Table 4.

Illustrative quotes from participant coping with moral distress

Content area	Theme	Quotation example
Coping strategies	Personal reflection	‘I think I just reflect constantly anyway, I don’t know if everyone does, I imagine most of us do… I generally just do it in my head when I’m exercising I’ll tend to think about, that went well, or that didn’t go quite so well, what can I do to improve that next time. No, it’s not something I think, right I need to go and meditate because that’s upset me or whatever.’ (Other 2) ‘Yeah I think the moment you make anything mandatory I think you lose quite a lot of the value… So I think it has to be voluntary, I think it has to be something people do because they recognise it for its own value.’ (Doctor 3)
	Mental compartmentalisation	‘So I tend to compartmentalise work and home, because I have had periods of time before where I have been really, really distressed and it just, it’s no good for your home life, so I’ve kind of, I box things off. I don’t know if that is the right way of doing it or not but that’s what I tend to do.’ (Nurse 2) ‘I drive quite a long distance to work and back, so mine sort of goes in the car. I have a little refection and sometimes a little blurt in the car and then by time I’ve walked through the house, picked the dogs up and walk out, it’s gone.’ (ACCP 1)
	Self-care	‘And then I think it’s just trying to keep your own health kind of optimal so that you are physically healthy it makes the difference to being mentally healthy I think. If you are physically healthy it gives you a bit of robustness.’ (ACCP 2) ‘Yeah I do, I tend to go for long walks I take my dogs, go off with my dogs on lots of long walks and fresh air and open space and I don’t mind admitting copious quantities of wine over that weekend. And yeah, that’s probably how I, fresh air, exercise, wine.’ (Nurse 2)
	Informal talking with colleagues	‘I will talk to either another senior registrar so peer support, that can be very helpful or, you know, consultants that I get on with. So in those circumstances I am looking for someone who is, again it’s not kind of, it’s not an explicit thought process but I will want someone who I know is on a similar wavelength and will be understanding. Oh yes, someone who, yes someone who’s opinion I value.’ (Doctor 4) ‘And it was really useful actually to see people that you are a little bit in awe of sort of like scary Band 7s, it was quite useful to see them sort of actually sort of coming down to our level, the ground level and being distressed by things they have seen… so it was good to see, I was so surprised to see this one particular Band 7 in floods of tears and I thought oh you are human, that’s awful isn’t it?’ (Nurse 2)
	Supportive environment	‘I think what you need is a culture where that’s available as and when you need it. And so you know it’s alright to sort of say, you know, to some of my bosses or some of my colleagues, actually something shit has just happened can we go and have a cup of tea and a chat… But for me I think that’s probably a better approach, is to have the culture where that’s okay and then you can go and find what you want from who you want.’ (Doctor 4) ‘I’ve worked in small hospitals and large hospitals as a nurse and I do think generally [support is better] in a smaller hospital… you’ve got a smaller team so you know each other better and when you’ve got a smaller team, smaller teams do tend to stay put more. Whereas bigger hospitals obviously you might not know the staff that you’re on with and things like that. …how are you going to have support from somebody that’s an agency who’s only there for the day.’ (ACCP 1) ‘I think our larger critical care units are not a good idea… I think the bigger units are less personalised and it’s hard to maintain and retain a proper team, so it’s better to keep the units down to 15 or 20 beds and try and have core teams that don’t rotate.’ (ACCP 2)
	Informal talking with friends and family	‘I think because I live with my husband who has no knowledge whatsoever of what goes on in this kind of environment, I do talk about work when I get home, but I don’t tend to sort of go into that kind of nitty gritty with him because, I don’t know really, I just don’t. I think he finds it a bit boring to be honest with you, it’s not anything he particularly knows about.’ (Nurse 2) ‘(I) have peer support, good family support and my wife is an anaesthetist as well so I can talk through stuff with her easily and all the family and friends, I have got lots of friends who are various members of the medical profession.’ (ACCP 2)
	Formal debrief	‘I have experienced both those both (formal and informal discussions) and I think for the type of a major clinical incident then I think that a formal sort of debriefing top down sort of debriefing to show that you are supported by your sort of managers is probably better for something that is really awful. But working in critical care you are going to come across something that is pretty awful every day. So I think that we as a sort of cohort of nurses just tend to talk to each other informally most of the time.’ (Nurse 2) ‘Unfortunately, the physical logistics of doing things like the debriefs are virtually impossible, they are not easy, they are really not. You know what it’s like you have a unit full of patients, you've got a million jobs to do, you’ve got five families to talk to and discuss it all with, trying to fit debriefs in around that as well, before you know it’s 5:30 and your team have gone home or are hoping to get home on time.’ (Doctor 2)
Interventions to support coping	Formal and structured support	‘But getting somebody in to discuss things or an away day or a coffee morning and things, sometimes you don’t get the right people going to that do you?… What about the group of staff that don’t go on the away day, that drops morale because they didn’t go on it. And also they’re working with locums and agency, so they’re actually having a bad day then. So you can get animosity even just doing something like that.’ (ACCP 1) ‘Well ideally a psychotherapist or somebody who has that professional backing or professional background to be able to support that because otherwise talking can only go so far.’ (Nurse 3)
	Group-based approach	‘You’re potentially opening yourself up to a whole room of strangers is a bit like alcoholics anonymous, some people wouldn’t be up for that.’ (Other 1) ‘…or, you know. I think you don’t want to criticise where you work and knowing that it can come back to you and there is that feeling the more junior you are the easier it is for you to go isn’t it, I think there is still that.’ (Nurse 6)
	Non-healthcare background	‘Yes, so she came in, to kind of give us techniques but she just didn’t really relate to healthcare it was more outside. So it just didn’t relate to any of us… They can’t relate it to us or how it would actually be working in a hospital.’ (Nurse 1) ‘I think it would be good to talk to people who know the environment because you don’t have to explain all of that do you, you can just go in at a level of like mutual understanding and then you can just talk about the problem.’ (Doctor 5)
	Informal approach	‘What I would say is that where, I don’t know, I have always found that the organic process has always been the most helpful. I don’t know whether that’s because in a sense you kind of have more control over who you go and chat to or whether it just has more authenticity.’ (Doctor 4)
	Nominated ICU staff for support	‘I do wonder whether a facilitated system would be useful because I think the danger can be that if you’ve got people who are distressed talking to each other about the distress they can actually spiral down further… Rather than lift themselves out so a moderated sort of peer review or peer forum I guess would be helpful.’ (Doctor 1) ‘… have an identified person, say go to Adam, if you have got a problem go to Adam or its Adam’s month to deal with all the grief or whatever. To say there is a role and you get a small bit of time for the role, the role exists in this place, it’s paid for, it’s budgeted and that’s when it happens and get the right people to do it.’ (ACCP 2)

ACCP, advanced critical care practitioner; ICU, intensive care unit.