forozeiya et al.,  2019 ; Musto & Schreiber,  2012 ; Porr et al.,  2019 ; Varcoe et al.,  2012 ), Iran (Nikbakht Nasrabadi et al.,  2018 ), Ireland (Deady & McCarthy,  2010 ), New Zealand (Woods,  2020 ), Norway (Jansen et al.,  2020 ), Taiwan (Hsun‐Kuei et al.,  2018 ), Uganda (Harrowing & Mill,  2010 ) and the United States (Prestia et al.,  2017 ; Sauerland et al.,  2014 ; Wiegand & Funk,  2012 ; Wilson et al.,  2013 ; Wolf et al.,  2016 ). Anger and frustration were not only responses to the moral distress generated by systemic constraints, notably workload (Varcoe et al.,  2012 ; Wolf et al.,  2016 ), but also a sense of powerlessness to act in accordance with professional values (de Sousa Vilela et al.,  2021 ; Hsun‐Kuei et al.,  2018 ; Wiegand & Funk,  2012 ; Wolf et al.,  2016 ), make meaningful change (Musto & Schreiber,  2012 ; Varcoe et al.,  2012 ) or discuss moral concerns (Deady & McCarthy,  2010 ).

I left here very distressed! It was a situation of a lot of conflict, anguish, frustration! I left frustrated because I didn't do what I could for the patient! I asked for intramuscular medication, but he [ doctor ] said she could wait for the procedure. So, I became nothing, because I spoke, the patient got worse and nothing was done. (de Sousa Vilela et al.,  2021 , p. 6: Brazil, intensive care)

RNs articulated that the moral distress associated with having insufficient time to spend with patients, episodes of ‘missed care’, and suboptimal care standards resulted in anxiety (Forozeiya et al.,  2019 ; Nikbakht Nasrabadi et al.,  2018 ; Porr et al.,  2019 ; Varcoe et al.,  2012 ), shame (Nikbakht Nasrabadi et al.,  2018 ; Varcoe et al.,  2012 ), guilt (Deady & McCarthy,  2010 ; Harrowing & Mill,  2010 ; Jansen et al.,  2020 ; Porr et al.,  2019 ; Wolf et al.,  2016 ; Woods,  2020 ) and fear (Varcoe et al.,  2012 ; Wolf et al.,  2016 ). Many reported feeling low, despair, and finding less meaning in life as a result of moral distress (Harrowing & Mill,  2010 ; Jansen et al.,  2020 ; Wiegand & Funk,  2012 ). Reported feelings of helplessness and hopelessness were not uncommon (Harrowing & Mill,  2010 ; Nikbakht Nasrabadi et al.,  2018 ; Prestia et al.,  2017 ; Wiegand & Funk,  2012 ). RNs experienced the weight of moral residue (Deady & McCarthy,  2010 ; Jansen et al.,  2020 ; Porr et al.,  2019 ; Prestia et al.,  2017 ; Sauerland et al.,  2014 ; Woods,  2020 ). This was manifested in loss of confidence in their nursing judgements and abilities (Jansen et al.,  2020 ; Prestia et al.,  2017 ; Sauerland et al.,  2014 ), depression (Deady & McCarthy,  2010 ; Prestia et al.,  2017 ) and feeling traumatised, paranoid (Prestia et al.,  2017 ) and burnt‐out (Deady & McCarthy,  2010 ).

Many RNs articulated how their social relationships, networks and activities, and their work performance were adversely affected (Forozeiya et al.,  2019 ; Jansen et al.,  2020 ; Robinson & Stinson,  2016 ; Wilson et al.,  2013 ).

It [ moral distress ] affects my family life, it affects my relationships, it affects my patients, and my relationships with my peers. (Robinson & Stinson,  2016 , p. 238: United States: Emergency Department)

Some distanced themselves from loved ones and social activities (Forozeiya et al.,  2019 ; Jansen et al.,  2020 ; Robinson & Stinson,  2016 ). Others reported using unhelpful coping strategies including substance misuse, food or alcohol consumption (Evanovich Zavotsky & Chan,  2016 ; Robinson & Stinson,  2016 ; Wolf et al.,  2016 ).

‘Oh my God, it's a 2‐martini night,’ or ‘Oh, I need to go home and have a glass of wine,’ and that gives me distress thinking okay now I'm thinking I'm turning to alcohol to calm this day I've had, which shouldn't ever be. (Wolf et al.,  2016 , p. 43)

Dreading the workplace (Forozeiya et al.,  2019 ; Jansen et al.,  2020 ), to protect themselves, some RNs reported distancing themselves from patients (Krautscheid et al.,  2017 ; Robinson & Stinson,  2016 ; Varcoe et al.,  2012 ) and the workplace (Forozeiya et al.,  2019 ; Robinson & Stinson,  2016 ).

When you are experiencing this, you don't want to come to work. You try to distance yourself from your patients. You try to be cold and uncaring. (Robinson & Stinson,  2016 , p. 238: United States, Emergency Department)

Moral distress meant some RNs contemplated working fewer hours (Forozeiya et al.,  2019 ; Nikbakht Nasrabadi et al.,  2018 ), taking a career break (Jansen et al.,  2020 ) or leaving their workplace (Asayesh et al.,  2018 ; Borhani et al.,  2014 ; Christodoulou‐Fella et al.,  2017 ; Davis et al.,  2012 ; Evanovich Zavotsky & Chan,  2016 ; Fernandez‐Parsons et al.,  2013 ; Forozeiya et al.,  2019 ; Hou et al.,  2021 ; Jansen et al.,  2020 ; Nikbakht Nasrabadi et al.,  2018 ; Robinson & Stinson,  2016 ; Wilson et al.,  2013 ; Woods et al.,  2015 ) or even the profession (Alberto Fruet et al.,  2019 ). Studies indicated a connection, between more frequent and/or intense moral distress and the intention to leave a position (Dyo et al.,  2016 ; Hamaideh,  2014 ; Hatamizadeh et al.,  2019 ; Hou et al.,  2021 ; Laurs et al.,  2020 ; Prompahakul et al.,  2021 ; Soleimani et al.,  2019 ). Others reported having left their workplace or positions completely (Asayesh et al.,  2018 ; Evanovich Zavotsky & Chan,  2016 ; Fernandez‐Parsons et al.,  2013 ; Varcoe et al.,  2012 ; Wilson et al.,  2013 ) or transferred to work elsewhere due to moral distress (Deady & McCarthy,  2010 ; Varcoe et al.,  2012 ).

However, not all RNs who had experienced moral distress left or considered leaving their positions (Borhani et al.,  2014 ; Evanovich Zavotsky & Chan,  2016 ). Some used moral distress as a learning experience to drive them. For example, a subsection of participants in one study (Varcoe et al.,  2012 ) reported that their moral distress motivated them and enabled them to build resolve. Nursing students experiencing moral distress reported seeing it as a form of learning, to avoid this happening to others in the future (Renno et al.,  2018 ).

4. DISCUSSION

4.1. understanding factors contributing to moral distress among rns and nursing students.

Evidence for the contribution of individual characteristics, including, age, length of service and gender, on moral distress was inconclusive. There is a need for further research to examine whether there are common individual characteristics that exacerbate nurses' experiences of moral distress. Identifying those who are most at risk of experiencing moral distress may enable more effective targeting and tailoring of interventions, as well as crucial learning around factors that might be protective against moral distress, especially among nurses working in similar roles and clinical environments. This evidence would be vital to inform development of interventions to prevent moral distress rather than mitigating the effects of moral distress that has already occurred and caused harm.

However, studies examining factors contributing to moral distress experiences were mostly correlational and used convenience sampling, which in itself runs the risk of selection bias. Furthermore, different measures were used to assess moral distress (Supplementary Material  File S2 Table  S1 ). Nevertheless, included studies mostly used established, validated outcome measures which focus on the frequency and intensity of moral distress across different items including, for example, end‐of‐life care, unsafe staffing, clinical decision‐making, institutional constraints, workplace culture and autonomy. Mainly these measures were the Moral Distress Scale‐Revised (MDS‐R) ( n =  19) (Hamric et al.,  2012 ), a scaled back version of Corley et al.'s ( 2001 ) seminal Moral Distress Scale (MDS) which, in this review, was used by 12 included studies. Three studies (Alberto Fruet et al.,  2019 ; Hou et al.,  2021 ; Pergert et al.,  2019 ) used translated versions of the original English language MDS (Corley et al.,  2001 ) and MDS‐R (Hamric et al.,  2012 ), two used a version of the MDS adapted for psychiatry (Delfrate et al.,  2018 ; Hamaideh,  2014 ) and one used Epstein et al.'s ( 2019 ) Measure of Moral Distress for Healthcare Professionals which is based on the MDS. However, measures used in the remaining five studies (Haghighinezhad et al.,  2019 ; Krautscheid et al.,  2020 ; Rathert et al.,  2016 ; Robaee et al.,  2018 ; Wands,  2018 ) were not underpinned by either the MDS or MDS‐R. Furthermore, Rathert et al. ( 2016 ) developed a bespoke measure focusing on ethical issues and conceptualised moral distress as moral stress. Notwithstanding the significance and immense contribution of Corley et al.'s ( 2001 ) seminal work in terms of enhancing our understanding of moral distress among nurses and for the purpose of research, arguably there is much more work to be done, not least because of the immense global societal change in the intervening years conjoined with serious concerns about the retention and sustainability of the nursing workforce worldwide. In addition to measures of moral distress, longitudinal assessment of how moral distress (and associated constructs including moral injury) develops is needed, as well as studies of the impact of interventions implemented to mitigate moral distress with long‐term follow‐up.

Despite equivocal evidence around the relationship between individual factors and moral distress, organisational factors, including RNs' and nursing students' perceived autonomy, ability to advocate and opportunity to raise concerns around care, were consistently reported to contribute to nurses' experiences of moral distress. Insufficient institutional support to behave ethically, inadequate resources, insufficient staffing and a wider ‘culture of silence’ (Pavlish et al.,  2016 ) all precipitated moral distress. Yet, insufficient resources and poor staffing levels were triggered by high levels of moral distress among team members, creating a vicious cycle (Delfrate et al.,  2018 ; Ganz et al.,  2013 ; Harrowing & Mill,  2010 ; Hsun‐Kuei et al.,  2018 ; Silverman et al.,  2021 ).

This emphasises the need to respond to moral distress through preventative organisational strategies in addition to individually focussed interventions. Existing supportive interventions for tackling moral distress include Moral Distress Reflective Debriefs (Morley & Horsburgh,  2021 ) and the Moral Distress Debriefing Framework (Shashidhara & Kirk,  2020 ). Hence, cultivating organisational cultures that optimise staff support and open safe spaces for discussion of morally challenging experiences through, for example, clinical ethics services or effective, reflective and supportive clinical supervision should be prioritised (Dittborn et al.,  2021 ; Morley, Sese, et al.,  2020 ), especially in the wake of COVID‐19. Indeed, reporting findings from their recent study, Dittborn et al. ( 2021 ) showed how clinical ethics support services supported healthcare professionals in ethically challenging situations during the COVID‐19 pandemic. However, further robust empirical investigation of these interventions to ascertain potential impact on moral distress experienced is needed. Similarly, reviewing and promoting existing organisational policies that enable nurses to raise concerns, promote nurses' advocacy role and support effective intra‐ and inter‐professional working through the lens of mitigating moral distress could serve to avert and ameliorate the impacts of morally challenging situations. Given the ubiquity of moral challenge in healthcare practice, removal of moral complexity is an unattainable goal. However, a renewed policy focus may prevent onset of moral distress, moral injury and, in turn, the short‐ and long‐term harms on nurses' physical and psychological health.

4.2. Addressing the effect of moral distress on nurses' health, well‐being, professional and career intentions

Moral distress disrupted nurses' physical and psychological health, well‐being and professional and career intentions. Nurses reported experiencing physical symptoms of fatigue, insomnia, hypertension, appetite loss, and exacerbation of existing cardiovascular, gastrointestinal and menstrual problems. Psychological effects included anxiety, depression, anger, frustration, helplessness, hopelessness, shame, guilt and fear which negatively affected well‐being. Interventions to support nurses experiencing moral distress therefore need to recognise the diversity of symptoms and sequalae of moral distress and provide holistic, integrated physical and mental healthcare in response. Similarly, both the short‐ and longer‐term effects of experiencing moral distress identified in our systematic review need to be supported. For example, nurses described how their experience of moral distress left them feeling traumatised, shocked or haunted (Forozeiya et al.,  2019 ; Harrowing & Mill,  2010 ; Varcoe et al.,  2012 ). There is considerable risk that the moral distress experienced by nurses (and other healthcare professionals) during the SARS‐CoV‐2 pandemic will result in moral injury and increased prevalence of PTSD. Indeed, emerging international evidence has documented concerning levels of reported PTSD symptoms among nurses and other healthcare workers, particularly among those who worked on the SARS‐CoV‐2 pandemic frontline (Bae et al.,  2022 ; Levi & Moss,  2022 ; Moon et al.,  2021 ). Timely signposting and referral to specialist psychological support services therefore needs to be a core component of interventions developed to mitigate moral distress to support recovery, rebuilding and retention of the nursing workforce.

Moral distress was also associated with increased risk of workforce turnover and loss. Experiencing moral distress resulted in as many as a quarter of nurses considering leaving their current role and up to half intending to leave the nursing profession. Prior to the SARS‐CoV‐2 pandemic, the nursing workforce was already depleted, with a deficit of 6 million nurses globally (World Health Organization,  2020 ). Shortfalls are predicted to increase (Douglas et al.,  2020 ) due to an ageing international nursing workforce (Denton et al.,  2021 ; Kwok et al.,  2016 ; Ryan et al.,  2017 ). Demand for healthcare is intensifying due to changing patient demographics, widening health inequalities and increasing chronicity. There are serious implications for the quality and safety of care provision and the health and well‐being of the nursing workforce. Protecting, sustaining and retaining a healthy, motivated and appropriately supported nursing workforce is central to the delivery of high quality, safe and effective care and meeting current and future population health needs (Gray et al.,  2020 ; World Health Organization,  2021 ). The risk of further loss of nursing personnel and expertise in the wake of the COVID‐19 due to moral distress pandemic places urgency on healthcare organisations and governments internationally to develop national strategies, organisational policies and interventions to mitigate the impact of moral distress on the nursing workforce.

The effects of moral distress on nursing students' own health, well‐being and intentions to remain do not appear to have been reported in the literature. Yet interestingly, nursing students responded to their moral distress by seeing it as a form of learning. They wanted to prevent this happening to others as they developed in their careers (Renno et al., 2018 ). This represents positive change from difficult situations: a form of post‐traumatic growth. Yet, there is an inherent risk that repeated exposure to moral distress may normalise it.

Our findings have implications for nursing education across all levels and preparing nursing students—the future workforce—for their clinical practice, including practice in a public health emergency. Nursing students are taught to manage their own resilience (Walsh et al., 2020 ) as they will become autonomous professionals and are expected to act ethically. Nurse education focuses on professional development and patients' interests and autonomy within the bounds of professional codes of conduct (e.g. Nursing and Midwifery Council,  2020 ). Arguably, this focus may lead to potential moral distress if the ability to exercise professional autonomy, act ethically to promote and uphold the patients' interests and remain resilient is obstructed by wider circumstance over which they have little control.

4.3. Strengths and limitations

Our systematic review was conducted by a multidisciplinary review team with a minimum of two reviewers engaged in the independent screening and extracting process. Some aspects of systematic review methodology were simplified to produce a review in a short enough time frame for the findings to remain relevant as healthcare services shift to the recovery phase of the pandemic. More specifically, searches were limited from 2010 to 2021 and empirical literature focused on nurses published in the English language. It is entirely possible that some potentially useful studies, notably those not published in the English language have been omitted. We also excluded pre‐prints and consequently identified only one study focusing on moral distress among nurses in the context of a pandemic. It is highly likely that over time the empirical literature pertaining to moral distress in the context of SARS‐CoV‐2 will grow. By limiting the search dates in this way we have ensured that the evidence assessed has context and relevance to current policy and practice.

5. CONCLUSIONS

This systematic review is important and timely given wider changes in the healthcare landscape and the SARS‐CoV‐2 pandemic which has substantially increased pressure on nurses and others providing care. This review adds specifically to understanding the effects of moral distress on RNs and nursing students. Several factors contribute to their moral distress experience that may be related to a perceived inability to enact moral agency. Experiences of moral distress are complex, relational and located at individual, team organisational and structural levels. The moral distress experience does not occur in a vacuum and there is potential for the interplay of complex relationships between individuals and organisational structures. Accordingly, moral distress is an inherently relational, complex and contextualised phenomenon. In challenging situations, there was a perception that RNs and nursing students were unable to enact an idealised version of their role. RNs and nursing students were constrained by personal perceptions of powerlessness, insufficient specialist practice and ethical knowledge, a perceived lack of agency to do the best for patients, and their families, and, at structural levels, relational and organisational constraints. Although encouraged to develop their own resilience, RNs and nursing students may be unable to exercise professional autonomy and uphold patient interests.

Moral distress impacted RNs' health and well‐being and manifest in emotional reactions including guilt, self‐doubt, loss of self‐confidence, anger and frustration. Health‐threatening behaviours were also identified. These emotions and behaviours may have detrimental longer term consequences for RNs. Enduring tropes of selfless and angelic nurses may further exacerbate the focus on the individual nurse, implying that the problem is a personal failing, lack of competence or transgression of professional codes. Increasing incidence of moral distress has implications for the nursing workforce. Specifically, a vicious cycle may develop in which RNs leave and those who continue are left under increasing pressure exacerbating moral distress in the workforce. The effects of moral distress on nursing students' own health, well‐being and intentions to remain does not appear to have been reported in the literature. Such research is urgently needed to sustain and protect the profession and optimise future patient safety.

AUTHOR CONTRIBUTIONS

Tessa Watts, Richard G. Kyle and Christine Bundy contributed to the conceptualisation and design of the study. Eunice Temeng, Tessa Watts, Anna Sydor, Dean Whybrow, Rachael Hewitt and Rachael Pattinson were responsible for retrieving and assessing studies for inclusion in the review. Tessa Watts and Bethan Jones were responsible for thematic synthesis. Tessa Watts and Bethan Jones drafted the first version of the article. All authors critically reviewed the article and have read and approved the final article.

FUNDING INFORMATION

This work was funded by Public Health Wales. Public Health Wales is an NHS organisation providing professionally independent public health advice and services to protect and improve the health and well‐being of the population of Wales. However, the views in this article are entirely those of the authors and should not be assumed to be the same as those of Public Health Wales.

CONFLICT OF INTEREST STATEMENT

Professor Richard Kyle was employed by Public Health Wales when the review was commissioned.

ETHICS STATEMENT

Research Ethics Committee approval was not required for this mixed‐methods systematic review.

PATIENT CONSENT

Patient consent was not required for this mixed‐methods systematic review.

Supporting information

Acknowledgements.

Elizabeth Gillen, specialist librarian for assisting with the search strategy design and searches.

Watts, T. , Sydor, A. , Whybrow, D. , Temeng, E. , Hewitt, R. , Pattinson, R. , Bundy, C. , Kyle, R. G. , & Jones, B. (2023). Registered Nurses' and nursing students' perspectives on moral distress and its effects: A mixed‐methods systematic review and thematic synthesis . Nursing Open , 10 , 6014–6032. 10.1002/nop2.1913 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

• Abdolmaleki, M. , Lakdizaji, S. , Ghahramanian, A. , Allahbakhshian, A. , & Behshid, M. (2019). Relationship between autonomy and moral distress in emergency nurses . Indian Journal of Medical Ethics , 4 , 20–25. 10.20529/IJME.2018.076 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Aiken, L. H. , Sloane, D. M. , Bruyneel, L. , van den Heede, K. , Griffiths, P. , Busse, R. , Diomidous, M. , Kinnunen, J. , Kózka, M. , Lesaffre, E. , McHugh, M. , Moreno‐Casbas, M. T. , Rafferty, A. M. , Schwendimann, R. , Scott, P. A. , Tishelman, C. , van Achterberg, T. , Sermeus, W. , & RN4CAST consortium . (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study . Lancet , 383 , 1824–1830. 10.1016/S0140-6736(13)62631-8 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ajoudani, F. , Baghaei, R. , & Lotfi, M. (2019). Moral distress and burnout in Iranian nurses: The mediating effect of workplace bullying . Nursing Ethics , 26 , 1834–1847. 10.1177/0969733018779210 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Alberto Fruet, I. M. , de Lima Dalmolin, G. , Zancan Bresolin, J. , Andolhe, R. , & Devos Barlem, E. L. (2019). Moral distress assessment in the nursing team of a hematology‐oncology sector . Revista Brasileira de Enfermagem , 72 , 58–65. 10.1590/0034-7167-2017-0408 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Altaker, K. W. , Howie‐Esquivel, J. , & Cataldo, J. K. (2018). Relationships among palliative care, ethical, climate, empowerment and moral distress in intensive care unit nurses . American Journal of Critical Care , 27 , 295–302. 10.4037/ajcc2018252 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Asayesh, H. , Mosavi, M. , Abdi, M. , Masoud, M. P. , & Jodaki, K. (2018). The relationship between futile care perception and moral distress among intensive care unit nurses . Journal of Medical Ethics and History of Medicine , 11 , 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150918/pdf/JMEHM‐11‐2.pdf [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Asgari, S. , Shafipour, V. , Taraghi, Z. , & Yazdani‐Charati, J. (2019). Relationship between moral distress and ethical climate with job satisfaction in nurses . Nursing Ethics , 26 , 346–356. 10.1177/0969733017712083 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Atashzadeh Shorideh, F. , Ashktorab, T. , & Yaghmaei, F. (2012). Iranian intensive care unit nurses' moral distress: A content analysis . Nursing Ethics , 19 , 464–478. 10.1177/0969733012437988 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bae, S. Y. , Yoon, H. J. , Kim, Y. , & Kim, J. (2022). Posttraumatic stress disorder and related factors among nurses working during the COVID‐19 pandemic . Journal of Nursing Management , 30 , 1096–1104. 10.1111/jonm.13615 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bayat, M. , Shahriari, M. , & Keshvari, M. (2019). The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization . Journal of Medical Ethics and History of Medicine , 12 , 8. 10.18502/jmehm.v12i8.1339 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Berhie, A. Y. , Tezera, Z. B. , & Azagew, A. W. (2020). Moral distress and its associated factors among nurses in Northwest Amhara regional state referral hospitals, Northwest Ethiopia . Psychology Research and Behavior Management , 13 , 161–167. 10.2147/PRBM.S234446 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Borhani, F. , Abbaszadeh, A. , Nakhaee, N. , & Roshanzadeh, M. (2014). The relationship between moral distress, professional stress, and intent to stay in the nursing profession . Journal of Medical Ethics and History of Medicine , 7 , 3. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Broetje, S. , Jenny, G. J. , & Bauer, G. F. (2020). The key job demands and resources of nursing staff: An integrative review of reviews . Frontiers in Psychology , 11 , 84. 10.3389/fpsyg.2020.00084 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Browning, A. M. (2013). Moral distress and psychological empowerment in critical care nurses caring for adults at the end of life . American Journal of Critical Care , 22 , 143–152. 10.4037/ajcc2013437 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Canciani, E. , Spotti, D. , & Bonetti, L. (2016). Translation and validation in Italian of the moral distress scale for psychiatric nurses (MDS‐P) . Professioni Infermieristiche , 69 , 68–75. [ PubMed ] [ Google Scholar ]
• Caram, C. S. , Peter, E. , & Brito, M. J. (2019). Invisibility of the self: Reaching for the telos of nursing within a context of moral distress . Nursing Inquiry , 26 , e12269. 10.1111/nin.12269 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Centre for Reviews & Dissemination . (2009). CRD's guidance on undertaking reviews in health care . University of York. [ Google Scholar ]
• Chana, N. , Kennedy, P. , & Chessell, Z. J. (2015). Nursing staffs' emotional well‐being and caring behaviours . Journal of Clinical Nursing , 24 , 2835–2848. 10.1111/jocn.12891 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chin, W. S. , Chen, Y. C. , Ho, J. J. , Cheng, N. Y. , Wu, H. C. , & Shiao, J. S. (2019). Psychological work environment and suicidal ideation among nurses in Taiwan . Journal of Nursing Scholarship , 51 , 106–113. 10.1111/jnu.12441 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Choe, K. , Kang, Y. , & Park, Y. (2015). Moral distress in critical care nurses: A phenomenological study . Journal of Advanced Nursing , 71 , 1684–1693. 10.1111/jan.12638 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Christodoulou‐Fella, M. , Middleton, N. , Papathanassoglou, E. D. E. , & Karanikola, M. N. K. (2017). Exploration of the association between nurses' moral distress and secondary traumatic stress syndrome: Implications for patient safety in mental health services . BioMed Research International , 2017 , 1908712. 10.1155/2017/1908712 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Colville, G. , Dawson, D. , Rabinthiran, S. , Chaudry‐Daley, Z. , & Perkins‐Porras, L. (2019). A survey of moral distress in staff working in intensive care in the UK . Journal of the Intensive Care Society , 20 , 196–203. 10.1177/1751143718787753 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Corley, M. C. , Elswick, R. K. , Gorman, M. , & Clor, T. (2001). Development and evaluation of a moral distress scale . Journal of Advanced Nursing , 33 , 250–256. 10.1111/j.1365-2648.2001.01658.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Crespo Drago, L. , Souza Ramos, F. R. , de Farias Brehmer, L. C. , Ramos Silveira, L. , & Menezes Brito, M. J. (2020). Nurse managers' moral suffering in a university hospital . Revista de Pesquisa: Cuidado e Fundamental , 12 , 1074–1080. [ Google Scholar ]
• Davis, S. , Schraderm, V. , & Belcheir, M. J. (2012). Influencers of ethical beliefs and the impact on moral distress and conscientious objection . Nursing Ethics , 19 , 738–749. 10.1177/0969733011423409 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• De Brasi, E. L. , Giannetta, N. , Ercolani, S. , Gandini, E. L. M. , Moranda, D. , Villa, G. , & Manara, D. F. (2021). Nurses' moral distress in end‐of‐life care: A qualitative study . Nursing Ethics , 28 , 614–627. 10.1177/0969733020964859 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• de Sousa Vilela, G. , Lima Cardoso Ferraz, C. M. , de Araújo Moreira, D. , & Menezes Brito, M. J. (2021). Ethics and moral distress expressions in intensive care nursing practice . Acta Paulista de Enfermagem , 34 , 1–11. [ Google Scholar ]
• Deady, R. , & McCarthy, J. (2010). A study of the situations, features, and coping mechanisms experienced by Irish psychiatric nurses experiencing moral distress . Perspectives in Psychiatric Care , 46 , 209–220. 10.1111/j.1744-6163.2010.00260.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Delfrate, F. , Ferrara, P. , Spotti, D. , Terzoni, S. , Lamiani, G. , Canciani, E. , & Bonetti, L. (2018). Moral distress (md) and burnout in mental health nurses: A multicenter survey . La Medicina del Lavoro , 109 , 97–109. 10.23749/mdl.v109i2.6876 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Denton, J. , Evans, D. , & Xu, Q. (2021). Being an older nurse or midwife in the healthcare workplace–a qualitative descriptive study . Journal of Advanced Nursing , 77 , 4500–4510. 10.1111/jan.14964 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Deschenes, S. , Gagnon, M. , Park, T. , & Kunyk, D. (2020). Moral distress: A concept clarification . Nursing Ethics , 27 , 1127–1146. 10.1177/0969733020909523 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dittborn, M. , Cave, E. , & Archard, D. (2021). Clinical ethics support services during the Covid‐19 pandemic in the UK: A cross‐sectional survey . Journal of Medical Ethics , 48 , 695–701. 10.1136/medethics-2021-107818 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dodek, P. M. , Norena, M. , Ayas, N. , & Wong, H. (2019). Moral distress is associated with general workplace distress in intensive care unit personnel . Journal of Critical Care , 50 , 122–125. 10.1016/j.jcrc.2018.11.030 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Douglas, J. A. , Bourgeois, S. , & Moxham, L. (2020). Early career registered nurses: How they stay . Collegian , 27 , 437–442. 10.1016/j.colegn.2020.01.004 [ CrossRef ] [ Google Scholar ]
• Dyo, M. , Kalowes, P. , & Devries, J. (2016). Moral distress and intention to leave: A comparison of adult and paediatric nurses by hospital setting . Intensive and Critical Care Nursing , 36 , 42–48. 10.1016/j.iccn.2016.04.003 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Emmamally, W. , & Chiyangwa, O. (2020). Exploring moral distress among critical care nurses at a private hospital in Kwa‐zulu Natal, South Africa . Southern African Journal of Critical Care , 36 , 104–108. https://hdl.handle.net/10520/ejc‐m_sajcc‐v36‐n2‐a7 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Epstein, E. G. , Whitehead, P. B. , Prompahakul, C. , Thacker, L. R. , & Hamric, A. B. (2019). Enhancing understanding of moral distress: The measure of moral distress for health care professionals . AJOB Empirical Bioethics , 10 , 113–124. 10.1080/23294515.2019.1586008 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Escolar Chua, R. L. , & Magpantay, J. C. J. (2019). Moral distress of undergraduate nursing students in community health nursing . Nursing Ethics , 26 , 2340–2350. 10.1177/0969733018819130 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Evanovich Zavotsky, K. , & Chan, G. K. (2016). Exploring the relationship among moral distress, coping, and the practice environment in emergency department nurses . Advanced Emergency Nursing Journal , 38 , 133–146. 10.1097/TME.0000000000000100 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fard, Z. R. , Azadi, A. , Veisani, Y. , & Jamshidbeigi, A. (2020). The association between nurses' moral distress and sleep quality and their influencing factor in private and public hospitals in Iran . Journal of Education and Health Promotion , 9 , 268. doi: 10.4103/jehp.jehp_291_20 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fernandez‐Parsons, R. , Rodriguez, L. , & Goyal, D. (2013). Moral distress in emergency nurses . JEN: Journal of Emergency Nursing , 39 , 547–552. 10.1016/j.jen.2012.12.009 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Forozeiya, D. , Vanderspank‐Wright, B. , Bourbonnais, F. F. , Moreau, D. , & Wright, D. K. (2019). Coping with moral distress – The experiences of intensive care nurses: An interpretive descriptive study . Intensive & Critical Care Nursing , 53 , 23–29. 10.1016/j.iccn.2019.03.002 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ganz, F. D. , Raanan, O. , Khalaila, R. , Bennaroch, K. , Scherman, S. , Bruttin, M. , Sastiel, Z. , Fink, N. F. , & Benbenishty, J. (2013). Moral distress and structural empowerment among a national sample of Israeli intensive care nurses . Journal of Advanced Nursing , 69 , 415–424. 10.1111/j.1365-2648.2012.06020.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Giorgi, A. (2009). The descriptive phenomenological method in psychology: A modified husserlian approach . Duquesne University Press. [ Google Scholar ]
• Gray, B. , Bright, D. , Bolton, S. , & Davies, A. R. (2020). Towards a healthy and sustainable workforce for the future: The current health and wellbeing of the nursing and midwifery workforce in Wales . Public Health Wales. [ Google Scholar ]
• Griffiths, P. , Recio‐Saucedo, A. , Dall'Ora, C , Briggs, J. , Maruotti, A. , Meredith, P. , Smith, G. B. , & Ball, J. (2018). Missed care study group. The association between nurse staffing and omissions in nursing care: A systematic review . Journal of Advanced Nursing , 74 , 1474–1487. 10.1111/jan.13564 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Haghighinezhad, G. , Atashzadeh‐Shoorideh, F. , Ashktorab, T. , Mohtashami, J. , & Barkhordari‐Sharifabad, M. (2019). Relationship between perceived organizational justice and moral distress in intensive care unit nurses . Nursing Ethics , 26 , 460–470. 10.1177/0969733017712082 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hamaideh, S. H. (2014). Moral distress and its correlates among mental health nurses in Jordan . International Journal of Mental Health Nursing , 23 , 33–41. 10.1111/inm.12000 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hamric, A. B. , Borchers, C. T. , & Epstein, E. G. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals . AJOB Primary Research , 3 , 1–9. 10.1080/21507716.2011.652337 [ CrossRef ] [ Google Scholar ]
• Harorani, M. , Golitaleb, M. , Davodabady, F. , Zahedi, S. , Houshmand, M. , Mousavi, S. S. , & Yousefi, M. S. (2019). Moral distress and self‐efficacy among nurses working in critical care unit in Iran‐an analytical study . Journal of Clinical and Diagnostic Research , 13 , LC06–LC09. [ Google Scholar ]
• Harrowing, J. N. , & Mill, J. (2010). Moral distress among Ugandan nurses providing HIV care: A critical ethnography . International Journal of Nursing Studies , 47 , 723–731. 10.1016/j.ijnurstu.2009.11.010 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hartin, P. , Birks, M. , & Lindsay, D. (2018). Bullying and the nursing profession in Australia: An integrative review of the literature . Collegian , 25 , 613–619. 10.1016/j.colegn.2018.06.004 [ CrossRef ] [ Google Scholar ]
• Hartin, P. , Birks, M. , & Lindsay, D. (2020). Bullying in nursing: How has it changed over 4 decades? Journal of Nursing Management , 28 , 1619–1626. 10.1111/jonm.13117 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hatamizadeh, M. , Hosseini, M. , Bernstein, C. , & Ranjbar, H. (2019). Health care reform in Iran: Implications for nurses' moral distress, patient rights, satisfaction and turnover intention . Journal of Nursing Management , 27 , 396–403. 10.1111/jonm.12699 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hiler, C. A. , Hickman, J. R. L. , Reimer, A. P. , & Wilson, K. (2018). Predictors of moral distress in a us sample of critical care nurses . American Journal of Critical Care , 27 , 59–66. 10.4037/ajcc2018968 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hong, Q. N. , Fàbregues, S. , Bartlett, G. , Boardman, F. , Cargo, M. , Dagenais, P. , Gagnon, M.‐P. , Griffiths, F. , Nicolau, B. , O'Cathain, A. , Rousseau, M.‐C. , Vedel, I. , & Pluye, P. (2018). The mixed methods appraisal tool (MMAT) version 2018 for information professionals and researchers . Education for Information , 34 , 285–291. 10.3233/EFI-180221 [ CrossRef ] [ Google Scholar ]
• Hou, Y. , Timmins, F. , Zhou, Q. , & Wang, J. (2021). A cross‐sectional exploration of emergency department nurses' moral distress, ethical climate and nursing practice environment . International Emergency Nursing , 55 , 100972. 10.1016/j.ienj.2021.100972 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• House of Commons Health and Social Care Committee . (2021). Workforce burnout and resilience in the NHS and social care: Second report of session 2021–22 . https://committees.parliament.uk/publications/6158/documents/68766/default/
• Hsun‐Kuei, K. , Chi‐Chun, C. , & Min‐Tao, H. (2018). Moral distress model reconstructed using grounded theory . Journal of Nursing Research , 26 , 18–26. 10.1097/JNR.0000000000000189 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jameton, A. (1984). Nursing practice: The ethical issues . Prentice Hall. [ Google Scholar ]
• Jansen, T. L. , Hem, M. H. , Dambolt, L. J. , & Hanssen, I. (2020). Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands . Nursing Ethics , 27 , 1315–1326. 10.1177/0969733019877526 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Johnstone, M. J. , & Hutchinson, A. (2015). Moral distress: time to abandon a flawed nursing construct . Nursing Ethics , 22 , 5–14. 10.1177/0969733013505312 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Karanikola, M. N. K. , Albarran, J. W. , Drigo, E. , Giannakopoulou, M. , Kalafati, M. , Mpouzika, M. , Tsiaousis, G. Z. , & Papathanassoglou, E. D. E. (2014). Moral distress, autonomy and nurse‐physician collaboration among intensive care unit nurses in Italy . Journal of Nursing Management , 22 , 472–484. 10.1111/jonm.12046 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kinman, G. , Teoh, K. , & Harriss, A. (2020). The mental health and wellbeing of nurses and midwives in the United Kingdom . https://www.som.org.uk/sites/som.org.uk/files/The_Mental_Health_and_Wellbeing_of_Nurses_and_Midwives_in_the_United_Kingdom.pdf [ PubMed ]
• Ko, H.‐K. , Chin, C.‐C. , Hsu, M.‐T. , & Lee, S.‐L. (2019). Phenomenon of moral distress through the aspect of interpretive interactionism . Nursing Ethics , 26 , 1484–1493. 10.1177/0969733018766579 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Krautscheid, L. , DeMeester, D. A. , Orton, V. , Smith, A. , Livingston, C. , & McLennon, S. M. (2017). Moral distress and associated factors among baccalaureate nursing students: A multisite descriptive study . Nursing Education Perspectives , 38 , 313–319. 10.1097/01.NEP.0000000000000214 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Krautscheid, L. , Mood, L. , McLennon, S. M. , Mossman, T. C. , Wagner, M. , & Wode, J. (2020). Examining relationships between resilience protective factors and moral distress among nursing students . Nursing Education Perspectives , 41 , 43–45. 10.1097/01.NEP.0000000000000471 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kwok, C. , Bates, K. A. , & Ng, E. S. (2016). Managing and sustaining an ageing nursing workforce: Identifying opportunities and best practices within collective agreements in Canada . Journal of Nursing Management , 24 , 500–511. 10.1111/jonm.12350 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Langley, G. C. , Kisorio, L. , & Schmollgruber, S. (2015). Moral distress experienced by intensive care nurses . Southern African Journal of Critical Care , 31 , 36–41. 10.7196/SAJCC.2015.v31i2.235 [ CrossRef ] [ Google Scholar ]
• Latimer, A. L. , Otis, M. D. , Flaherty, C. , & Ross, M. A. (2021). A survey of moral distress and end of life care in mechanical circulatory support nurses . Heart & Lung , 50 , 65–70. 10.1016/j.hrtlng.2020.06.010 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Laurs, L. , Blaževičienė, A. , Capezuti, E. , & Milonas, D. (2020). Moral distress and intention to leave the profession: Lithuanian nurses in municipal hospitals . Journal of Nursing Scholarship , 52 , 201–209. 10.1111/jnu.12536 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lee, E. K. , & Kim, J. S. (2020). Nursing stress factors affecting turnover intention among hospital nurses . International Journal of Nursing Practice , 26 , e12819. 10.1111/ijn.12819 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Levi, P. , & Moss, J. (2022). Intensive care unit Nurses' lived experiences of psychological stress and trauma caring for COVID‐19 patients . Workplace Health and Safety , 70 , 358–367. 10.1177/21650799211064262 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lizarondo, L. , Stern, C. , Carrier, J. , Godfrey, C. , Rieger, K. , Salmond, S. , Apostolo, J. , Kirkpatrick, P. , & Loveday, H. (2020). Chapter 8: Mixed methods systematic reviews. In Aromataris E. & Munn Z. (Eds.), JBI manual for evidence synthesis . JBI. 10.46658/JBIMES-20-09 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Maluwa, V. M. , Andre, J. , Ndebele, P. , & Chilemba, E. (2012). Moral distress in nursing practice in Malawi . Nursing Ethics , 19 , 196–207. 10.1177/0969733011414968 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Martín‐Del‐Río, B. , Solanes‐Puchol, Á. , Martínez‐Zaragoza, F. , & Benavides‐Gil, G. (2018). Stress in nurses: The 100 top‐cited papers published in nursing journals . Journal of Advanced Nursing , 74 , 1488–1504. 10.1111/jan.13566 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• McCarthy, J. , & Deady, R. (2008). Moral distress reconsidered . Nursing Ethics , 15 , 254–262. 10.1177/0969733007086023 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mehlis, K. , Bierwirth, E. , Laryionava, K. , Mumm, F. H. , Hiddemann, W. , Heußner, P. , & Winkler, E. C. (2018). High prevalence of moral distress reported by oncologists and oncology nurses in end‐of‐life decision making . Psycho‐Oncology , 27 , 2733–2739. 10.1002/pon.4868 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Melnyk, B. M. (2020). Burnout, depression and suicide in nurses/clinicians and learners: An urgent call for action to enhance professional well‐being and healthcare safety . Worldviews on Evidence‐Based Nursing , 17 , 2–5. 10.1111/wvn.12416 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Melnyk, B. M. , Orsolini, L. , Tan, A. , Arslanian‐Engoren, C. , Melkus, G. D. , Dunbar‐Jacob, J. , Rice, V. H. , Millan, A. , Dunbar, S. B. , Braun, L. T. , Wilbur, J. , Chyun, D. A. , Gawlik, K. , & Lewis, L. M. (2018). A national study links nurses' physical and mental health to medical errors and perceived worksite wellness . Journal of Occupational and Environmental Medicine , 60 , 126–131. 10.1097/JOM.0000000000001198 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Moaddaby, S. , Adib, M. , Ashrafi, S. , & Leili, E. K. (2021). Perception of the futile care and its relationship with moral distress in nurses of intensive care units . Journal of Holistic Nursing & Midwifery , 31 , 85–92. [ Google Scholar ]
• Moon, D.‐J. , Han, M. A. , Park, J. , & Ryu, S. Y. (2021). Post‐traumatic stress and related factors among hospital nurses during the Covid‐19 outbreak in Korea . Psychiatric Quarterly , 92 , 1381–1391. 10.1007/s11126-021-09915-w [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morley, G. , Bradbury‐Jones, C. , & Ives, J. (2020). What is ‘moral distress’ in nursing? A feminist empirical bioethics study . Nursing Ethics , 27 , 1297–1314. 10.1177/0969733019874492 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morley, G. , & Horsburgh, C. C. (2021). Reflective debriefs as a response to moral distress: Two case study examples . HEC Forum , 35 , 1–20. 10.1007/s10730-021-09441-z [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morley, G. , Ives, J. , Bradbury‐Jones, C. , & Irvine, F. (2019). What is ‘moral distress’? A narrative synthesis of the literature . Nursing Ethics , 26 , 646–662. 10.1177/0969733017724354 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morley, G. , Sese, D. , Rajendram, P. , & Horsburgh, C. C. (2020). Addressing caregiver moral distress during the Covid‐19 pandemic . Cleveland Clinic Journal of Medicine . 10.3949/ccjm.87a.ccc047 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Musto, L. , & Schreiber, R. S. (2012). Doing the best I can do: Moral distress in adolescent mental health nursing . Issues in Mental Health Nursing , 33 , 137–144. 10.3109/01612840.2011.641069 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nikbakht Nasrabadi, A. , Khoobi, M. , Cheraghi, M. A. , Joolaei, S. , & Ahmadi Hedayat, M. (2018). The lived experiences of clinical nurse managers regarding moral distress . Journal of Medical Ethics and History of Medicine , 11 , 13. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Nursing and Midwifery Council . (2020). The NMC register: 1st April 2019‐31st March 2020 . https://www.nmc.org.uk/globalassets/sitedocuments/nmc‐register/march‐2020/nmc‐register‐march‐2020.pdf
• O'Connell, C. B. (2015). Gender and the experience of moral distress in critical care nurses . Nursing Ethics , 22 , 32–42. doi: 10.1177/0969733013513216 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Pace, R. , Pluye, P. , Bartlett, G. , Macaulay, A. C. , Salsberg, J. , Jagosh, J. , & Seller, R. (2012). Testing the reliability and efficiency of the pilot mixed methods appraisal tool (MMAT) for systematic mixed studies review . International Journal of Nursing Studies , 49 , 47–53. 10.1016/j.ijnurstu.2011.07.002 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Page, M. J. , McKenzie, J. E. , Bossuyt, P. M. , Boutron, I. , Hoffmann, T. C. , Mulrow, C. D. , Shamseer, L. , Tetzlaff, J. M. , Akl, E. A. , Brennan, S. E. , Chou, R. , Glanville, J. , Grimshaw, J. M. , Hróbjartsson, A. , Lalu, M. M. , Li, T. , Loder, E. W. , Mayo‐Wilson, E. , McDonald, S. , … Moher, D. (2021). The prisma 2020 statement: An updated guideline for reporting systematic reviews . British Medical Journal , 372 , 105906. 10.1016/j.ijsu.2021.105906 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Pauly, B. M. , Varcoev, C. , & Storch, J. (2012). Framing the issues: moral distress in health care . Healthcare Ethics Committe Forum , 24 , 1–11. https://link.springer.com/content/pdf/10.1007/s10730‐012‐9176‐y.pdf?pdf=button [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pavlish, C. , Brown‐Saltzman, K. , So, L. , & Wong, J. (2016). Support: An evidence‐based model for leaders addressing moral distress . The Journal of Nursing Administration , 46 , 313–320. [ PubMed ] [ Google Scholar ]
• Pergert, P. , Bartholdson, C. , Blomgren, K. , & af Sandeberg, M. (2019). Moral distress in paediatric oncology: Contributing factors and group differences . Nursing Ethics , 26 , 2351–2363. 10.1177/0969733018809806 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Porr, C. , Gaudine, A. , Woo, K. , Smith‐Young, J. , & Green, C. (2019). How community nurses manage ethical conflicts: A grounded theory study . Global Qualitative Nursing Research , 6 , 233339361989495. 10.1177/2333393619894958 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Prestia, A. S. , Sherman, R. O. , & Demezier, C. (2017). Chief nursing officers' experiences with moral distress . JONA: The Journal of Nursing Administration , 47 , 101–107. [ PubMed ] [ Google Scholar ]
• Prompahakul, C. , Keim‐Malpass, J. , LeBaron, V. , Yan, G. , & Epstein, E. G. (2021). Moral distress among nurses: A mixed‐methods study . Nursing Ethics , 28 , 1165–1182. 10.1177/0969733021996028 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rathert, C. , May, D. R. , & Chung, H. S. (2016). Nurse moral distress: A survey identifying predictors and potential interventions . International Journal of Nursing Studies , 53 , 39–49. 10.1016/j.ijnurstu.2015.10.007 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Reader, R. L. (2015). Students' experiences in associate degree nursing programs: A qualitative study looking at moral distress . Teaching & Learning in Nursing , 10 , 118–123. 10.1016/j.teln.2015.05.001 [ CrossRef ] [ Google Scholar ]
• Renno, H. M. S. , Ramos, F. R. S. , & Brito, M. J. M. (2018). Moral distress of nursing undergraduates: Myth or reality? Nursing Ethics , 25 , 304–312. doi: 10.1177/0969733016643862 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rezaee, N. , Mardani‐Hamooleh, M. , & Ghaljeh, M. (2019). Ethical challenges in cancer care: A qualitative analysis of nurses' perceptions . Research & Theory for Nursing Practice , 33 , 169–182. 10.1891/1541-6577.33.2.169 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ritchie, V. , O'Rourke, T. , & Stahlke, S. (2018). Nurse practitioners' experiences of moral distress in the continuing care setting . The Journal for Nurse Practitioners , 14 , 745–752. 10.1016/j.nurpra.2018.07.021 [ CrossRef ] [ Google Scholar ]
• Robaee, N. , Atashzadeh‐Shoorideh, F. , Ashktorab, T. , Baghestani, A. , & Barkhordari‐Sharifabad, M. (2018). Perceived organizational support and moral distress among nurses . BMC Nursing , 17 , 1‐N.PAG. 10.1186/s12912-017-0270-y [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Robinson, R. , & Stinson, C. K. (2016). Moral distress: A qualitative study of emergency nurses . Dimensions of Critical Care Nursing , 35 , 235–240. [ PubMed ] [ Google Scholar ]
• Royal College of Nursing . (2019). RCN employment survey 2019 . https://www.rcn.org.uk/professional‐development/publications/pub‐007927
• Ryan, C. , Bergin, M. , & Wells, J. (2017). Valuable yet vulnerable—A review of the challenges encountered by older nurses in the workplace . International Journal of Nursing Studies , 72 , 42–52. 10.1016/j.ijnurstu.2017.04.006 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sarkoohijabalbarezi, Z. , Ghodousi, A. , & Davaridolatabadi, E. (2017). The relationship between professional autonomy and moral distress among nurses working in children's units and pediatric intensive care wards . International Journal of Nursing Sciences , 4 , 117–121. 10.1016/j.ijnss.2017.01.007 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sauerland, J. , Marotta, K. , Peinemann, M. A. , Berndt, A. , & Robichaux, C. (2014). Assessing and addressing moral distress and ethical climate, part 1 . Dimensions of Critical Care Nursing , 33 , 234–245. 10.1097/DCC.0000000000000050 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shashidhara, S. , & Kirk, S. (2020). Moral distress: A framework for offering relief through debrief . The Journal of Clinical Ethics , 31 , 364–371. [ PubMed ] [ Google Scholar ]
• Silverman, H. J. , Kheirbek, R. E. , Moscou‐Jackson, G. , & Day, J. (2021). Moral distress in nurses caring for patients with Covid‐19 . Nursing Ethics , 28 , 1137–1164. 10.1177/09697330211003217 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Soleimani, M. A. , Sharif, S. P. , Yaghoobzadeh, A. , Sheikhi, M. R. , Panarello, B. , & Win, M. T. M. (2019). Spiritual well‐being and moral distress among Iranian nurses . Nursing Ethics , 26 , 1101–1113. doi: 10.1177/0969733016650993 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stelnicki, A. M. , & Carleton, R. N. (2021). Mental disorder symptoms among nurses in Canada . Canadian Journal of Nursing Research , 53 , 264–276. 10.1177/0844562120961894 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stovall, M. , Hansen, L. , & van Ryn, M. (2020). A critical review: Moral injury in nurses in the aftermath of a patient safety incident . Journal of Nursing Scholarship , 52 , 320–328. 10.1111/jnu.12551 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sun, X. , Cao, F. , Yao, J. , & Chen, L. (2012). Research in validity and reliability of the Chinese version of moral distress scale . Chinese Journal of Practical Nursing , 36 , 52–55. [ Google Scholar ]
• Tahghighi, M. , Rees, C. S. , Brown, J. A. , Breen, L. J. , & Hegney, D. (2017). What is the impact of shift work on the psychological functioning and resilience of nurses? An integrative review . Journal of Advanced Nursing , 73 , 2065–2083. 10.1111/jan.13283 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Thomas, J. , & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews . BMC Medical Research Methodology , 8 , 1–10. 10.1186/1471-2288-8-45 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Trautmann, J. , Epstein, E. , Rovnyak, V. , & Snyder, A. (2015). Relationships among moral distress, level of practice independence, and intent to leave of nurse practitioners in emergency departments: Results from a national survey . Advanced Emergency Nursing Journal , 37 , 134–145. 10.1097/TME.0000000000000060 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Varcoe, C. , Pauly, B. , Storch, J. , Newton, L. , & Makaroff, K. (2012). Nurses' perceptions of and responses to morally distressing situations . Nursing Ethics , 19 , 488–500. 10.1177/0969733011436025 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Walsh, P. , Owen, P. A. , Mustafa, N. , & Beech, R. (2020). Learning and teaching approaches promoting resilience in student nurses: An integrated review of the literature . Nurse Education in Practice , 45 , 102748. 10.1016/j.nepr.2020.102748 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wands, B. A. (2018). A survey of moral distress in certified registered nurse anesthetists: A theoretical perspective for change in ethics education for advance practice nurses . International Journal of Nursing Sciences , 5 , 121–125. 10.1016/j.ijnss.2018.03.006 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wiegand, D. L. , & Funk, M. (2012). Consequences of clinical situations that cause critical care nurses to experience moral distress . Nursing Ethics , 19 , 479–487. 10.1177/0969733011429342 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wilson, M. A. , Goettemoeller, D. M. , Bevan, N. A. , & McCord, J. M. (2013). Moral distress: Levels, coping and preferred interventions in critical care and transitional care nurses . Journal of Clinical Nursing , 22 , 1455–1466. 10.1111/jocn.12128 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wocial, L. D. , & Weaver, M. T. (2013). Development and psychometric testing of a new tool for detecting moral distress: The moral distress thermometer . Journal of Advanced Nursing , 69 , 167–174. 10.1111/j.1365-2648.2012.06036.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wojtowicz, B. , Hagen, B. , & Van Daalen‐Smith, C. (2014). No place to turn: Nursing students' experiences of moral distress in mental health settings . International Journal of Mental Health Nursing , 23 , 257–264. 10.1111/inm.12043 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wolf, L. A. , Perhats, C. , Delao, A. M. , Moon, M. D. , Clark, P. R. , & Zavotsky, K. E. (2016). “It's a burden you carry”: Describing moral distress in emergency nursing . JEN: Journal of Emergency Nursing , 42 , 37–46. 10.1016/j.jen.2015.08.008 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Woods, M. (2020). Moral distress revisited: The viewpoints and responses of nurses . International Nursing Review , 67 , 68–75. 10.1111/inr.12545 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Woods, M. , Rodgers, V. , Towers, A. , & La Grow, S. (2015). Researching moral distress among New Zealand nurses: A national survey . Nursing Ethics , 22 , 117–130. 10.1177/0969733014542679 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization . (2020). State of the World's Nursing 2020: Investing in education, jobs and leadership . https://www.who.int/publications/i/item/9789240003279
• World Health Organization . (2021). Global Strategic Directions for Nursing and Midwifery (2021–2025) . https://www.who.int/publications/i/item/9789240033863
• Yeganeh, M. R. , Pouralizadeh, M. , & Ghanbari, A. (2019). The relationship between professional autonomy and moral distress in ICU nurses of Guilan University of Medical Sciences in 2017 . Nursing Practice Today , 6 , 133–141. 10.18502/npt.v6i3.1256 [ CrossRef ] [ Google Scholar ]

• Open access
• Published: 24 April 2024

“Just pee in the diaper” - a constructivist grounded theory study of moral distress enabling neglect in nursing homes

• Stine Borgen Lund 1 ,
• Wenche K. Malmedal 1 ,
• Laura Mosqueda 2 &
• John-Arne Skolbekken 1  

BMC Geriatrics volume  24 , Article number:  366 ( 2024 ) Cite this article

64 Accesses

Metrics details

A growing body of evidence shows that many nursing home residents’ basic care needs are neglected, and residents do not receive qualitatively good care. This neglect challenges nursing staff´s professional and personal ideals and standards for care and may contribute to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: “How do nursing home staff manage their moral distress related to neglectful care practices?”

A qualitative design was chosen, guided by Charmaz´s constructivist grounded theory. The study was based on 10 individual interviews and five focus group discussions (30 participants in total) with nursing home staff working in 17 different nursing homes in Norway.

Nursing staff strive to manage their moral distress related to neglectful care practices in different ways: by favouring efficiency and tolerating neglect they adapt to and accept these care practices. By disengaging emotionally and retreating physically from care they avoid confronting morally distressing situations. These approaches may temporarily mitigate the moral distress of nursing staff, whilst also creating a staff-centred and self-protecting work culture enabling neglect in nursing homes.

Conclusions

Our findings represent a shift from a resident-centred to a staff-centred work culture, whereby the nursing staff use self-protecting strategies to make their workday manageable and liveable. This strongly indicates a compromise in the quality of care that enables the continuation of neglectful care practices in Norwegian nursing homes. Finding ways of breaking a downward spiralling quality of care are thus a major concern following our findings.

Peer Review reports

A growing body of evidence shows that basic care needs of nursing home residents are regularly neglected, and residents do not always receive qualitatively good care of basic human needs. Hence, these neglectful practices may include not providing sufficient basic care or ignoring residents’ needs related to nursing home residents’ physical, psychological, emotional, and social needs. Examples of this include omitting mouthcare on a regular basis, ignoring residents with challenging or aggressive behaviour, and lack of attention to a residents’ need for social stimuli. The literature presents different perspectives of what constitutes neglect of nursing home residents’ basic needs. In this paper we use neglective care practices given examples of above to address these practices regardless of the perspective taken [ 1 , 2 , 3 , 4 , 5 , 6 , 7 ].

Not being able to provide sufficient care or observing colleagues providing compromised quality of care is found to be a major stressor for nursing staff [ 8 , 9 , 10 , 11 , 12 ]. This may lead to physiological and emotional stress [ 10 ], compassion fatigue [ 13 ], troubled conscience [ 14 ] and stress of conscience [ 8 ], among other forms of pressure, all of which may potentially result in moral distress [ 9 , 11 , 15 , 16 , 17 ]. Moral distress has been recognised as a major problem for health care staff in all care systems for over four decades [ 18 , 19 ]. The concept of moral distress was introduced by the philosopher Andrew Jameton in 1984 and has been further developed and enhanced by him and other scholars in recent decades [ 18 ]. We lean toward Nathaniel’s definition of moral distress based on a synthesis of previous definitions by Jameton (1984), Wilkinson (1987-88) and Nathaniel (2004):

“Moral distress is pain affecting the mind, the body, or relationships that results from a patient care situation in which the nurse is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action, yet, as a result of real or perceived constraints, participates, either by act or omission, in a manner he or she perceives to be morally wrong” (p. 421) [ 20 ].

Moral distress occurs when nurses or other health care staff are unable to act in accordance with their personal values or/and professional judgement when it comes to external constraints, such as lack of resources, or internal characteristics related to moral judgement [ 21 ].There is a high prevalence of moral distress in caring for people with dementia [ 16 , 22 ]. However, knowledge about moral distress in nursing homes in general is limited, and few studies relate this to compromised quality of care [ 9 , 11 , 16 , 17 , 22 ]. Organisational, institutional or structural constraints, such as a lack of resources, which may contribute to compromised quality of care and suffering residents, are among the main reasons for moral distress among nursing home staff [ 9 , 11 , 16 ]. In addition, individual and cultural obstacles like having to act in contradiction to personal knowledge, beliefs or values is a major stressor [ 9 ]. Nursing staff may not only be troubled by what they have done, but also by what they have not done or should have done [ 15 ].

Moral distress affect nursing staff negatively both psychologically and physically [ 23 ]. Not being able to provide care, or providing compromised quality to the elderly contributes to staff reports of feeling emotionally drained or physically exhausted [ 16 ]. This may lead to feelings of inadequacy, frustration, anger, powerlessness, helpless, heavy or troubled conscience, sadness, guilt and shame [ 9 , 11 , 14 , 22 , 24 ], which over time can increase the risk of a person becoming cynical, bitter, callous and resigned [ 25 ]. Physical symptoms of moral distress include fatigue, exhaustion, headaches, stomach pain, and sleeplessness [ 15 ]. Furthermore, moral distress in nursing homes is associated with illness, decreased job-satisfaction, risk of burn-out, absence from work and increased intention to leave– all with the potentially negative impact on the quality of care [ 11 , 25 , 26 , 27 ].

Different ways of handling moral distress are presented in the literature, describing possible responses by caregivers to avoid or combat their moral distress: to acquiesce, maintaining a lack of awareness, to withdraw from distressing situations, to fight, or to reach a satisfactory resolution [ 23 , 28 ]. Cognitive dissonance reduction strategies are other ways caregivers handle moral distress. This can mitigate against distress through three different approaches: changing one’s appraisal, minimising the importance of dissonant thoughts, or creating new congruent ones [ 10 ]. A theory of conformity has also been developed, whereby beliefs, attitudes and behaviours corresponding to group norms [ 29 ] are nurtured as a way to manage moral distress related to providing substandard care [ 30 ].

To our knowledge, no studies have explored the consequences of being a part of a neglectful work culture on nursing home staff, and how individuals manage this. In accordance with the constructivist grounded theory (CGT) approach guiding our work [ 31 ], we have sought to understand the processes influencing a neglectful work culture in nursing homes. We wanted to investigate the social influences that shape staff members’ experiences of neglectful care practices and responses to them, focusing on the relation to moral distress. In this study we identify processes that shape staff members’ perceptions, experiences, and responses regarding neglectful care practices, and their relation to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: “How do nursing home staff manage their moral distress related to neglectful care practices?”

Structure and organisation of Norwegian nursing homes

Norwegian nursing homes are 24- hours skilled nursing facilities providing a level of care between specialized care sector, such as hospital and home-based care. The average size of nursing homes in Norway is over 50 beds, but this varies considerably [ 32 ]. The mean age for residents in Norwegian nursing homes is 85 years, and severe and complex comorbidities are highly prevalent. Consequently, polypharmacy is also common, requiring close follow-up, supervision, and support in activities of daily living. Almost 8 to 10% have dementia with accompanying neuropsychiatric symptoms such as agitation, aggression, anxiety, and depression [ 33 ].

Norwegian nursing home care is delivered under the National Regulation of Quality of Care to ensure that residents’ basic needs including physical, psychological, and social needs are met, in addition to respect, security and independence [ 32 , 34 ]. The Ministry of Health and Care Services launched the Dignity Guarantee for elder persons in 2010, where healthcare services should work towards a “dignified, safe and meaningful life” for older persons [ 35 ]. Norwegian nursing homes strive to promote resident-centred care (RCC) to meet the existing quality standards for care [ 36 ]. RCC is influenced by a person-centred care (PCC) first introduced by Kitwood in 1997, and decades of practice and research confirms that person-centred care has become the gold standard to strive for in long-term care and dementia care. RCC facilitates a holistic view of the resident, recognising residents’ preferences and values, promotes autonomy, and right to self-determination. RCC emphasises partnerships between the health- carer and resident, in addition to care flexibility in attempt to contribute to meaningful lives and promote well-being for the residents [ 37 , 38 , 39 ].

There is no mandatary staff-to resident ratio, standards for nursing staff´s qualifications or requirements regarding skill-mix [ 40 ]. A high number of unskilled personnel are hired due to a shortage of registered nurses (RN), recruitment problems, and challenges of keeping nurses (RN) in nursing homes. Norwegian nursing homes are characterised by high physical and psychological workload and time pressure, high turnover among RN´s and licenced practical nurses (LPN´s), lack of competent personnel, high absence from work and intention to leave, all of which have a negative effect on quality of care [ 26 , 41 ].

Based on the aim and research question, qualitative method and research design was found appropriate. We chose to use constructivist grounded theory (CGT) approach and interviewed nursing homes staff with experience in direct resident care in nursing homes.

• Constructivist grounded theory

CGT is a contemporary version of Grounded theory emanating from the idea that interactions between people create new insights and knowledge, acknowledges multiple realities, and underpins how participants construct meaning in the relation to the area of inquiry. CGT locates the research process and product in historical, situational, and social conditions. It is both flexible and structured, uses constant comparisons and provide tools for constructing theory. CGT requires simultaneous data-collection and analysis, performed in an iterative process. Rather than discovering theory the researcher is constructing theory [ 31 ]. Our research team consists of researchers from different professions and disciplines; the first author SBL is a Critical care nurse with decades of clinical and research experience in neurocritical care, with patients having severe cognitive deficits and challenges. The co-authors are all professors; JAS is a licenced psychologist with decades of experience in qualitative research. WKM is a registered nurse and LM is a Doctor of Medicine, both have long experience in the research field of elder abuse and neglect. Our diverse research backgrounds and experiences provide a broader perspective on the theme and possibilities for richer interpretations of our results.

Research design

For this study, data were gathered through a combination of focus-group (FG) discussions and individual interviews. We initially chose focus groups for their potential to provide insights into specific themes as well as to produce rich data, and of logistic reasons making the data collection doable. In addition, group processes can produce a synergistic effect, potentially creating new knowledge and perspectives [ 42 ]. Focus groups are used to find a range of reflections of people across several groups. It also is suitable in studies wanting to explore experiences, attitudes, and how knowledge is produces and used in a particular cultural context- such as working in a neglectful work culture. As insufficiencies in care provision can be a sensitive topic to discuss openly in group interactions, we supplemented the focus groups with individual interviews.

We started initial sampling by strategically selecting nursing homes (long-term care facilities) in an urban city in mid-Norway. Nursing care staff was recruited through an information letter about the study distributed via the nursing home management. In addition, other participants were reached via the online information-channel for nursing students, and a practice seminar where the first author was lecturing about elder abuse and neglect in nursing homes. After initial sampling and data analysis of FG discussions, we purposely conducted individual interviews to see if this enrichened and deepened the emergent sub-categories [ 43 , 44 ]. As the study evolved and the categories becomes more conceptual, we continued with theoretical sampling which was more focused and directed to specific participants. Thus, we wanted to include participants which might voice other perspectives in attempt to provide more variation in the sample. Hence, three participants that had left nursing home practice for conscientious reasons were reached through colleagues asking them to participate.

Participants

Participants were recruited over a 19-month period from April 2019 to November 2020. From March 2020, the Covid-19 pandemic interfered with our recruitment, and nursing home staff were not easily available in this period. Five FG discussions (with respectively 3, 4, 4, 5, 4 participants) were held and 10 individual interviews were conducted. A total of 30 nursing home staff (27 females, three males; ages: 22–62 years; work experience in nursing homes: 1–28 years) from 17 different nursing homes (four rural, 13 urban) from municipalities in central Norway participated. Only nursing staff with experience in providing direct care to residents in long-term nursing homes were included. Four of the participants were invited for member- checking, and two accepted to be contacted via telephone. The sample included 13 registered nurses (RN), 12 licensed practical nurses (LNP), one social worker (SW), one social educator (SE) and three nurse assistants (A). A more detailed overview of participants has been given elsewhere [ 45 ].

Data collection

We used a semi-structured interview guide, which was developed and adjusted in accordance with our analyses (Additional file 1 ). After initial analyses, we supplemented FG discussions with individual interviews to provide further insight into this possibly sensitive theme. After the participants’ spontaneous responses had been explored, we introduced case descriptions and examples of neglect from a survey instrument on elderly abuse [ 2 ], which led to the development of additional categories. The discussions/interviews lasted 60–90 min and were digitally recorded and transcribed verbatim by a skilled transcriber (HF). This study was conducted according to the guidelines of the Declaration of Helsinki and approved by The Norwegian Centre for Research Data (NSD) (protocol code 221,320, approved 26.02.2019). We used the COREQ checklist to ensure methodological quality (Additional file 2) [ 46 ].

Data analysis

The CGT framework guided this process, involving initial, focused and theoretical coding [ 31 ]. The first author performed the initial analyses using line-by-line coding with pen and paper. In addition, the first four FG discussions were coded by the second and last author to ensure credibility. The most frequent initial codes were tested amongst large segments of data, and those codes showing most analytical strength were raised to tentative categories. Focused coding enabled sorting, synthesizing and conceptualizing data, and transformed the fractured data from the initial coding process back to more abstract concepts, thus were beneficial in raising the analytical level. To identify consistencies and differences in the data, we used constant comparisons, continually refining concepts and relevant theoretical categories. This process enabled identification of sub-categories and core categories. Theoretical coding was then used to theorize the data and focused codes, and the codes selected in focused coding were enhanced to more abstraction and formation of a core category. The analysis was done iteratively, moving back and forth between coding the data-material and reading relevant literature and theory in this stage and was continuously redefining tentative categories.

After the five FG discussions and 10 individual interviews, further data collection from participants did not create new properties or provide further insight into our categories. We then carried out member-checking by telephone, which involved taking back our tentative ideas and categories for confirmation, to check and refine our categories. These calls confirmed our tentative sub-categories and categories and supported our core category, and we concluded that sufficient saturation was reached [ 31 , 47 ].

Field reports and memos were used to provide an audit trail during the data-collection and analysis phases. Field reports were written immediately after each interview containing an overview of the context, participants, and major themes. Analytical memos were written from the early phases of the data-collection and analysis; when reading through the transcripts for the first time and during initial coding and was helpful in questioning and exploring tacit and more explicit treads in the data. Memo-writing was an effective way to conceptualize early data to codes and raise initial codes to more abstract and focused codes. The growing memo-library provided a detailed record of thoughts, ideas, reflections and interpretations during the analytic process. NVivo software version 20 was used to assist the data organisation and coding process.

Our core category is that nursing home staff facilitate staff-centred and self-protective care practices to mitigate their moral distress related to neglectful care practices, as illustrated in Fig.  1 .

Illustration of the relationships between sub-categories, categories and core category

Adapting to and accepting neglectful care practices

When faced with moral distress related to neglect, nursing staff responded by adapting to and accepting neglectful care practices through favouring efficiency and tolerating neglectful care.

Favouring efficiency

Staff wanted to provide care in accordance with professional and personal nursing ideals that promote residents´ integrity, dignity, and autonomy, as well as spending time to build trusting relations and provide resident-centred care. However, the existing work culture in many nursing homes, and a discrepancy between resources and demands, created a conflict between the ideals and the reality of care provision. This induced staff to compromise on their personal standards of care provision, creating feelings of insufficiency, frustration and despair and leading to increased moral distress.

And– how easy it is to– if it has been very busy times– to put on a slightly bigger diaper because we may not have time go to the bathroom. It’s terrible, but it happens. Unfortunately. (FI, RN 1)

One way to manage their moral distress related to neglectful care practices or not being able to meet residents basic care needs was to increase the efficiency of care. By rigidly following routines the nursing staff were able to do work more effectively and faster, which enabled them to cover more of the residents’ basic care needs. Institutional routines were well established among both staff and the residents, and followed without hesitation and staff did not reflect much on this practice. Putting residents to bed early in the afternoon before the night shift due to limited availability of staff at night or waking them up to provide morning care before a hectic day shift, enabled provision of basic physical care. Despite this, few questions were raised about institutional routines. Some respondents reflected that such routines were mainly for the staff’s convenience, whilst also being contradictory to the resident’s wishes.

Another way of meeting excessive care demand was through being more task-oriented and providing standardised care at a high tempo. However, this frequently led to omission or neglect of more time-consuming activities, as well as less visible duties, such as putting lotion on fragile skin or mouth-care. There were examples of staff becoming emotionally “blunted” when adapting to time limitations and cutting corners on a regular basis to maintain efficiency. Providing basic care then became just another task to tick off the list, and to some the nursing home appeared more like a “care factory” where residents became just another task to be performed as quickly as possible, resulting in their objectification and depersonalisation.

I accept that things go faster, if you see what I mean? At first, I thought it was strange to observe because I felt “damn, what outlook on humanity do you have?” You work with someone who just rushes off. Care activities [e.g. morning care] should be something good and nice, but it goes by so fast that it can look like it’s just a matter of finishing a package… (II, LPN 11) .

Although working efficiently and constantly, staff still struggled to meet the never-ending care demands.

This resulted in need of prioritised care, leaving little time for chatting or meeting residents´ broader psychosocial needs. Basic physical care was also regularly missed or delayed, especially in the evening and weekends when fewer carers were present. This resulted in neglectful care practices which created feelings of guilt and shame in the nursing staff, as staff had to face the realities.

It was a Saturday morning; I was ashamed because she [an older resident] had… a daughter [who] came to visit at 12 o’clock and she still hadn’t had her morning routine, and it wasn’t because we had taken a coffee break. And then I felt ashamed, that I simply hadn’t had time to do it, but that’s how it was. (II, SW 1)

There were examples of staff wanting to provide resident-centred care, who were not willing to let the residents pay the consequences for the lack of resources. However, taking the necessary time to perform personal care, without skipping or rushing a task, resulted in less efficiency, and having to leave unfinished care to the next shift. This was not always endorsed, and the staff had to endure negative feedback and even scolding from colleagues.

This routine- and task-oriented culture favoured staff´s needs to accomplish their never-ending care duties. When adapting to a work culture favouring efficiency, they tended to create a staff-centred work culture at the expense of resident-centred care provision. However, the opposite was experienced in some rare occasions when members of staff challenged these norms, disputing a work culture that puts carers’ needs before those of residents.

Tolerating neglectful care

Nursing staff described a workday with never-ending duties constantly stretching their limits. It was difficult, and for some nearly impossible, to perform in a satisfactory way under the existing work conditions. Staff felt they had to be superhuman in order to cover residents’ care needs, something they clearly are not– leading them to face daily neglect of residents and their needs. This experience of being on a “mission impossible” contributed to a pragmatic attitude, whereby staff tolerated and accepted that care was neglected on a regular basis.

Then you realise that if you’re going to be able to complete it, [the work] then you don’t get time to do what you should have done, and you change [attitudes] whether you want it or not– the view of what you’re doing changes, the boundaries are shifting. (II, LPN 11)

This sense of resignation was described as a survival mechanism by participants who were pushed beyond the limits of what they were able to perform. Having to leave residents waiting for help to go to the bathroom was normal due to limited time or available staff. Practices such as putting a diaper on a continent resident in case they were unable to follow the resident to the bathroom in time, thus became normalised. The following statement indicating a tolerance for a neglectful care:

There are some of those who use a diaper that still can tell when they have to go to the toilet to pee, but I have experienced that [they are told] “but you can just pee in the diaper”. (II, A3)

Increased tolerance for neglect among colleagues was also observed in situations where supporting resident´s autonomy and letting them refuse care were frequently used as plausible reasons for omitting tasks. Cognitive impairment and failing memory became acceptable excuses for omitting basic physical care, or not meeting psychosocial needs. Ageist attitudes among colleagues, such as “they are old and it goes only downhill from here”, also served as an excuse for neglecting care.

Yes, I think maybe this change starts when you stop trying– that it will be like you convince yourself that this person doesn’t like to shower anyway so she doesn’t even have to be offered it. There’s no point in asking, just leave it. (II, RN 9)

Increased tolerance of omissions and neglect of care duties was also explained because of shortcomings in the caregivers, relating to lack of education and competence, or staff not being sufficiently trained to recognise and reflect on ethical and moral dilemmas in dementia care. In addition, exhaustion from overwhelming demands, and near burn-out were presented as plausible reasons for the tolerance of neglect that was observed and experienced.

But I do notice there is a huge difference among people in what they think is important, and how much responsibility they take. I also think that a lot of this is unconscious, or that you don’t see it. Or that you do see it– I’ll do that later– then it will be forgotten. (FG, SE 1)

There were examples of concerns raised about the effects of the prevailing work culture on the quality of care. Staff struggled when observing colleagues neglecting residents. Some felt they had been forced to lower their own standards of care and developed a bad conscience as a result. Others challenged a work culture tolerating neglect by setting clear standards for the care they expected, thus making themselves and colleagues responsible and accountable for their care provision. This enabled labelling the omission of care as neglectful, which was not always popular among colleagues.

But I– we have to talk about this too, you know, that I am aware that if we don’t turn that person now– and a pressure ulcer occurs, it is our fault, I usually say (FG, RN 11).

An increased tolerance for neglectful care practices was partly a response to challenging work-conditions, which were met with pragmatism and other techniques for handling the huge workload, thus promoting staff-centred care practices. Not all staff members blamed themselves for this neglectful care. Instead, they blamed a system that did not allocate sufficient resources. They argued that existing working conditions put staff in a position that made it nearly impossible to provide good care, forcing them to accept neglectful practices.

I’ve been in quite a few situations like this myself where you see that things don’t work out in practice, you can’t run fast enough, you don’t have enough arms to do things, and then you don’t feel like it’s your fault. (II, RN 9)

A work culture tolerating neglect made work more bearable for nursing staff under demanding circumstances. By contrast, managing moral distress related to neglectful care practices in constructive ways typically only took place when staff recognized it and refused to be part of a neglectful work culture. This occurred when staff acknowledged themselves and colleagues as responsible and accountable for their lack of sufficient care.

Avoiding morally distressing situations

Nursing staff applied two different approaches to distance and protect themselves from the moral distress related to neglectful care: disengaging emotionally from care and retreating physically from care.

Disengaging emotionally from care

Participants reported once being eager to care for the residents, but this changed and instead they began to dread going to work. Physical and emotional exhaustion was common after many years of working in nursing homes. Despite taking professional pride in their work, and being satisfied with caring for the elderly, they frequently questioned their ability and motivation for continuing working until retirement under the existing conditions.

No, the main thing for me is that I feel very constrained as a nurse, I do take pride in performing a qualitatively good job. It makes me despair, and I’m really looking forward to retirement, because I think the squeeze is only getting worse. (II, RN 13)

Realising that they work with carers who do not want to provide good quality care, or cannot be bothered to, was an important source of moral distress. This was exemplified by situations where colleagues had been found asleep in resident rooms or pretended to have provided care when they obviously had not. When trying to raise their concerns regarding neglectful care practices or inviting colleagues to reflect on their duty to provide care, this was not always endorsed or welcomed by colleagues. Limited time was often given as an excuse by colleagues for not engaging in these staff conversations, but lack of interest and willingness to engage in reflective conversations were also observed.

But, in a way you don’t have the will to want to do a good job, it may be why… We are different, some want to do a good job, some want to do a very good job, some want to do a bad job, and some want to do a medium good job. All those shadings exist. (FI 5, RN 11)

Participants further presented disengaging from resident care as a way of protecting themselves from the experience of not being able to meet the care demands. Turning to more pragmatic attitudes to resident-centred care, and lowering standards of care were ways to deal with the resulting moral distress.

You can change over time and get such a view [reductionist view of people] gradually if you feel that it’s what is needed to get the job done in the hours you are present. (II, LPN 11)

They struggled with moral distress when observing colleagues or noticing that they themselves disengaged from care, frequently acknowledged this to protect themselves from the strain of being a part of a neglectful work culture. Nevertheless, they also questioned the negative effect this disengagement may have on residents, as well as on their own professional ideals, integrity, and self-esteem. Some longed for a work culture where reflections and discussions about insufficient care practices were welcomed.

Retreating physically from care

Staff referred to episodes where they or their colleagues avoided and retreated from care provision, implicitly or explicitly. Explicit examples included colleagues avoiding or ignoring difficult residents: for instance, not answering the bell when a person calls for assistance, instead letting someone else respond. Spending time on private mobile phones or drinking coffee with colleagues instead of engaging with residents were also cited by respondents as ways of distancing themselves from care.

… those who had the least stressful time at work was those who just didn’t care, because they persevere then. They endure year after year after year. It is those who are constantly trying to reach the goals all the time who quit. (II, LPN 10)

When staff tried to express the stresses and burden that poor resourcing has placed on care provision, managers typically offered courses in stress-management, or encouraged staff to step down to part-time work. These offers changed the focus from a problematic system to the individual carer, increasing feelings of guilt and self-blame for not managing their present work conditions.

So, I feel I’m getting sick because it’s about the system, it’s about how we’re treated, but it’s the individuals who will be taken. “You can’t do it [work full-time], what’s wrong with you? What’s wrong with you since you can’t do it?” (II, RN 13) .

Not all nursing staff members accepted existing conditions but chose to leave the nursing home and even the profession. This sometimes originated from a wish to protect themselves and their own physical and mental health. By leaving the nursing home they also protected the resident from their own neglectful care provision. They were thus neither willing to be part of a work culture that undermines their professional and personal values, nor be faced with a troubled conscience and moral distress on a regular basis.

I still did a good job. But I gradually started to stop caring. I can’t do that. It’s people I am dealing with. (II, LPN 10)

Another reason for leaving or considering leaving their job was a feeling of losing hope for a better future. Participants felt they were experiencing a downward spiral with dwindling available resources failing to meet increasing demands; they became deeply concerned about the effect this may have on care provision. Despite these issues, staff still found providing care to residents meaningful and fulfilling. They still questioned how long it will be before neglectful care practices results in serious resident harm or death– and concluded that they were not willing to be a part of these scenarios. By retreating from care, they were protecting residents and themselves from future unavoidable harm.

Nursing home staff find their work very meaningful and as having high standards for care provision and wanting to provide resident-centred care. However, existing work conditions and a neglectful work culture create a conflict between their ideals and the reality of care provision. Consequently, nursing staff find themselves becoming a part of a work culture challenging their professional and personal standards, and contributing to moral distress.

Our main findings are that participants acknowledge facilitating staff-centred and self-protecting care strategies to alleviate moral distress related to being a part of a neglectful work culture. These responses compromise the quality of care and enable the continuation of neglect in nursing homes.

Facilitating staff-centred care by adapting to and accepting neglect

To alleviate their moral distress, nursing home staff justify their practices by favouring efficiency to complete their care duties in sufficient time. This is a familiar approach, as the work culture in nursing homes traditionally promotes a strong focus on delivering routine physical care and completing task-based work efficiently and quickly [ 48 , 49 ]. This approach may resolve feelings of moral distress by achieving what appears to be a satisfactory resolution as basic (physical) care is provided [ 23 , 28 ]. Hence, the nursing staff can achieve a (temporarily) mitigation of their feelings of guilt, shame and frustration when resources and demands mismatches. However, while in the past Norwegian nursing home residents were typically frail and mostly bed-dependent, they are presently recognised as having complex medical conditions, cognitive deficits, and/or psychiatric illness, and challenging behaviours such as agitation and aggression [ 33 ]. For this patient population, the availability of skilled staff with sufficient time for holistic care provision is crucial for sufficient quality of care.

Our study participants experienced meeting residents’ complex care needs when constantly pulled between “task and time” as challenging, which is confirmed in prior research [ 49 ]. Favouring efficiency to get the job done makes the nursing staff´s workday liveable. This is in accordance with research demonstrating that nursing staff tend to reconcile their expectations for care as a way of adapting to the work culture, minimising their exposure to personal harm [ 50 ]. Despite this emphasis on efficient, routine- and task-oriented provision of care, although intended to counter neglect, it nevertheless serves to promote neglectful care practices.

When staff adapt to the mismatch between resources and demands by working faster and in a more standardised way, care provision becomes quick and efficient, but also uncaring and dehumanizing [ 50 , 51 ]. This leaves little room for individualised and resident-centred care which is the gold standard for high quality of care for nursing home residents [ 9 , 22 , 37 , 38 , 52 , 53 ]. There may be limited opportunities for supporting and stimulating residents´ self-caring abilities, which further exacerbates functional and cognitive decline [ 49 , 54 , 55 ]. Favouring efficiency is a problem-focused coping strategy aimed at solving neglectful care practices in nursing homes by regularising and normalising them. When staff are compromising nursing values and lower care standards to maintain efficiency, it further aggravates the carers’ moral distress, and a vicious cycle of neglect is established.

Our participants tolerated neglectful care to manage challenging working-conditions, including work overload and limited time for care. Acceptance of a difficult situation that is hard to change, and adapting by changing one’s expectations and behaviours, are well-established coping strategies [ 56 ], like when trivializing morally challenging situations to mitigate moral distress [ 57 ]. This finding can also be in line with the theory of conformity; tolerance of neglect may be explained by a tendency to conform to existing cultural norms, to minimise cognitive dissonance [ 30 ]. Accordingly, simple acquiescence has been demonstrated as a response to moral distress. Nursing staff may be aware of the moral situation creating distress but accept the outcome without objecting [ 28 ]. This acceptance may lead to staff becoming resigned, cold or blasé, eventually resulting in compromised quality of care [ 25 , 57 , 58 ]. This is confirmed by our participants, who describe a reductionist care culture illustrated by terms such as “care-factory” or “finishing a packet” about morning care provision. In addition, the admonition “just pee in the diaper” is illustrative of a cultural shift from resident-centred care to care provided at the convenience of nursing staff.

Participants tolerate neglectful activities such as omitting showering or social activities, which resonates with research demonstrating that staff “defend” their omissions by downplaying certain care activities to make them less relevant as examples of low care quality. This serves to retain their self-image as caring and compassionate nurses, in line with cognitive dissonance theory [ 10 ]. Furthermore, here are practices reflecting ageistic attitudes, which might also confirm this theory in line with prior research finding that negative stereotypes of aging may affect the quality of care accordingly [ 59 ]. Intentional or not, this handling of cognitive dissonance and moral distress, depicts neglectful behaviour as less severe, and thus easier for the staff to face in their everyday work. This is also indicated by previous research showing that nursing staff regularly fail to recognise their own practices as neglectful, normalising missed care as a way of legitimising neglect [ 45 ]. Tolerating neglect may be a way of enabling existing and insufficient care practices. Intentional or not, tolerance of neglect will indisputably have a negative influence on the quality of care, as well as the well-being of both staff and residents in nursing homes [ 22 , 58 , 60 ].

Self-protection through avoiding morally distressing situations

Participants further respond to the moral stress related to a neglectful work culture by disengaging emotionally from the caring process. This may reflect further efforts to manage moral distress related to neglectful care provision [ 50 ]. Distancing is a well-known coping strategy, as when nursing staff disengage or become detached from a situation to minimise its significance. Not bothering too much enable some of our participants to continue working. This finding is corroborated by research demonstrating that withdrawing emotionally, distancing, and numbing of the conscience are approaches that helps staff to continue working in healthcare [ 28 , 57 ]. Nevertheless, this avoidance behaviour which initial is a way to mitigate their moral distress also becomes a source of guilt and despair, bringing the personal and professional long-term effects of this coping mechanism into question [ 28 ].

Our participants have experienced colleagues who regularly disengage emotionally and physically from their care duties. We cannot know whether this observed behaviour is intentional or not. Distancing from direct patient care may, however, be an intentional way of avoiding morally distressing situations [ 28 ]. It has also been shown that a lack of awareness of moral or ethical dilemmas may be a way of handling moral distress, as when staff do not recognise a moral event. This is confirmed in our study by examples of staff refusing to reflect or discuss their own care practices. This may be a way of protecting themselves from moral distress through distancing and/or hardening their emotions [ 10 ]. Other research confirms that avoidance of discussion about situations causing moral distress can influence quality of care negatively [ 25 ].

Heavy workloads and time pressure have been demonstrated to create emotional and physical stress among nursing staff [ 16 , 26 , 50 ]. Distress, exhaustion, and avoidance (of care) have also been associated with absence from work [ 57 ] and intention to quit [ 16 ]. This raises concern at a time when there is an increased need for residential care for an increasingly aging population, and difficulties in recruiting skilled nursing staff in Norwegian nursing homes [ 22 ]. It has previously been concluded that unfavourable working conditions are the strongest predictors of Norwegian nurses wishing to leave elderly care [ 26 ]. Other researchers have found that work overload may not be directly linked to staff turnover and intention to quit, but to role-conflict and ambiguity leading to moral distress [ 16 ]. However, this is compounded by research confirming that full withdrawal is a response to moral distress [ 28 ]. Our participants verify both these outcomes when they have chosen to retreat from care as a way of protecting both themselves and residents from the burden of neglectful care. For some, this is directly related to the excessive workload, making working in accordance with their own values impossible.

A worrisome finding in our study is participants describing the quality of care in nursing homes as being locked in a “downward spiral” and their concern for the future of care provision. Other researchers have found that nursing staff are leaving their jobs to escape the increasing stress related to losing confidence in their ability to promote sufficient resident safety and quality of care [ 61 ]. This may be intended as a constructive approach, to protect both themselves and the residents from neglectful care. On the other hand, the staff who stay, despite their dissatisfaction, may be confined to a role where they are unable to influence the neglectful work culture in a positive way [ 62 ].

Strengths and limitations

The Covid-19 lockdown affected the recruitment process in this study, as nursing home staff were less available and gathering for focus group discussions was no longer an option. This reduced our ability to work towards a true theoretical sampling, to be able to saturate our categories and to provide a grounded theory. However, we managed to reach participants for member-checking, thus strengthening our results. We also managed to recruit a diverse sample of participants from a variety of nursing homes, and we were able to reach former staff who had quit working in nursing homes. Our research team consists of researchers from different disciplines, providing a broader perspective on the theme and possibilities for diverse interpretations of our results.

Despite that much of the care provision in nursing home is of good quality and resident-centred, a growing body of evidence shows that many nursing home residents’ basic care needs are neglected, and residents do not receive qualitatively good care. This challenges nursing staff´s professional and personal ideals and standards for care and may contribute to moral distress. Our study brings new knowledge on how nursing home staff`s attempt to mitigate their moral distress related to neglectful care practices. We interpret our results as representing a shift from a resident-centred to a staff-centred work culture, where nursing home staff feel compelled to facilitate self-protecting care strategies to make their workday bearable and liveable. This strongly indicates a compromise in the quality of care that enables the continuation of neglectful care practices in Norwegian nursing homes. Finding ways of breaking a downward spiralling quality of care are thus a major concern following our findings. This should be of great interest for managers and policy makers giving the structural and organizational premises for care provision, but also for those being most affected by neglectful care provision such as nursing home resident and their caregivers. Facilitating better working conditions and work culture for caregivers in nursing homes may alleviate the sources creating moral distress.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Focus group

Individual interview

Licensed practical nurse

The Norwegian Centre for Research Data

Resident-centred care

Registered nurse

Social educator

Social worker

Andersson I, Eklund AJ, Nilsson J, Baath C. Prevalence, type, and reasons for missed nursing care in municipality health care in Sweden - A cross sectional study. BMC Nurs. 2022;21(1):95.

Article   PubMed   PubMed Central   Google Scholar  

Botngard A, Eide AH, Mosqueda L, Malmedal WK. Elder abuse in Norwegian nursing homes: a cross-sectional exploratory study. BMC Health Serv Res. 2020;20(1):9.

Kangasniemi M, Papinaho O, Moilanen T, Leino-Kilpi H, Siipi H, Suominen S, et al. Neglecting the care of older people in residential care settings: a national document analysis of complaints reported to the Finnish supervisory authority. Health Soc Care Community. 2022;30(4):e1313–24.

Article   PubMed   Google Scholar  

Lev S, Dolberg P, Lang B. They just did what they usually do: Mistreatment, abuse, and neglect in nursing homes from the perspective of Ministry of Health auditing teams. Geriatr Nurs. 2022;48:24–31.

Malmedal W, Ingebrigtsen O, Saveman BI. Inadequate care in Norwegian nursing homes - as reported by nursing staff. Scand J Caring Sci. 2009;23(2):231–42.

Myhre J, Malmedal WK, Saga S, Ostaszkiewicz J, Nakrem S. Nursing home leaders’ perception of factors influencing the reporting of elder abuse and neglect: a qualitative study. J Health Organ Manag. 2020;34(6):655–71.

Article   Google Scholar  

Yon Y, Ramiro-Gonzalez M, Mikton CR, Huber M, Sethi D. The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. Eur J Public Health. 2019;29(1):58–67.

Ericson-Lidman E, Norberg A, Persson B, Strandberg G. Healthcare personnel’s experiences of situations in municipal elderly care that generate troubled conscience. Scand J Caring Sci. 2013;27(2):215–23.

Midtbust MH, Gjengedal E, Alnes RE. Moral distress - a threat to dementia care? A qualitative study of nursing staff members’ experiences in long-term care facilities. BMC Health Serv Res. 2022;22(1):290.

Mortensen AH, Stojiljkovic M, Lillekroken D. Strategies to manage cognitive dissonance when experiencing resistiveness to care in people living with dementia: a qualitative study. J Adv Nurs. 2022;78(2):486–97.

Nikunlaakso R, Selander K, Weiste E, Korkiakangas E, Paavolainen M, Koivisto T et al. Understanding Moral distress among Eldercare workers: a scoping review. Int J Environ Res Public Health. 2022;19(15).

Preshaw DHL, Brazil K, McLaughlin D, Frolic A. Ethical issues experienced by healthcare workers in nursing homes. Nurs Ethics. 2016;23(5):490–506.

Zhang YY, Zhang C, Han XR, Li W, Wang YL. Determinants of compassion satisfaction, compassion fatigue and burn out in nursing: a correlative meta-analysis. Medicine. 2018;97(26).

Munkeby H, Bratberg G, Devik SA. Meanings of troubled conscience in nursing homes: nurses’ lived experience. Nurs Ethics. 2023;30(1):20–31.

Mareš J. Moral distress: terminology, theories and models. Kontakt. 2016;18(3):e137–44.

Pijl-Zieber EM, Awosoga O, Spenceley S, Hagen B, Hall B, Lapins J. Caring in the wake of the rising tide: Moral distress in residential nursing care of people living with dementia. Dementia. 2018;17(3):315–36.

Weiste E, Paavolainen M, Olin N, Korkiakangas E, Saari E, Koivisto T et al. Elderly Care Practitioners’ Perceptions of Moral Distress in the Work Development Discussions. Healthcare. 2023;11(3).

Salari N, Shohaimi S, Khaledi-Paveh B, Kazeminia M, Bazrafshan MR, Mohammadi M. The severity of moral distress in nurses: a systematic review and meta-analysis. Philos Ethics Humanit Med. 2022;17(1):13.

Davis JA, Fowler M, Fantus S, Fins JJ, Joy M, Kruse K, Burgart A, Lindsey M, Mooney-Doyle K, Uritsky T, Grady C. Healthcare Professional narratives on Moral Distess: disiplinary perspectives. In: Ulrich CM, Grady C, editors. Moral Distress in the Health professions. Switzerland: Springer International Publishing; 2018.

Google Scholar  

Nathaniel AK. Moral reckoning in nursing. West J Nurs Res. 2006;28(4):419–38.

Deschenes S, Gagnon M, Park T, Kunyk D. Moral distress- A concept clarification. Nurs Ethics. 2020;27(4):1127–46.

Spenceley S, Witcher CS, Hagen B, Hall B, Kardolus-Wilson A. Sources of moral distress for nursing staff providing care to residents with dementia. Dementia. 2017;16(7):815–34.

Morley G, Ives J, Bradbury-Jones C, Irvine F. What is ‘moral distress’? A narrative synthesis of the literature. Nurs Ethics. 2019;26(3):646–62.

Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of Conscience in relation to stress of Conscience. Nurs Ethics. 2007;14(3).

Burston AS, Tuscett AG. Moral distress in nursing- contributing factors, outcomes and interventions. Nurs Ethics. 2012;20(3):312–24.

Bratt C, Gautun H. Should I stay or should I go? Nurses’ wishes to leave nursing homes and home nursing. J Nurs Manag. 2018;26(8):1074–82.

Harvey C, Thompson S, Pearson M, Willis E, Toffoli L. Missed nursing care as an ‘art form’: The contradictions of nurses as carers. Nurs Inq. 2017;24(3).

Morley G, Bradbury-Jones C, Ives J. The moral distress model: an empirically informed guide for moral distress interventions. J Clin Nurs. 2022;31(9–10):1309–26.

Cialdini RB, Goldstein NJ. Social influence: compliance and conformity. Annu Rev Psychol. 2004;55:591–621.

Price L, Duffy K, McCallum J, Ness V. Are theoretical perspectives useful to explain nurses’ tolerance of suboptimal care? J Nurs Manag. 2015;23(7):940–4.

Charmaz K. Constructing grounded theory. 2nd ed. Silverman D, editor: SAGE; 2014.

Ågotnes G. The institutional practice. On nursing homes and hospitalizations. Cappelen Damm Akademisk; 2017.

Helvik AS, Selbaek G, Saltyte Benth J, Roen I, Bergh S. The course of neuropsychiatric symptoms in nursing home residents from admission to 30-month follow-up. PLoS ONE. 2018;13(10):e0206147.

Regulation of quality of care in health. and social services regulated in the municipal health act and the social service act 2003 [ https://lovdata.no/dokument/SF/forskrift/2003-06-27-792?q=FOR -2003-06-27-792.

Forskrift om en verdig eldreomsorg. Verdighetsgarantien.[Regulations on dignified care for the elderly. The dignity guarantee], FOR-2010-11-12-1426. (2010). 2010.

Ree E. What is the role of transformational leadership, work environment and patient safety culture for person-centred care? A cross-sectional study in Norwegian nursing homes and home care services. Nurs Open. 2020;7(6):8.

Vassbø T, Kirkevold M, Edvardsson D, Sjögren K, Lood Q, Bergland Å. The meaning of working in a personcentred way in nursing homes: a phenomenological-hermeneutical study. BMC Nurs. 2019;18:45.

Røsvik J, Brooker D, Mjorud M, Kirkevold Ø. What is person-centred care in dementia? Clinical reviews into practice: the development of the VIPS practice model. Rev Clin Gerontol. 2013;23.

Rutten JERBR, Tan F, Prins M, van der Roest H, Heijkants C, et al. Work environment and person-centred dementia care in nursing homes-A cross-sectional study. J Nurs Manag. 2021;29(7):8.

Saunes IS, Karanikolos M, Sagan A, Norway. Health system review. Health Syst Transition. 2020;22(1):63.

Gautun H. En utvikling som må snus. Bemanning og kompetanse i sykehjem Og Hjemmesykepleien. Oslo: Oslo Velferdsforskningsinstituttet NOVA; 2020. Contract No.: 14/20.

Barbour R. Doing focus groups. Flick U. editor. London: Sage; 2018.

Book   Google Scholar  

Mills J, Chapman Y, Bonner A, Francis K. Grounded theory: a methodological spiral from positivism to Postmodernism. J Adv Nurs. 2007;58(1):7.

Tie YC, Birks M, Francis K. Grounded theory research: a design framework for novice researchers. SAGA Open Med. 2019;7:8.

Lund SB, Skolbekken J-A, Mosqueda L, Malmedal WK. Legitimizing neglect - a qualitative study among nursing home staff in Norway. BMC Health Serv Res. 2023;23(1):212.

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ)- a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.

Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893–907.

Knopp-Sihota JA, Niehaus L, Squires JE, Norton PG, Estabrooks CA. Factors associated with rushed and missed resident care in western Canadian nursing homes: a cross-sectional survey of health care aides. J Clin Nurs. 2015;24(19–20):2815–25.

Norman RM, Sjetne IS. Adaptation, modification, and psychometric assessment of a Norwegian version of the Basel extent of rationing of nursing care for nursing homes instrument (BERNCA-NH). BMC Health Serv Res. 2019;19(1):969.

Pickering CEZ, Nurenberg K, Schiamberg LB. Recognizing and responding to the toxic work environment: Worker Safety, Patient Safety, and Abuse/Neglect in nursing homes. Qual Health Res. 2017;27(12):1870–81.

Jones T, Drach-Zahavy A, Amorim-Lopes M, Willis E. Systems, economics, and neoliberal politics: theories to understand missed nursing care. Nurs Health Sci. 2020;22(3):586–92.

Courtney M, O’Reilly M, Edwards H, Hassall S. The relationship between clinical outcomes and quality of life for residents of aged care facilities. Australian J Adv Nurs. 2009;26.

Kitson A, Conroy T, Wengstrom Y, Profetto-McGrath J, Robertson-Malt S. Defining the fundamentals of care. Int J Nurs Pract. 2010;16(4):423-34.

Andfossen NB, Andreassen S, Obstfelder A, Olsen RM. Kapasitets- Og kvalitetsutfordringer i kommunale helse- og omsorgstjenester: oppgaver som blir satt på vent, oversett, glemt eller utelatt. [Capacity and quality challenges in municipal health- and care services: tasks that are put on hold, overlooked, missed or omitted]. Senter for omsorgsforskning; 2021.

Malmedal W, Hammervold R, Saveman B-I. The dark side of Norwegian nursing homes: factors influencing inadequate care. J Adult Prot. 2014;16(3):133–51.

Lambert VA, Lambert CE. Nurses workplace stressors and coping strategies. Indian J Palliat Care. 2016;14.

Jansen T-L, Hem MH, Danbolt LJ. Hanssen i. coping with moral distress on acute psychiatric wards- A qualitative study. Nurs Ethics. 2022;29(1):171–80.

Andela M, Truchot D, Huguenotte V. Job demands, emotional dissonance and elderly abuse: the moderating role of organizational resources. J Elder Abuse Negl. 2018;30(5):368–84.

Lopez J, Perez-Rojo G, Noriega C, Velasco C. Personal and work-related factors Associated with Good Care for Institutionalized older adults. Int J Environ Res Public Health. 2021;18(2).

Ericson-Lidman E, Strandberg G. Dealing with troubled conscience in municipal care of older people. Nurs Ethics. 2013;20(3):300–11.

Zhu J, Rodgers S, Melia KM. The impact of safety and quality of health care on Chinese nursing career decision-making. J Nurs Manag. 2014;22(4):423–32.

Olsen RM, Bjerkan J. Patient safety culture in Norwegian home health nursing: a cross-sectional study of healthcare provider’s perceptions of the teamwork and safety climates. Saf Health. 2017;3(1).

Download references

Acknowledgements

We are grateful to all informants who participated in the focus-group discussions and individual interviews. We thank Janne Myhre and Anja Botngård for contributing as co-moderators in the focus-group discussions. In addition, we thank Heidi Fors and Gunn Steinsheim for transcribing the data material.

This research received no external funding.

Open access funding provided by Norwegian University of Science and Technology

Author information

Authors and affiliations.

Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), 7491, Trondheim, PO Box 8905, Norway

Stine Borgen Lund, Wenche K. Malmedal & John-Arne Skolbekken

Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA

Laura Mosqueda

You can also search for this author in PubMed   Google Scholar

Contributions

SBL, WKM, JAS and LM developed the study aim, research question and design. SBL performed the majority of the analyses and interpretation of data, and WKM and JAS contributed with data analysis and interpretation of data, all authors discussed the data material. WKM supervised the project. SBL drafted the manuscript. All authors contributed with critical revision during the writing of the manuscript and read and approved the final manuscript.

Corresponding author

Correspondence to Stine Borgen Lund .

Ethics declarations

Ethics approval and consent to participate.

Informed consent was obtained from all subjects involved in the study. The study was approved by The Norwegian Centre for Research Data (NSD) under SIKT (protocol code 221320, approved 26.02.2019). SIKT is an organization under the Ministry of Education and Research providing data protection services for Norwegian research institutions - https://sikt.no/en/data-protection-services which serves to check that research in Norway is performed in line with the Personal Data Act.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Authers’ information

SBL (She/her/hers), Research Fellow, RN. LM (She/her/hers), Professor, MD. WKM (She/her/hers), Professor, PhD, RN. JAS (He/him/his), Professor, PhD, Licensed Psychologist. SBL is doing this research as part of her dissertation research. JAS have contributed with his experience in qualitative research. WKM and LM have long experience in the research field of elder abuse and neglect.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Lund, S.B., Malmedal, W.K., Mosqueda, L. et al. “Just pee in the diaper” - a constructivist grounded theory study of moral distress enabling neglect in nursing homes. BMC Geriatr 24 , 366 (2024). https://doi.org/10.1186/s12877-024-04920-7

Download citation

Received : 04 August 2023

Accepted : 25 March 2024

Published : 24 April 2024

DOI : https://doi.org/10.1186/s12877-024-04920-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Moral distress
• Missed care
• Nursing home
• Long-term care

BMC Geriatrics

ISSN: 1471-2318

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Critical care nurse leaders' moral distress: A qualitative descriptive study

Affiliations.

• 1 University of Alabama in Huntsville College of Nursing; The University of Alabama Capstone College of Nursing.
• 2 The University of Virginia School of Nursing.
• 3 The University of Alabama Capstone College of Nursing.
• 4 The University of Alabama in Huntsville College of Nursing.
• PMID: 38476080
• DOI: 10.1177/09697330241238347

Background: Unit-based critical care nurse leaders (UBCCNL) play a role in exemplifying ethical leadership, addressing moral distress, and mitigating contributing factors to moral distress on their units. Despite several studies examining the experience of moral distress by bedside nurses, knowledge is limited regarding the UBCCNL's experience.

Research aim: The aim of this study was to gain a deeper understanding of the lived experiences of Alabama UBCCNLs regarding how they experience, cope with, and address moral distress.

Research design: A qualitative descriptive design and inductive thematic analysis guided the investigation. A screening and demographics questionnaire and a semi-structured interview protocol were the tools of data collection.

Participant and research context: Data were collected from 10 UBCCNLs from seven hospitals across the state of Alabama from February to July 2023.

Ethical considerations: This study was approved by the Institutional Review Board at the University of Alabama in Huntsville. Informed consent was obtained from participants prior to data collection.

Findings: UBCCNLs experience moral distress frequently due to a variety of systemic and organizational barriers. Feelings of powerlessness tended to precipitate moral distress among UBCCNLs. Despite moral distress resulting in increased advocacy and empathy, UBCCNLs may experience a variety of negative responses resulting from moral distress. UBCCNLs may utilize internal and external mechanisms to cope with and address moral distress.

Conclusions: The UBCCNL's experience of moral distress is not dissimilar from bedside staff; albeit, moral distress does occur as a result of the responsibilities of leadership and the associated systemic barriers that UBCCNLs are privier to. When organizations allocate resources for addressing moral distress, they should be convenient to leaders and staff. The UBCCNL perspective should be considered in the development of future moral distress measurement tools and interventions. Future research exploring the relationship between empathy and moral distress among nurse leaders is needed.

Keywords: Moral distress; critical care; nurse leader; nursing ethics; nursing leadership.