Decision-making in the neonatal intensive care unit (NICU) is complex. In grey zones (where there are multiple morally acceptable pathways), families and clinicians may disagree about the best plan. While negative moral phenomena (NMP) such as moral distress are well recognised within clinicians, little is known about parental experiences. We sought to understand parental experiences of decision-making, particularly if parents experienced NMP. This was a mixed-methodology phenomenological study, using surveys. Statistical analysis was used for categorical data and thematic analysis for textual data. Four tertiary or quaternary NICUs in Australia and Canada. Parents of infants admitted to NICUs between July 2018 and August 2022 who engaged in decision-making in grey zones. 71 parents (80% mothers) completed the survey. 80% were bereaved.Thematic analysis revealed five themes: (1) decision burdens, (2) internal tensions, (3) actualising beliefs and values through decision-making, (4) inauthentic shared decision-making (SDM) and (5) external factors that shaped decision-making.Parents reported variable experiences of SDM. Despite decisions being described as burdensome, 89% wanted to be very involved in SDM, while 63% felt included. Actualisation of beliefs and values was important. Time pressures, competing interests and environmental factors influenced internal tensions experienced. Despite framing as SDM, some parents reported feeling coerced and experiences consistent with NMP. Some parents do experience significant NMP during SDM in the grey zones of the NICU. Clinician awareness of NMP and their antecedents may enhance communication and the SDM process in this challenging setting.

Introduction Although studies of moral injury proliferated over the past decade, few studies have examined common moral injury symptom presentations. Methods Data were analyzed from a population-based sample ( N = 645) of combat veterans, healthcare workers, and first responders. All participants endorsed exposure to a potentially morally injurious event (PMIE) and completed the Moral Injury and Distress Scale (MIDS). Results Latent profile analysis revealed three distinct symptom profiles based on MIDS items assessing psychological, emotional, social, and spiritual symptoms of moral injury. The majority of participants (74.7%, n = 482) reported minimal moral injury symptoms. Approximately one in five participants (20.2%, n = 130) endorsed moderate levels of moral injury symptoms, and one in twenty (5.1%, n = 33) reported severe moral injury symptoms. All participants with the severe profile screened positive for probable moral injury on the MIDS (score ≥ 27); however, 9.1% had scores within normal limits on measures of posttraumatic stress and depression. After adjusting for demographics, those with moderate or severe moral injury symptoms were more likely than those with minimal moral injury symptoms to be younger, have fewer years of education, and identify as Hispanic. Discussion These findings support the use of the MIDS in measurement-based care to identify distinct clinical presentations of moral injury, including those with moderate to severe presentations that warrant further evaluation and potentially treatment.

Oncology nurses are at particular risk for closely related types of distress, such as compassion fatigue, burnout, occupational stress, and moral distress, because they are often the ones who must carry out what they consider to be medically futile treatments that may cause pain in a dying older patient. This study aimed to examine the influence of selected coping mechanisms on occupational stressors among oncology nurses in Jordan. A descriptive, correlational, cross-sectional design was employed. Data were collected between February and March 2024 from oncology nurses working in three major teaching hospitals in Jordan. Occupational stressors were assessed using the Nurse Stress Scale (NSS), and coping mechanisms were measured using the Brief COPE. Descriptive statistics, Pearson correlation analysis, and hierarchical multiple regression analysis were used to examine relationships between occupational stressors and coping mechanisms. Pearson correlation analysis revealed a statistically significant moderate positive correlation between the NSS Death and Dying subscale and the Brief-COPE Problem-Focused Coping subscale (r = 0.254, p < 0.01). A significant positive correlation was also found between overall coping mechanisms and occupational stressors (r = 0.33, p < 0.01). Regression analysis further demonstrated that coping mechanisms were significant predictors of occupational stressors (β = 0.441, p < 0.001). The findings indicate that higher coping scores were associated with higher stress levels, suggesting that coping strategies were more frequently employed in response to elevated occupational stress rather than serving as a protective factor. Jordanian oncology nurses who experience higher stress levels related to death and dying are more likely to employ problem-focused coping strategies, such as actively addressing challenges, seeking solutions, and obtaining support. Although these coping strategies are adaptive, the overall high stress levels observed suggest that occupational stress remains a serious concern for nurses' well-being and professional performance.

Moral courage and resilience protect ICU nurses from compassion fatigue, burnout, and moral distress: a multicenter cross-sectional and structural equation modeling study

“Moral distress” was introduced in nursing ethics to describe the experience of having the moral conviction about the right thing to do while having limited agency to enact it. It exists at the intersection of moral philosophy, moral psychology, and moral communities that influence our desires to act. Although moral distress has significantly impacted bioethics scholarship, it has had almost no presence in business ethics scholarship. We argue that moral distress is useful for understanding important problems of business ethics. We claim it may be missing from business ethics discourse not because it is not present but rather because it is ever-present, an existential condition brought on by the tension between profit maximization and other moral purposes. We consider how the moral communities of medicine and business can be morally supportive or distressing and set forth a taxonomy of moral conditions involving the relationship between knowledge, action, and desire.

Purpose: People living with delirium, dementia and exhibiting behaviours of concern (DDBoC) are becoming increasingly common in hospitals. Allied Health (AH) are a group of professionals who frequently work with people with DDBoC in the inpatient setting to support their rehabilitation goals. Little is known about the effect working with DDBoC has on the mental health and wellbeing of AH staff. The aim of this study was to examine the impact of working with patients living with DDBoC on AH staff on inpatient wards. Materials and methods: This study used a mixed methods concurrent triangulation design with three data collection methods: (i) retrospective audit (Jan 2021 to Dec 2022) of clinical incident data to establish prevalence of incidents related to patients with DDBoC and involving AH; (ii) cross-sectional online survey of AH staff wellbeing, and exposure to and experience with patients living with DDBoC; and (iii) semi-structured one-on-one interviews with AH staff exploring experiences working with DDBoC. The study period was between April and June 2023. Results: Thirty-nine incidents related to DDBoC involving AH staff were reported during the study period. Survey participants reported frequent exposure to DDBoC (44% reported >5 encounters in the past month) and high levels of support seeking (n = 35/50; 70%). Twenty-six percent (n = 13/50) of participants reported low levels of resilience and 28% (n = 14/50) reported high levels of burnout. Analysis of interview transcripts yielded four key themes: 'What we experience', 'How we are impacted', 'How we manage' and 'How we work together'. Despite most participants reporting normal levels of stress (n = 35; 70%), interview data suggested senior staff may experience and respond to stress differently. Work in this area impacted on team communication, confidence, and response to external factors outside team control. Conclusions: Working with DDBoC has a complex effect on AH staff wellbeing, eliciting feelings of reward, empathy, stress, fatigue and moral distress where person-centred care cannot be provided. AH staff appear to under-report incidents and require strategies to support their wellbeing when working with this patient population.

Operationalizing joy in nursing education: Simulation and interprofessional learning as catalysts for resilience and renewal.

Exploring moral distress in research students in a paediatric humanitarian research setting: a qualitative study from the Mavrovouni closed controlled access center, Lesvos, Greece.

Moral distress of intensive care unit nurses: a systematic review and meta-analysis.

The effect of motivational interviewing on ethical decision making and moral distress levels in intensive care nurses: Randomized controlled trial.

Nurses' Experiences of Serious Illness Conversations With Marginalized Patients in COVID-19.

Nurses are indispensable to the healthcare system, playing a vital role in patient care across various settings. While the nursing profession can be rewarding, it is also fraught with significant emotional and ethical challenges [1]. Among these challenges, moral distress stands out as a critical issue that can profoundly affect the mental health and well-being of nursing staff. Moral distress arises when nurses recognize the ethically appropriate course of action but cannot follow through due to external constraints such as institutional policies, lack of resources, or conflicting professional responsibilities. This unresolved distress can accumulate over time and contribute to more severe mental health outcomes, including depression [2].

This qualitative study explored nurses' experiences of facing death while caring for bedridden patients in palliative and long-term care settings. Nurses are the primary witnesses to the final phase of life, where technical competence and emotional endurance coexist. Understanding how nurses perceive death and how knowledge, time, and communication affect their caregiving can provide insights into improving end-of-life nursing practices. The study was conducted with 70 primary nurse-caregivers of bedridden patients who were hospitalized in the palliative clinic of a university and an educational research hospital in Istanbul between April and August 2024. The research data were obtained through face-to-face interviews using a semi-structured interview form. The interviews were recorded on a voice recorder. The data obtained from the interviews were analysed thematically. Three main themes were identified: Deficits in Knowledge and Education, Time Management, and Communication and Coordination. Nurses expressed uncertainty and emotional tension when providing care for dying patients. Inadequate end-of-life education heightened their fear of making mistakes. Heavy workload and limited time constrained emotional presence at the bedside. Fragmented communication among healthcare professionals increased feelings of isolation and moral distress. Across these themes, nurses experienced a silent but persistent awareness of death that shaped their professional identity and coping strategies. Nurses caring for bedridden patients constantly face death, balancing medical duties with human vulnerability. Including death education, emotional support, and effective interdisciplinary communication in nursing practice can improve nurses' resilience and the quality of end-of-life care.

The sources and effects of moral distress on nursing performance in emergency departments; a review of literature

Medication errors are frequent in Neonatal Intensive Care Units, where complex weight-based dosing and fragile physiology amplify the consequences of mistakes. Nurse-initiated medication queries function as a critical yet vulnerable safety barrier, but little is known about how neonatal intensive care nurses experience and navigate these decisions in everyday practice. To explore how registered nurses in Neonatal Intensive Care Units experience and interpret initiating medication-safety queries during drug administration, and how they perceive individual, interpersonal and organisational-environmental conditions shaping these decisions. Interpretative phenomenological study using Interpretative Phenomenological Analysis, rooted in Heideggerian hermeneutic philosophy and subsequently interpreted through the Human Factors Engineering lens. Purposive, maximum-variation sampling recruited neonatal intensive care nurses from three Saudi Arabian hospitals; 25 semi-structured interviews were conducted between February and May 2025 and analysed using a six-stage protocol supported by rigorous strategies for credibility and trustworthiness. Interviews with 25 registered nurses yielded four interrelated experiential themes: (1) knowledge and confidence barriers-fear of appearing incompetent and uncertainty about calculations suppressed queries despite clinical experience; (2) interpersonal dynamics-physician approachability and peer support facilitated queries, whereas hierarchical norms created communication barriers; (3) organisational and system pressures-high workloads and a blame culture discouraged queries, while supportive policies and a strong safety climate empowered nurses and (4) moral and professional tensions-nurses experienced ethical conflict as they balanced patient advocacy with maintaining collegial relationships. Nurse-initiated medication queries in Neonatal Intensive Care Units are not simply a function of individual vigilance or technological support. Sustained medication safety requires integrated interventions that strengthen nurses' clinical self-efficacy, reduce obstructive hierarchies, redesign workload and escalation pathways and explicitly address the moral distress arising when safety concerns are voiced or suppressed. For critical care nurses working in Neonatal Intensive Care Units, nurse-initiated medication queries are a key, yet fragile, safety barrier. Findings underscore the need for organisations to combine electronic decision-support with assertiveness and communication training, NICU-specific workload optimisation, and ethically oriented debriefing and supervision. System-level changes targeting safety culture and hierarchical barriers are essential to sustaining proactive medication safety behaviours among NICU nurses.

Evolving nursing roles in assisted dying services in New Zealand: A scoping review.

This study explored the lived experience of moral distress among intensive care unit (ICU) nurse practitioners (NPs). Although ICU NPs were interviewed, many reflected on their prior experience as registered nurses (RNs) to describe the differences in responsibility, authority, and moral burden in their advanced practice role. This study aimed to describe the lived experience of moral distress in ICU NPs, specifically emphasizing its effect on their professional and personal lives. The researcher used a descriptive phenomenological study design to examine moral distress among the ICU NP population. Employing purposive sampling, the researcher conducted one-on-one interviews with 17 ICU NPs to explore moral distress, identify themes, and provide thematic analyses using the Colaizzi method. The overarching theme, A Unique NP Experience, captured how moral distress was shaped by the dual expectations of advanced clinical decision making and constrained authority in hierarchical care settings. Three themes supported this experience: moral distress causes, negative emotional and psychological effects, and participants' reflective interpretations. Moral distress was described as distinct from that experienced in RN roles, often surfacing during ethically complex ICU cases such as end-of-life decisions. This research aimed to catalyze a thoughtful conversation regarding moral distress as experienced by NPs and to promote interventions that mitigate moral distress and its negative effects. The findings hope to encourage further moral distress research in NPs of all specialties, as well as to examine the perceived hierarchy that exists in the acute care setting.

This article presents a scoping review of research on learning and teaching a second or a foreign language (L2 research) that employed Q methodology. The main aim was to assess the published Q studies on language learners’ and language educators’ opinions and beliefs concerning a variety of personally and socially important issues. This review was implemented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of three academic databases was conducted, namely, Academic Search Complete, Scopus, and Web of Science. Titles and abstracts of articles in these databases were subjected to the inclusion of the terms ‘Q methodology/Q method’, ‘language learning’, and ‘language teaching’. In total, 53 relevant articles published in English language peer-reviewed academic journals between the year 2013 and 2023 were analysed. We examined the geographical distribution of L2 studies that employed Q as well as the topics and key methodological decisions made by their authors. This scoping review found evidence of growing popularity of Q methodology among L2 researchers, particularly over the past 4 years. The published articles explored a wide variety of issues, including L2 motivation, language beliefs and novel for L2 research topics, such as boredom in the L2 classroom and language teachers’ moral distress. This scoping review concludes by considering implications for future development of L2 research employing Q.

ABSTRACT Background: Moral injury has garnered increasing attention in recent decades, extending from the military to professions like healthcare and policing. Defined as psychological, social and spiritual suffering resulting from moral transgressions, moral injury is now recognised as a multidimensional phenomenon. A growing body of empirical and theoretical research is establishing a foundational understanding of its psychological, moral and contextual dimensions. Their findings underscore the need to broaden the understanding of moral injuries sustained in the workplace, as well as work-related mental health more generally, by incorporating ethics- and context-informed approaches. This applies to both research and practice. However, the actual practical implications of their findings remain unexplored. Objective: This contribution makes a start in addressing the gap between emerging moral injury research and its practical implementation. It seeks to identify potential interventions and caution against approaches that may inadvertently exacerbate harm. Approach: Drawing on recent interdisciplinary literature, this contribution synthesises key findings and translates them into practical recommendations. It proposes individual, organisational and wider societal levels of intervention, as such with particular attention to ethics-informed and context-sensitive strategies. Results: Research findings point to several promising interventions, including resilience training, ethics education, and moral case deliberation, targeted at both frontline practitioners and leadership. Organisational approaches such as Just Culture initiatives and practices of transformative recognition are also suggested. Conversely, the paper identifies potential pitfalls in popular responses such as the uncritical use of positive psychology or ‘integritism’, which may inadvertently reinforce moral distress. Conclusions: Adequately addressing moral injury in high-impact professions requires a comprehensive, multi-level approach. Cross-disciplinary collaboration is likely to be beneficial, involving mental health professionals, ethicists, chaplains and organisational specialists, to address the various dimensions of moral injury. This contribution has offered several research-informed suggestions for interventions, which nevertheless require further theoretical development and empirical examination.

'Moral resilience' is a concept whereby individuals sustain and restore their integrity in the face of moral distress. While the key aspect of this concept is the individual's integrity, some indicate that personal and professional integrity differ. In clinical practice, a phenomenon is observed where nurses demonstrate resilience and behave ethically in accordance with their professional values. However, this phenomenon cannot be fully explained by moral resilience. This study proposes the concept of ethical resilience, a phenomenon in which resilience and ethical behaviour are demonstrated towards ethical issues, by undertaking concept synthesis. Articles that mention ethical resilience were selected from among those released on PubMed and CINAHL and Web of Science and Eric (up to 20 January 2024). Walker and Avant's method was used for the concept synthesis. Four attributes were extracted for ethical resilience: (1) grasping ethical issues, (2) integrity as a nurse, (3) flexible and tenacious approach, and (4) collaboration to resolve ethical issues. Based on the results of concept synthesis, nurses' ethical resilience was defined as the ability to sustain or restore professional competence when facing ethical issues while assessing the situation and collaborating with others. This concept describes a positive approach to ethical issues oriented towards professional ethical behaviour. The concept of ethical resilience was derived from previous studies accumulated to this date. Research on resilience to ethical issues and moral distress is still in its infancy, and thus it must be examined further. It is expected that discussion on these matters will advance further along with the concept of ethical resilience.