moral distress道德困境研究

目的：了解深圳市护理实习生道德困扰、职业倦怠现状，探究其相关性。方法：用便利抽样法选取深圳4所市属公立医院299名实习护生为研究对象，采用一般资料问卷、中文版护士道德困扰量表、护士职业倦怠问卷进行调查。结果：实习护生的道德困境得分为27.89 ± 28.62，职业倦怠得分为47.69 ± 22.36。在职业倦怠得分上，不同学历(F = 12.916, P < 0.001)、不同年龄段(F = 8.170, P < 0.001)的护理实习生之间具有统计学差异。是否选择护理为继续就业及进修意愿的护理实习生的道德困扰(t = 3.109, P = 0.002)、职业倦怠(t = 5.398, P < 0.001)得分有统计学差异；道德困扰与职业倦怠相关系数r = 0.287 (P < 0.001)。结论：深圳市护理实习生普遍存在道德困扰及职业倦怠，两者之间相互影响。建议实习护生管理者、教育者能重视这一现象并帮助实习护生降低道德困扰及职业倦怠。

目的：构建基于赋权理论的护理学本科生道德勇气培训方案，并了解其应用效果，为道德勇气培养相关研究提供参考。方法：选取即将实习的在校本科护理学专业学生作为研究对象，采取抽签法进行分组。试验组采用基于赋权理论的护理学本科生道德勇气培训方案进行干预，对照组采取常规讲授式授课方式进行干预，比较两组的道德勇气培训效果。结果：培训后，试验组道德勇气得分(72.37 ± 10.98)分，对照组道德勇气得分(66.84 ± 10.23)分，两组差异具有统计学意义(t = −2.780, P < 0.01)。结论：基于赋权的道德勇气培训方案能有效提升护理学专业本科生道德勇气及道德操守、良好照护承诺、同情心及真正与患者同在维度的表现，该培训方案能够为道德勇气培养相关研究提供一定参考。

近年国家呈现未富先老态势，国民健康不容乐观，全国随之推行健康中国建设，护理服务业因其护理功效的广泛性与持久性受到关注，尤其是历经严峻的新冠疫情之后，加之行业乱象频发，我国对护理人才的需要呈现爆发式增长。本文聚焦医院护工群体的现状，以成都市为调查点，通过探究自我认同、社会支持的情况与相互关系。借助定量与定性分析得出：自我认同偏低，其原因为自我现状感知消极、工作体验消极，而社会支持对于自我认同的提高确实存在着重要作用，但朋友支持反而不利于自我认同的提高。希望政府给予具有经济性、有效性、可行性且方便实施的方式营造健康的行业大环境；建议医院划分职责纠纷用好护工；鼓励行业划分职业等级以此吸收新鲜血液。助力医院护工脱离生存困境，助力医疗体系改革，响应“十四五”全面建成健康中国规划。

叙事护理是以人性化服务为出发点，将叙事融入到临床护理工作中的一种模式，它有着很强的人文属性，通过叙事能使患者的不良情绪得以减轻，使患者的治疗依从性得以提高，最终有利于患者疾病的恢复、身心的健康，完全契合整体护理的开展。本文就叙事护理的概念、意义、实施步骤、国内外现状、影响因素等方面就行综述，以期为临床进一步开展叙事护理提供参考。

本研究采用民族志方法考察医学生在医学教育过程中如何形成对患者的想象。通过一年田野调查，研究发现医学生在各种教学情境中逐渐构建出符号化、理想型和情绪中立三类患者形象，这些想象在便于知识传授的同时也弱化了学生的伦理关怀和同理心。文章指出医学社会化中隐性课程的影响以及医学知识的文化偏见，讨论医学生对患者的想象如何影响未来临床实践，并提出医学人文教育改革建议。

医生向来被认为是崇高的职业，但其处境却不容乐观。本文从心智感知角度解释医生形象。研究1发现相较于刻板印象内容理论的积极形象，心智感知理论表明我们过于关注医生的能动性，而忽略感受性。研究2a与2b发现高能动性削弱人们对医生的痛苦感受性。研究启发未来对医患关系的研究，警惕“造英雄”现象，后续应继续探索英雄角色可能的负面效应。

内部审计在公司治理中扮演重要的角色，但同时也存在角色冲突，使内部审计陷入道德困境。我们在研究审计伦理和职业道德的基础上，认为道德勇气是内部审计师必备的道德特征之一，强调道德勇气在克服冲突和恐惧方面的重要作用。内部审计师遵守国际内部审计师协会和中国内部审计协会的职业道德规范，提高内部审计的独立性和客观性。如果企业存在财务造假、欺诈等问题使内部审计师面临道德困境时，企业最高管理者或董事会、审计委员会应与内部审计保持一致，增强他们的道德勇气，发挥内部审计的监督功效。

道德判断，一直作为道德心理领域的研究重点而备受关注。近年来，二元道德理论的兴起，为道德判断的研究提供了一个崭新视角，并开始引导人们转向关注道德判断的内在心理机制。本研究通过文献梳理发现，二元道德理论以全新的伤害概念，重新界定了传统的道德判断，其主要观点认为，伤害感知是道德判断的核心成分，且伤害感知与道德判断互为因果关系。此外，伤害感知自身存在的连续性和包容性，同时赋予了道德判断的多元化特征。

AED医疗急救网络满足了突发事件中突发心脏骤停者的迫切急救需求，提高了医疗网络信息化服务的普及度与可行性。在不断改革的信息社会中，AED医疗急救网络给现代急救医疗网络系统带来了特殊的法律困境。本文以上海为例，针对AED医疗急救网络的基本构架、运行流程、运行模式进行研究，发现其问题的产生是由于实体性医疗和虚拟性医疗中存在矛盾、急救角色陷入道德自主性和有效性困境、医疗的责任性和合法性界定模糊等多方面综合作用的结果，从AED医疗急救网络中医疗、角色、法理、政府四个主体方面进行改善，同时也需要注意可能存在的负面影响。通过对公众进行急救理论和急救技能的普及培训、加强医疗质量监控、建立社区医疗资源共享平台、依靠反身法干预网络自治、利用高校社团辐射公益组织等措施的实行，有助于提高我国医疗急救网络的运行能力和效率，完善社会安全性的配套保障和医疗卫生紧急事件的处理能力，为全面推动医疗急救网络事业发展、切实保障人民群众生命安全和城市运行安全有着较高的现实指导意义。

Abstract Objective To investigate the experiences of healthcare staff in nursing homes during the COVID-19 pandemic. Design Individual interviews. Latent qualitative content analysis. Setting Ten nursing homes in Sweden. Subjects Physicians, nurses and nurse assistants working in Swedish nursing homes. Main outcome measures Participants’ experiences of working in nursing homes during the COVID-19 pandemic. Results Four manifest categories were found, namely: Balancing restrictions and allocation of scarce resources with care needs; Prioritizing and acting against moral values in advance care planning; Distrust in cooperation and Leadership and staff turnover – a factor for moral distress. The latent theme Experiences of handling ethical challenges caused by the COVID-19 pandemic gave a deeper meaning to the categories. Conclusion During the pandemic, nursing home staff encountered ethical challenges that caused moral distress. Moral distress stemmed from not being given adequate conditions to perform their work properly, and thus not being able to give the residents adequate care. Another aspect of moral distress originated from feeling forced to act against their moral values when a course of action was considered to cause discomfort or harm to a resident. Alerting employers and policymakers to the harm and inequality experienced by staff and the difficulty in delivering appropriate care is essential. Making proposals for improvements and developing guidelines together with staff to recognize their role and to develop better guidance for good care is vital in order to support and sustain the nursing home workforce. KEY POINTS The COVID-19 pandemic has affected both patients and staff in nursing homes, in Sweden and worldwide. Our study highlights that during the COVID-19 pandemic, nursing home staff encountered several ethical challenges which caused moral distress. Moral distress stemmed from not being given adequate conditions to perform their work, thus not giving the residents appropriate care. Moral distress could also originate from nursing home staff’s feeling of being forced to act against their moral values.

Burnout and moral distress are increasingly recognized as critical challenges within healthcare systems, particularly in high-stress environments such as intensive care units (ICUs). This cross-sectional study investigates the prevalence and interrelationships of moral distress, burnout, and turnover intentions among ICU nurses in Latvia, a country facing significant nursing shortages and structural workforce challenges. A total of 155 ICU nurses completed validated instruments assessing moral distress, the three subscales of burnout (personal, work-related, and client-related), and intentions to leave the profession. The results indicate that 68.2% of respondents experienced moderate to high levels of moral distress, especially related to providing aggressive treatment contrary to clinical judgment. Burnout scores were highest in the personal and work-related dimensions, with emotional exhaustion strongly correlated with moral distress. Approximately 30% of participants reported active intentions to leave their positions. Regression and mediation analyses confirmed that moral distress significantly predicted both burnout and turnover intentions, with burnout partially mediating this relationship. These findings highlight urgent risks not only to nurse well-being but also to healthcare quality and sustainability. This study underscores the importance of systemic interventions, including structured workload assessment tools, psychological support, and ethical consultation services. The results contribute to the international literature and offer context-specific insights for workforce resilience in Eastern European health systems.

Exploring how nursing home nurses who care for residents with dementia experience moral distress.

Latvia faces one of the lowest nurse-to-population ratios in the EU, resulting in critical staff shortages in intensive care units (ICUs). Nurses frequently care for more patients than recommended, which not only compromises patient safety but also places heavy psycho-emotional burdens on staff. The aim of this study was to examine organizational-level relationships between objectively measured ICU nursing workload and subjectively reported psycho-emotional outcomes, including moral distress, burnout, and intention to leave one’s job. A secondary analysis combined data from two cross-sectional studies conducted in 2025. Workload was measured using 3420 Nursing Activities Score (NAS) protocols from three hospitals, while 155 ICU nurses from 16 units completed validated instruments assessing moral distress, burnout, and turnover intentions. The findings revealed persistent nurse shortages, with one ICU showing deficits exceeding 70% and mean NASs above 100 points per nurse per shift. Nurses reported moderate moral distress, particularly in situations of unsafe patient ratios and aggressive treatment, while burnout levels were moderate to high, especially in personal and work-related dimensions. About one-quarter of respondents were actively considering leaving their jobs. Moral distress significantly correlated with burnout (r = 0.357, p < 0.001), and organizational-level comparison indicated that higher workload was associated with greater emotional strain. These results not only highlight urgent national challenges but also resonate with international evidence on the link between unsafe staffing, moral distress, and workforce sustainability. Implementing systematic workload monitoring, safe staffing ratios, and structured support mechanisms is essential to safeguard ICU nurses’ well-being, reduce turnover, and protect patient safety in both Latvian and global contexts.

Deficiencies emerge in the care provided by nurses because of the complex treatment plans, shortage of labour resources and communication problems in neonatal intensive care units (NICUs). Knowing how to provide quality patient care but being unable to maintain it because of individual or institutional issues can lead to moral distress among nurses.

BACKGROUND Moral distress affects the health of home care nurses and can lead to the decision to leave the profession early. Little is known about the ways to reduce moral distress in the context of home care nursing. OBJECTIVE Identification of interventions to reduce moral distress in home care nurses. METHOD Interviews with home care nurses (n=20; 04-08/2023) from different organizations and with from different federal states and with care ethicists (n=6; 10/2023-04/2024) were conducted, transcribed and analyzed via qualitative content analysis. RESULTS On the one hand, interventions were identified that directly address the situations triggering moral distress or relate to the organization of work: e.g., support from superiors, evaluation of informal care, adaptation of the performance and billing system, family-friendly working time models, greater scope for decision-making, and improved cooperation between healthcare stakeholders. On the other hand, the respondents would like to see "ethical interventions", such as ethics counseling, and more opportunities for professional exchange, e.g., in the context of team meetings on ethical issues. CONCLUSIONS In addition to improving working conditions and creating a positive organizational culture, outpatient ethics consultations at provider level or across care services represent an important intervention.

Abstract Objectives The purpose of this study was to determine whether integrating ethical simulation-based education (SBE) into prelicensure nursing students’ curriculum would impact moral distress levels. Methods A longitudinal mixed methods design was used to measure moral distress levels and collect qualitative data related to the SBE. Results In the final sample (n=48), there was no statistically significant difference among moral distress scores over the three measured time points. Thematic analysis revealed four primary themes: (1) powerlessness as a student; (2) students have a basic moral understanding; (3) discomfort in speaking up with integrity; and (4) students understand the importance of emotional intelligence. Conclusions The final and lowest survey score, combined with the results of the thematic analysis, indicates that integrating ethical SBE throughout curriculum could impact moral distress. In addition, training educators in maintaining psychologically safe environments can empower students and potentially reduce burnout.

Background Moral distress is a significant challenge faced by clinical internship nursing students. Most current studies investigate the impact of external factors on nursing students’ moral distress. However, there is a lack of in-depth exploration of the interactions between various moral distress items. Research objective This study aims to construct a network structure of moral distress among clinical internship nursing students, while exploring the touchpoints of moral sensitivity and moral resilience on moral distress, to identify potential targets for moral distress intervention. Research design A cross-sectional design utilized acceptable validity scales. Network analysis was conducted using R (Version 4.4.0). Regularized partial correlation was utilized to describe the associations between different nodes in the network. Central nodes were identified through centrality indices. Participants and research context The participants in this study are 372 nursing students undergoing clinical internships at a comprehensive teaching hospital in Changsha, China. Ethical considerations This study was approved by the hospital ethics committee (Review Number: Express 241098). Written informed consent was obtained from all participants. Results In the moral distress network, the connections between MD3 “I provide life-sustaining treatment per the family’s wishes” and MD4 “Despite only extending survival, I implement life-saving measures” are the strongest. MD18 “Decline in service quality due to poor team communication,” MD19 “I ignore situations lacking adequate information for informed consent,” and MD17 “I collaborate with colleagues unable to meet the patient’s treatment needs” are the central nodes of the moral distress network. In the relational network, MD19 is a critical connection point linking moral distress with moral sensitivity and moral resilience. Conclusion Future interventions for moral distress could focus on the strongly related and significant distress (MD3, MD4, MD18, MD19, MD20, and MD17) mentioned in this study, and develop scientific and targeted interventions to reduce clinical internship nursing students’ moral distress.

Background/Objectives: Turnover intention among intensive care unit (ICU) nurses remains consistently higher than that observed in other clinical departments. A weakened professional identity and exposure to ethically challenging situations may further intensify nurses’ intention to leave. This study aimed to examine the influence of moral distress, person-centred care, and nursing professional pride on turnover intention among ICU nurses in South Korea. Methods: A descriptive cross-sectional design was employed using a convenience sample of 203 ICU nurses from three general hospitals in South Korea. Data were obtained between 26 September and 31 October 2024 and analysed using IBM SPSS Statistics for Windows, version 29.0.2.0, with t-tests, one-way analysis of variance, Pearson’s correlation coefficients, and stepwise multiple regression analysis. Results: Two subdomains of nursing professional pride—role satisfaction and willingness to stay—along with gender (male) and the futile care subdomain of moral distress were the main factors influencing turnover intention. These variables collectively explained 24.9% of the variance in turnover intention (F = 17.78, p < 0.001). Conclusions: Strengthening nursing professional pride—particularly role satisfaction and willingness to stay—and reducing futile care-related moral distress may help lower ICU nurses’ turnover intention. Organisational strategies, including ethical management programmes and supportive policies, are recommended to enhance nursing professional pride, alleviate moral distress, and promote long-term nurse retention.

This study aimed to explore the lived experiences of moral distress among nursing students during clinical practicums in psychiatric wards. In-depth interviews were conducted with ten nursing students between July 7 and July 20, 2025. The collected data were analyzed and described using Colaizzi’s phenomenological method. A total of four categories, 11 theme clusters, and 25 themes were derived. The four categories were as follows: structured daily routine and excluded autonomy, intersection of control and care, stagnant recovery time, and becoming one’s only place to live. These results indicate that moral distress experienced by nursing students reflects both personal struggles and the restrictive nature of psychiatric ward environments. Based on these findings, it is necessary to create a recovery-oriented environment in psychiatric wards and to develop and implement programs that enhance nursing students’ moral sensitivity.

No abstract available

BACKGROUND Exploring the potential relationships among moral distress (MD), general health (GH) levels, secondary traumatic stress (STS) and levels of empathy within nursing personnel is of specific interest. AIMS This study aimed to investigate the occurrence of MD and its associations with GH, STS, and empathy levels among nurses employed in eight public hospitals across the Attica Basin in Greece. METHODS Between January and March 2020, a cross-sectional study was conducted among nursing staff working in surgical, medical, and psychiatric units of 6 public hospitals and 2 psychiatric institutions in the Attica Basin. Respondents completed the validated Greek versions of the Moral Distress Scale-Revised, the Jefferson Scale of Empathy for Health Professionals, the 28-item General Health Questionnaire, and the Secondary Traumatic Stress Scale. Participants were asked to complete a paper-pencil data sheet consisting of 27 sociodemographic questions. RESULTS A total of 267 out of 350 distributed questionnaires were completed and returned, corresponding to a response rate of 76.3%. The findings showed that nurses experienced moderate MD in both frequency and intensity, moderate-to-high GH and empathy, and moderate levels of STS. Psychiatric nurses reported lower STS and better GH than their counterparts in general hospital settings. Multivariate analysis demonstrated a statistically significant association between increased STS and deterioration in GH. A rise in the frequency of MD is significantly linked to an increase in its intensity. LINKING EVIDENCE TO ACTION Incorporating proven screening methods, programs that build resilience, supportive workplace cultures, ongoing evaluations over time, and peer support systems creates a complete approach to lowering moral distress and secondary traumatic stress, improving nurse well-being, maintaining work efficiency, and enhancing the overall safety and quality of healthcare services.

Moral distress is a prevalent and disruptive force in palliative care practice, undermining clinicians’ capacity to uphold ethical integrity amid systemic and situational constraints. As frontline providers are increasingly challenged by complex end-of-life scenarios, the cultivation of moral resilience emerges as an essential strategy for sustaining compassionate, ethically grounded care. This short communication advocates for a deliberate shift toward fostering moral resilience through education, interprofessional collaboration and institutional reform to safeguard healthcare providers’ well-being and enhance ethical practice in palliative settings.

Decline in compassionate care is potentially linked to moral distress and fostering different aspects of organizational citizenship behavior can reduce the outcome of moral distress. This study aimed to determine the mediating role of organizational citizenship behavior in the relationship between compassionate care and moral distress among nurses. For this purpose, a correlational study design using structural equation modeling was employed. Between December 2023 and March 2024, 300 nurses were selected through convenience sampling from hospitals in Fars Province, southern Iran. Data were collected using the Organizational Citizenship Behavior Questionnaire, the Compassionate Care Questionnaire for Nurses, and the Moral Distress Questionnaire. Data analysis was conducted using SPSS version 22 and Smart-PLS software. Our findings showed that compassionate care, combined with the mediating role of organizational citizenship behavior, significantly impacted moral distress (t = 2.442, P < 0.015, β = -0.071). Pearson’s correlation coefficients showed that compassionate care had a positive and significant relationship with organizational citizenship behavior (r = 0.444, P < 0.001) and a negative and significant relationship with moral distress (r = -0.353, P < 0.001). It is therefore recommended that managers in clinical systems focus on training nurses who exhibit appropriate organizational citizenship behavior in health-care settings.

Nursing interns often faced moral distress in clinical practice, similar to registered nurses, which can lead to compassion fatigue. The roles of moral resilience and professional identity in influencing the psychological well-being of nursing interns are recognized, but the interrelationships among moral distress, moral resilience, professional identity, and compassion fatigue in this group remain unclear. This study aimed to investigate the impact of moral distress on compassion fatigue among nursing interns and to explore the mediating role of moral resilience and professional identity. A quantitative cross-sectional study was conducted with 467 nursing interns. Data were collected using Compassion Fatigue Short Scale, Moral Distress Scale-revised, Rushton Moral Resilience Scale, and Professional Identity Scale. Data analyses were performed using SPSS 22.0 and Amos 21.0, adhering to the STROBE statement. The mean scores for compassion fatigue, moral distress, moral resilience, and professional identity were 35.876, 44.887, 2.578, and 37.610, respectively. Moral distress was positively correlated with compassion fatigue. Structural equation modeling showed that moral resilience and professional identity partially mediated the relationship between moral distress and compassion fatigue (β = 0.448, P < 0.001). The findings suggest that moral distress directly influences compassion fatigue among nursing interns and also exerts an indirect effect through moral resilience and professional identity. Interventions aimed at enhancing moral resilience and fostering a strong professional identity may help mitigate the adverse effects of moral distress on compassion fatigue among nursing interns.

Moral sensitivity, missed nursing care and moral distress among healthcare professionals have received considerable attention in recent years. These factors represent important healthcare challenges for new nurses (graduation to 2 years of work experience). However, studies on the relationships among these variables in the context of new nurses in China remain lacking. AIMS To explore the relationships among moral sensitivity, missed nursing care and moral distress in the context of new nurses in China. RESEARCH DESIGN A cross-sectional descriptive survey was conducted. PARTICIPANTS AND RESEARCH CONTEXT A total of 228 new nurses were recruited from three tertiary hospitals in Qingdao, Shandong Province, China. Participants provided their sociodemographic and professional information and completed the Chinese Moral Sensitivity Questionnaire-Revised Version, the Chinese Missed Nursing Care Survey Version and the Chinese Moral Distress Scale-Revised Version. The data were analysed using Spearman's correlation analysis and multiple linear regression analysis. RESULTS The means and standard errors of moral sensitivity, missed nursing care and moral distress were 40.71 (0.39), 9.82 (0.78) and 34.87 (2.41), respectively. The variable of missed nursing care exhibited a significant negative relationship with moral sensitivity and a significant positive relationship with moral distress. Regression analysis revealed that the main factors influencing new nurses' moral distress were educational background, nature of job, current unit, frequency of night shifts and the dimensions of moral strength and responsibility. These factors can explain 14.9% of the total variation. CONCLUSION The findings revealed that higher rates of missed nursing care were associated with lower moral sensitivity and greater moral distress among new nurses. Therefore, developing interventions to reduce missed nursing care may be a promising strategy for improving moral sensitivity and preventing moral distress among new nurses. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE In hospitals, moral distress can be improved by focusing on modifiable factors such as staffing resources, leading to better promoting new nurses' health and improving the quality of care. This study can highlight practices accounting for moral sensitivity and missed nursing care in nursing research and training programmes. REPORTING METHOD Strengthening the reporting of observational studies in epidemiology (STROBE) statement. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.

No abstract available

Background Moral distress is a far-reaching problem for nurses in different settings as it threatens their health. Aim This study examined which situations lead to moral distress in home-care nursing, how and with which consequences home-care nurses experience moral distress, and how they cope with morally stressful situations and the resulting moral distress. Research design A qualitative interview study with reflexive thematic analysis was used. Participants and research context We conducted semi-structured interviews with 20 home-care nurses in Germany. Ethical considerations The study was approved by the Data Protection Office and Ethics Committee of the German Federal Institute for Occupational Safety and Health. Findings Twenty (14 female and 6 male) home-care nurses were interviewed between April and August 2023 at their chosen location. The situations leading to moral distress were inadequate care of the person in need of care, not being able to protect one’s health, extended responsibility for the entire care arrangement, work–privacy conflicts, and conflicts between the understanding of care or professional ethics and the performance and billing system. The nurses experienced moral distress as they worked alone and provided care in the patient’s territory. Short- and long-term strains with destructive cognitions, negative emotions, physical symptoms, and health consequences were reported. They faced challenges in coping with moral distress on institutional and individual levels. Conclusions In cases of tension between the service and billing system and the understanding of these nurses’ care services, moral distress is unavoidable. Alternative forms of organization and billing modalities, such as payment by time and the expansion and refinancing of service, should be implemented. The latter relates to systematic case and ethics meetings. Further, a transfer of medical activities, such as the prescription of wound material to registered nurses, could prevent morally stressful situations and improve patients’ quality of care.

Abstract Aims To examine a novel moderated‐mediation model, investigating whether personal accountability moderates the link between nurse workload and missed nursing care and whether missed nursing care mediates the association between workload and moral distress. Design Nested diary study. Methods Data spanning from February 2019 to February 2023 were collected from 137 nurses working in various inpatient wards in two medium‐sized hospitals. Nurses reported care given to specific patients on three to five occasions across different shifts, establishing nurse‐patient dyads. Validated measures of missed nursing care, personal accountability, moral distress and workload were analyzed using mixed linear models to test the nested moderated‐mediation model. Results Under high workload conditions, nurses with higher personal accountability reported lower frequencies of missed nursing care compared to those with lower personal accountability. In contrast, under low workload conditions, personal accountability did not significantly influence missed nursing care occurrences. Furthermore, the interaction between workload and personal accountability indirectly affected nurses' moral distress through missed nursing care. Specifically, higher personal accountability combined with lower missed nursing care contributed to reduced levels of moral distress among nurses. Conclusion The study highlights accountability's dual role—safeguarding against care omissions and influencing nurses' moral distress amid rising workload pressures. Implication for the Profession and/or Patient Care Cultivating a culture of accountability within healthcare settings can serve as a protective factor against the negative effects of workload on patient care quality and nurse psychological distress, highlighting the need for organizational interventions to promote accountability among nursing staff. Impact By recognizing accountability's pivotal role, organizations can implement targeted interventions fostering accountability among nurses, including training programs focused on enhancing responsibility/ownership in care delivery and creating supportive environments prioritizing accountability to achieve positive patient outcomes. Reporting Method The study has adhered to STROBE guidelines. Patient or Public Contribution No patient or public contribution.

BACKGROUND Compassion fatigue and burnout have detrimental effects on nursing students. Moral distress has been recognized as a contributing factor to both, potentially impacting the intention to leave nursing programme. AIM To examine relationships among moral distress, compassion fatigue and burnout on intention to leave the nursing programme among nursing students. METHODS A cross-sectional correlational design was used. Four hundred eighty-four nursing students from nine higher educations participated. Data were collected using the Moral Distress Scale-Revised, Compassion Fatigue Self-Test, and a single item examining the intention to leave. RESULTS Mild to moderate levels of moral distress but high levels of compassion fatigue and burnout were reported. In regression analysis, year of study (OR = 14.323, CI = 1.273-161.143, p < 0.031), length of clinical learning (OR = 1.061, CI = 1.020-1.103, p < 0.003), moral distress (OR = 3.181, CI = 1.848-5.475, p < 0.001), burnout (OR = 1.165, CI = 1.118-1.214, p < 0.001) were associated with a higher chance of intention to leave. Attendance of an ethics course for >30 h (OR = 0.164, CI = 0.041-0.653, p < 0.010) and the interaction between moral distress and burnout (OR = 0.977, CI = 0.968-0.987, p < 0.001) were associated with a significant decrease in the intention to leave. CONCLUSION Burnout is a strong predictor for intention to leave the nursing programme among nursing students. Interventions addressing moral distress, compassion fatigue, and burnout might prevent intention to leave the nursing programme.

To explore nursing students' moral distress (MD) experiences in clinical settings.

PURPOSE This study investigates the relationship between burnout levels of moral distress and missed nursing care in pediatric nurses. DESIGN AND METHOD A cross-sectional study was conducted between November and December 2023. Pediatric nurses working in two hospitals and providing direct care to children (n = 140) completed the Moral Distress Scale-Revised Pediatric Nurses, MISSCARE Survey - Pediatric Version and Burnout Measure-Short Version questionnaire. Multivariate regression analysis modeling was applied to test the mediating effect on the relationship between burnout, moral distress, and missed nursing care. RESULTS There was a significant positive correlation between the Moral Distress Scale-Revised Pediatric Nurses and its sub-dimensions and the Burnout Measure-Short Version (p < 0.05). There was a significant positive correlation between the mean MISSCARE- Survey-Ped score of the nurses participating in the study and its sub-dimensions and Burnout Measure-Short Version (p < 0.05). Providing Benefit-Do No Harm, one of the Moral Distress Scale-Revised Pediatric Nurses sub-dimensions, and Labour Resources, one of the MISSCARE sub-dimensions, were found to be predictors of burnout. The ethical principle of Providing Benefit-Do No Harm was found to mediate between moral distress and burnout and reduce burnout associated with missed care. CONCLUSIONS Accordingly, as the nurses' moral distress and inability to meet the necessary patient care increase, their burnout levels also increase. Providing Benefit-Do No Harm is an basic ethical principle that will positively affect the burnout level of pediatric nurses. PRACTICE IMPLICATIONS This study may provide insights into ethics training, communication improvement strategies, and individual support intervention programs aimed at reducing moral distress, and burnout and improving the coping mechanisms of nurses working in pediatric wards.

Background: Moral Distress (MD) is a unique form of distress that occurs when people believe they know the ethically correct action to take but are constrained from doing so. Limited clinical experience and insufficient ethical knowledge contribute to nursing students’ MD, which can potentially cause negative outcomes. The aims of this study are: (1) to describe the MD intensity of nursing students, and (2) to analyze differences and associations between MD intensity and socio-demographic and academic variables. Methods: A cross-sectional study design with a convenience sample of the second, third, and delayed graduation students was included; only students willing to participate and who had attended their scheduled internships in the last six months were eligible for inclusion. To measure the level of MD, we used the It-ESMEE. We collected socio-demographic and academic variables. The data collection occurred from January 2024 to March 2024. Results: The students who adhered to the collection were N = 344. The findings reveal that the students perceived a high level of MD in situations related to clinical internship and class. They perceived higher levels of MD when nursing was not their first career choice, were separated or divorced, did not have children, and were not an employed student. The overall MD score is statistically significantly lower among students who had nursing as their first career choice (β = −0.267, p < 0.05), have children (β = −0.470, p < 0.01), and are employed (β = −0.417, p < 0.01). In contrast, being separated or divorced (β = 0.274, p < 0.01) was associated with a higher MD score. Conclusions: This study has some limitations: data reflect a local context, and the findings may not be generalizable to other regions or educational environments. Additionally, students’ recollections of their experiences could be influenced by the passage of time, and there may be a selection bias since only students willing to participate were included. The findings suggest that nursing education programs should incorporate more robust training in ethical decision-making and stress management to better prepare students for the moral challenges in their professional practice.

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. 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.

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OBJECTIVE This study explored the impact of moral distress (MD) and respondent characteristics on intent to leave employment. BACKGROUND Managing patient care, within organizational constraints, may create physical discomfort or mental peace disturbances such as MD, negatively impacting RN retention. METHODS Responses from 948 RNs were collected using an anonymous online survey. The impact of MD on intent to leave employment was explored. RESULTS MD was significantly higher among RNs intending to leave employment. System-level and team-level integrity attributes were significant factors predicting intent to leave, controlling for potential confounders. The odds of intending to leave were 147% higher for new graduate RNs, 124% higher for direct care RNs, and 63% higher for 2nd-career RNs. Gender and race were not significant predictors. CONCLUSION Exploring root causes contributing to MD frequency and severity is critical to maintain a healthy work environment. Mitigating MD in the work environment may enhance nursing practice and improve patient care. Support for new graduate and 2nd-career RNs can be realized, further reducing turnover for these vulnerable populations of the nursing workforce.

During clinical placement, nursing students may experience unease and moral distress, which negatively impacts their professional values and vocational choices. However, no instrument exists to measure moral distress in nursing students. Thus, this study constructs measurement items for moral distress and explores the factors that influence the vocational choices of nursing students. The participants were recruited from three universities in South Korea Between September and October 2021. This study was adopted with a convenience sample of 270 Korean fourth-year nursing students who completed their clinical practice at tertiary general hospitals in three provinces in the North, Middle, and South areas of South Korea. Data were collected through a self-administered structured questionnaire. The study developed the items and subscales of the Moral Distress Scale using multistep methods following the recommendations of the Consensus-Based Standards for the Selection of Health Status Measurement Instrument. The study constructed 22 items of the three factors of Moral Distress Scale. The three factors of the Moral Distress Scale were “moral distress by low quality of care,” “moral distress by a heavy workload and an insufficient workforce,” and “unfair and distrust.” The factors influencing the vocational choice of the nursing students were high professional values, intention not to choose nursing as a future career, lacking vision for choosing nursing, democratic family climate, and having at least one parent who was a medical professional. Moral distress in undergraduate nursing students may not influence their intention to choose the nursing profession. Fostering the professionalism and professional values of nursing students through university education curricula may help maintain their professional identity.

Background: The relationship between moral resilience, moral distress, and moral injury among nurses during the COVID-19 pandemic has been widely investigated; however, the literature in the post-COVID-19 era is scarce. Research aim: To examine the impact of moral resilience on moral distress and moral injury among nurses after the COVID-19 pandemic. Research design: Cross-sectional study. Participants and research context: We obtained a convenience sample of 1118 nurses in Greece. We collected demographic data (gender, age) and work-related data (understaffed wards, shift work, clinical experience). We measured moral resilience with the revised “Rushton Moral Resilience Scale”, moral distress with the “Moral Distress Thermometer”, and moral injury with the “Moral Injury Symptom Scale-Healthcare Professionals” version. We adjusted all multivariable models for demographic variables. Ethical considerations: The Ethics Committee of the Faculty of Nursing, National and Kapodistrian University of Athens approved our study protocol (approval number; 474, approved: November 2023). Our study followed the Declaration of Helsinki. Findings/results: Multivariable linear regression analysis showed that moral resilience reduced moral distress and moral injury. In particular, we found that increased response to moral adversity was associated with decreased moral distress (adjusted coefficient beta = −1.81, 95% confidence interval [CI] = −2.07 to −1.54). Moreover, we found that increased response to moral adversity (adjusted coefficient beta = −8.24, 95% CI = −9.37 to −7.10) and increased moral efficacy (adjusted coefficient beta = −3.24, 95% CI = −5.03 to −1.45) were associated with reduced moral injury. Conclusions: Moral resilience can reduce the level of moral distress and moral injury among nurses. However, the persistence of moderate moral resilience among Greek nurses does not guarantee its sustainability. To ensure that this resilience is maintained and potentially enhanced, it is imperative for nurse leaders and policymakers to strategically design interventions to address issues at the organizational, team, and individual levels.

Background Nurses frequently face situations in their daily practice that are ethically difficult to handle and can lead to moral distress. Objective This study aimed to explore the phenomenon of moral distress and describe its work-related predictors and individual consequences for home-care nurses in Germany. Research design A cross-sectional design was employed. The moral distress scale and the COPSOQ III-questionnaire were used within the framework of an online survey conducted among home-care nurses in Germany. Frequency analyses, multiple linear and logistic regressions, and Rasch analyses were performed. Participants and research context The invitation to participate was sent to every German home-care service (n = 16,608). Ethical considerations The study was approved by the Data Protection Office and Ethics Committee of the German Federal Institute for Occupational Safety and Health. Results A total of 976 home-care nurses participated in this study. Job characteristics, such as high emotional demands, frequent work-life-conflicts, low influence at work, and low social support, were associated with higher disturbance caused by moral distress in home-care nurses. Organizational characteristics of home-care services, such as time margin with patients, predicted moral distress. High disturbance levels due to moral distress predicted higher burnout, worse state of health, and the intention to leave the job and the profession, but did not predict sickness absence. Conclusions To prevent home-care nurses from experiencing severe consequences of moral distress, adequate interventions should be developed. Home-care services ought to consider family friendly shifts, provide social support, such as opportunities for exchange within the team, and facilitate coping with emotional demands. Sufficient time for patient care must be scheduled and short-term takeover of unknown tours should be prevented. There is a need to develop and evaluate additional interventions aimed at reducing moral distress, specifically in the home-care nursing sector.

Background: Research shows that the longer nurses care for terminally ill patients, the greater they experience moral distress. The same applies to nursing students. This study aims to analyze episodes of moral distress experienced by nursing students during end-of-life care of onco-hematologic patients in hospital settings. Methods: This study was conducted in the interpretative paradigm using a hermeneutic phenomenological approach and data were analyzed following the principles of the Interpretative Phenomenological Analysis. Results: Seventeen participants were included in the study. The research team identified eight themes: causes of moral distress; factors that worsen or influence the experience of moral distress; feelings and emotions in morally distressing events; morally distressing events and consultation; strategies to cope with moral distress; recovering from morally distressing events; end-of-life accompaniment; internship clinical training, and nursing curriculum. Conclusions: Moral distress is often related to poor communication or lack of communication between health care professionals and patients or relatives and to the inability to satisfy patients’ last needs and wants. Further studies are necessary to examine the quantitative dimension of moral distress in nursing students. Students frequently experience moral distress in the onco-hematological setting.

“Moral distress” is a term used to describe a phenomenon that is of great clinical significance and may have disastrous consequences not only for nurses (or other healthcare professionals), but also for patients. It was first defined by Jameton as “constraint distress”, namely, “the psychological distress of being in a situation in which one is constrained from acting on what one knows to be right.” Later, the definition of moral distress expanded to include not only the so-called “constraint distress”, but also the so-called “uncertainty distress” that compromises the values and moral integrity of the person who is experiencing it. At any rate, in the literature there have been offered various and overlapping accounts of moral distress. Moral distress is inherent in nursing. Not surprisingly, during the COVID-19 pandemic the risk of moral distress among ICU nurses is high. The unprecedented and unique pandemic nursing care circumstances revealed a new broader concept of nurse moral distress that is integrated, with an intrapersonal dimension and an interpersonal dimension. There have been proposed various interventions for mitigating moral distress among nurses working in COVID-19 healthcare settings. Among these interventions are included nurses’ self-reflection to be aware of their own moral distress, nurses’ autobiographic narration of memories and emotions, creating conditions promoting’ spirituality, addressing newly appeared institutional shortcomings in mental healthcare settings, and training nurses in ethical issues and dilemmas. Exploring nurses’ moral distress in the COVID-19 context and developing interventions to address it are ongoing. Starting points for future research emerged from this literature review.

BACKGROUND Moral distress is increasingly recognized as a critical challenge in critical care settings, where nurses frequently encounter ethically complex situations that can undermine their moral integrity. With the growing adoption of artificial intelligence (AI) in clinical decision-making, there is a need to understand whether AI integration may help mitigate the ethical burden experienced by nurses. AIM This study aims to examine the relationship between moral distress and moral integrity and investigate the mediating role of AI integration in this association. METHODS A cross-sectional correlation design was employed among 250 ICU nurses recruited from three private hospitals. Data was collected using three structured questionnaires. Descriptive statistics, Pearson correlations, multiple regression, and structural equation modeling (SEM) were used to examine direct and indirect effects. RESULTS Moral distress was negatively associated with both AI integration (r = -0.42, p < 0.01) and moral integrity (r = -0.56, p < 0.01), while AI integration demonstrated a positive association with moral integrity (r = 0.48, p < 0.01). The regression model explained 48% of the variance in moral integrity. SEM results indicated that AI integration partially mediated the association between moral distress and moral integrity (indirect β = -0.16, p < 0.001). CONCLUSION Moral distress significantly undermines nurses' moral integrity, yet AI integration provides a partial protective effect by enhancing ethical clarity and decision support. While AI cannot fully offset the impact of chronic moral strain, it represents a promising tool to strengthen ethical practice in critical care environments.

BACKGROUND Both vulnerability and integrity represent action-guiding concepts in nursing practice. However, they are primarily discussed regarding patients-not nurses-and considered independently from rather than in relation to each other. AIM The aim of this paper is to characterize the moral dimension of nurses' vulnerability and integrity, specify the concepts' relationship in nurses' clinical practice and, ultimately, allow a more fine-grained understanding. DESIGN This discursive paper demonstrates how vulnerability and integrity relate to each other in nursing practice and carves out which types of vulnerability pose a threat to nurses' moral integrity. The concept of vulnerability developed by Mackenzie et al. (2014) is applied to the situation of nurses and expanded to include the concept of moral integrity according to Hardingham (2004). Four scenarios are used to demonstrate where and how nurses' vulnerabilities become particularly apparent in clinical practice. This leads to a cross-case discussion, in which the vulnerabilities identified are examined against the background of moral integrity and the relationship between the two concepts is determined in more detail. RESULTS AND CONCLUSION Vulnerability and integrity do not only form a conceptual pair but also represent complementary moral concepts. Their joint consideration has both a theoretical and practical added value. It is shown that only specific forms of vulnerability pose a threat to moral integrity and the vulnerability-integrity relationship is mediated via moral distress. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The manuscript provides guidance on how the concrete threat(s) to integrity can be buffered and moral resilience can be promoted. Different types of threats also weigh differently and require specific approaches to assess and handle them at the micro-, meso- and macro-level of the healthcare system.

Aim: This study aimed to investigate the relationship between moral self, moral integrity, and moral sensitivity in decision-making among nurses. Background: nurses face moral dilemmas almost on a daily basis. Studies have demonstrated that nurses with high moral sensitivity make thoughtful decisions and exhibit professional responsibility. The current study seeks to examine personality variables that may be related to moral sensitivity among nurses. Design: A cross-sectional study. Ethical considerations: This study was approved by the IRB of the authors University’s ethics committee (number: AU-HEA-LO-20220317). Written consent was obtained from all participants. Methods: A structured questionnaires were administered to a sample of 187 Israeli nurses. Results: The degree of nurses’ moral self, moral integrity and moral sensitivity was relatively high. “Patient-centered care” was found to be the most significant component of moral sensitivity. The next component is “Using knowledge bases,” followed by “Exercising professional judgment.” While the concept of patient-centered care was found to be related to the nurses’ moral self, the other components were found to be related to their moral integrity. The mediation model found that moral integrity mediates and even strengthens the moral self in its connection with moral sensitivity. Conclusions: Understanding the role of moral self and moral integrity in explaining moral sensitivity, can contribute to achieving a desirable combination of “the good and the right” in nursing practice, thereby enhancing nurses’ work. From a practical perspective, these findings are also relevant to nursing education. Nursing education plays a pivotal role in fostering moral and ethical decision-making in both clinical aspects and ethical moral sensitivity. Strengthening the moral self and moral integrity among nursing students can aid in making balanced and morally sensitive decisions while also building moral and ethical support systems to assist students in distressing and emergency situations.

Background and aim Nurses encounter various ethical issues in their daily practice, and the inability to manage these challenges can adversely impact their care delivery. This study aimed to evaluate the effects of education based on ethical leadership (EL) on moral distress (MD), perceived organisational justice (OJ) and clinical competence (CC) among nurses. Methods This study was conducted from 2020 to 2021 using a two-group pretest–post-test design. Eighty nurses were purposively selected from Hajar and Kashani teaching hospitals in Shahrekord, Iran and were randomly assigned to either a control group or an intervention group. Data were collected through a demographic questionnaire, the CC Assessment Questionnaire, the MD Scale and the OJ Scale. EL-based education focusing on trust, integrity, reciprocity, self-regulation and public service was delivered over 5–2-hour sessions. Statistical analyses were performed using SPSS software (V.24.0), employing tests such as mean, SD, median, IQR, χ2, Fisher’s exact test, independent sample t-test, Mann-Whitney U test and Friedman test. Results No significant differences were observed between the groups regarding the scores of MD, perceived OJ and CC at pretest and immediately after the intervention (p>0.05). However, significant between-group differences were noted in the scores of MD, perceived OJ and CC 3 months postintervention (p<0.01). Conclusion Education based on EL significantly reduces MD and enhances perceived OJ and CC among nurses. As a simple and safe intervention, EL-based education can effectively improve nurses’ abilities to manage ethical issues and challenges.

BACKGROUND Prison populations experience disproportionately high rates of mental disorders and suicidality, often receiving inadequate care in settings primarily designed for punishment rather than treatment. Prisons, increasingly serving as de facto psychiatric institutions, present distinct ethical, legal, and clinical challenges for mental health professionals. OBJECTIVES This paper explores the ethical dilemmas in correctional mental health care, focusing on confidentiality, the principle of equivalence of care, and the dual role of clinicians. It critically examines clinical practices such as suicide prevention, psychopharmacological treatment, management of violence, and end-of-life decisions, and offers recommendations for ethical care in prison environments. METHODS A comprehensive literature review was conducted using PubMed and major journals in psychiatry and bioethics, supplemented by policy documents from WHO, UN, and WPA. Guided by expert consultation, the thematic analysis included 97 articles and 6 book chapters. Expert feedback from the EPA ethics committee informed the final recommendations. RESULTS Key findings highlight tensions between institutional control and therapeutic ethics, especially regarding confidentiality breaches, consent, and coercive practices. Structural factors-Overcrowding, under-resourcing, and stigmatization-Compromise the feasibility of equivalence of care. Ethical concerns intensify around suicide, substance use, neurocorrections, solitary confinement, and the death penalty. CONCLUSION Correctional mental health care requires ethically robust, rights-based approaches responsive to both clinical needs and institutional constraints. Implementing context-sensitive guidelines, improving training, ensuring continuity of care, and upholding patient autonomy are critical for safeguarding dignity and therapeutic integrity within prisons.

The transition from nursing education to professional practice is a critical period for newly graduated nurses, marked by significant moral challenges that can lead to moral distress and impact the development and application of clinical judgment. Understanding how moral distress affects newly graduated nurses is vital to support their integration into professional roles and ensure the delivery of quality care. Newly graduated nurses may experience moral distress due to conflicts between professional values and institutional constraints, which impact their ability to exercise effective clinical judgment. The purpose of this qualitative meta-ethnographic review is to investigate the phenomenon of moral distress among newly graduated nurses and its implications for clinical judgment. The research question is: How do newly graduated nurses experience moral distress, and how does it affect their clinical judgment? Methodologically, the study is grounded in Ricoeur’s three-fold mimesis, which offers a rich interpretative framework for exploring the complexities of moral distress in nursing practice. Guided by the seven steps of meta-ethnography, the analysis reveals significant variations in the conceptualization and experiences of moral distress, thus highlighting inadequacies in existing definitions. The findings from 12 qualitative studies were synthesized into an integrative model of moral challenges. This integrative model presents moral distress as a multifaceted phenomenon that intersects with clinical judgment. The integrative model of moral challenges demonstrates how institutional constraints, moral uncertainty, moral conflict and lack of moral attention can hinder newly graduated nurses' ability to exercise effective clinical judgment and deliver quality care. The integrative model of moral challenges is a crucial contribution to research on moral distress. The review reveals limited research on the way moral distress affects the clinical judgment of newly graduated nurses and highlights the importance of promoting reflective practice and moral deliberation among newly graduated nurses to strengthen their clinical judgment and professional development.

PURPOSE Moral distress arises when clinicians feel unable to act according to their ethical beliefs due to various constraints. Medical students transitioning from classroom to clinical settings are particularly vulnerable due to limited authority and fear of repercussions. This study examines how medical students experience and report moral distress, the role of supervising physicians, and the implications for professional development. METHOD 407 case reports from third-year students at a U.S. allopathic medical school were quantitatively and qualitatively analyzed to assess instances of moral distress and students' experiences and relationship with clinical mentors. RESULTS Moral distress was reported in 170 (41.8%) cases. Of those, "actions by another" (n=56, 32.9%) and "systemic concerns" (n=39, 22.9%) were the most common causes of moral distress. Mentor status (attending vs. trainee) had no significant impact on moral distress scores (p=0.6). Students without moral distress were more likely to rate their mentors more positively than those with moral distress (73.9% vs 54.0%, p<0.001) and want to emulate them (79.7% vs 55.9%, p<0.001). CONCLUSIONS Moral distress is commonly experienced among medical students, frequently driven by observing others' behaviors. Positive role modeling and mentoring can significantly influence students' moral distress and professional development.

Nurses frequently encounter complex ethical dilemmas and high-stress environments. Moral resilience, characterized by the ability to navigate these challenges with confidence and integrity, is essential for optimal patient care and personal well-being. This study aimed to culturally adapt and validate the Persian version of the Rushton Moral Resilience Scale (RMRS) among Iranian nurses. This methodological study employed a convenience sample of 659 nurses working in clinical wards of public and private hospitals in Kermanshah City, Iran. The RMRS was translated into Persian using the forward-backward translation method proposed by Polit and Yang. To assess the psychometric properties of the Persian RMRS, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and reliability were conducted. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) supported the factor structure of the Persian RMRS, identifying four factors comprising 15 items, which accounted for 50.98% of the total variance. The CFA model exhibited good fit indices: χ²/df = 2.35, RMSEA = 0.061, NNFI/TLI = 0.91, CFI = 0.94, GFI = 0.94, and SRMR = 0.049. The scale demonstrated satisfactory internal consistency, with a Macdonald Omega coefficient of 0.728 and an Intraclass Correlation Coefficient (ICC) of 0.715 (95% CI: 0.677–0.749). The present study successfully adapted and validated the Persian version of the Rushton Moral Resilience Scale (RMRS) for Iranian nurses. The scale demonstrated sound psychometric properties, including acceptable reliability and validity. These findings suggest that the Persian RMRS can be a valuable tool for researchers and healthcare professionals to assess moral resilience among Iranian nurses, enabling a deeper understanding of this construct and its implications for patient care and well-being. Not applicable.

BackgroundMoral suffering is a growing concern in healthcare, especially in the nursing profession. It encompasses various forms, such as moral distress and moral injury, both of which impact nurses' professional integrity and mental and physical health. Despite extensive research, there is still no consensus on their definitions, distinctions, or causes, which impedes effective interventions. However, given their overlapping characteristics and consequences, joint consideration could offer critical insights to refine existing concepts.AimTo explore how nurses in clinical practice perceive moral suffering and analyze the essence of their experience of moral suffering.Research designData were collected through qualitative, semi-structured online interviews. The interview transcripts were analyzed using qualitative content analysis.Participants and research contextA total of 47 registered nurses from different clinical settings in German hospitals participated in the study.Ethical considerationsThe study protocol was approved by the Institutional Review Board at University Medicine Greifswald. All participants provided written informed consent.FindingsThe essence of moral suffering was determined in five main categories with corresponding subcategories: A trigger situation (1) in which a person in a specific moral disposition is present (2), whereupon they assess the situation as morally meaningful (3) and, accordingly, moral suffering is experienced in its three specific dimensions: (4) the characteristics (dynamic, context-dependence, temporality, fuzziness), dimensions of experience (rational and emotional integrity-related manifestation), and dimensions of action (handling, coping, prevention). This experience of moral suffering has consequences (5).ConclusionsThis study illuminates the complex nature of moral suffering among nurses, revealing its multidimensional essence and the interplay between personal and professional factors. The results underscore the need for a systemic approach to address moral suffering in nursing, emphasizing the importance of ethical leadership and workplace health promotion, and fostering shared values within healthcare teams.

BACKGROUND Ethical challenges encountered in global health settings during clinical placements shape nursing students' moral development and professional integrity. PURPOSE This study aimed to explore how 4th-year baccalaureate nursing students and recent nursing graduates navigate ethical challenges in resource-limited global health settings, from the perspectives of students, faculty members, and preceptors. DESIGN This qualitative study utilized Sally Thorne's interpretive description methodology to generate knowledge that could inform teaching practices within a Canadian School of Nursing. METHODS Purposive sampling and one-on-one semi-structured interviews were carried out with 17 participants including 4th-year nursing students and recent nursing graduates who completed clinical placements in resource-limited international settings, faculty members who taught them, and clinical preceptors who supervised their clinical rotations. Data analysis followed a constant comparative and iterative approach. FINDINGS The proposed Relational Interplay model illustrates participants' experiences, and emphasizes the interdependent roles of students, preceptors, and faculty in navigating ethical challenges. Four key themes emerged: grappling with cognitive dissonance, engaging in an internal process, undergoing personal transformation, and deepening relational practice. CONCLUSIONS Findings from this study may inform the development of global health nursing practicum curricula and provide valuable insights for faculty, preceptors, and students involved in global health nursing experiences.

Ethical challenges are inherent in nursing practice. They affect patients, families, teams, organizations, and nurses themselves. These challenges arise when there are competing core values or commitments and diverse views on how to balance or reconcile them. When ethical conflict, confusion, or uncertainty cannot be resolved, moral suffering ensues. The consequences of moral suffering in its many forms undermine safe, high-quality patient care, erode teamwork, and undermine well-being and integrity. My experience as a nurse in the pediatric intensive care unit and later as a clinical nurse specialist in confronting these moral and ethical challenges has been the foundation of my program of research. Together we will explore the evolution of our understanding of moral suffering-its expressions, meanings, and consequences and attempts to measure it. Moral distress, the most described form of moral suffering, took hold within nursing and slowly within other disciplines. After 3 decades of research documenting the existence of moral distress, there were few solutions. It was at this juncture that my work pivoted toward exploring the concept of moral resilience as a means for transforming but not eliminating moral suffering. The evolution of the concept, its components, a scale to measure it, and research findings will be explored. Throughout this journey, the interplay of moral resilience and a culture of ethical practice were highlighted and examined. Moral resilience is continuing to evolve in its application and relevance. Many vital lessons have been learned that can inform future research and guide interventions to harness the inherent capabilities of clinicians to restore or preserve their integrity and to engage in large-scale system transformation.

Ethical leadership in nursing is pivotal for fostering a transparent workplace culture and encouraging error reporting, a critical behavior for enhancing patient safety. In Saudi Arabia, cultural and organizational factors may influence nurses’ willingness to report errors, making this an essential area of study. This study investigates the correlation between ethical leadership and error reporting behavior, emphasizing the mediating influence of moral courage among nurses in Saudi Arabia. This cross-sectional research used a simple random sampling technique to recruit 269 clinical nurses from four specialized medical centers affiliated with King Abdullah Medical City in Makkah, Saudi Arabia. Data was collected between October and December 2024 using online self-reported questionnaires that included validated scales for ethical leadership, moral courage, error reporting, and demographic information form. This study was conducted in accordance with the STROBE guidelines. Structural equation modeling was used to investigate hypothesized relationships. Ethical leadership significantly impacted error reporting behavior (β = 0.58, p < 0.001) and ethical courage (β = 0.35, p < 0.001). Moral courage was a significant predictor of error reporting behavior (β = 0.30, p = 0.01) and partially mediates the link between ethical leadership and error reporting (β = 0.11, p = 0.01). The total effect of ethical leadership on error reporting behavior was substantial (β = 0.69), with a BC 95% CI of (0.51, 0.89). The findings highlight the critical role of ethical leadership in fostering moral courage and promoting error reporting behavior among nurses. The mediation effect of moral courage underscores the importance of cultivating an ethical work environment that empowers nurses to act with integrity and report errors without fear of retaliation. These insights emphasize the need for nursing managers to prioritize ethical leadership practices and create transparent workplace cultures that enhance patient safety. By addressing cultural and organizational barriers, healthcare institutions in Saudi Arabia can further encourage error reporting, ultimately improving the quality of care and patient outcomes.

No abstract available

PURPOSE To assess whether causes of moral distress vary by academic institution. Moral distress is experienced when healthcare providers are unable to provide the right care to patients because of institutional or resource constraints. MATERIALS AND METHODS A survey was performed based on Moral Distress Scale-Revised for Health Care Professionals for 16 clinical scenarios assessing frequency and severity of moral distress among academic radiologists. The survey was sent to members of the RSNA quality committee for distribution to their department. Measure of moral distress for health care professionals (MMD-HP) was calculated for individuals and moral distress indices (MDI) for clinical scenarios. MMD-HP were compared by sex, ethnicity, age, years of practice, weekly work hours, practice setting/type and consideration of leaving the workplace. Statistical analysis was performed using Kruskal-Wallis test and Kendall ordinal correlation. RESULTS 126 respondents from five institutions from 5 different states, were included in the analysis. MMD-HP ranged from 24-66 (maximum 266). Median MMD-HP was higher in radiologists working >60 hours/week (59 vs. 32.5, p=0.048). Radiologists across institutions consistently reported four main sources of moral distress: pressure to perform unsafe numbers of studies (108/126, 85%), high workloads impeding resident teaching (102/126, 81%), lack of administrative support for patient care issues (102/126, 81%), and pressure to conduct unnecessary imaging (111/126, 88%). Higher MMD-HPs correlated significantly with job turnover intentions or past job changes (p<0.001). The average percentage of radiologists with an intention to leave or having left as position was 44% with a range of 26%-84%. CONCLUSION Moral distress is pervasive in radiology, with four primary causes consistently identified across academic institutions. Strong association between higher moral distress levels and job turnover intentions highlights its impact on workforce retention.

Background: Since the beginning of the COVID-19 pandemic, moral distress among healthcare workers in the Intensive Care Unit (ICU) has garnered both media and academic attention. Moral distress has been theorized as occurring when individuals are constrained from doing what they perceive as morally right. This study sought to empirically examine the lived experiences of moral distress among clinical and administrative healthcare professionals in a sample of Canadian ICUs during the COVID-19 pandemic. Methods: Qualitative case study methodology was used as the overarching approach, collecting and comparing data from two distinct cases: one ICU in Ontario and one in Alberta. Data collection involved two primary sources: semi-structured interviews with staff and document review of institutional and government directives to provide contextual data. Data analysis commenced concurrently with data collection, and generated within- and across-case themes, as well as allowed descriptive accounts of moral distress. Results: Thirty-six healthcare workers across two sites were interviewed. Participants described three primary categories of constraints leading to moral distress. These were: 1) The rapidity and opaqueness of policy development, specifically pertaining to 2) the implementation of family visitation and treatment triage decisions, and 3) resource shortages, which reduced patient interactions, shifted professional responsibilities. Each of these constraints yielded circumstances and forced decisions that were perceived as morally wrong because they compromised care quality and outcomes. Conclusions: While sharing similarities with the growing literature on moral distress in the context of the COVID-19 pandemic, this study reveals new insights on how provincial and institutional policy has direct bearing on experiences of moral distress. Policies and circumstances forced ICU staff to choose between actions they considered the most right and the least wrong. Understanding these specific policy-driven constraints highlights the need for healthcare systems and processes that mitigate moral distress and sustain our health workforce.

Moral distress, or the inability to carry out what one believes to be ethically appropriate because of constraints or barriers, is understudied in obstetrics and gynecology. We sought to characterize moral distress among Maternal-Fetal Medicine (MFM) fellows using a standardized survey. We disseminated a national anonymized survey study of MFM fellows electronically regarding moral distress using a validated questionnaire with supplemental questions pertaining to specific challenges within MFM clinical care. Multivariable linear regression modeling was used to examine the association between abortion restrictions, maternal mortality, and moral distress, controlling for demographic variables. Thematic analysis was performed for the free text responses elaborating upon moral distress and grouped by thematic elements. We hypothesized that training in states with more abortion restrictions and higher maternal mortality would be associated with higher moral distress scores. Among 245 total responses (61% response rate), 177 complete responses (44% complete response rate) were included for analysis. Most of our respondents identified as female (78.5%), White (71.8%), and training in urban programs (83.1%). 37.9% of respondents reported training in the Northeast, with the remainder of respondents evenly distributed across the United States. The mean score for the validated questions was 85.9 ± 48.8, with female gender identity associated with higher measures of moral distress on the validated portion of the questionnaire as compared to male gender identity (90.1 ± 49.2 vs. 70.4 ± 44.7, p < 0.05), whereas more advanced training was associated with higher measures of moral distress on the supplemental questions as compared to those less advanced in training (20.9 ± 11.8 vs. 28.5 ± 15.9 vs. 25.9 ± 15.6 for PGY-5 vs. PGY-6 vs. PGY-7 and PGY-8 combined, respectively, p < 0.05). After adjustment, higher measure of moral distress on the validated questionnaire was associated with training in states designated “Abortion restrictive” as compared to “Abortion most protective” (beta estimate 27.80 and p < 0.01). Of 34 free responses, 65% referred to limitations on abortion access and reproductive justice as causes of significant moral distress. MFM fellows who identify as female reported higher measures of moral distress, as well as those training in states with more abortion restrictions. Among free text respondents, abortion restrictions underlie a significant proportion of moral distress.

Moral distress forms a major threat to the well-being of healthcare professionals, and is argued to negatively impact patient care. It is associated with emotions such as anger, frustration, guilt, and anxiety. In order to effectively deal with moral distress, the concept of moral resilience is introduced as the positive capacity of an individual to sustain or restore their integrity in response to moral adversity. Interventions are needed that foster moral resilience among healthcare professionals. Ethics consultation has been proposed as such an intervention. In this paper, we add to this proposition by discussing Moral Case Deliberation (MCD) as a specific form of clinical ethics support that promotes moral resilience. We argue that MCD in general may contribute to the moral resilience of healthcare professionals as it promotes moral agency. In addition, we focus on three specific MCD reflection methods: the Dilemma Method, the Aristotelian moral inquiry into emotions, and CURA, a method consisting of four main steps: Concentrate, Unrush, Reflect, and Act. In practice, all three methods are used by nurse ethicists or by nurses who received training to facilitate reflection sessions with these methods. We maintain that these methods also have specific elements that promote moral resilience. However, the Dilemma Method fosters dealing well with tragedy, the latter two promote moral resilience by including attention to emotions as part of the reflection process. We will end with discussing the importance of future empirical research on the impact of MCD on moral resilience, and of comparing MCD with other interventions that seek to mitigate moral distress and promote moral resilience.

Over the past 2 years, the COVID-19 pandemic has placed an immense burden on the healthcare system as a whole (Docea et al., 2020). The field of oncology has been especially burdened (Schrag et al., 2020), as cancer centers urgently developed and implemented guidelines of care (Richards et al., 2020) to protect an exceptionally vulnerable patient population (Zhang et al., 2020). These ever-evolving guidelines increased strain and responsibility on hospital staff, oftentimes resulting in moral distress. Moral distress is defined as the psychological feelings that occur when one knows the ethical and right course of action, but cannot carry it out due to institutional or other constraints (Jameton, 1993). Pandemic-induced moral distress is widely documented among nurses (Rosa et al., 2020; Smallwood et al., 2021; Lake et al., 2022; Spilg et al., 2022), physicians (Patterson et al., 2021; Rimmer, 2021; Smallwood et al., 2021; Spilg et al., 2022), allied health professionals (Patterson et al., 2021; Smallwood et al., 2021; Spilg et al., 2022), and social workers (Golightley and Holloway, 2020; Guan et al., 2021), but the moral distress faced by clinical research staff has yet to be explored. The purpose of this editorial is to highlight the moral challenges faced by clinical research staff [e.g., Clinical Research Coordinators (CRCs)] as they carry out their job responsibilities, such as facilitating informed consent, collecting data, and communicating with distressed participants on a regular basis.

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There is a clear need for interventions that reduce moral distress among healthcare providers (HCPs), given the high prevalence of moral distress and the far-ranging negative consequences it has for them. Healthcare ethics consultants are frequently called upon to manage moral distress, especially among nursing staff. Recently, researchers have both broadened the definition of moral distress and demarcated subcategories of the phenomenon with the intent of creating more targeted and effective interventions. One of the most frequently occurring subcategories of moral distress in this new taxonomy has been labeled “moral-constraint distress,” though scholars have argued that not all constraints on HCPs’ moral agency are inappropriate given the often-competing healthcare values of patients, families, and clinical staff. To attempt to reduce the instances of moral distress in cases in which the constraints on HCPs’ moral agency are justified, we propose an intervention that focuses on shifting the HCPs’ “frame of reference” on moral-constraint distress, teaching HCPs how to distinguish unjustified and justified constraints on their moral agency. The anchors of this blueprint for reducing moral-constraint distress are the philosophical concepts of “values pluralism” and “values imposition.” The rationale for this intervention is that, in situations where the constraint on moral agency is justified but the experience of moral distress could nevertheless be severe, the emphasis needs to be on helping the HCP to “think differently” rather than “act differently.”

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Intensive care unit (ICU) professionals engage in ethical decision making under conditions of high stakes, great uncertainty, time-sensitivity and frequent irreversibility of action. Casuistry is a way by which actionable knowledge is obtained through comparing a patient case to previous cases from experience in clinical practice. However, within the field of study as well as in practice, evidence-based medicine is the dominant epistemic framework. This multiple case study evaluated the use of casuistic reasoning by intensive care unit (ICU) professionals during moral case deliberation. It took place in two Dutch hospitals between June 2020 and June 2022. Twentyfive moral case deliberations from ICU practice were recorded and analyzed using discourse analysis. Additionally, 47 interviews were held with ICU professionals who participated in these deliberations, analyzed using thematic analysis. We found that ICU professionals made considerable use of case comparisons when discussing continuation, withdrawal or limitation. Analogies played a role in justifying or complicating moral judgements, and also played a role in addressing moral distress. The language of case-based arguments is most often not overtly normative. Rather, the data shows that casuistic reasoning deals with the medical, ethical and contextual elements of decisions in an integrated manner. Facilitators of MCD have an essential role in (supporting ICU professionals in) scrutinizing casuistic arguments. The data shows that during MCD, actual reasoning often deviated from principle- and rule-based reasoning which ICU professionals preferred themselves. Evidence-based arguments often gained the character of analogical arguments, especially when a patient-at-hand was seen as highly unique from the average patients in the literature. Casuistic arguments disguised as evidence-based arguments may therefore provide ICU professionals with a false sense of certainty. Within education, we should strive to train clinicians and ethics facilitators so that they can recognize and evaluate casuistic arguments.

OBJECTIVES: During the COVID-19 pandemic, ICU professionals have faced moral problems that may cause moral injury. This study explored whether, how, and when moral injury among ICU professionals developed in the course of the COVID-19 pandemic. DESIGN: This is a prospective qualitative serial interview study. SETTING: Two hospitals among which one university medical center and one teaching hospital in the Netherlands. SUBJECTS: Twenty-six ICU professionals who worked during the COVID-19 pandemic. INTERVENTIONS: None. MEASUREMENTS MAIN RESULTS: In-depth interviews with follow-up after 6 and 12 months. In total, 62 interviews were conducted. ICU professionals narrated about anticipatory worry about life and death decisions, lack of knowledge and prognostic uncertainty about COVID-19, powerlessness and failure, abandonment or betrayal by society, politics, or the healthcare organization, numbness toward patients and families, and disorientation and self-alienation. Centrally, ICU professionals describe longitudinal processes by which they gradually numbed themselves emotionally from patients and families as well as potentially impactful events in their work. For some ICU professionals, organizational, societal, and political responses to the pandemic contributed to numbness, loss of motivation, and self-alienation. CONCLUSIONS: ICU professionals exhibit symptoms of moral injury such as feelings of betrayal, detachment, self-alienation, and disorientation. Healthcare organizations and ICU professionals themselves should be cognizant that these feelings may indicate that professionals might have developed moral injury or that it may yet develop in the future. Awareness should be raised about moral injury and should be followed up by asking morally injured professionals what they need, so as to not risk offering unwanted help.

Supplemental digital content is available in the text. BACKGROUND “Best Case/Worst Case” (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients. METHODS We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress. RESULTS BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51–95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0–10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding “witnessing providers giving false hope” from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds. CONCLUSION BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members. LEVEL OF EVIDENCE Therapeutic, level III.

BACKGROUND Intensive care settings are characterized by their structure, which constantly changes in parallel with scientific and technological developments, the uncertainty of the lifeline between birth and death, the challenges in the fair distribution of limited resources, the participation of individuals in medical decisions, and witnessing the pain experienced by individuals. These characteristics also affect the level of moral distress, which can make it difficult for ICU nurses to provide the most appropriate individualized care for their patients. AIM AND OBJECTIVES The purpose of this study was to determine the moral distress levels and individualized care perceptions of intensive care nurses. STUDY DESIGN This study employed a cross-sectional descriptive survey design. METHODS This descriptive study was conducted with 128 nurses working in the intensive care units of a university hospital in Turkey. Data were collected using an 'Information Form', 'the Moral Distress Scale', and 'the Individualized Care Scale-Nurse Version'. RESULTS 78.9% of the nurses stated that there was staff shortage, and 36.0% stated that the physical conditions were not suitable for care in the intensive care units in which they worked. The mean score on the Moral Distress Scale was 79.2 ± 46.4. The mean total score on the Individualized Care Scale-Nurse Version was 3.5 ± 0.8. CONCLUSION This study revealed that the intensive care nurses had moderate levels of moral distress and good levels of individualized care perceptions although there was no significant relationship between their moral distress levels and individualized care perceptions. Also, the nurses adopted care behaviours supporting patients' feelings and autonomy. RELEVANCE TO CLINICAL PRACTICE In our study, the intensive care nurses did not reflect their moderate-level moral distress in the individualized care provided. It could be beneficial to measure intensive care nurses' moral distress and care levels at frequent intervals so that early precautions could be taken to prevent the accumulation of moral distress and care difficulties among intensive care nurses.

Making moral decisions is a crucial part of nursing practice since intensive care units (ICUs) commonly provides moral conundrums pertaining to patient autonomy, informed consent, and resource allocation. Critical care nursing requires intricate decision-making in high-pressure environments in shaping patient care and professional conduct. Despite their importance in ICUs, ethical considerations often cause moral distress and uncertainty for nurses. The absence of standardized training and institutional support leads to inconsistencies in professional conduct, affecting patient care quality and teamwork. Research involved ICU nurses from multiple hospitals, with a sample size of 150 participants selected through stratified random sampling. Both descriptive and inferential statistical analysis were performed, such as logistic regression models to examine the impact of ethical training on critical care decision-making and chi-square tests to investigate associations between professional behaviour and ethical awareness. The findings revealed a significant correlation between ethical awareness and professional conduct, with nurses who received formal ethical training demonstrating higher adherence to ethical principles. Ethical challenges related to appropriate care and resource allocation were the most frequently reported dilemmas. Additionally, nurses with institutional support and ethical guidelines exhibited lower levels of moral distress and improved interdisciplinary collaboration. Resolving these moral dilemmas improves decision-making, lessens moral suffering, and creates a more moral and professional intensive care unit, all of which contribute to better patient care.

This cross-sectional study, conducted in 2023 on 386 ICU nurses from hospitals affiliated with Tehran University of Medical Sciences, investigated the relationships between moral resilience, moral distress, and second victim syndrome. Participants were selected through simple random sampling, and data were collected using Rushton’s Moral Resilience Scale, Hamric’s Moral Distress Questionnaire, and Burlison’s Second Victim Scale. Analysis was performed using descriptive statistics and Pearson’s correlation in SPSS v24. The results showed a significant positive correlation between second victim syndrome and moral distress, indicating that increased second victim experiences were associated with higher moral distress. There was also a significant negative correlation between moral resilience and second victim syndrome, confirmed by regression and structural equation modeling. However, no significant correlation was found between moral resilience and moral distress. Overall, the study highlights that second victim syndrome contributes to moral distress, while moral resilience acts as a protective factor. It is recommended that targeted interventions – such as resilience training, peer support groups, professional debriefing, and organizational mental health initiatives be imple- mented to mitigate these psychological challenges in high-stress ICU environments.

Moral disengagement can lead to anti-social behaviour by employees in business. In the healthcare field, moral disengagement can lead nurses to make unethical decisions and behaviours that can harm patient well-being. Therefore, this paper will examine the factors influencing moral disengagement among ICU nurses with the aim of contributing to the reduction of the level of moral disengagement among nurses. Between January 2024 and January 2025, ICU nurses from second-level and above general hospitals in Henan and Hubei, China, were selected as survey respondents. The questionnaire survey was conducted using a general information questionnaire, a moral disengagement scale, a moral resilience scale, and a moral disengagement energy scale, and multiple linear stepwise regression was used to analyze the influencing factors of ICU nurses' moral disengagement. 305 ICU nurses scored (91.40 ± 34.37) on the Moral Disengagement Scale. The multiple linear stepwise regression analysis results showed that years of working experience, whether or not they had received ethics training(16.219 p < 0.001), ears of experience (-7.673, p = 0.018), moral resilience(-18.452,p < 0.001), and moral distress (5.523,p < 0.001) were the influencing factors of moral disengagement among ICU nurses (p < 0.05). The adjusted R2 = 0.499,which explains 49.9% of the total variation, suggests that the model explains the influences of moral disengagement well. The moral disengagement of ICU nurses is moderately high, and individualized interventions can be carried out for high-risk groups to reduce this level and improve ethical decision-making to protect patient's rights and interests.

This paper examines the ethical dilemmas surrounding futile care in Indian intensive care units, specifically focusing on the moral distress experienced by healthcare professionals when administering potentially non-beneficial interventions to terminally ill patients. Through analysis of recent literature, including systematic reviews and randomized controlled trials, this commentary explores the complex intersection of medical ethics, cultural values, resource allocation, and decision-making frameworks within India's unique healthcare landscape. The paper highlights the need for culturally sensitive approaches to end-of-life care, improved communication between healthcare providers and families, and institutional support systems to address moral distress among ICU staff. Additionally, it proposes policy recommendations and practical strategies to navigate these challenging ethical terrain while respecting patient dignity, family autonomy, and professional integrity in the Indian healthcare system.

Moral resilience can help Intensive Care Unit (ICU) nurses overcome moral dilemmas caused by the death of patients, while enhancing their competence to cope with death. Death-coping competence is also related to the cognitive level of nurses about good death. However, few studies have focused on the relationships among between moral resilience, perception of good death, and death-coping competence. To explore the focused on the relationships among ICU nurses’ moral resilience, good-death perception and death-coping competence, and to examine the mediating role of moral resilience between good-death perception and death-coping competence. This was a quantitative study with a cross-sectional descriptive correlational design. The participants completed an online survey in which moral resilience, perception of good death and coping with death competence using the Rushton Moral Resilience Scale for nurses, Chinese version of Good Death Inventory and coping with death scale-short version, respectively. A total of 254 ICU nurses were recruited from five tertiary general hospitals in Shandong province of China to participate in the survey. This study was approved by the ethics committee of Zibo Central Hospital. Informed consent was obtained from all the nurses. Good-death perception positively affects death-coping competence (r = 0.565, p < 0.01). The mediation analysis revealed that the direct effect of good-death perception on death-coping competence in the presence of the mediator was significant. Hence, moral resilience partially mediated the relationship between good-death perception and death-coping competence. And the mediating effect is 0.099. ICU nurses’ good-death perceptions can directly predict their death-coping competence, and they can also indirectly affect their death-coping competence through the mediating effect of moral resilience. not applicable.

Intensive Care Unit (ICU) nurses are at high risk for compassion fatigue and moral distress. Grounded in the Conservation of Resources Theory, this study proposes that compassion fatigue depletes emotional resources, thereby intensifying moral distress. However, the specific pathway and key components driving this relationship remain unclear. To investigate the nonlinear relationship between compassion fatigue and moral distress among ICU nurses and to identify core symptoms of compassion fatigue that most significantly influence moral distress. A nationwide cross-sectional online survey was conducted from July to December 2023, recruiting 645 ICU nurses from China. Compassion fatigue and moral distress were assessed using the Professional Quality of Life Scale and the Moral Distress Scale-Revised, respectively. The dose-response relationship was analyzed using restricted cubic splines, with moral distress as the outcome and compassion fatigue as the predictor, and network analysis with in silico interventions was applied to identify key compassion fatigue symptoms affecting moral distress. A significant nonlinear relationship was identified of compassion fatigue on moral distress (nonlinear F = 10.02, p < 0.01; adjusted model R² = 0.161), with moral distress increasing sharply at moderate compassion fatigue levels before plateauing. Network analysis and in silico simulations revealed three core compassion fatigue symptoms with the strongest influence on moral distress: “feeling trapped in the helping system” (a burnout symptom), “difficulty remembering important work aspects” (a secondary traumatic stress symptom), and “being a very sensitive person” (a secondary traumatic stress-related trait). Adjusting these symptoms led to significant changes in moral distress levels. This study confirms a nonlinear relationship of compassion fatigue on moral distress and identifies actionable targets for intervention. Addressing specific compassion fatigue symptoms can disrupt the resource loss spiral, offering a strategic approach to enhancing ICU nurse well-being and care quality. Not applicable.

AIM This study aimed to examine the level of vicarious posttraumatic growth among intensive care unit nurses in China and explore the mediating role of death coping ability in the relationship between moral resilience and vicarious posttraumatic growth. STUDY DESIGN A multicentre, cross-sectional study was conducted in accordance with the STROBE guidelines. METHODS Between January and March 2025, a questionnaire survey was conducted among 666 intensive care unit nurses from nine tertiary Grade A hospitals across five provinces in China. Participants completed three standardised instruments: the Rushton Moral Resilience Scale, the Coping with Death Scale-Short Version, and the Vicarious Posttraumatic Growth Inventory. We used IBM SPSS 27.0 for descriptive statistics, univariate analyses, and correlation analyses, and employed AMOS 27.0 to perform structural equation modelling for testing mediation effects. RESULTS Intensive care unit nurses demonstrated a moderate level of vicarious posttraumatic growth. Moral resilience was positively associated with both death coping ability and vicarious posttraumatic growth. Death coping ability was found to play a partial mediating role in the relationship between moral resilience and vicarious posttraumatic growth. CONCLUSION Moral resilience and death coping ability are key factors associated with vicarious posttraumatic growth among intensive care unit nurses. Nurses with stronger moral resilience are more likely to cope constructively with death-related stress, which may support psychological growth in trauma-intensive environments. IMPACT This study highlights the need to enhance intensive care unit nurses' moral and emotional capacities through ethics education, emotional coping training, and institutional support strategies. Strengthening these competencies may foster professional development and mental wellbeing in critical care settings.

No abstract available

Background Intensive Care Unit (ICU) nurses frequently confront significant psychological challenges, including compassion fatigue, moral distress, and diminished moral resilience. These issues not only affect their well-being but also impact the quality of care provided to patients. The interplay of these factors is complex and not fully understood, particularly how compassion fatigue influences the relationship between moral resilience and moral distress. Objectives To explore the complex interplay between compassion fatigue and moral distress among ICU nurses, and to elucidate how compassion fatigue influences the protective role of moral resilience against moral distress. Research design A cross-sectional study was conducted using a nationwide random sample of ICU nurses in China. Latent profile analysis identified subgroups based on levels of compassion fatigue. Moderation analysis examined whether compassion fatigue moderated the association between moral resilience and moral distress. Results Among 612 ICU nurses, latent profile analysis revealed three distinct groups with high, moderate, and low levels of compassion fatigue. Being female was protective against high compassion fatigue, while ages 30–49 yrs., lack of bachelor’s degree, and dissatisfaction with salary increased compassion fatigue risk. Moderation analysis showed compassion fatigue significantly moderated the relationship between moral resilience and moral distress. Nurses with higher compassion fatigue exhibited a stronger association between low moral resilience and high moral distress. Conclusion Compassion fatigue and moral distress are interconnected phenomena among ICU nurses. Demographic factors like gender, age, education, and income satisfaction impact compassion fatigue risk. High compassion fatigue impairs moral resilience, exacerbating moral distress. Comprehensive interventions targeting both compassion fatigue and moral resilience, tailored to nurses’ demographic profiles, are needed to support this workforce.

Backgrounds Moral distress significantly affects pediatric ICU nurses, leading to nurse burnout, increased turnover and reducing patient care quality. Despite its importance, there’s a notable gap in knowledge on how to manage it effectively. Aims This review aimed to systematically identify and analyze coping strategies and interventions targeting moral distress among pediatric nurses in ICU, uncovering research gap and future studies directions. Methods A scoping review was conducted followed framework by Levac, Colquhoun, and O'Brien and Arksey and O'Malley. Searches were performed in 11 electrical databases, like PubMed and China Biology Medicine disc, within a timeframe of the database construction to November 2023, and performed literature screening and data extraction. Results Sixteen articles were ultimately included. Coping strategies adopted by pediatric ICUs nurses can be categorized into adaptive and maladaptive strategies, with the latter including passive acceptance, taking leave, and drinking, while the former involve pursuing interests outside of work, reflection and philosophizing, and communication. Nine articles described and evaluated the effectiveness of interventions for moral distress, categorizing them into individual and institutional levels. Individual-level interventions include Interprofessional Perspective-Taking, the PICU Resiliency Bundle, Ethics Education/Skills, and the Center for Caring. Institutional-level interventions encompasses Comprehensive Care Round, Goals of Care Conversations, Pediatric Ethics and Communication Excellence Rounds, Nursing Ethics Council, and Medical Ethical Decision-Making, though not all were effective in alleviating moral distress. Conclusions Nurses often use self-adjustment strategies for moral distress, institutional ethical support focusing on enhancing nurses’ moral resilience, promoting reflective thinking and improving communication remains crucial. Various interventions for moral distress are currently available, but nurse engagement is low and their effectiveness remained to be verified. Future studies should explore what aids or hinders these interventions. There’s also a need for large, multicenter trials and ongoing evaluations to create effective support systems for pediatric ICU nurses.

BACKGROUND Since the outbreak of COVID-19, researchers worldwide have focused more on the issue of secondary traumatic stress (STS) experienced by nurses. This stress has an adverse effect on the health of nurses and the quality of nursing care, potentially undermining the stability of the nursing team and hindering the ability to meet the growing demand for nursing services. The impact of the COVID-19 pandemic, and the rise in global demand for ICU nursing, has placed a significant strain on ICU nurses, severely damaging their mental and physical health. Notably, ICU nurses also face high levels of moral distress, and moral resilience can effectively alleviate this distress and improve the quality of care. AIMS This study aimed to examine the levels of moral resilience and STS among ICU nurses, to explore their relationship and identify the factors influencing STS. STUDY DESIGN This cross-sectional study involved 229 ICU nurses from two tertiary hospitals in Xi'an, China, who participated between November and December 2023. The data were collected through email using anonymous electronic questionnaires, encompassing a self-designed demographic- and work-life-related characteristic questionnaire; the Rushton Moral Resilience Scale; and the Secondary Traumatic Stress Scale. Descriptive statistics, t-tests, analysis of variance and hierarchical regression analysis were performed to analyse the data. RESULTS The findings of the study indicated that ICU nurses' moral resilience and STS scores were at an intermediate level. Hierarchical regression analysis indicated that STS was negatively correlated with the subscales of the Rushton Moral Resilience Scale, specifically moral adversity coping (β, -0.156; 95% CI, -1.241 to -0.039) and relational integrity (β, -0.245; 95% CI, -1.453 to -0.388), which are significant predictors of STS. Additionally, good sleep quality (β, -.396; 95% CI, -14.948 to -7.117) and seeking psychological counselling because of work difficulties (β, .107; 95% CI, 0.237-9.624) emerged as significant predictors of STS among ICU nurses, with the model's explanation of the variance in STS increasing to 45.5%, △R2 = .167, F = 16.482 (p < .001). CONCLUSION This study found that ICU nurses have moderate levels of moral resilience and STS, which are negatively correlated. This suggests that improving the moral resilience of ICU nurses may help reduce their STS levels. RELEVANCE TO CLINICAL PRACTICE The study revealed that ICU nurses' moral resilience and secondary traumatic stress levels were at a moderate level, indicative of the need to take measures to enhance their moral resilience and reduce their secondary traumatic stress, as their presence not only affects the health of ICU nurses but also diminishes the quality of care and increases turnover rates.

Objectives There is little research on moral uncertainties and distress of palliative and hospice care providers (PHCPs) working in jurisdictions anticipating legalising voluntary assisted dying (VAD). This study examines the perception and anticipated concerns of PHCPs in providing VAD in the State of Queensland, Australia prior to legalisation of the practice in 2021. The findings help inform strategies to facilitate training and support the health and well-being of healthcare workers involved in VAD. Design The study used a qualitative approach to examine and analyse the perception and anticipated concerns of PHCPs regarding challenges of providing assisted dying in Queensland. Fourteen PHCPs were recruited using a purposive sampling strategy to obtain a broad representation of perspectives including work roles, geographical locations and workplace characteristics. Data were collected via one in-depth interview per participant. The transcripts were coded for patterns and themes using an inductive analysis approach following the tradition of Grounded Theory. Setting The study was conducted in hospital, hospice, community and residential aged care settings in Queensland, Australia. These included public and private facilities, secular and faith-based facilities, and regional/rural and urban facilities. Participants Interviews were conducted with fourteen PHCPs: 10 nurses and 4 physicians; 11 female and 3 male. The median number of years of palliative care practice was 17, ranging from 2 to 36 years. For inclusion, participants had to be practising palliative and hospice care providers. Results PHCPs are divided on whether VAD should be considered part of palliative care. Expectations of moral distress and uncertainty about practising VAD were identified in five areas: handling requests, assessing patient capacity, arranging patient transfers and logistical issues, managing unsuccessful attempts, and dealing with team conflicts and stigma. Conclusions The possibility of having to practise VAD causes moral distress and uncertainty for some PHCPs. Procedural clarity can address some uncertainties; moral and psychological distress, however, remains a source of tension that needs support to ensure ongoing care of both patients and PHCPs. The introduction of VAD post-legalisation may present an occasion for further moral education and development of PHCPs.

AIM To investigate the correlation between intensive care unit (ICU) nurses' demographic characteristics, teamwork, moral sensitivity and missed nursing care. BACKGROUND Teamwork, moral sensitivity and missed nursing care are important health challenges among ICU nurses. Clarifying the relationship between variables is benefit to improve the quality of patients care. Nevertheless, a comprehensive conceptualisation of the relationship between teamwork, moral sensitivity and missed nursing care remains lacking. DESIGN A cross-sectional design. METHODS This study follows the STROBE checklist. ICU nurses were recruited by two hospitals between November 2023 and January 2024, in Shandong Province, China. The demographic characteristic questionnaire, teamwork perceptions questionnaire, moral sensitivity questionnaire-revised version into Chinese and the Chinese version of the missed nursing care questionnaire were used for investigation. Multiple linear regression was used to clarify the factors affecting missed nursing care. Pearson correlation was used to test the correlation between teamwork, moral sensitivity and missed nursing care. RESULTS The level of missed nursing care for ICU nurses was low, with overall mean score of 37.49. Missed nursing care for ICU nurses in the labour dispatch were much higher than nurses with the contract system and personnel agency (p < 0.05). The 12-h shifts of ICU nurses also influenced missed nursing care. Furthermore, teamwork has a positive relationship with moral sensitivity (r = 0.653, p < 0.001). CONCLUSION Hospital and nursing managers should pay attention to the clinical sense of belonging of ICU nurses, reasonably set the working shifts, which will help to reduce the occurrence of missed nursing care. RELEVANCE TO CLINICAL PRACTICE It is recommended that nursing managers should invest in strategies to enhance nurse teamwork and implement a 12-h shift pattern, which can alleviate moral distress and improve quality of care. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution. (The data of this were collected from nurses and not related to patients. They were informed of the research process and precautions, signed informed consent.).

BACKGROUND Secondary traumatic stress is acknowledged as a substantial psychological risk factor in nursing practice with the potential to negatively impact nurses' mental health. However, little is known about the mechanisms underlying the spiritual climate and secondary traumatic stress among ICU nurses. OBJECTIVES This study aimed to assess the spiritual climate, moral resilience, and secondary traumatic stress in Chinese ICU nurses and to investigate whether moral resilience mediates the relationship between spiritual climate and secondary traumatic stress. METHODS A cross-sectional study design was used to recruit 229 intensive care unit nurses. The nurses completed online questionnaires comprising demographic characteristics, spiritual climate, moral resilience, and secondary traumatic stress. Data analysis and structural equation modeling were conducted using SPSS 26.0 and AMOS 24.0. RESULTS STS scores were (38.42 ± 13.27). Secondary traumatic stress was correlated with spiritual climate and moral resilience (r1 = -0.370, r2 = -0.575; p < 0.01), and spiritual climate was positively correlated with moral resilience (r = 0.427; p < 0.01). A mediating effect of moral resilience between spiritual climate and secondary traumatic stress held (mediating effect of 0.235, 95 % CI: -2.108 to -0.823, accounting for 57.32 % of the total effect). CONCLUSIONS The spiritual climate has a significant direct influence on secondary traumatic stress in ICU nurses and serves to reduce their secondary traumatic stress through moral resilience. Creating a positive spiritual climate and enhancing the moral resilience of ICU nurses are effective methods to reduce their secondary traumatic stress. IMPLICATIONS FOR CLINICAL PRACTICE This study highlights that the spiritual climate for ICU nurses can reduce their secondary traumatic stress, and that moral resilience diminishes the secondary traumatic stress related to the spiritual climate. Establishing support systems and improving the environment are primary tasks for nursing administrators. These include, but are not limited to, improving the spiritual climate of the department, providing moral resilience training, and taking other measures to prevent and regulate secondary traumatic stress in ICU nurses in order to maintain their mental health.

BACKGROUND For a hospitalized patient, transitioning to comfort measures only (CMO) involves discontinuation of life-prolonging interventions with a goal of allowing natural death. Nurses play a pivotal role during the provision of CMO, caring for both the dying patient and their family. OBJECTIVE To examine the experiences of ICU nurses caring for patients receiving CMO. METHODS Between October 2020 and June 2021, nurses in the neuro- and medical-cardiac intensive care units at Harborview Medical Center in Seattle, WA, completed surveys about their experiences providing CMO. Surveys addressed involvement in discussions about CMO and questions asked by family members of dying patients. We also assessed nurses' moral distress related to CMO and used ordinal logistic regression to examine predictors of moral distress. RESULTS Surveys were completed by 82 nurses (response rate 44%), with 79 (96%) reporting experience providing CMO in the previous year. Most preferred to be present for discussions between physicians or advanced practice providers and family members about transitioning to CMO (89% most of the time or always); however, only 31% were present most of the time or always. Questions from family about time to death, changes in breathing, and medications to relieve symptoms were common. Most nurses reported moral distress at least some of the time when providing CMO (62%). Feeling well-prepared to answer specific questions from family was associated with less moral distress. CONCLUSION There is discordance between nurses' preferences for inclusion in discussions about the transition to CMO and their actual presence. Moral distress is common for nurses when providing CMO and feeling prepared to answer questions from family members may attenuate distress.

Background Nurses’ clinical competence is one of the fundamental necessities for providing safe and effective care. Moral distress, as one type of occupational stressors, can affect various aspects of clinical competence, especially under conditions of complicated medical settings such as the coronavirus disease 2019 (COVID-19) epidemic. This study was conducted with the aim of determining the relationship between moral distress and clinical competence in nurses working in COVID-19 intensive care units (ICUs). Methods The study was a cross-sectional study. A total of 194 nurses working in COVID-19 ICU affiliated to Shahid Sadoughi University of Medical Sciences, Yazd, central Iran, participated in the study. Data were collected using Demographic Information Questionnaire, Moral Distress Scale, and Clinical Competence Checklist. Data were analyzed with SPSS20 using descriptive and analytical statistics. Results The mean score of moral distress, clinical competence, and skills application were 1.79 ± 0/68, 65.16 ± 15.38, and 145.10 ± 38.20, respectively. Based on Pearson correlation coefficient, there was an inverse and significant relationship between the moral distress score and its dimensions with clinical competence and skills application (P < 0.001). Moral distress was a significant negative predictor that accounted for 17.9% of the variance in clinical competence (R^2 = 0.179, P < 0.001) and 16% of the variance in utilization of clinical competence (R^2 = 0.160, P < 0.001). Conclusion Considering the relationship between moral distress, clinical competence and skills application, to maintain the quality of nursing services, nursing managers can strengthen clinical competence and skills application by using strategies to deal with and reduce moral distress in nurses, especially in critical situations.

OBJECTIVES: Moral case deliberation (MCD) is a team-based and facilitator-led, structured moral dialogue about ethical difficulties encountered in practice. This study assessed whether offering structural MCD in ICUs reduces burnout symptoms and moral distress and strengthens the team climate among ICU professionals. DESIGN: This is a parallel cluster randomized trial. SETTING: Six ICUs in two hospitals located in Nijmegen, between January 2020 and September 2021. SUBJECTS: Four hundred thirty-five ICU professionals. INTERVENTIONS: Three of the ICUs organized structural MCD. In three other units, there was no structural MCD or other structural discussions of moral problems. MEASUREMENTS AND MAIN RESULTS: The primary outcomes investigated were the three burnout symptoms—emotional exhaustion, depersonalization, and a low sense of personal accomplishment—among ICU professionals measured using the Maslach Burnout Inventory on a 0–6 scale. Secondary outcomes were moral distress (Moral Distress Scale) on a 0–336 scale and team climate (Safety Attitude Questionnaire) on a 0–4 scale. Organizational culture was an explorative outcome (culture of care barometer) and was measured on a 0–4 scale. Outcomes were measured at baseline and in 6-, 12-, and 21-month follow-ups. Intention-to-treat analyses were conducted using linear mixed models for longitudinal nested data. Structural MCD did not affect emotional exhaustion or depersonalization, or the team climate. It reduced professionals’ personal accomplishment (−0.15; p < 0.05) but also reduced moral distress (−5.48; p < 0.01). Perceptions of organizational support (0.15; p < 0.01), leadership (0.19; p < 0.001), and participation opportunities (0.13; p < 0.05) improved. CONCLUSIONS: Although structural MCD did not mitigate emotional exhaustion or depersonalization, and reduced personal accomplishment in ICU professionals, it did reduce moral distress. Moreover, it did not improve team climate, but improved the organizational culture.

Background The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. Methods A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. Results All 178 respondents (response rate: 25–32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to ‘team cooperation’, ‘team solidarity’ and ‘work ethic’. Lessons learned were mostly related to ‘quality of care’ and ‘professional qualities’. Conclusions Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals’ dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. Trial registration The trial was registered on The Netherlands Trial Register, number NL9177.

Background Intraoperative deaths, though statistically rare, may evoke varied emotions among operating room (OR) staff that remain underrecognized and inadequately addressed. Aim To synthesise the qualitative evidence regarding experiences of OR staff following patient death in the OR. A secondary aim is to unpack strategies to support OR staff following an intraoperative death experience. Design Narrative review of qualitative studies. Data sources Peer-reviewed databases (PubMed, EMBASE, CINAHL, Web of Science, Scopus and Cochrane Review Library) and grey literature sources (such as thesis databases) were extensively searched for peer-reviewed primary studies and non-peer-reviewed literature respectively reporting on intraoperative deaths or deaths occurring in the OR. Results Six studies were retained. The synthesis revealed that unexpected OR deaths or those deaths perceived as sudden or preventable evoked more severe and enduring psychological repercussions, marked by guilt, hypervigilance, emotional and moral distress. In contrast, anticipated fatalities, particularly in patients with advanced illness, evoked less intense emotions but did not eliminate emotional tolls. The findings revealed divergent coping mechanisms among OR professionals: surgeons often engaged in meaning-making or employed emotion-focused and problem-focused strategies to process loss. In contrast, anaesthetists described emotional desensitisation over time. Nurses, meanwhile, navigated a pervasive culture of silence. Conclusion The emotional toll captured underscores urgent needs for interventions, such as team-based debriefing support, alongside systemic reforms to normalise vulnerability and integrate emotional stewardship into institutional policies.Addressing this is not only ethically imperative but critical to sustaining a resilient workforceand ensuring patient safety in an era of escalating surgical demand.

Introduction Recently, moral distress in pediatric nursing has gained academic attention, yet comprehensive literature reviews on this group are scarce. Aims This study aims to offer a detailed overview of moral distress among pediatric nurses, focusing on understanding its characteristics, prevalence, underlying causes, and consequences on the quality of patient care. Methods Employing a scoping review approach as recommended by the Joanna Briggs Institute, this study will systematically search through PubMed, Scopus, Web of Science, APA PsycInfo, and CINAHL databases using specific search strategies. Titles, abstracts, and full texts will be independently screened by two reviewers according to the eligibility criteria. Relevant data will be extracted, categorized, and subjected to narrative synthesis to draw comprehensive insights. Conclusion The anticipated findings of this study will shed light on the nature, frequency, and drivers of moral distress among pediatric nurses, along with its broader implications for healthcare practitioners, organizational practices, and patient care outcomes.

Objective Pandemics negatively impact healthcare workers’ (HCW’s) mental health and well-being causing additional feelings of anxiety, depression, moral distress and post-traumatic stress. A comprehensive review and evidence synthesis of HCW’s mental health and well-being interventions through pandemics reporting mental health outcomes was conducted addressing two questions: (1) What mental health support interventions have been reported in recent pandemics, and have they been effective in improving the mental health and well-being of HCWs? (2) Have any mobile apps been designed and implemented to support HCWs’ mental health and well-being during pandemics? Design A narrative evidence synthesis was conducted using Cochrane criteria for synthesising and presenting findings when systematic review and pooling data for statistical analysis are not suitable due to the heterogeneity of the studies. Data sources Evidence summary resources, bibliographic databases, grey literature sources, clinical trial registries and protocol registries were searched. Eligibility criteria Subject heading terms and keywords covering three key concepts were searched: SARS-CoV-2 coronavirus (or similar infectious diseases) epidemics, health workforce and mental health support interventions. Searches were limited to English-language items published from 1 January 2000 to 14 June 2022. No publication-type limit was used. Data extraction and synthesis Two authors determined eligibility and extracted data from identified manuscripts. Data was synthesised into tables and refined by coauthors. Results 2694 studies were identified and 27 papers were included. Interventions were directed at individuals and/or organisations and most were COVID-19 focused. Interventions had some positive impacts on HCW’s mental health and well-being, but variable study quality, low sample sizes and lack of control conditions were limitations. Two mobile apps were identified with mixed outcomes. Conclusion HCW interventions were rapidly designed and implemented with few comprehensively described or evaluated. Tailored interventions that respond to HCWs’ needs using experience co-design for mental health and well-being are required with process and outcome evaluation.

  Health professions education in the Philippines operates at the intersection of psychosocial strain, generational change, digital transformation, and structural resource limitations. This integrative narrative review synthesizes contemporary empirical and conceptual studies—spanning moral distress and burnout, intergenerational dynamics, Generation Z learning behaviors, licensure intentions, program viability, and clinical placement scarcity—to develop a unified understanding of the pressures confronting students, faculty, and academic leaders in licensure-based programs. A structured search and thematic synthesis yielded six cross-cutting themes: (1) moral distress and moral fatigue as pervasive psychosocial burdens across learners and educators; (2) role overload and burnout driven by simultaneous teaching, administrative, and regulatory demands; (3) intergenerational gaps influencing communication, pedagogy, and leadership practice; (4) the distinctive learning preferences and success definitions of Generation Z and emerging Generation Alpha; (5) structural tensions between enrolment-driven viability and licensure-driven quality; and (6) long-standing scarcity and maldistribution of clinical placement sites. Cross-theme integration reveals that these forces do not operate independently but converge to shape institutional decision-making, faculty engagement, learner preparedness, and ultimately licensure outcomes. The review highlights the absence of integrative, Philippine-focused research linking generational shifts with licensure expectations, faculty well-being, and structural constraints. It proposes a systems-level conceptual view that positions leadership as the central mediating function that must balance viability, quality, well-being, and generational responsiveness. Findings underscore the need for leadership models that are adaptive, data-driven, and psychosocially sensitive; governance structures that account for licensure cultures; and institutional strategies that integrate digital pedagogies, faculty support, and clinical training reform. The review contributes a synthesized evidence base to guide policy, leadership development, and future empirical work in Philippine health professions education..  

The aim of this paper is to present a systems approach to support leaders in creating a satisfying and meaningful career experience for colleagues which promotes optimal subjective well-being and healthspan. The intention is to help people do better. Kindness is helping people do better. There is an occupational health challenge in healthcare, with high rates of professional burnout, moral distress, turnover and work–life disintegration. An evidence synthesis of a narrative literature review identified subjective well-being and healthspan determinants primarily in the sphere of control of organisations. They are categorised into four domains: agency (control over work–life), collective effervescence (meaning, energy and harmony in groups of people with shared purpose), camaraderie (social connectedness) and positivity (optimism and caring). Ten systems that can improve staff subjective well-being and healthspan are presented.

Abstract Background Moral distress affects a significant proportion of clinicians who have received requests and participated in euthanasia or physician-assisted suicide (E/PAS) globally. It has been reported that personal and professional support needs are often unaddressed, with only a minority of those reporting adverse impacts seeking support. Objectives This study aimed to review studies from 2017 to 2023 for the perceived risks, harms, and benefits to doctors of administering E/PAS and the ethical implications for the profession of medicine resulting from this practice. Methods The search explored original research papers published in peer-reviewed English language literature between June 2017 and December 2023 to extend prior reviews. This included both studies reporting quantitative and qualitative data, with a specific focus on the impact on, or response from, physicians to their participation in E/PAS. The quantitative review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The qualitative review used the Critical Appraisal Skills Programme to assess whether studies were valid, reliable, and trustworthy. Results Thirty studies (quantitative n = 5, qualitative n = 22, mixed methods n = 3) were identified and fulfilled acceptable research assessment criteria. The following 5 themes arose from the synthesis of qualitative studies: (1) experience of the request prior to administration; (2) the doctor’s role and agency in the death of a patient; (3) moral distress post-administration; (4) workload and burnout; and (5) professional guidance and support. Both quantitative and qualitative studies showed a significant proportion of clinicians (45.8–80%) have been adversely affected by their involvement in E/PAS, with only a minority of those reporting adverse impacts seeking support. Significance of results Participation in E/PAS can reward some and cause moral distress in others. For many clinicians, this can include significant adverse personal and professional consequences, thereby impacting the medical profession as a whole.

Organ procurement procedures have evolved significantly over the past decade, resulting in new moral uncertainties. The dead donor rule (DDR), a foundational principle, mandates that organ procurement occurs only after death is confirmed. However, developments such as donation after circulatory death (DCD) and normothermic regional perfusion (NRP) have raised ethical issues, creating moral distress and moral injury among anesthesiologists. This review highlights the recent changes in the organ procurement processes and the potential impact on anesthesiologists and also discusses the strategies to prevent and manage moral distress. A narrative review was conducted using a structured search strategy across Ovid MEDLINE, Embase, and Web of Science. The search included the terms "anesthesiology", "moral distress", "dead donor rule", "brain death", and "normothermic regional perfusion". Of the 77 identified articles, 18 met inclusion criteria focusing on the ethical, psychological, and educational aspects of the anesthesiologist’s role in organ procurement. The increasing use of novel organ procurement techniques such as NRP after DCD may result in moral distress among anesthesiologists. While the literature on moral distress continues to expand in the healthcare field, more needs to be written on this topic with anesthesiologists involved in organ procurement. Anesthesiologists are participating in novel organ procurement techniques with minimal control of decision-making. As a result, moral distress may occur with negative consequences. Solutions to the identification and prevention of moral distress with organ procurement include expanded ethics education, peer and mentor support, and institutional support. Addressing these issues can empower anesthesiologists to navigate complex scenarios, mitigating moral distress and increasing wellness and patient safety.

Introduction Moral distress is a significant challenge in contemporary nursing practice, posing a substantial threat to nurses’ well-being and patient safety. Nurses in the emergency department are considered a high-risk group for experiencing this distress due to their unique working environment. Although numerous qualitative studies have explored this issue, a systematic synthesis of this fragmented evidence is notably absent. This qualitative meta-synthesis aims to integrate existing evidence to construct a comprehensive conceptual framework of the experiences, processes and coping mechanisms related to moral distress among emergency nurses. Methods and analysis This study will be a qualitative systematic review and meta-synthesis, adhering to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement and the Joanna Briggs Institute (JBI) methodology. A systematic search will be conducted in international and Chinese databases, including PubMed, CINAHL, Embase, CNKI, etc. All peer-reviewed qualitative studies exploring the first-person experiences of emergency nurses will be included. Two independent reviewers will perform study selection, data extraction and methodological quality appraisal using the JBI Critical Appraisal Checklist for Qualitative Research. Data synthesis will employ a theory-integrated meta-aggregation approach, systematically mapping findings onto the Stress, Appraisal, and Coping Theory to construct a nuanced conceptual framework that explains the dynamic process of moral distress. Confidence in the synthesised findings will be assessed using the ConQual approach. Ethics and dissemination As this study is a secondary analysis of published data, ethical approval is not required. The findings will be disseminated through publication in a peer-reviewed journal and presentations at academic conferences. PROSPERO registration number CRD420251041396.

Abstract Nurses working in oncology frequently have to make tough moral choices, such as how to break bad news or how to make sure a dying patient receives good palliative or end-of-life care. In the context of patient care, this may limit the ethical and moral options available to nurses. This can cause moral dissonance and ethical insensitivity on the job and can be very stressful. To be able to meet ethical problems in trying times calls for capacity to recognize and know how to manage the concerns. The purpose of this article was to describe common ethical challenges and to present some methods that may be helpful when confronting them. This narrative review discusses the ethical standards that oncology nurses should uphold and implement in their daily work. Many common ethical dilemmas are also explored, and the study hopes to shed light on how novice nurses, such as students and fresh recruits, may experience when caring for cancer patients and their family caregivers. Importantly, this review also addresses aspects of how nurses can improve their skills so that they can deal with the ethical quandaries and moral discomfort that arise on a daily basis in cancer care.

No abstract available

Background Family physicians (GPs) working with patients experiencing social inequities have witnessed patients’ healthcare needs proliferate. Alongside increased workload demands fostered within current remuneration structures, this has generated concerning reports of family physician attrition and possible experiences of moral distress. Aim To explore stories of moral distress shared by family physicians caring for patients experiencing health needs related to social inequities. Design and setting A critical narrative inquiry, informed by the analytic lens of moral distress, conducted in Ontario, Canada. Method Twenty family physicians were recruited through purposive and snowball sampling via word of mouth and email mailing lists relevant to addictions and mental health care. Physicians participated in two narrative interviews and had the opportunity to review the interview transcripts. Results Family physicians’ accounts of moral distress were linked to policies governing physician remuneration, scope of practice, and the availability of social welfare programmes. These structural elements left physicians unable to get patients much needed support and resources. Conclusion This study provides evidence that physicians experience moral distress when unable to offer crucial resources to improve the health of patients with complex social needs resulting from structural features of the Canadian health and social welfare system. Further research is needed to critically interrogate how health and social welfare systems around the world can be reformed to improve the health of patients and increase family physicians’ professional quality of life, potentially improving retention.

Background: Palliative care professionals have had to adapt to rapidly changing COVID-19 restrictions with personal protective equipment and physical distancing measures impacting face-to-face communication with patients and relatives. Aim: To explore the narratives of palliative care doctors working during the pandemic to understand their experiences at a personal and professional level. Design: In-depth narrative interviews were carried out via video call. Interviews were transcribed verbatim and analysed using a joint paradigmatic and narrative approach to elucidate common themes and closely explore individual narratives. Setting/participants: Eight palliative care doctors who had worked on a hospice inpatient unit in the UK before and during the pandemic were recruited from two hospices in Scotland. Results: Three intersecting themes are described, the most significant being moral distress. Participants articulated a struggle to reconcile their moral convictions with the restrictions enforced, for example, wanting to provide support to patients through physical proximity but being unable to. To differing degrees, this resulted in internal conflict and emotional distress. Two further themes arose: the first concerned a loss of humanity in interaction and a striving to re-humanise communication through alternative means; the second being a change in staff morale as the pandemic progressed. Conclusions: Restrictions had a considerable impact on palliative care doctors’ ability to communicate with and comfort patients which led to moral distress and contributed to decreasing morale. Future research could explore moral distress in palliative care settings internationally during the pandemic with a view to compare the factors affecting how moral distress was experienced.

The number of people requiring palliative care is increasing. This can result in moral and ethical conflicts that may lead to psychological distress and moral injury. (MI). Solutions are needed to counteract career abandonment—supervision (SV) could be one solution. This study examines the extent to which palliative care nurses link MI to their everyday experiences and whether SV can contribute to the identification and prevention of moral distress and MI. In addition, factors that influence the implementation of, participation in, and perception of SV are analyzed. A qualitative study design was chosen for the investigation, consisting of guided interviews, narrative-generating questions with seven participants working in palliative care, and participant observation with audio recording during two supervisions of two palliative care teams with 16 participants in total. The data was analyzed using qualitative content analysis according to Mayring. The results show differences in workload between acute and palliative care wards. Time pressure and hierarchical structures promote distress and MI and are particularly evident on acute wards. The interviewees described specific experiences of MI. In addition, factors were identified that influence participation in SV. The analysis of SV showed that workload is a key cause of moral distress and can have an impact on health. SV can be used for sensitization and exchange. Implementation and acceptance of SV depend on individual and structural factors. In palliative care, signs of moral distress are present and are specifically addressed in SV, which means that SV can be a tool for dealing with stressful situations.

Congenital heart defects (CHD) are a significant cause of prenatal and postnatal morbidity and mortality, leading to complex ethical and moral decisions for parents when diagnosed in utero. The decision to continue or terminate a pregnancy after a CHD diagnosis involves multifaceted considerations, including cultural, religious, and personal values, alongside medical, ethical, and socioeconomic factors. This systematic review delves into the multifaceted moral considerations involved in the decision-making process regarding continuing a pregnancy following a CHD diagnosis. A systematic review of the literature was conducted using a narrative synthesis approach. Peer-reviewed qualitative, quantitative, and mixed-methods studies addressing ethical issues related to parental decision-making and clinical care following a prenatal CHD diagnosis were included. A comprehensive search was performed across multiple databases: MEDLINE, PsycINFO, Scopus, Web of Science (WOS), CINAHL, ProQuest, ERIC, and Embase. Findings were synthesized thematically to identify key ethical tensions, factors contributing to moral complexity, challenges faced by parents and healthcare providers, and supportive strategies. The synthesis of 25 studies from North America, Europe, Australia, and the Middle East (Iran) revealed a universal parental experience of acute psychological crisis following a prenatal diagnosis of CHD. However, the ethical frameworks guiding parental decision-making were highly context-dependent. Three overarching themes emerged: (1) a central ethical tension between the sanctity of life and the quality of life, with perspectives strongly shaped by religious beliefs, legal statutes, and cultural norms; (2) The Lived Experience of the Decision-Making Crisis; and (3) Strategies for Navigating the Ethical Terrain. A prenatal CHD diagnosis initiates a profound moral journey for parents that extends far beyond a medical decision. The resulting psychological crisis—driven by the tension between sanctity and quality of life—underscores the need for a shift in clinical practice. Evidence supports the adoption of a holistic, multidisciplinary framework grounded in cultural sensitivity and empathetic communication to empower parents in making value-congruent choices during one of life’s most difficult experiences.

Abstract Purpose We aimed to develop a tool that would allow assessment of ethics competency and moral distress during the Internal Medicine Clerkship and to introduce curricular changes that could empower students to better address ethical dilemmas and challenges encountered during the clerkship. Materials and Methods A structured ethics assignment was introduced where students could reflect on impactful stressful scenarios and address questions related to emotional responses, identified ethical issues, management themes, and professional obligations. A 4-tiered grading rubric and individual narrative feedback was provided for each assignment, and small-group debriefing sessions were introduced for reflective thought and future planning. De-identified assignments were analyzed and classified into subgroups according to 5 main ethical issue subgroups and 10 specific management themes. Assignments were also analyzed for the presence of moral distress. Results 357 students completed the reflective ethics activities. The most commonly identified ethical issues were related to Shared Medical Decision Making (>40%), Primary of Patient Welfare challenges, (>20%), and Social/Organizational dilemmas. Management themes often pertained to Patient Wishes/Legal Obligations, Professional Behaviors, and Limited Resources. 87% of assignments demonstrated moral distress. Conclusion Medical school is a stressful time and challenges are augmented during clinical years. Our reflective activity demonstrated significant exposures to ethical dilemmas, reviewed earlier principles of ethics training, and provided a safe forum in which to discuss these important aspects of healthcare. We captured powerful images of challenging situations eliciting moral distress, and students greatly appreciated the activity. We encourage future investigations that support student well-being and enable smooth transitions into residency training.

AIMS To describe, through an integrative literature review, the factors contributing to the development of burnout and moral distress in nursing professionals working in intensive care units and to identify the assessment tools used most frequently to assess burnout and moral distress. METHODS An integrative literature review was carried out. PubMed, CINAHL, PsycINFO, SciELO, Dialnet, Web of Science, Scopus, and Cochrane databases were reviewed from January 2012 to February 2023. Additionally, snowball sampling was used. The results were analysed by using integrative synthesis, as proposed by Whittemore et al., the Critical Appraisal Skills Programme for literature reviews, the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for quantitative observational studies, and the Joanna Briggs Institute checklist for qualitative research were used to evaluate evidence quality. RESULTS Forty-one articles were selected for review: 36 were cross-sectional descriptive articles, and five were literature reviews. The articles were grouped into five-factor categories: 1) personal factors, 2) organisational factors, 3) labour relations factors, 4) end-of-life care factors, and 5) factors related to coronavirus disease 2019 (COVID-19). The Maslach Burnout Inventory-Human Services Survey and the Moral Distress Survey-Revised instruments were the most commonly used to measure burnout and moral distress. CONCLUSIONS This review highlights the multiple personal, organisational, relational, situational, and end-of-life factors promoting burnout and moral distress among critical care nurses. Interventions in these areas are necessary to achieve nurses' job satisfaction and retention while improving nurses' quality of care.

OBJECTIVES Moral distress, reported among healthcare workers across a variety of settings, is associated with negative mental health consequences, burnout, and intention to leave a position. The scant literature exploring medical students' moral distress does not specifically examine moral distress during the surgical clerkship nor does it characterize the type of moral distress experienced by medical students. Thus, we aimed to explore and characterize medical students' moral distress during the surgical clerkship. SETTING/PARTICIPANTS This study was conducted at the University of Michigan Medical School evaluating narrative essays written by 3 cohorts of students (2018-19, 2019-20, 2020-21) who completed the surgical clerkship during their third year of medical school. DESIGN Deductive content analysis was used to evaluate 180 narrative essays for the presence of moral distress using a 5-subcategorization schema developed by Morley et al. (constraint-distress, tension-distress, dilemma-distress, uncertainty-distress, and conflict-distress). RESULTS Four of the 5 sub-categories of moral distress (constraint-distress, tension-distress, dilemma-distress and uncertainty-distress) were identified in medical student essays. There were no examples of conflict-distress. CONCLUSIONS Medical students described 4 of the 5 sub-types of moral distress during their surgical clerkship. The sub-types of moral distress most often experienced by medical students are different than sub-types of moral distress previously reported among nurses, suggesting the varied roles and responsibilities of the healthcare team impact the scenarios most likely to present moral distress. Additionally, medical students were hesitant to raise concerns with their team when they experienced events discordant with their moral beliefs; they cited their position in the medical hierarchy, fearing implications on their future career, and perceived lack of knowledge and experience as factors limiting their willingness to share. Finally, this study identifies morally distressing scenarios as opportunities for transformative learning for medical students specifically in the realm of professional identity formation.

Abstract Aim To understand how pre‐registration student nurses experience moral distress and refine the concept in this population. Background The experience of moral distress has positive and negative effects for health professionals and negatively impacts on patient care. Moral distress is a fluid concept which permits the experience to be varied among different populations. Despite empirical research, a concept analysis has not been performed in the student nurse population. Data Sources Electronic databases were searched via Ebsco Host Complete and included Cinahl, Medline, APA Psych in March 2024. Search terms included ‘Moral Distress’ AND ‘Student’, ‘Moral Distress’ and ‘Baccalaureate.’ Search limits included articles between 2014 and 2024, English Language. Twenty‐five papers were included in the review and consisted of eight quantitative studies, 11 qualitative studies, three mixed methods studies and three literature/systematic reviews. Methods An integrated mixed research synthesis (Sandelowski, Voils, Barroso 2006) was conducted and organized into Walker, Avant's (2005) framework of antecedents, attributes and consequences. Braun and Clarkes (2006) thematic analysis was then used to generate themes from the literature. Results Antecedents emerged as students having moral sensitivity, they recognize unethical circumstances. Attributes identified roots of moral distress. These roots include poor patient care, harm to the patient and unsafe care. Students experience of morally reprehensible events is exacerbated by the disempowerment they experience as being ‘just a student’. Student nurses who do not exhibit moral courage and do not oppose immoral practices do so due to internal constraints which transpire as fear of conflict, withdrawal of learning opportunities, and fear of disruption to learning. This is influenced by their registered nurse supervisor relationship. Consequences of moral distress identify negative feelings, coping mechanisms and positive effects. Conclusion The attributes of moral distress in the student nurse population have distinctive features which should be considered by nurse educators and in empirical research. Patient or Public Contribution None, as this is a concept analysis that contributes to theory development and is not empirical research.

Numerous studies have evidenced moral distress among midwives; however, to date no research synthesis on causes of moral distress among midwives has been conducted. A scoping review was carried out to identify, comprehensively map, and categorize possible causes of moral distress among midwives, and to identify knowledge gaps. Six data bases were searched using Boolean logic. To be included, studies had to (a) present empirical findings on (b) causes of moral distress (c) among midwives (d) in English, German, French, or Italian. We included a final set of 43 studies. The vast majority of studies came from high-income countries (83.7%) and used a qualitative approach (69.8%); 48.8% of the studies were published in the past 5 years. Identified single reasons of moral distress were grouped into eight broader clusters, forming a coherent framework of reasons of moral distress: societal disregard, contemporary birth culture, resources, institutional characteristics, interprofessional relationships, interpersonal mistreatment of service users, defensive practice, and challenging care situations. These clusters mostly capture moral distress resulting from a conflict between external constraints and personal moral standards, with a smaller proportion also from an intraindividual conflict between multiple personal moral standards. Despite projected increases in demand for midwives, the midwifery workforce globally faces a crisis and is experiencing substantial strain. Moral distress further exacerbates the shortage of midwives, which negatively affects birth experiences and birth outcomes, ultimately rendering it a public health issue. Our findings offer points of leverage to better monitor and alleviate moral distress among midwives, contributing to reducing attrition rates and improving birth experiences and birth outcomes. Further research is essential to explore the issue of ecological moral distress, develop evidence-based interventions aimed at alleviating moral distress among midwives, and evaluate the effects of both individual and system-level interventions on midwives, intrapartum care, and service users’ outcomes.

Given the longevity of the COVID-19 pandemic, it is important to address the perceptions and experiences associated with the progression of the pandemic. This narrative can inform future strategies aimed at mitigating moral distress, injury, and chronic stress that restores resilience and well-being of HCWs. In this context, a longitudinal survey design was undertaken to explore how health care workers are experiencing the COVID-19 pandemic over time. A qualitative design was employed to analyze the open ended survey responses using a thematic analysis approach. All physicians and staff at an academic health science centre in Toronto, Ontario, Canada were invited to participate in the survey. The majority of survey respondents were nurses and physicians, followed by researchers/scientists, administrative assistants, laboratory technicians, managers, social workers, occupational therapists, administrators, clerks and medical imaging technologists. The inductive analysis revealed three themes that contributed to moral tensions and injury: 1) experiencing stress and distress with staffing shortages, increased patient care needs, and visitor restrictions; 2) feeling devalued and invisible due to lack of support and inequities; and 3) polarizing anti- and pro-public health measures and incivility. Study findings highlight the spectrum, magnitude, and severity of the emotional, psychological, and physical stress leading to moral injury experienced by the healthcare workforce. Our findings also point to continued, renewed, and new efforts in enhancing both individual and collective moral resilience to mitigate current and prevent future moral tensions and injury.

Background There is ongoing debate regarding how moral distress should be defined. Some scholars argue that the standard “narrow” definition overlooks morally relevant causes of distress, while others argue that broadening the definition of moral distress risks making measurement impractical. However, without measurement, the true extent of moral distress remains unknown. Research aims To explore the frequency and intensity of five sub-categorizations of moral distress, resources used, intention to leave, and turnover of nurses using a new survey instrument. Research design A mixed methods embedded design included a longitudinal, descriptive investigator-developed electronic survey with open-ended questions sent twice a week for 6 weeks. Analysis included descriptive and comparative statistics and content analysis of narrative data. Participants Registered nurses from four hospitals within one large healthcare system in Midwest United States. Ethical considerations IRB approval was obtained. Results 246 participants completed the baseline survey, 80 participants provided data longitudinally for a minimum of 3 data points. At baseline, moral-conflict distress occurred with the highest frequency, followed by moral-constraint distress and moral-tension distress. By intensity, the most distressing sub-category was moral-tension distress, followed by “other” distress and moral-constraint distress. Longitudinally, when ranked by frequency, nurses experienced moral-conflict distress, moral-constraint distress, and moral-tension distress; by intensity, scores were highest for moral-tension distress, moral-uncertainty distress, and moral-constraint distress. Of available resources, participants spoke with colleagues and senior colleagues more frequently than using consultative services such as ethics consultation. Conclusions Nurses experienced distress related to a number of moral issues extending beyond the traditional understanding of moral distress (as occurring due to a constraint) suggesting that our understanding and measurement of moral distress should be broadened. Nurses frequently used peer support as their primary resource but it was only moderately helpful. Effective peer support for moral distress could be impactful. Future research on moral distress sub-categories is needed.

As a term used in nursing and other health professions to describe when one is prevented by institutional constraints from pursuing the right course of action, moral distress has gained traction to examine the effects of restructuring on health and social care providers. Using a critical narrative methodology, this paper presents the counter-stories of nine pediatric oncology nurses in Ontario, Canada, whose stories illustrate the embeddedness of their caregiving and moral distress within institutional contexts that leave them stretched thin amongst multiple caregiving and administrative demands, and that limit their capacities to be the nurses they want to be. Informed by feminist philosophical theorizations of moral distress, we elucidate how the nurses' counter-stories: (i) re-locate the sources of their moral distress within institutional constraints that fracture their moral identities and moral relationships, and (ii) dis-locate dominant narratives of technological cure by ascribing value and meaning to the relational care through which they sustain moral responsibilities with patients and their families. By making visible the relational care that they find meaningful and that brings them in proximity to patients and families, these counter-stories assist nurses in restoring their damaged moral identities. This study demonstrates the power of identifying and mobilizing counter-stories in tracing and critically examining the conditions that structure nurses' experiences of moral distress. The findings add theoretical and empirical depth to contemporary understandings of moral distress and complement ongoing public discussion of burnout among nurses and other health care workers during the COVID-19 pandemic. These counter-narratives may act as resources for resistance among nurses, help to reduce the distance between management and health care workers, and catalyze changes in policy and practice so that nurses, and the full scope of their caregiving, are valued.

OBJECTIVES The review aims to synthesize and consolidate the factors and situations in which student nurses experience moral distress during their clinical practice and its potential implications for patient care and outcomes. DESIGN A qualitative systematic review. DATA SOURCES The articles were sourced from PubMed, Embase, CINAHL, Scopus, PsycInfo, Web of Science, ERIC (ProQuest), and ProQuest Dissertations and Theses Global Database between their inception dates to December 2022. Reference lists of included studies were also screened for additional studies. REVIEW METHODS Published and unpublished primary studies of any qualitative research methods focused on student nurses' experiences of moral distress regardless of their education level were included in this review. Two reviewers independently screened titles and abstracts, assessed full-text articles for eligibility, extracted data, and appraised the quality of included studies. Sandelowski and Barroso's (2007) two-step meta-synthesis approach and Braun and Clarke's (2006) thematic analysis framework were used to analyze and interpret findings from included studies. RESULTS Seven studies met the inclusion criteria and were included in the review. The meta-synthesis revealed an overarching theme, "Moral Distress and its Intertwined Roots". This was supported by the four main themes: 1) Inadequacy and lack of autonomy, 2) Unprofessionalism of healthcare professionals, 3) Differing cultural views and values of patients and their relatives, and 4) Healthcare needs versus resource constraints. CONCLUSION This review highlights the experiences of student nurses in situations of moral distress, including feelings of inadequacy and powerlessness when faced with ethical challenges, and the negative impact of resource constraints, unprofessional behavior, and cultural differences. Collaborative efforts between healthcare professionals and student nurses are needed to promote shared decision-making, prioritize ethical training, and provide culturally sensitive care to address these challenges and ultimately improve patient care.

ABSTRACT Aims To gain insight into the world of rural veterinarians during the Mycoplasma bovis incursion within southern Aotearoa New Zealand by exploring their experiences during the incursion, and to understand the consequences, positive and negative, of these experiences. Methods A qualitative social science research methodology, guided by the philosophical paradigm of pragmatism, was used to collect data from an information-rich sample (n = 6) of rural veterinarians from Otago and Southland. Interview and focus group techniques were used, both guided by a semi-structured interview guide. Veterinarians were asked a range of questions, including their role within the incursion; whether their involvement had any positive or negative impact for them; and their experience of conflicting demands. Analysis of the narrative data collected was guided by Braun and Clarke’s approach to reflexive thematic analysis. Results and findings All six participants approached agreed to participate. Analysis of the data provided an understanding of the trauma they experienced during the incursion. An overarching theme of psychological distress was underpinned by four sub-themes, with epistemic injustice and bearing witness the two sub-themes reported to be associated with the greatest experience of psychological distress. These, along with the other two identified stressors, led to the experience of moral distress, with moral residue and moral injury also experienced by some participants. Conclusions Eradication programmes for exotic diseases in production animals inevitably have an impact on rural veterinarians, in their role working closely with farmers. Potentially, these impacts could be positive, recognising and utilising veterinarians’ experience, skills and knowledge base. This study, however, illustrates the significant negative impacts for some rural veterinarians exposed to the recent M. bovis eradication programme in New Zealand, including experiences of moral distress and moral injury. Consequently, this eradication programme resulted in increased stress for study participants. There is a need to consider how the system addresses future exotic disease incursions to better incorporate and utilise the knowledge and skills of the expert workforce of rural veterinarians and to minimise the negative impacts on them. Clinical relevance To date, the experience of moral distress by rural veterinarians during exotic disease incursions has been under-reported globally and unexplored in New Zealand. The findings from this study contribute further insights to the existing limited literature and provide guidance on how to reduce the adverse experiences on rural veterinarians during future incursions. Abbreviations MPI: Ministry for Primary Industries; PITS: Perpetration-induced traumatic stress; PTSD: Post-traumatic stress disorder.

To provide a critical analysis of the concept of moral distress (MD) in critical care (CC) nursing. Despite extensive inquiry pertaining to the legitimacy of MD within nursing discourse, some authors still question its relevancy to the profession. However, amid the global COVID-19 pandemic, MD is generating a significant amount of discussion anew, warranting the further exploration of the concept within CC nursing to provide clarity and expand on the definition. Rodger's Evolutionary Concept Analysis method was used to guide this analysis. Related terms, attributes, antecedents, and consequences of MD were identified using current literature. The results of this analysis demonstrate strong congruence between the attributes, antecedents, and negative consequences pertaining to MD. However, a new theme has emerged from this review of the contemporary literature, highlighting the potential unexpected positive outcomes perceived by nurses who experience MD, including the provision of better care, increased levels of empathy, and enhanced opportunities for ethical reflection.

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Moral distress has been identified as an occupational hazard for clinicians caring for vulnerable populations. The aim of this systematic review was (i) to summarize the literature reporting on prevalence of, and factors related to, moral distress among nurses within acute mental health settings, and (ii) to examine the efficacy of interventions designed to address moral distress among nurses within this clinical setting. A comprehensive literature search was conducted in October 2022 utilizing Nursing & Allied Health, Embase, CINAHL, PsychInfo, and PubMed databases to identify eligible studies published in English from January 2000 to October 2022. Ten studies met inclusion criteria. Four quantitative studies assessed moral distress among nurses in acute mental health settings and examined relationships between moral distress and other psychological and work-related variables. Six qualitative studies explored the phenomenon of moral distress as experienced by nurses working in acute mental health settings. The quantitative studies assessed moral distress using the Moral Distress Scale for Psychiatric Nurses (MDS-P) or the Work-Related Moral Stress Questionnaire. These studies identified relationships between moral distress and emotional exhaustion, depersonalization, cynicism, poorer job satisfaction, less sense of coherence, poorer moral climate, and less experience of moral support. Qualitative studies revealed factors associated with moral distress, including lack of action, poor conduct by colleagues, time pressures, professional, policy and legal implications, aggression, and patient safety. No interventions targeting moral distress among nurses in acute mental health settings were identified. Overall, this review identified that moral distress is prevalent among nurses working in acute mental health settings and is associated with poorer outcomes for nurses, patients, and organizations. Research is urgently needed to develop and test evidence-based interventions to address moral distress among mental health nurses and to evaluate individual and system-level intervention effects on nurses, clinical care, and patient outcomes.

This methodological research developed and evaluated the moral distress scale from 1994 to 1997. Although nurses confront moral questions in their practice daily, few instruments are available to measure moral concepts. The methodological design used a convenience sample consisted of 214 nurses from several Unites States hospitals. The framework guiding the development of the moral distress scale (MDS) included Jameton's conceptualization of moral distress, House and Rizzo's role conflict theory, and Rokeach's value theory. Items for the MDS were developed from research on the moral problems that nurses confront in hospital practice. The MDS consists of 32 items in a 7-point Likert format; a higher score reflects a higher level of normal distress. Mean scores on each item ranged from 3.9 to 5.5, indicating moderately high levels of moral distress. The item with the highest mean score (M=5.47) was working where the number of staff is so low that care is inadequate. Factor analysis yielded three factors: individual responsibility, not in the patient's best interest, and deception. No demographic or professional variables were related to moral distress. Fifteen percent of the nurses had resigned a position in the past because of moral distress. The results support the reliability and validity of the MDS.

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Nurses exposed to community health nursing commonly encounter situations that can be morally distressing. However, most research on moral distress has focused on acute care settings and very little research has explored moral distress in a community health nursing setting especially among nursing students. To explore the moral distress experiences encountered by undergraduate baccalaureate nursing students in community health nursing. A descriptive qualitative design was employed to explore the community health nursing experiences of the nursing students that led them to have moral distress. The study included 14 senior nursing students who had their course in Community Health Nursing in their sophomore year and stayed in the partner communities in their junior year for 6 and 3 weeks during their senior year. Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants. Nursing students are vulnerable and likely to experience moral distress when faced with ethical dilemmas. They encounter numerous situations which make them question their own values and ideals and those of that around them. Findings of the study surfaced three central themes which included moral distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of powerlessness, and the differing values and mindsets of the people they serve in the community. This study provides educators a glimpse of the morally distressing situations that often occurs in the community setting. It suggests the importance of raising awareness and understanding of these situations to assist nursing students to prepare themselves to the "real world," where the ideals they have will be constantly challenged and tested.

Contemporary sociopolitical circumstance impedes the delivery of primary health care in keeping with its underlying philosophy and tenets. Skills to negotiate the maintenance of best practice and quality care in an evolving practice environment are fundamental to nursing. Nurse education needs to incorporate the ideals of best practice ideology to ensure that all are prepared to negotiate the realities of nursing practice. In this discussion paper the experience of moral distress by community health nurses is used to illustrate why skills in political advocacy and action are equally essential as clinical skills in nurse education and professional practice.

In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke's six analytic phases were used. Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally 'flat', cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients' suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.

Moral distress has received much attention in the international nursing literature in recent years. In this article, we describe the evolution of the concept of moral distress among nursing theorists from its initial delineation by the philosopher Jameton to its subsequent deployment as an umbrella concept describing the impact of moral constraints on health professionals and the patients for whom they care. The article raises worries about the way in which the concept of moral distress has been portrayed in some nursing research and expresses concern about the fact that research, so far, has been largely confined to determining the prevalence of experiences of moral distress among nurses. We conclude by proposing a reconsideration, possible reconstruction and multidisciplinary approach to understanding the experiences of all health professionals who have to make difficult moral judgements and decisions in complex situations.

Because of prolonged exposure to ethical dilemmas, including the inability to control pain, uncertainties in goals of care, and transition to end-of-life care, moral distress remains a problem for oncology nurses. Caring for.

The phenomenon of 'moral distress' has continued to be a popular topic for nursing research. However, much of the scholarship has lacked conceptual clarity, and there is debate about what it means to experience moral distress. Moral distress remains an obscure concept to many clinical nurses, especially those outside of North America, and there is a lack of empirical research regarding its impact on nurses in the United Kingdom and its relevance to clinical practice. To explore the concept of moral distress in nursing both empirically and conceptually. Feminist interpretive phenomenology was used to explore and analyse the experiences of critical care nurses at two acute care trauma hospitals in the United Kingdom. Empirical data were analysed using Van Manen's six steps for data analysis. The study was approved locally by the university ethics review committee and nationally by the Health Research Authority in the United Kingdom. The empirical findings suggest that psychological distress can occur in response to a variety of moral events. The moral events identified as causing psychological distress in the participants' narratives were moral tension, moral uncertainty, moral constraint, moral conflict and moral dilemmas. We suggest a new definition of moral distress which captures this broader range of moral events as legitimate causes of distress. We also suggest that moral distress can be sub-categroised according to the source of distress, for example, 'moral-uncertainty distress'. We argue that this could aid in the development of interventions which attempt to address and mitigate moral distress. The empirical findings support the notion that narrow conceptions of moral distress fail to capture the real-life experiences of this group of critical care nurses. If these experiences resonate with other nurses and healthcare professionals, then it is likely that the definition needs to be broadened to recognise these experiences as 'moral distress'.

Nurse clinicians may experience moral distress when they are unable to translate their moral choices into moral action. The costs of unrelieved moral distress are high; ultimately, as with all unresolved professional conflicts, the quality of patient care suffers. As a systematic process for change, this article offers the AACN's Model to Rise Above Moral Distress, describing four A's: ask, affirm, assess, and act. To help critical care nurses working to address moral distress, the article identifies 11 action steps they can take to develop an ethical practice environment.

To identify the frequency and intensity of Moral Distress, and to analyze the associations between Moral Distress and sociodemographic and labor characteristics of the nursing team of a Hematology-Oncology. A cross-sectional study was carried out with 46 nursing professionals from a Hematology-Oncology sector of a hospital institution in Rio Grande do Sul State, Brazil, through the application of the Moral Distress Scale - Brazilian version. In the data analysis, descriptive statistics and nonparametric association tests were used. Mortal Distress intensity of 3.27 (SD= 1.79) and frequency of 1.72 (SD= 1.02) were found in this team. The Moral Distress of greater intensity and frequency were related to the denial of the role of Nursing as a patient's advocate and the disrespect to the patient's autonomy, respectively. It is suggested a greater space for discussion among professionals, multiprofessional team and managers, so that adequate conditions of action and communication are provided.

: To examine practices for addressing moral distress, a collaborative project was developed by the Johns Hopkins Berman Institute of Bioethics, the Johns Hopkins School of Nursing, the American Journal of Nursing, and the Journal of Christian Nursing, along with the American Association of Critical-Care Nurses and the American Nurses Association. Its purpose was to identify strategies that individuals and systems can use to mitigate the detrimental effects of moral distress and foster moral resilience. On August 11 and 12, 2016, an invitational symposium, State of the Science: Transforming Moral Distress into Moral Resilience in Nursing, was held at the Johns Hopkins School of Nursing in Baltimore, Maryland. Forty-five nurse clinicians, researchers, ethicists, organization representatives, and other stakeholders took part. The result of the symposium was group consensus on recommendations for addressing moral distress and building moral resilience in four areas: practice, education, research, and policy. Participants and the organizations represented were energized and committed to moving this agenda forward. The full report is available online at http://journals.lww.com/ajnonline/Pages/Moral-Distress-Supplement.aspx.

Moral distress, moral sensitivity, and moral courage among healthcare professionals have been explored considerably in recent years. However, there is a paucity of studies exploring these topics among baccalaureate nursing students. The purpose of this study was to explore the relationship between and among moral distress, moral sensitivity, and moral courage of undergraduate baccalaureate nursing students. The research employed a descriptive-correlational design to explore the relationships between and among moral distress, moral sensitivity, and moral courage of undergraduate nursing students. Participants and research context: A total of 293 baccalaureate Filipino nursing students who have been exposed to various clinical areas participated in the study. Ethical considerations: Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants. Results indicate that a majority of the nursing students in the clinical areas encounter morally distressing situations that compromise quality patient care. However, despite the fact that they want to do what is in the best interest of their patients, their perception of being the inexperienced among the healthcare team drives the majority of them to ignore morally distressing situations to avoid conflict and confrontation. Another interesting finding is that 79.20% of the respondents hardly consider quitting the nursing profession even if they frequently encounter morally distressing situations. Analysis also shows associations between moral distress intensity and frequency ( r = 0.13, p < 0.05) and moral distress intensity and moral sensitivity ( r = 0.25, p < 0.05). The dimensions of moral courage are also related to both moral distress and moral sensitivity. Results of the study imply that moral distress is a reality among all healthcare professionals including nursing students and requires more consideration by nurse educators.

Moral distress has been explored within a number of nursing contexts, including critical care, neuroscience, and end-of-life decision making. Although the antecedents and consequences of this concept continue to be uncovered, its unique attributes remain ambiguous. This analysis aims to clarify the concept of moral distress, contribute new insights about moral distress to nursing as a whole and to the subspecialty of neuroscience nursing in particular, and enhance advancements in nursing knowledge and practice. Literature published in English between 1987 and 2009 was searched using the Cumulative Index to Nursing and Allied Health Literature and Google Scholar databases. Eleven journal articles were used in the final analysis. Rodgers' evolutionary model of concept analysis was used in this study. Four comprehensive attributes were formulated to describe moral distress in neuroscience nursing: negative feelings, powerlessness, conflicting loyalties, and uncertainty. These attributes are intimately related, holding true meaning only when viewed within the context of one another and with respect to the historical and philosophical underpinnings of nursing praxis. This analysis demonstrates the fluidity, complexity, and multifacetedness of moral distress. Knowledge of the conceptual attributes presented herein will facilitate recognition and validation of personal experiences within the neuroscience nursing community.

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In nursing practice, the ability to make decisions regarding patients and to act on them is considered to be an expression of the professional nursing role. Problems may arise when a nurses would like to perform an action they believe morally correct but which are conflictual with the habits, organization or politics of the health structure in which they work. This inevitably produces moral distress in nurses who feel impotent to act as they feel they should. Although a certain amount of moral distress is part and parcel of the nursing profession , when it is excessive or prolonged it may become unacceptable and culminate in burn-out and the relative consequences. The aim of the study was to compare the level of moral stress in 111 Italian nurses working in different Operative Units to identify those clinical situations significantly associated with moral stress using the MDS scale. Similarly to studies performed in the USA, the level of moral stress in the 3 different work contexts was moderate, although some clinical situations were related to significant stress levels.

The June 2022 U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization abolished federal protections for reproductive choice. In states where subsequent legislation has restricted or banned access to abortion services, physicians and trainees are prevented from providing ethically justified evidence-based care when patients with previable pregnancies are seeking an abortion. Pregnant patients' vulnerabilities, stress, and the undue burden that they experience when prevented from acting in accordance with their reproductive decision-making can evoke negative emotional consequences, including moral distress in clinicians. Moral distress occurs when clinicians feel a moral compulsion to act a certain way but cannot do so because of external constraints, including being hindered by state laws that curtail practicing in line with professional standards on reproductive health care. Moral distress has the potential to subvert prudent clinical judgment. The authors provide recommendations for managing moral distress in these circumstances based on the professional virtues. The fundamental professional virtues of integrity, compassion, self-effacement, self-sacrifice, and humility inform the management of moral distress and how to respond thoughtfully and compassionately, without over-identification or indifference to the plight of patients denied abortions. The authors also discuss the role of academic leaders and medical educators in cultivating a virtue-based professional culture at the forefront of clinical and educational processes in a post- Dobbs world.

This paper utilizes data generated during a qualitative study in palliative and maternity care settings to guide discussion of the current discourse, which emphasizes patient autonomy and derides paternalism. Data are presented which illustrate that this ideology is established in nursing practice. Respect for patient autonomy is identified as an essential element of individualized, patient-centred and ethical care but conversely, it is suggested that overemphasis may confuse and suppress beneficent intervention. The value of ethical theory to provide an objective means to explore ethical dilemmas in practice is not debated, but exploration of the issues raised by the data suggest, that principle-based ethical theory suffers the following constraints: the predetermined balance of ethical principles in favour of respect for autonomy prevents an unbiased perspective and optimum guidance; in contrast to caring relationship, application of ethical theory does not reveal the particulars necessary to guide ethical decisions aimed at promoting good for the individual; current discourse appears to disregard the inherent inequality in the relationship between the helped and helper and practitioners' need to preserve their own moral integrity. Consequently, this paper argues that beneficence derived through caring should not be superseded uncritically and suggests that mutual nurse-patient relationship, which balances respect for patient autonomy and beneficent guidance based on practitioner's clinical expertise, protects the moral integrity of both patient and practitioner. For conciseness, the term patient will be used to indicate recipients of both nursing and midwifery care and while both nurses and midwives are not always specified, any term referring to nurses, denotes both.

In 2023, thousands of young Norwegian physicians joined an online movement called #legermåleve (#doctorsmustlive) and shared stories of their own mental and somatic health issues, which they considered to be caused by unacceptable working conditions. This paper discusses this case as an extreme example of physicians' and healthcare workers' suffering in late modern societies, using Vosman and Niemeijer's approach of rethinking care imaginaries by a structured process of thinking along, counter-thinking and rethinking, bringing to bear suffering as a heuristic device. Thinking along, taking the physicians' stories and arguments literally, reveals an image of an unbearable workload. Counter-thinking resituates their suffering within the broader conditions of late modernity, suggesting that the root cause may lie not in the quantity of the workload itself but in its qualities and in its perceived threat to their integrity as caregivers through epistemic and moral injury and an inability to respond to this threat. In rethinking, the ambiguity of suffering- its dual potential as both a constraint and an opening- becomes central. Following the physicians' own interpretations and the solutions emerging from this framing, both their suffering and that of their patients could paradoxically be exacerbated by further decentering physicians and reinforcing utilitarian, data-driven approaches. However, staying with their suffering and reinterpreting its causes opens possibilities to leverage critiques of medicalization at large and of their own suffering in particular, challenging the assumption that the weight of care must always grow heavier. From this reframing, I argue, it is possible to reclaim and reimagine care and the clinical space as a nexus of epistemic and moral privilege, recentering response-ability both relationally and socially.

Financial incentives and disincentives are fundamental to a category of proposals, usually characterised as forms of managed care, whereby the pecuniary interests of health care providers are directly affected by their clinical decision-making. Presently, Australian health care administrators and private insurers are adopting financial incentives as a means of ensuring provider compliance with 'health outcome' and cost-constraint objectives. To the extent that this has occurred, health-care relationships are transformed to emulate, more closely, a commercial transaction. This paper questions the ideological assumptions which inform the use of financial incentives in the health care domain and raises concerns with regard to the potential for financial incentives to undermine the moral integrity of clinical decision-making. It also challenges the legitimacy of rationing health care resources through the use of this measure, particularly when adopted by private insurers of health care.

We explore conceptions of responsibility and integrity in global health research and practice as it is being carried out in the academic setting. Our specific motivation derives from the recent publication of a study by a clinical research team involving the delivery of mental health care services in a Ghanaian prayer camp. The study was controversial on account of the prayer camp's history of human rights abuses and therefore was met with several high-profile critiques. We offer a more charitable evaluation of the Joining Forces study. Our analysis has three primary goals. First, we respond to criticism suggesting that the Joining Forces research team needed to maintain some form of morally "clean hands" in relation to the human rights abuses at Mount Horeb prayer camp. We argue that, for academic global health practitioners working under severe resource constraints, what is reasonable and responsible to pursue is a complex proposition without a one-size-fits-all ethical answer. Second, we offer an explanation for why the Joining Forces study team designed the project as they did in spite of their obvious vulnerability to ethical concern. We argue that the Joining Forces study was a morally risky, but ethically earnest effort to reach a neglected patient population and promote behavior change in prayer camp staff. Third, we identify an open ethical question born of the researchers' commitment to pragmatism that, to our knowledge, has not been previously addressed in published discussion of the Joining Forces project. Namely, was the incomplete disclosure of information to prayer camp staff defensible? We close with a broader reflection on the notion of moral integrity in the pursuit of the salutary aims of global health.

COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical, practical and medical dilemmas. Adapting to crisis conditions requires a rethink of traditional best practices in surgical management, delving into an area of unknown risk profiles. Key challenging areas include cancelling elective operations, modifying procedures to adapt local services and updating the consenting process. We aim to provide an ethical rationale to support change in practice and guide future decision-making. Using the four principles approach as a structure, Medline was searched for existing ethical frameworks aimed at resolving conflicting moral duties. Where insufficient data were available, best guidance was sought from educational institutions: National Health Service England and The Royal College of Surgeons. Multiple papers presenting high-quality, reasoned, ethical theory and practice guidance were collected. Using this as a basis to assess current practice, multiple requirements were generated to ensure preservation of ethical integrity when making management decisions. Careful consideration of ethical principles must guide production of local guidance ensuring consistent patient selection thus preserving equality as well as quality of clinical services. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. As such, the need for surgery must be sufficiently pressing to proceed with conventional or non-conventional operative management; otherwise, delaying intervention is justified. For delayed operations, it is our duty to quantify the long-term impact on patients' outcome within the constraints of pandemic management and its long-term outlook.

The economic crisis in the Kurdistan Region of Iraq has severely affected public sector salaries and healthcare infrastructure. These disruptions have increased pressures on the healthcare workforce and exposed gaps in the region's institutional and workforce resilience. This study explored physicians' experiences and adaptive responses to the prolonged financial instability and its consequences for healthcare delivery. A qualitative design was adopted using semi-structured interviews with 25 physicians from various specialties working in both public and private sectors across the Kurdistan Region. The study was conducted from March to August 2024 during a period of heightened financial instability. Data were analyzed thematically using a structured six-step qualitative analysis, using an inductive qualitative thematic analysis approach. Ten interrelated but analytically distinct themes emerged: workload-related operational stress, salary instability, psychological stress, burnout and hopelessness, coping mechanisms, institutional inaction, clinical decisions under constraints, proposed reforms, need for support, emerging innovations, and impact on patient care. Physicians described increased workloads, delayed or reduced salaries, emotional exhaustion, and a deep sense of hopelessness. Institutional inaction compounded these challenges, forcing doctors to ration care and delay procedures. Despite adversity, participants demonstrated moral resilience through volunteering, free care, and semi-private models. Limited innovations-such as telemedicine and community outreach-were also noted. Collectively, these findings reveal a fragile health system sustained primarily by physicians' ethical commitment rather than institutional stability. The Kurdistan healthcare system endures economic hardship through the moral endurance and adaptability of its physicians. Sustaining healthcare quality requires transforming this individual resilience into institutional resilience through salary stabilization, leadership accountability, and structured psychosocial and professional support. Framing these findings through a resilience lens highlights the urgent need to strengthen both workforce resilience and system-level resilience to sustain healthcare delivery during prolonged crises.

Ethical dilemmas in critical care may cause healthcare practitioners to experience moral distress: incoherence between what one believes to be best and what occurs. Given that paediatric decision-making typically involves parents, we propose that parents can also experience moral distress when faced with making value-laden decisions in the neonatal intensive care unit. We propose a new concept-that parents may experience "moral schism"-a genuine uncertainty regarding a value-based decision that is accompanied by emotional distress. Schism, unlike moral distress, is not caused by barriers to making and executing a decision that is deemed to be best by the decision-makers but rather an encounter of significant internal struggle. We explore factors that appear to contribute to both moral distress and "moral schism" for parents: the degree of available support, a sense of coherence of the situation, and a sense of responsibility. We propose that moral schism is an underappreciated concept that needs to be explicated and may be more prevalent than moral distress when exploring decision-making experiences for parents. We also suggest actions of healthcare providers that may help minimize parental "moral schism" and moral distress.

To measure the level of moral distress in PICU and neonatal ICU health practitioners, and to describe the relationship of moral distress with demographic factors, burnout, and uncertainty. Cross-sectional survey. A large pediatric tertiary care center. Neonatal ICU and PICU health practitioners with at least 3 months of ICU experience. A 41-item questionnaire examining moral distress, burnout, and uncertainty. The main outcome was moral distress measured with the Revised Moral Distress Scale. Secondary outcomes were frequency and intensity Revised Moral Distress Scale subscores, burnout measured with the Maslach Burnout Inventory depersonalization subscale, and uncertainty measured with questions adapted from Mishel's Parent Perception of Uncertainty Scale. Linear regression models were used to examine associations between participant characteristics and the measures of moral distress, burnout, and uncertainty. Two-hundred six analyzable surveys were returned. The median Revised Moral Distress Scale score was 96.5 (interquartile range, 69-133), and 58% of respondents reported significant work-related moral distress. Revised Moral Distress Scale items involving end-of-life care and communication scored highest. Moral distress was positively associated with burnout (r = 0.27; p < 0.001) and uncertainty (r = 0.04; p = 0.008) and inversely associated with perceived hospital supportiveness (r = 0.18; p < 0.001). Nurses reported higher moral distress intensity than physicians (Revised Moral Distress Scale intensity subscores: 57.3 vs 44.7; p = 0.002). In nurses only, moral distress was positively associated with increasing years of ICU experience (p = 0.02) and uncertainty about whether their care was of benefit (r = 0.11; p < 0.001) and inversely associated with uncertainty about a child's prognosis (r = 0.03; p = 0.03). In this single-center, cross-sectional study, we found that moral distress is present in PICU and neonatal ICU health practitioners and is correlated with burnout, uncertainty, and feeling unsupported.

The management of migrants with kidney failure and no medical insurance raises complex medical, social, financial, and ethical issues. The survey aimed to investigate (i) current practices in managing these patients, and (ii) the perspective of European nephrologists on ethical dilemmas and optimal care. The survey was piloted by the ISN Western Europe Regional Board, with members of the Young Nephrologists' Platform (YNP) of the European Renal Association (ERA), and disseminated to European nephrologists in the ISN and YNP networks. Responses were collected anonymously via SurveyMonkey. A total of 378 responses were collected from 29 European countries. Most (57%) managed fewer than 3 migrant patients with kidney failure per week, while 10% managed more than 11. Most respondents indicated that access to dialysis was unrestricted (59%), although only 25% said migrant patients were systematically eligible for kidney transplantation. Many nephrologists (38%) were unaware of the directives of governmental bodies or hospital protocols regarding migrant patients. The most common obstacles to patient management included language non concordance (64%), uncertainty about the future (56%), and lack of knowledge of medical history (49%). Two-thirds felt managing migrant patients was a moral duty, though 52% reported stress within the clinical caregiving team. Despite strong commitment from European nephrologists, a fragmented legal framework, remaining barriers, and uneven case distribution hinder optimal care for migrant patients with kidney disease.

Working as a neonatologist in a neonatal intensive care unit (NICU) is stressful and involves ethically challenging situations. These situations may cause neonatologists to experience high levels of moral distress, especially in the context of caring for extremely premature infants (EPIs). In Greece, moral distress among neonatologists working in NICUs remains understudied and warrants further exploration. This prospective qualitative study was conducted from March to August 2022. A combination of purposive and snowball sampling was used and data were collected by semi-structured interviews with twenty neonatologists. Data were classified and analyzed by thematic analysis approach. A variety of distinct themes and subthemes emerged from the analysis of the interview data. Neonatologists face moral uncertainty. Furthermore, they prioritize their traditional (Hippocratic) role as healers. Importantly, neonatologists seek third-party support for their decisions to reduce their decision uncertainty. In addition, based on the analysis of the interview data, multiple predisposing factors that foster and facilitate neonatologists' moral distress emerged, as did multiple predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. The predisposing factors that foster and facilitate neonatologists' moral distress thus identified include the lack of previous experience on the part of neonatologists, the lack of clear and adequate clinical practice guidelines/recommendations/protocols, the scarcity of health care resources, the fact that in the context of neonatology, the infant's best interest and quality of life are difficult to identify, and the need to make decisions in a short time frame. NICU directors, neonatologists' colleagues working in the same NICU and parental wishes and attitudes were identified as predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. Ultimately, neonatologists become more resistant to moral distress over time. We concluded that neonatologists' moral distress should be conceptualized in the broad sense of the term and is closely associated with multiple predisposing factors. Such distress is greatly affected by interpersonal relationships. A variety of distinct themes and subthemes were identified, which, for the most part, were consistent with the findings of previous research. However, we identified some nuances that are of practical importance. The results of this study may serve as a starting point for future research.

The COVID-19 pandemic has had a profoundly detrimental impact on the emotional wellbeing of health care workers. Numerous studies have shown that their rates of the various forms of work-related distress, which were already high before the pandemic, have worsened as the demands on health care workers intensified. Yet much less is known about the specific social processes that have generated these outcomes. This study adds to our collective knowledge by focusing on how one specific social process, the act of treating critically ill COVID-19 patients, contributed to emotional pain among health care workers. This article draws from 40 interviews conducted with intensive care unit (ICU) staff in units that were overwhelmed with COVID-19 patients. The study participants were recruited from two suburban community hospitals in Massachusetts and the interviews were conducted between January and May 2021. The results show that the uncertainty over how to treat critically ill COVID-19 patients, given the absence of standard protocols combined with ineffective treatments that led to an unprecedented number of deaths caused significant emotional pain, characterized by a visceral, embodied experience that signaled moral distress, emotional exhaustion, depersonalization, and burnout. Furthermore, ICU workers' occupational identities were undermined as they confronted the limits of their own abilities and the limits of medicine more generally. The inability to save incurable COVID-19 patients while giving maximal care to such individuals caused health care workers in the ICU an immense amount of emotional pain, contributing to our understanding of the social processes that generated the well-documented increase in moral distress and related measures of work-related psychological distress. While recent studies of emotional socialization among health care workers have portrayed clinical empathy as a performed interactional strategy, the results here show empathy to be more than dramaturgical and, in this context, entailed considerable risk to workers' emotional wellbeing.

ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power. We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations. By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups. ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.

Priority setting at intensive care units is legally regulated in accordance with the so-called ethical platform, which states that all priorities must be based on three lexically ranked principles: the principle of human dignity (a ban on discrimination, e.g. based on social standing), the principle of needs and solidarity, and the principle of cost-effectiveness. Prioritization for intensive care is particularly difficult as it requires comparisons between widely different patient categories, occurs in acute situations and is fraught with great uncertainty about the prognosis. Sometimes the degree of severity is maximal for several patients: without treatment, they die. Then treatment effect and cost-effectiveness become more decisive for prioritization decisions. Moreover, withholding and withdrawing intensive care are increasingly considered as morally equivalent. Difficult priority decisions risk moral stress among the intensive care staff.

The hospitalization of infants in the neonatal intensive care unit (NICU) is an ethically challenging situation. A limited number of studies have extended the concept of moral distress to parents of infants hospitalized in the NICU. This topic requires further investigation. The present prospective qualitative study was conducted from February 2023 to May 2023. Data were collected through semistructured in-depth interviews, which were conducted in-person with fifteen parents of infants who were hospitalized in the NICU at the time of the interviews. Purposive sampling was used. The data were classified and analyzed using thematic analysis. Three themes emerged from the data analysis performed for this empirical study. One intrapersonal dimension featuring two aspects (one dynamic and one static) and another interpersonal dimension focusing on parental moral distress emerged from the data analysis. Furthermore, seven subthemes emerged across these themes: (1) self-directed negative feelings were experienced by parents due to their inability to fulfill their caregiving/parental roles; (2) intense internal conflict was experienced by parents in response to a moral dilemma that was difficult, which was perceived as irresolvable; (3) objectively unjustified, self-directed negative feelings of guilt or failure were experienced by parents; (4) parents experienced moral distress due to the poor image of the ill infants; (5) inadequate information may predispose parents to experience moral distress (6) neonatologists' caring behaviors were unduly perceived by parents as paternalistic behaviors; (7) reasonable or justified institutional rules were unduly perceived by parents as constraint. In general, the results of this study support the integrated definition of parental moral distress proposed by Mooney-Doyle and Ulrich. Furthermore, the present study introduces new information. The study distinguishes between the dynamic and static aspects of the intrapersonal dimension of the phenomenon of parental moral distress. Moreover, participants experienced moral distress because they unduly perceived certain situations as causing moral distress. In addition, inadequate information may predispose parents to experience moral distress. The findings of this study may contribute promote family-centered care in the NICU context.

The COVID-19 pandemic poses unprecedented challenges for the German health care system. What is already the case in some other countries, may occur in Germany in the near future also: Faced with limited ICU resources, doctors will be forced to decide which patients to treat and which to let die. This paper examines the legal implications of such decisions. It takes up arguments from the general discussion on prioritization in medicine. A constitutional hurdle for the application of utilitarian criteria (in particular patients' age or social role) comes from the principle that every human life is of equal value and must not be traded off against others ("life value indifference"). However, the limits that the Grundgesetz (German Basic Law) sets for state actions do not apply directly to doctors. According to the Musterberufsordnung (professional code of conduct), doctors act based on their conscience and the requirements of medical ethics and humanity. The implications of this normative standard for the prioritizing in an exceptional situation as the COVID 19 pandemic have not been sufficiently clarified. This uncertainty leads to emotional and moral burdens for doctors. The authors conclude that the German law grants a limited freedom of choice that allows physicians to apply utilitarian criteria in addition to purely medical decision algorithms.

To explore the topic of moral distress in nurses related to witnessing futile care. Literature related to moral distress and futility; analysis of narratives written by 108 nurses attending one of two national continuing education courses on end-of-life care regarding their experiences in the area. Nurses were invited to share a clinical situation in which they experienced moral distress related to a patient receiving care that they considered futile. Nurses described clinical situations across care settings, with the most common conflict being that aggressive care denies palliative care. Conflicts regarding code status, life support, and nutrition also were common. Patients with cancer were involved quite often, second only to geriatric patients and patients with dementia. The instances created strong emotional responses from nurses, including feeling the need for patient advocacy and that futile care was violent and cruel. Important spiritual and religious factors were cited as influencing the clinical experiences. Instances of futile care evoke strong emotional responses from nurses, and nurses require support in dealing with their distress. The ethical dilemma of futile care is complex. Additional research and support are needed for patients, families, and nurses.

Midwife health is intrinsically linked to the quality of safe patient care. To ensure safe patient care, there is a need to deliver emotional support to midwives. One option that midwives may turn to may be a confidential online intervention, instead of localised, face-to-face support. Following the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards, this realist synthesis approach explores the ethical considerations in permitting confidentiality, anonymity and amnesty in online interventions to support midwives in work-related psychological distress. An iterative search methodology was used to select nine papers for review. To assimilate information, papers were examined for ideas relating to ethical dimensions of online interventions to support midwives in work-related psychological distress. This review takes a narrative approach. Online interventions can support the development of insight, help seeking and open discussion. Additionally, Internet support groups can become morally persuasive in nature. Anonymity and confidentiality are both effective and therapeutic features of online interventions when used in collaboration with effective online moderation. Yet, ethical dilemmas remain where users cannot be identified. Confidentiality and anonymity remain key components of successful online interventions. However, sanctioning the corollary component of amnesty may provoke moral discomfort for those seeking immediate accountability. For others, amnesty is seen as essential for open disclosure and help seeking. Ultimately, the needs of midwives must be balanced with the requirement to protect the public and the professional reputation of midwifery. In supporting midwives online, the principles of anonymity, confidentiality and amnesty may evoke some resistance on ethical grounds. However, without offering identity protection, it may not be possible to create effective online support services for midwives. The authors of this article argue that the principles of confidentiality, anonymity and amnesty should be upheld in the pursuit of the greatest benefit for the greatest number of people.

Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs. English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed. Original articles, review articles, and commentaries were considered. Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review. Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured. The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.

Nurses encountered a myriad of ethical challenges during the height of the COVID-19 pandemic, such as allocation of scarce resources, the need to balance duty of care with safety of self as well as visitation restrictions. The impact of these challenges on the nursing workforce requires investigation. The aim of this review was to scope and describe the reported literature on ethical challenges faced by nurses during the COVID-19 pandemic, including contextual characteristics and strategies reported to address these challenges. The review was conducted in accordance with JBI methods for scoping reviews and reported using PRISMA-ScR guidance. A published protocol guided conduct of the review. The following databases were searched for eligible studies from November 2019 to January 2023: PubMed, CINAHL, Ovid, PsycINFO, the Cochrane Library, and Scopus. No language restrictions were applied. Studies were reviewed for inclusion by two independent reviewers, and a data extraction form was developed to extract data relevant to the review questions. Results were analyzed and presented according to the concepts of interest, using tables, figures, and supporting narrative synthesis. After searching the databases, 2150 citations were retrieved with 47 studies included in the review. Studies represented 23 countries across five continents. Most of the studies used qualitative designs. Ethical challenges were described in several ways, often without appealing to common ethics language or terms. Few studies reported on strategies to address the specific challenges, which may reflect the dynamic nature of the pandemic. The scoping review highlights the complex and, at times, overwhelming impact of ethical challenges faced by nurses across the globe during the COVID-19 pandemic. Findings from the review can be used as a basis for further research to explore, develop, and implement strategies to address ethical challenges faced by nurses during future public health crises.

The ethical and moral complexities are inherent to nursing practice. Ethical dilemmas of professional nurses and nursing students' ethical concerns with their preceptors are well-documented. No reviews have synthesized students' ethical dilemmas regarding patient care. This review aimed to develop a comprehensive understanding of nursing students' ethical dilemmas regarding patient care in clinical settings. An integrative review based on Whittemore and Knafl's methodology. Literature was searched within PubMed, CINAHL, Google Scholar, Scopus, and Science Direct databases and 13 articles including eight qualitative, three quantitative, one mixed methods and one secondary data analysis were reviewed. The articles were published from January 2000-March 2019. The Mixed Methods Critical Appraisal Tool was used for quality assessment. Two reviewers independently reviewed the articles and the third reviewer validated the extracted and synthesized findings. Literature summary tables were developed for data extraction and thematic synthesis techniques and narratives were used for data synthesis. For synthesis, findings from strongly and moderately rated studies were given more weight and those from the low-quality studies were used to support the synthesized themes. Three themes emerged: a) applying learned ethical values vs. accepting unethical practices, b) desiring to provide ethical care but lacking autonomous decision making, and c) Silence vs. whistleblowing patient care neglects. Nursing students feel torn between the conflicts of whether to provide ethical care or accept unethical practices, stay silent about patient care neglect or confront and report it, provide ethical and quality care or adapt to the culture due to lack of autonomous decision making. Such conflicts can be detrimental to students' professional learning and mental health. Therefore, educators and nursing institutions should develop programs to support students and help them develop ethical competence and courage to confront such dilemmas.

Quality of care is essential for further progress in reducing maternal and newborn deaths. The integration of educated, trained, regulated and licensed midwives into the health system is associated with improved quality of care and sustained decreases in maternal and newborn mortality. To date, research on barriers to quality of care for women and newborns has not given due attention to the care provider's perspective. This paper addresses this gap by presenting the findings of a systematic mapping of the literature of the social, economic and professional barriers preventing midwifery personnel in low and middle income countries (LMICs) from providing quality of care. A systematic search of five electronic databases for literature published between January 1990 and August 2013. Eligible items included published and unpublished items in all languages. Items were screened against inclusion and exclusion criteria, yielding 82 items from 34 countries. 44% discussed countries or regions in Africa, 38% in Asia, and 5% in the Americas. Nearly half the articles were published since 2011. Data was extracted and presented in a narrative synthesis and tables. Items were organized into three categories; social; economic and professional barriers, based on an analytical framework. Barriers connected to the socially and culturally constructed context of childbirth, although least reported, appear instrumental in preventing quality midwifery care. Significant social and cultural, economic and professional barriers can prevent the provision of quality midwifery care in LMICs. An analytical framework is proposed to show how the overlaps between the barriers reinforce each other, and that they arise from gender inequality. Links are made between burn out and moral distress, caused by the barriers, and poor quality care. Ongoing mechanisms to improve quality care will need to address the barriers from the midwifery provider perspective, as well as the underlying gender inequality.

Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves. To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions. Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines. First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied. We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors. Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being. Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs. The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample. This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in The National Health Service needs healthy, motivated staff to provide high-quality patient care. Nurses, midwives and paramedics experience poor psychological health (e.g. stress/anxiety) because of pressured environments and the difficulties of healthcare work. This study planned to better understand the causes of poor psychological ill-health in nurses, midwives and paramedics and find which interventions might help and why. We analysed the literature using a method called ‘realist review’ to understand how interventions work (or not), why, and for who. We tested our findings with patients, the public, nurses, midwives and paramedics in our stakeholder group. We reviewed over 200 papers/reports and identified five main findings: (1) existing solutions (interventions) are disjointed, focus mainly on the individual (not the system) and do not recognise enduring stressors enough; (2) when there is a blame culture it is difficult to encourage staff psychological well-being; (3) the needs of the system often override staff psychological well-being at work; (4) upholding and implementing personal and professional values at work can have negative personal costs; and (5) it is difficult to design, identify and implement solutions that work well for staff groups in different circumstances with varied causes of poor psychological health. Healthcare organisations should consider: (1) changing (rebalancing) the working environment to help healthcare professionals rest, recover and thrive; (2) investing in multiple-level system (not just individual) approaches to staff psychological well-being; (3) continuing to reduce stigma; (4) ensuring the essential needs of staff are prioritised (rest-breaks/hydration/hot food) as building blocks for other solutions; (5) addressing the blame culture, assuming staff are doing their best in difficult conditions; (6) prioritising staff needs, as well as patient needs. We will provide guidance and recommendations to policy-makers and organisational leaders to improve work cultures that tackle psychological ill-health and suggest new areas for research.

Ethical and bioethical issues are central to the identity and practice of physical therapy. A comprehensive overview of how these issues are addressed in the literature is essential for advancing education, clinical practice, and professional reflection. The objective was to systematically map ethical and bioethical issues in the physical therapy literature, describe the methodologies employed, and identify key gaps to inform education, practice, and policy. Medline (via PubMed), Embase, Cochrane Central, CINAHL, PsycINFO, PEDro, grey literature sources, and academic library resources were searched from inception to October 2024. The review protocol was prospectively published on medRxiv. Studies addressing ethical or bioethical issues in physical therapy were included, encompassing both normative and descriptive (empirical) approaches. After screening titles, abstracts, and full texts, 108 studies met the inclusion criteria. Data were extracted using a modified Joanna Briggs Institute standardized form. A narrative synthesis was conducted to map ethical themes and characterize methodological approaches across studies. Identification and mapping of ethical and bioethical themes and characterization of research methodologies applied. A total of 15,464 records were identified; 3223 duplicates were removed. Of 12,241 titles and abstracts screened, 385 full texts were assessed, and 108 studies were included. Major themes included ethical reasoning (n = 33), ethical reasoning and education (n = 19), ethical theories (n = 12), care relationships (n = 15), justice and equity (n = 8), perception of ethical issues (n = 13), and codes of ethics (n = 8). Key challenges involved physical touch, informed consent, professional boundaries, and moral distress. Structural barriers, cultural contexts, and disparities in ethics education were recurring concerns. Ethical reasoning was often situational and intuitive, whereas formal codes were frequently perceived as disconnected from clinical practice. Ethical complexities in physical therapy arise from its embodied, relational, and context-sensitive nature. The literature reveals variability in how ethics is taught and applied across settings and highlights underexplored areas, including oncology, end-of-life care, digital health and artificial intelligence, and equity, diversity, and inclusion. Findings emphasize the need to strengthen ethics education, reinforce the application of existing codes of ethics, and provide organizational support for ethical deliberation. This synthesis provides a foundation for future research and can inform curricular development, clinical practice, and policy initiatives in physical therapy ethics.

Diasporic nurse leaders often navigate emotional and institutional complexities that remain invisible in dominant leadership models. The purpose of this paper is to explore how two nurse leaders in diaspora enact leadership amid trauma, displacement, and institutional erasure. This qualitative study employed a braided narrative methodology, drawing on intersectionality, transnational feminist theory, narrative inquiry, and trauma-informed leadership. Two first-person narratives were analyzed thematically through collaborative reflexive synthesis. Five interwoven themes emerged: diasporic double consciousness, ethical witnessing, guilt and gratitude, institutional invisibility, and embodied empathy. These themes reflect how diasporic leaders transform geopolitical grief into justice-driven leadership. Rather than neutrality or detachment, leadership is framed as trauma-informed, relational, and ethically rooted in cultural memory and moral proximity. This study advances decolonial nursing theory by centering Arab feminist thought, emotional labor, and transnational care, offering a framework for equity-centered and culturally attuned leadership.