Moral Distress Among Nurses Working in COVID-19 Wards: A Cross-sectional Study

To evaluate the frequency and intensity of moral distress in Brazilian nurses. Cross-sectional study performed with nurses from 27 Brazilian states through application of the Brazilian Moral Distress Scale in Nurses (Portuguese acronym: EDME-Br) and descriptive statistical analysis. Participation of 1,226 Brazilian nurses in the study. The intensity and frequency of overall moral distress were rated as moderate level, with averages of 3.08 (± 1.45) and 2.94 (± 1.37), respectively. Specifically, the highest intensity and frequency was related to the factors Acknowledgement, power and professional identity and Work teams, while the lowest was related to the factor Defense of values and rights. Moral distress occurs in precarious work environments, with little expressiveness of the nurses' role. One highlights the importance of the problem in terms of its amplitude and multicausality, reaching professionals acting in different work contexts.

Healthcare providers in intensive care units face numerous moral distresses due to conflicts between professional principles, personal values, and the demands of patients’ families. In contrast, family satisfaction is considered one of the important indicators for evaluating the quality of medical services. Therefore, the present study aims to investigate the relationship between healthcare providers’ moral distress and family satisfaction in intensive care units. A cross-sectional study was conducted in four intensive care units with the collaboration of 128 family members and 70 healthcare providers (16 physicians and 54 nurses). The samples were selected using an available sampling method according to the inclusion criteria. Data were collected using the moral distress scale and the family satisfaction-ICU questionnaire. The results showed that mean scores for the frequency and intensity of moral distress were 49.88 ± 3.25 and 62.27 ± 2.51, respectively, indicating a moderate level of moral distress among ICU healthcare providers. The mean FS-ICU score was 59.83 ± 3.19, suggesting a generally good level of family satisfaction. The results revealed a significant inverse relationship between the frequency of moral distress and family satisfaction. This indicates that as the frequency of moral distress among ICU healthcare providers increases, family satisfaction tends to decrease (P = 0.03, r = − 0.7). These results emphasize the importance of reducing moral distress in healthcare settings through organizational support, the development of specific ethical strategies, and strengthening the communication skills of the healthcare team. In order to improve the experience of patients’ families, it is suggested that educational and support programs be designed for healthcare providers to increase their ability to deal with ethical challenges and provide quality services.Supplementary InformationThe online version contains supplementary material available at 10.1038/s41598-025-19770-5.

The objectives of this study are to assess and compare differences in the intensity, frequency, and overall severity of moral distress among a diverse group of healthcare professionals. Participants from within Baylor Health Care System completed an online seven-point Likert scale (range, 0 to 6) moral distress survey containing nine core clinical scenarios and additional scenarios specific to each participant's discipline. Higher scores reflected greater intensity and/or frequency of moral distress. More than 2,700 healthcare professionals responded to the survey (response rate 18.14 percent); survey respondents represented multiple healthcare disciplines across a variety of settings in a single healthcare system. Intensity of moral distress was high in all disciplines, although the causes of highest intensity varied by discipline. Mean moral distress intensity for the nine core scenarios was higher among physicians than nurses, but the mean moral distress frequency was higher among nurses. Taking into account both intensity and frequency, the difference in mean moral distress score was statistically significant among the various disciplines. Using post hoc analysis, differences were greatest between nurses and therapists. Moral distress has previously been described as a phenomenon predominantly among nursing professionals.This first-of-its-kind multidisciplinary study of moral distress suggests the phenomenon is significant across multiple professional healthcare disciplines. Healthcare professionals should be sensitive to situations that create moral distress for colleagues from other disciplines. Policy makers and administrators should explore options to lessen moral distress and professional burnout that frequently accompanies it.

Nursing is a profession that has always been accompanied with common ethical concerns. There are some evidences which indicate that narrative writing on traumatic experiences may improve an individual's emotional health. This study aimed to determine the effectiveness of narrative writing on moral distress of nurses working in intensive care unit. This study was a clinical trial with pre- and post-test design. The frequency and intensity of moral distress was measured by a valid and reliable questionnaire (Corely) at baseline and after 8 weeks. The intervention group was asked to write about their deepest emotions and stressful experiences in the intensive care unit for 8 weeks. Using consensus sampling, 120 nurses of intensive care unit and neonatal intensive care unit of the teaching hospitals (in Iran) were invited to and were randomly allocated into the intervention and control groups. Participation was voluntary, data were anonymized, and the confidentiality of the participating nurses and their institutions maintained. The ethical approval was obtained from an IRB or research ethics committee. In total, 106 nurses completed the trial consisting of 87.75% females. The mean work experience of nurses in the intervention and control groups was 7.21 ± 4.96 and 8.28 ± 5.45 years, respectively. Independent t-test showed no statistical difference neither in the intensity of moral distress (P = 0.8), nor in its frequency (P = 0.5) between the two groups. As nurses constantly face ethical tensions, moral distress is a phenomenon that results from the different situations of critical care units. Their concern about receiving negative feedback from the managerial level may have influenced the outcome of the intervention. Narratives writing by the nurses showed no effect on reducing the intensity and frequency of moral distress. It seems that due to the intensity of moral distress in clinical settings, we need to test variety solutions to reduce the problem.

Background: No systematic review in the literature has analyzed the intensity and frequency of moral distress among ICU nurses. No study seems to have mapped the leading personal and professional characteristics associated with high levels of moral distress. This systematic review aimed to describe the intensity and frequency of moral distress experienced by nurses in ICUs, as assessed by Corley’s instruments on moral distress (the Moral Distress Scale and the Moral Distress Scale–Revised). Additionally, this systematic review aimed to summarize the correlates of moral distress. Methods: A systematic search and review were performed using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (MEDLINE/PubMed), and Psychological s Information Services (PsycINFO). The review methodology followed PRISMA guidelines. The quality assessment of the included studies was conducted using the Newcastle–Ottawa Scale. Results: Findings showed a moderate level of moral distress among nurses working in ICUs. The findings of this systematic review confirm that there are a lot of triggers of moral distress related to patient-level factors, unit/team-level factors, or system-level causes. Beyond the triggers of moral distress, this systematic review showed some correlates of moral distress: those nurses working in ICUs with less work experience and those who are younger, female, and intend to leave their jobs have higher levels of moral distress. This systematic review’s findings show a positive correlation between professional autonomy, empowerment, and moral distress scores. Additionally, nurses who feel supported by head nurses report lower moral distress scores. Conclusions: This review could help better identify which professionals are at a higher risk of experiencing moral distress, allowing the early detection of those at risk of moral distress, and giving the organization some tools to implement preventive strategies.

Due to the unique nature of the neonatal intensive care unit (NICU) and its moral distress, this study aimed to investigate moral distress in the NICU. This cross-sectional study was conducted on 234 physicians and nurses working in the neonatal wards of eight hospitals. The Corley’s Moral Distress Scale was used to collect data. Findings showed that 25 of the participants were physicians and 209 were nurses. The intensity and frequency of distress among physicians and nurses were assessed as moderate. The mean intensity and frequency of moral distress among nurses and physicians were 48.3%, 41.5% and 46.46%, 15.62% respectively. The results showed that the mean intensity and frequency of distress were higher, however not significantly, among nurses. The intensity and frequency of moral distress had a statistically significant and direct correlation with the intention to leave and the number of staff in each working shift among the nurses. Moral distress in the NICU practitioners was moderate, so addressing this issue and trying to alleviate it was important. Identifying the causes behind moral distress can help adopt appropriate measures to prevent and reduce them.

In the modern healthcare landscape, moral distress has become an increasingly common phenomenon among healthcare professionals. This condition is particularly prevalent among palliative care professionals who are confronted with bioethical issues in their daily practice. Although some studies described the effects of poor ethical climate and negative affectivity on moral distress, how these variables could be incorporated into a single model is still unclear. Thus, this study aims to investigate whether ethical relationships with the hospital could be related to the intensity and frequency of moral distress, both directly and as mediated by professionals’ negative affectivity. Sixty-one Portuguese palliative care professionals completed web-based self-report questionnaires. After exploring descriptive statistics, mediation analyses were performed using the partial least squares method. The results indicated that the presence of positive relationships with the hospital reduced the professionals’ negative affectivity levels. This, in turn, led palliative care professionals to experience a lower frequency and intensity of moral distress. Being a physician was positively associated with negative affectivity but not with the frequency of moral distress. Considering the protective role of ethical relationships with hospitals, health organizations could consider implementing interventions to improve hospitals’ ethical climate and provide staff with ethics training programs.

Background:Moral distress and moral courage among healthcare professionals have received considerable attention in recent years. However, there is a paucity of studies investigating these topics among nurses. Thus, the present study aimed to evaluate the association between moral distress and moral courage among nurses in an Iranian sample population.Materials and Methods:The present cross-sectional study was conducted during February–December 2018. Corley's Moral Distress (MDS-R) and Sekerka's moral courage scales were used to collect the data. MDS-R is a 21-items scale which includes frequency and intensity ranges from 0 (never) to 4 (very frequently) and 0 (none) to 4 (great extent), respectively. In addition, the moral courage scale contains 15 items ranging from “never true” (1 point) to “always true” (7 points). In total, 225 eligible nurses were entered into this study. Finally, SPSS-16 was used for statistical analysis at the α = 0.05 level.Results:The mean scores of the frequency and intensity of moral distress and moral courage were 45.41 (95% CI = 43.37-47.45), 44.24 (95% CI = 42.98-45.42), and 59.63 (95% CI = 58.50-60.87), respectively. Eventually, a significant relationship was found between the moral courage and frequency of moral distress (r = 0.46, p < 0.001) and the intensity of moral distress (r = 0.73, p < 0.001).Conclusions:In general, encouraging healthcare managers and administrators is considered as crucial for developing supportive structures and highly sensitive management which promotes moral courage while reducing moral distress in nurses' work setting.

Objective: The purpose of this study was to evaluate the intensity and frequency of moral distress and determine clinical situations leading to moral distress in oncology units. The study also examined the relationship between moral distress scores and demographic characteristics of oncology nurses. Design: This descriptive study was performed between 25 January 2012 and 29 June 2013. Setting: The study was conducted in the oncology units of eight training hospitals in Tehran, Iran. Subjects: One hundred and forty eight nurses (131 females, 17 males; mean age 32.5 years; range 24 to 52 years) who had worked in oncology units of training hospitals in Tehran were included in the study. Main outcome measure(s): The main outcome measures included intensity and frequency of moral distress, which were assessed by the Moral Distress Scale – Revised (MDS-R). Results: Most of the 148 nurses had high to moderate scores. Nurses had experienced higher moral distress when receiving informed consent forms from patients and asking patients to carry out physicians’ order for unnecessary tests in patients’ last stages of life. Conclusion: Moral distress exists in oncology nurses and interventions will be developed and tested to decrease and prevent it.

Moral Distress and relationship between Physician and Nurses

Background:Moral distress is an unpleasant feeling that arises when one is forced to behave in such a way that it violates one’s personal beliefs and values about what is right and what is wrong. Moral distress, unlike other forms of distress, contains an incompatible conflict between one’s personal moral limitations and the acts that accompany it.Objective:to investigate moral distress and its effects on the ICU nursing staff, their professional quality of life as well as, related factors.Methods:The total sample of this cross-sectional study comprised of 258 ICU nurses working in reference hospitals for COVID 19 recruited online using google forms. The study tools are: a) “Measure of Moral Distress for Healthcare Professionals (MMD-HP)” to assess intensity and frequency of moral distress b) “Professional Quality of Life Scale (ProQOL-5)” to assess professional quality of life. Data were analyzed using IBM SPSS Statistics 25,0 (IBM Analytics, IBM Software Group Statistical Package).Results:Overall MMD-HP score ranged from 3 to 262 with a mean score of 116.52 (SD= 68.56). Distress score ranged from 5 to 79 with a mean score of 43.67 (SD=17.44) while intensity score ranged from 3 to 108 with a mean score 52.04 (SD=22.69). Bivariate analysis showed there is a statistically significant positive correlation between the intensity of moral distress and overall moral distress score with years of service in ICU and age. Nurses’ Assistants (m=48.1 p=0.021) scored higher than Registered nurses in distress and intensity score (m=54.1 p=0.020) while female also scored higher in overall MMD-HP (m=121.2 p=0.049). Multivariate logistic regression analysis, showed that secondary trauma scale was independently associated with a higher distress scale score and a higher MMD-HP.Conclusion:Educational support that provide information about dealing with moral distress during the coronavirus pandemic and how ICU nurses should deal with ethical issues that may confront in the everyday professional life is essential. Hospitals should monitor moral distress and there should be workshops that could build moral resilience and maintain high professional quality of life.

The inner struggle of nurses, exploring moral distress among hospital nurses: A cross-sectional study

Moral Sensitivity and Moral Distress in Critical Care Unit Nurses

BackgroundNurses constitute the largest group of service providers in the healthcare system and significantly influence the quality of healthcare services. Factors such as ethical considerations may be related to the quality of care. This study aimed to determine the relationship between moral distress and the quality of clinical care among nurses working in Gonabad, Iran.MethodsAn analytical cross-sectional study was conducted on 252 nurses working in emergency, internal medicine, surgery, psychiatry, critical care and maternity wards at Allameh Bohlool Hospital from May to July 2023. This research used demographic information questionnaire, the revised Moral Distress Scale (MDS-R), and the Quality Patient Care Scale (QUALPAC). The significance level for the study was set at p < 0.05.ResultsThere was a significant relationship between the frequency of moral distress and the quality of clinical care (p = 0.032), as well as between the intensity of moral distress and the quality of clinical care (p = 0.043). Nurses who experienced moral distress more frequently and intensely provided better quality care. However, there was no significant relationship between the effect of moral distress and the quality of clinical care (r = 0.032, p = 0.619). Additionally, a significant statistical relationship was found between the intensity of moral distress and the physical dimension of clinical care quality (r = 0.171, p = 0.007), indicating that increased moral distress intensity was associated with higher quality of physical care.ConclusionsNurses who experience higher levels of moral distress, both in terms of frequency and intensity, perform better in the care they provide and deliver it in the best possible manner, particularly in the physical dimension of care.

Reducing nurses' autonomy can impair their decision-making and ability for appropriate interventions. Lowered independence hinders ethical reasoning, which may lead to moral distress. This descriptive correlation study investigates the relationship between professional independence and moral distress in 173 nurses working in emergency departments in Tabriz, Iran. Data were collected using questionnaires designed to assess professional autonomy and moral distress and analysed using descriptive and inferential statistics via the SPSS 13 software. The level of professional autonomy among emergency nurses was low (83.2±16.9), and moral distress, moderate (7.43±3.52). A statistically significant negative relationship was reported between professional independence and the frequency of moral distress (p=0.018). Bivariate analysis related professional autonomy with the frequency and intensity of moral distress. Multiple regression analysis showed that age significantly predicted moral distress (frequency, intensity, and total scores). Lack of autonomy hinders nurses from functioning effectively and efficiently in practice and even can lead to moral distress. Increasing professional independence and the use of experienced nurses as mentors in emergency settings to support younger nurses can help with the reduction of moral distress.