Coping with moral distress: a qualitative study exploring psychological strategies used by healthcare professionals

Abstract

Background

Moral distress is a specific type of stress related to the moral dimension of clinical practice. Literature shows that moral distress is associated with depressive symptoms, job resignation and burnout. However, few studies have explored the psychological factors that can modulate moral distress. The aim of this qualitative study was to explore the range of psychological strategies employed by healthcare professionals (HPs) to cope with moral distress.

Methods

Using a snowball sampling technique, a purposeful sample of interdisciplinary HPs working in a large public hospital in Milan (Italy) was recruited. Semi-structured interviews were conducted. HPs were asked to recall morally distressing situations and how they coped in their aftermath. The interviews were audio-recorded, transcribed and analyzed through content analysis to identify psychological strategies used to cope with moral distress.

Results

We interviewed 20 HPs (11 physicians, seven nurses, one midwife and one physiotherapist; 15 females; mean age = 50.26; SD = 8.19). Eight strategies used to cope with morally distressing situations were identified: Reframing the situation, Trying to modify the situation, Limiting own involvement, Tolerating the situation, Meeting and sharing with colleagues, Rejecting and withdrawing from the situation, Searching for alternative actions, and Venting. Typically, HPs used more than one strategy (mean = 4.1; SD = 1.14) and recounted learning and adapting strategies over time.

Conclusions

Our findings suggest that psychological strategies used to cope with moral distress seemed partially distinct from those used for emotional distress. Future research is needed to explore possible distinctions between general coping and moral coping. In the future, identifying strategies associated with different levels of moral distress could inform and guide the implementation of preventive interventions for HPs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-025-02926-3.

Introduction

Moral distress has become a well-known construct, receiving increased attention from scholars and healthcare professionals (HPs) especially in the context of the COVID-19 pandemic. Moral distress has been documented across different healthcare fields and disciplines such as nursing, intensive care, gynecology, oncology, palliative care, emergency services, pharmacy, physiotherapy, and psychology [1]. The concept of moral distress has evolved over time [2] and even today there is debate as to whether to adopt a narrow or a broader definition [3]. Moral distress was first described in 1984 by Jameton as occurring when “a nurse knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” [4]. In recent years some authors [5] have supported a broader definition of moral distress that includes any psychological distress caused not only by moral constraints but also by moral uncertainty, moral conflict, or by moral dilemma. Additionally, a crescendo effect model of moral distress has been proposed [6], which distinguishes between initial moral distress experienced during a situation and the lingering distress or moral residue, that may remain after the event.

Moral distress is a subjective experience and may be triggered by different situations. Hamric and Epstein [7] classified the most common causes of moral distress into patient, unit and system-level causes. Patient-level causes are those that involve the patient and/or family (e.g., performing treatments that cause unnecessary suffering due to family demands for overly aggressive treatment). At the unit level, moral distress can be triggered by problems such as poor communication or inadequate collaboration between team members that impacts negatively patient care (e.g., witnessing false hope, inconsistent messages). System-level causes include situations that occur outside the boundaries of the unit such as poor staffing, pressure from administrators to reduce costs and lack of adequate resources such as supplies or bed capacity.

In the last decade the impact of moral distress on healthcare professionals’ well-being has been extensively studied. Some authors [8, 9] argue that experiencing moral distress does not necessarily result in negative consequences if properly managed. However, consistent with the crescendo effect model, other studies showed that, if unaddressed, moral distress is associated with burnout [10] depressive symptoms [11], withdrawal from care and job resignation among HPs [12]. Therefore, it is of pivotal importance to understand the factors that might modulate the experience of moral distress when it arises and to prevent its negative impact on HPs and healthcare organizations.

Organizational factors that were found to be associated with lower moral distress were positive ethical climate, organizational support, and low nurse-patient ratios [13–16]. Structured interventions such as ethical debriefing, moral distress rounds or specialist consultations were also found to be effective in reducing moral distress within healthcare organizations [17]. However, little is known about the psychological factors that can modulate HPs’ experience of moral distress.

Coping strategies have been widely studied in the field of stress and can be defined as “the cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and conflicts among them” [18]. Over the last twenty years, different coping models have been developed [18, 19], encompassing diverse coping strategies. In a meta-analytic study [20], 5 categories of coping strategies were identified as core across models including: problem solving, support seeking, avoidance, distraction, and positive cognitive restructuring. As moral distress is a specific type of stress, exploring the range of psychological strategies used to cope with moral distress may be a promising yet underdeveloped research area with clinical and educational implications. In a preliminary qualitative study conducted during the pandemic [21], we found that physicians reported specific individual responses to cope with moral distress including avoidance, acquiescence, resistance, and reinterpretation. Another recent qualitative study explored the experience of coping with moral distress of seven intensive care nurses [22]. The nurses described moral distress as common in their daily practice, leading to a dynamic multifaceted coping process involving avoidance (such as feigning illness to take a sick day), connection (seeking support from colleagues), and moving forward (adapting and learning from distressing situations). Based on these early findings, this project aimed to explore the specific psychological strategies used by interdisciplinary healthcare professionals (HPs) to cope with morally distressing situations.

Materials and methods

Study design and partecipants’ recruitment

To identify the strategies that HPs utilize to cope with morally distressing situations a general inductive approach [23] was adopted. The general inductive approach is a systematic procedure for analyzing qualitative data in which the analysis is guided by specific objectives, without the restraints imposed by structured methodologies [23]. The study was conducted at a public teaching general hospital in the north of Italy. A purposeful sample of interdisciplinary HPs was recruited. The principal investigator of the study (GL) contacted the chief physicians and nurse managers of the main clinical areas of the hospital (e.g., surgery, oncology, mental health, emergency medicine) to describe the project. A flyer was developed to disseminate the project, containing a brief definition of moral distress [6], the aim of the study and the modality of data collection (semi-structured interviews) along with the assurance that all data would have been anonymized. The chief physician and nurse managers of the various units proposed the study to HPs using the flyer and word-of mouth. HPs were eligible to participate if fulfilling a clinical role (e.g., providing direct care to patients) and believing themselves to have experienced moral distress at least once in their healthcare career. Emails and telephone numbers of interested HPs were provided to the principal investigator, who then contacted prospective participants to further explain the study and to schedule an interview if they wished to participate. Additional HPs were identified and contacted using a snowball sampling technique [24] that utilizes social networks of the interviewed participants to recruit additional participants.

Data collection

Between October 2022 and May 2023, HPs were interviewed face-to-face in the hospital-based research office or online, based on the participants’ preference, by one of three researchers (GL, CLB, MM) whose backgrounds are in clinical psychology, psychotherapy and qualitative methodology. The researchers worked in the same hospital as the participants but did not have any previous relationship with the interviewees. One researcher (GL) pilot tested the interview with a volunteer physician and received positive feedback. Before beginning the interviews, the researchers explained the aim of the study, including that the interviews would be audio-recorded and that all identifying information emerging during the interviews would be anonymized. Then, the researchers sought written informed consent and collected sociodemographic data of the participants. The interviews were semi- structured. The structure of the interview was developed for this study (Supplementary material). Upon beginning the interviews, HPs were offered the same definition of moral distress provided in the flyer, that describes moral distress as the suffering that arises when one cannot act according to what one perceives as morally right due to internal or external constraints [6]. After presenting this definition, HPs were asked to recall a situation where they experienced moral distress during their professional career. Once the situation had been described, two additional questions were asked with the aim of specifically exploring the strategies used by HPs to cope with moral distress: (1) “How did you manage the moral distress you felt?” and (2) “What strategies did you use to cope with moral distress?”. During the interviews, the researchers followed the flow of the interviewees and facilitated the expression of the experience by using active listening, open-ended questions (e.g., “How was that for you?”) and by reflecting and summarizing the contents expressed (e.g., “So you are saying that it was difficult and that you tried not to be involved”). All the interviews were transcribed verbatim. Data collection was terminated when the researchers conducting the interviews judged that no new information was discovered during data collection, that is when additional data did not lead to any new content [25].

Data analysis

Sociodemographic data were analyzed through descriptive statistics using SPSS 19. The interviews were analyzed by the same researchers who conducted the interviews (GL, CLB, MM), according to the principles of inductive content analysis [26]. For this study, inductive content analysis was applied solely to the parts of the interviews where HPs, responding to the second question, described thoughts or behaviors they used to cope with morally distressing situations. The aim of content analysis was to identify thoughts or behaviors reported by participants and group them conceptually into strategies used to cope with moral distress. Content analysis occurred over several steps and Excel was used for data management. In the first phase, the three researchers independently read the transcripts and tried to identify emerging thoughts or behaviors that HPs described to cope with moral distress and grouped them into strategies. Subsequently, during several joint meetings, the three researchers shared the strategies they had identified. Through ongoing discussions, they compared, refined, and labeled them, ensuring there was no conceptual overlap. A coding scheme containing the labels and the descriptions of the different strategies was created. The researchers then returned to the transcripts to codify the thoughts or behaviors reported by HPs to cope with moral distress according to the scheme. In the situation when thoughts or behaviors described in the interviews did not fit the strategies reported in the coding scheme, modifications were made accordingly by adding a new strategy or refining the label of an existing strategy. After this step, the strategies were discussed in a joint meeting with two senior clinical researchers, an Italian clinical psychologist (EV) and an American nurse, clinical psychologist, and bioethicist (ECM), who were external to the data collection and coding, who provided feedback on the conceptual clarity and labeling of the strategies. Once the coding scheme with all the strategies was determined, two researchers (GL, CL) independently coded all the behaviors and thoughts reported in the interviews according to the scheme. Inter-rater agreement between the two researchers was satisfactory at 90% with agreement in coding of 95/105 behaviors and thoughts reported. Disagreements in coding were resolved through discussion between the two researchers. Finally, excerpts from the interviews were selected to illustrate each strategy and the frequency of each strategy was calculated. To ensure the representativeness of the data, for each strategy we chose excerpts coming from participants of different disciplines.

To ensure the trustworthiness of the study, we followed the checklist developed for qualitative content analysis studies during the article writing process [27].

Ethics approval

The project was reviewed and approved by the Ethical Committee of the University of Milan (Comitato Etico, Università degli Studi di Milano, reference number 48/22). The research was conducted in accordance with the principles of the Declaration of Helsinki. Prior to data collection participants signed an informed consent to use their sociodemographic data and interviews for research purposes. Participants were reassured about the anonymization of the transcripts.

Results

Participants

22 HPs were contacted of which two did not complete interviews for a completion rate of 91% (20/22); one did not reply to emails and the other was unable to be scheduled. We conducted 20 interviews (18 in person and two online), which lasted an average of 38.9 min (SD = 8.1). Of those, 11 were conducted with physicians, seven with nurses, one with a midwife and one with a physiotherapist. Fifteen HPs (75%) self-identified as women. The mean age was 50.3 (range = 36–67) and the mean years of experience was 25.7 (range = 12–41). The sociodemographic data of the sample are reported in Table 1.

Table 1.

Patient sociodemographic and clinical characteristics

Variable	N (%)
Gender
Man  Woman  Transgender  Nonbinary	5 (25%) 15 (75%) 0 0
Age (years)
Mean (SD)	50.26 (8.19)
Years of experience
Mean (SD)	25.65 (9.08)
Profession
Physician  Nurse  Other healthcare professional	11 (55%) 7 (35%) 2 (10%)
Hospital ward
Intensive Care Unit (ICU)  Physiotherapy and Rehabilitation  Maternity and Neonatal Care  Neuroscience and Mental Health  Gastroenterology, Cardiology and Pulmonology  Oncology  Infectious Disease  Surgery	2 (10%) 2 (10%) 1 (5%) 1 (5%) 1 (5%) 7 (35%) 1 (5%) 5 (25%)

Moral distress coping strategies

From the analysis of the interviews, we identified 105 thoughts and behaviors used to cope with moral distress which were organized into eight strategies: Reframing the situation; Trying to modify the situation; Limiting own involvement; Tolerating the situation; Meeting and sharing with colleagues; Rejecting and withdrawing from the situation; Searching for alternative actions; and Venting. These strategies are presented below with representative verbatim quotes from HPs. Table 2 provides a description of the strategies and the percentage of their use within our sample. On average, each HP reported utilizing 4.1 strategies (SD = 1.15).

Table 2.

General description of the strategies and distribution of the 105 thoughts/behaviors according to each strategy

Strategy	Description of the strategy	Frequency n (%)
Reframing the situation	Reframing the morally distressing situation by acknowledging limits that are inherent in oneself/others, recognizing others’ perspectives, trusting others, and focusing on values that could be upheld despite the constraints	31 (29%)
Trying to modify the situation	Trying to modify the morally distressing situation by speaking up, raising arguments, taking charge, or seeking help	24 (23%)
Limiting own involvement	Detaching emotionally from the morally distressing situation to safeguard well-being	13 (12%)
Tolerating the situation	Passively accepting the morally distressing situation	11 (11%)
Meeting and sharing with colleagues	Meeting and sharing with colleagues for support, exchange of opinions, deliberation, and validation	10 (9%)
Rejecting and withdrawing from the situation	Rejecting and actively withdrawing from situations compromising moral values and well- being	7 (7%)
Searching for alternative actions	Searching for alternative actions, given the existing constraints, to uphold moral values	5 (5%)
Venting	Venting emotions through communication, recreational or physical activities	4 (4%)

Reframing the situation

Some HPs seemed to reduce moral distress by reinterpreting or looking at the morally distressing situation from a different perspective. A reframing of the morally stressing situation was accomplished by a combination of acknowledging limits, recognizing others’ perspectives, trusting others, and recognizing the values that were able to be upheld despite the circumstances.

Acknowledging limits. Some HPs acknowledged their own limitations and constraints, thereby accepting their inability to act according to their values in some circumstances. HPs recognized that they may not have complete control over the circumstances, and that healthcare systems and colleagues have their own limits. During this process, HPs reported the importance of understanding that ethical decision-making and action can be influenced by various external factors. When HPs recognized and acknowledged that they were not solely responsible for all the outcomes, this helped to assuage their moral distress.

” I also accept the idea that you can’t save everyone. Some things you really have to let go because you don’t have a chance. In my head I don’t even know where to ask for a solution.” (#19, physiotherapist, 27 years of experience).

Recognizing others’ perspectives. Some HPs were able to consider the perspective and values of other individuals involved in the morally distressing situation, including colleagues, patients, and families. Understanding these different viewpoints helped HPs to appreciate the complexity of the morally distressing situation and be less absolute and rigid about what they deemed as right.

“I perceived selfishness on the part of the sons who wanted us to continue prolonging this poor man’s suffering. Then I tried to put myself in the son’s shoes, and then I thought that this dad obviously had built well. He was a good father, he was loved. I’ve been a son too.” (#3, nurse, 18 years of experience).

Trusting others. When experiencing moral uncertainty or conflict, some HPs were able to set aside their judgment and embrace the stances of their colleagues and patients. For some HPs, trusting others meant trusting the healthcare team’s judgment, even though it differed from their own, or similarly trusting in patients’ ability to determine what was best for them. Trusting others seemed to relieve some of the crushing responsibility and moral burden that HPs can experience.

“I have the hope that maybe I am wrong. Yes, that although I believe that I should not continue with the treatment because I see the suffering it causes in that patient, I might be mistaken. Who knows…maybe the doctors are right.” (#4, nurse, 12 years of experience).

Recognizing the values upheld. A few HPs reframed the moral distress situations by focusing and acknowledging the values that were nonetheless pursued and the meaningful aspects of their work. While recalling morally distressing situations, HPs highlighted the meaningful dimensions of their role or the positive impact the healthcare system can have on the lives of many patients and families, despite its flaws. This strategy seemed to preserve a sense of professional integrity and fulfillment by counterbalancing the emotional toll of morally distressing situations.

“I try to focus on the positive aspects. When I request a medication for a patient that costs millions, I have never felt pressured by the hospital administration not to ask for it. So, there is also a positive side. I see many spaces for improvement, but the public healthcare system still holds up.” (#11, physician, 37 years of experience).

“(during COVID-19 pandemic) At the end of the day you would say “Well, at least we saved one patient.” (#20, nurse, 18 years of experience).

Trying to modify the situation

Some HPs reported trying to actively change the situation generating moral distress in a variety of ways, such as speaking up, raising arguments, taking charge and asking for help.

Speaking up. Some HPs used assertive communication to express their values, concerns or disagreements to their chiefs, colleagues or patients. This strategy seemed to contribute to a more open and constructive dialogue within the healthcare team and with the patients and family members.

“I say that I don’t agree with a certain approach… over the years I’ve learned to modulate the expression of what I think, but I always express my opinion.” (#7, nurse, 28 years of experience).

Raising argument. A few HPs tried to modify the morally distressing situation by raising arguments when speaking up was not enough. For some participants, arguing was the last chance to express their concerns, stand up for their ethical values and advocate for a particular course of action. In some cases, this strategy involved rebellion against established practices, or even disputes with colleagues, superiors, or other individuals involved in the decision-making process.

“I have even had arguments with our doctors to have them intervene on sedation. It’s exhausting to assist a patient in pain, who is struggling to breathe. I remember getting angry with a doctor and saying, ‘Look, now you come over here and sedate this patient, or I won’t leave.’ There was a heated exchange, but eventually, he came and sedated the patient.” (#3, nurse, 18 years of experience).

Taking charge. In some cases, HPs, tried to actively modify the morally distressing situation, by taking charge of tasks or decisions that belonged to others. This strategy reflects a sense of responsibility and a commitment to patient care, that is often pursued at one’s own personal costs.

“Because you can’t change other people’s minds anyway. There are things you can’t change, so I just take responsibility for them. Rather than engaging in conflict, if possible, I’d rather take charge. I’ll do it.” (#7, nurse, 28 years of experience).

Asking for help. Other HPs tried to overcome the morally distressing situation and ensure patient care was delivered effectively by asking favors or seeking help from colleagues or specialists.

“I get angry. I find myself working in a hospital where I feel there are no conditions to do what I want to do well. However, organizational problems can be solved. I know that if I call that doctor and ask for a favor, he will come.” (#1, physician, 31 years of experience).

Limiting own involvement

Some HPs managed the unpleasant emotional activation elicited by morally distressing situations by limiting their own involvement and establishing boundaries to safeguard their well-being. When experiencing moral distress, some HPs emotionally distanced themselves from the distressing situation.

“I force myself not to be dragged into the situation excessively, that is I force myself to stay detached.” (#17, physician, 20 years of experience).

“I no longer invest emotionally.” (#18, physician, 24 years of experience).

Others tried to limit their emotional involvement setting a physical distance between them and the morally distressing situation.

“I put up this wall. If they’re doing something that’s a bit exhausting to watch, I keep my distance. Over time, I realized there were two options: either you immerse yourself and stay in it, maybe suffering or you would orbit around the patient in case your presence is needed.” (#20, nurse, 25 years of experience).

" It hurts me too much so I try to distance myself from events as long as I can. The less I stay here (in the hospital), the better.” (#10, midwife, 20 years of experience).

Additionally, some HPs described the effort to compartmentalize and separate the negative aspects of a morally distressing situation from all the other working activities to preserve their professional integrity.

“I said to myself I also have a personal life out there. So, I try to turn off. It’s 5pm and I need to go home!” (#1, physician, 27 years of experience).

After having finished their shift, HPs described the need to intentionally impose a distance from what was morally distressing for them. Setting boundaries that effectively separated the work environment from personal life, needs and values was described as an integral component of this strategy.

“You have to think that you come, you do your hours, and you go away.” (#2, nurse, 25 years of experience).

Tolerating the situation

Some HPs passively tolerated the situation generating moral distress. In a hierarchical healthcare setting, some HPs recounted that they passively accepted behaviors, situations, or orders that they perceived as wrong or morally questionable because they felt powerlessness, not experienced enough to express a moral opinion, or compelled to obey to authority figures.

“I kept quiet because I was the last one there. However, I wanted to say so many things, but I didn’t say them and kept quiet, which was very frustrating.” (#6, nurse, 28 years of experience).

“If someone important within the hospital asks you to do something like this (skipping the waiting list for a patient), you must comply. It’s hard to say “No, honey, there’s a waiting list.” (#13, physician, 13 years of experience).

For some respondents, a lack of self-efficacy and a sense of obligation generated a passive acceptance of situations that conflicted with their moral values.

“You tolerate it, because there is nothing to do.” (#14, physician, 23 years of experience).

Other HPs reported that they started to use this “survival” strategy after having tried to influence colleagues or to actively change the situation with ineffective results.

“I found myself thinking, ‘What should I report or file a charge for when it seems that nothing changes anyway?” (#16, physician, 22 years of experience).

Another HP shared that “In my career, I was taught to obey without discussing.” (#15, physician, 41 years of experience). For this particular HP, obedience to authority figures was considered a fundamental value and aspect of professionalism, leading to passive tolerance of morally distressing situations because obedience took priority over other values.

Meeting and sharing with colleagues

Several HPs reported that they use the regular team meetings to discuss morally distressing situations with colleagues, express own moral concerns and seek support. Through discussion in team meeting, the responsibility regarding complex situations is shared and the burden of moral distress does not rest on the individual clinician but rather is mutually shared, borne, explored, and utilized to achieve collective deliberation and responsibility.

“In our work context, it happens that we don’t always agree with each other. That’s why we engage in discussions, and in the end, we always aim to prioritize what is the best choice for the patient. Usually, we have a team meeting and if one colleague does not agree we explore why a colleague do not agree with a clinical decision…we always take one or more days to really understand if that colleague is right.” (#20, nurse, 18 years of experience).

Moreover, some HPs reported that meeting to share and unburden moral distress with colleagues, even informally, was helpful to receive reassurance and validation. Sharing moral concerns and seeking input from colleagues can provide HPs with a sense of confirmation and validation for their unsettled feelings and moral distress.

“During COVID, we were never entirely alone; there was always a colleague present. Given my nature, I often question whether I missed something. When I compare myself with someone and they assure me that they would have done the same thing, it always brings me a great sense of reassurance.” (#8, physician, 15 years of experience).

Rejecting and actively withdrawing from the situation

When faced with several situations that seriously compromised their moral values and integrity, some HPs took tangible actions to withdraw themselves from these situations. Some described a refusal to participate in specific requests that were deemed as morally wrong.

“They requested that we alter the patient priorities to avoid potential payment cuts. While I understand the concern, I chose not to change the priority classifications, as doing so would compromise the alignment with the actual needs of the patients.” (#16, physician, 22 years of experience).

Others requested to be assigned to a different unit or decided to change positions, hospitals or careers.

“I realized that the world is a big place, and despite the fact that I was two years away from retirement, there were so many different opportunities. So, I took a leap, went somewhere else, and basically started over. I didn’t want to give in to certain things.” (#9, physician, 41 years of experience).

“Then I left that unit because I didn’t agree with some choices… I had refused to do certain things.” (#2, nurse, 25 years of experience).

Some HPs reflected on the fact that preserving their moral integrity was most important and essential not just for their own well-being but also to safeguard the quality of patient care.

“I strongly disagree with some of the directives imposed by the management, to the extent that I am willingly leaving. I find it challenging to provide the level of care I aspire to for my patients. A seemingly trivial example is the limited time available during visiting hours. In our clinic, there are usually fifty patients to see in three hours. Often, I find myself unable to fully address each patient due to time constraints. To be honest, this doesn’t align with my vision of being a doctor. The profession I studied for is something different.” (#14, physician, 23 years of experience).

Searching for alternatives

When facing morally distressing situations, some HPs reported they tried to find alternative ways to uphold their values and act morally, while accepting the existing limitations.

" This young man’s name was C. When I met him, he was in an advanced stage of illness, as his parents refused care (for religious reasons), so the die had been cast. I said to myself “what can I do?”. See how C.‘s blood pressure is, if he had pain give him painkillers, in short, my role was to assist C in his daily needs. When I find myself in situations where I have little leeway, I wonder what more I can do. One more phone call? One more word?” (#1, physician, 37 years of experience).

Some HPs described how they tried to find new ways to uphold their values in patient care by modifying care plans, helping patients with administrative tasks, or at least by maintaining the relationship with patient.

“I was on a shift in the emergency room when a patient, who had ingested drugs, was brought in. I had planned to discharge her the next morning after keeping her in ER overnight for observation. A nurse arrived and, with visible frustration, stated, ‘Doctor, I need this stretcher. ‘There weren’t even chairs available for the patient to stay overnight. It became quite challenging at that point. Consequently, I suggested to the patient that I would schedule an appointment for her in my clinic the next day.” (#11, physician, 41 years of experience).

“Usually, my idea is always to look for a valid alternative; in some way, I try to save the situation.” (#19, physiotherapist, 27 years of experience).

Venting

Some HPs released and alleviated the emotional burden elicited by morally distressing situations, by talking to colleagues, friends, and family members.

“That night, I felt really unwell due to what happened with that patient. Fortunately, I had plans to meet up with a friend, and I asked her if she’d like to have a drink and a chat because I really needed to unwind. It was helpful to talk about my feelings, and she shared her thoughts as well. Then, we digressed and talked about something else. This relaxed me a lot.” (#5, nurse, 34 years of experience).

Other HPs engaged in physical exercise to unload the tension or saved time for recreational activities that soothed and restored them. This strategy seemed to help HPs decompress and reduce the emotional toll of moral distress.

“I do relaxing things that can recharge me when I am out of work. I walk and I write poetry.” (#7, nurse, 28 years of experience).

“I usually discharge distress doing sport” (#17, physician, 20 years of experience).

Discussion

In this study we explored the psychological strategies adopted by interdisciplinary HPs to cope with moral distress. The results highlighted that HPs used various strategies, with the most common being reframing the situation, followed by attempting to modify it. These two strategies accounted for 29% and 23% of all strategies used, respectively.

Overall, the strategies used by HPs to cope with moral distress seemed to serve two general functions that are to reduce the discrepancy between one’s own values and the situations in which the HPs were involved and to manage the unpleasant emotions elicited by this discrepancy. The strategy of trying to actively modify the situations or the constraint causing moral distress was an attempt to align the situation with one’s own values. Other strategies, such as reframing the situation or searching for alternative actions, aimed to preserve and uphold one’s own values either retrospectively by reinterpreting the situation or by identifying alternative actions that could preserve moral values. Strategies such as limiting one’s own involvement and venting focused on managing the unpleasant emotions generated by moral distress. The strategy of meeting and sharing with colleagues seemed to be an attempt to actively change the situation by sharing own moral concerns with the healthcare team and by activating a process of group deliberation through which the team could take corrective actions or could change the situation. At the same time, sharing moral concerns and perspectives with colleagues, also helped HPs to manage the emotions elicited by moral distress. Other strategies tried to resolve moral distress either by setting aside one’s own values and therefore tolerating the situation, or by upholding one’s own values and rejecting the situation. In this latter case, some HPs reported eventually stepping down from a position or asking to be reassigned to another clinical setting.

The two general functions played by the different strategies resemble those applied in the theory of cognitive dissonance [28] to reduce the dissonance between thoughts and behaviors. Moral distress could therefore be theorized as a specific type of distress that occurs when there is dissonance between one’s own values and own behaviors or behaviors carried on by a social group with which a person identifies [29]. As disagreements persist over a definition of moral distress, this theoretical perspective could help refine the concept and ground it in a theoretical framework.

Interestingly we noticed that the strategies were activated at different times with respect to the morally distressing situation. Some strategies, such as trying to change the situation, venting or limiting one’s involvement, were mainly used by HPs during the unfolding of morally distressing situations. Other strategies, such as reframing the situation or finding alternatives, required more time to be activated. The latter strategies were often used after HPs had unsuccessfully tried other strategies within their organizations or after having progressed through the morally distressing situation. This temporal aspect of coping was highlighted by Beehr and Mc Garth [30] who classified coping styles as proactive, dynamic, reactive, and residual. According to the classification system of Beehr and Mc Grath [30], reframing the situation, finding alternatives or rejecting and withdrawing from the situation could be classified as reactive coping strategies, because these were generally activated during the short-term aftermath of the event, whereas the other strategies could be grouped as dynamic coping because they were mounted while the event was happening. The temporal aspect of coping is particularly important because it offers the opportunity to intervene to support HPs not only during the unfolding of the situation but also when moral distress has subsided [31].

Some of the strategies identified in this study appear to align with the “4 A’s to Rise Above Moral Distress” model developed by the American Association of Critical-Care Nurses [31], which proposes a normative approach or what should be done, to address moral distress. This model outlines four key stages to act upon moral distress: Ask, Affirm, Assess, and Act. Strategies identified in our study highlight how HPs self-report handling moral distress in actual practice. Some strategies HPs identified, including attempting to modify the situation, meeting and sharing with colleagues, and searching for alternatives, align with the Act stage of the 4 A’s model. However, unlike the 4 A’s model, which primarily emphasizes behavioral strategies, our results also highlight the presence of cognitive and emotional strategies to cope with moral distress, such as reframing the situation, venting and limiting own involvement. This suggests that coping with moral distress involves not only actions but also mental processes of meaning-making and emotional regulation. Understanding the psychological strategies that HPs typically utilize may be helpful to integrate actual interventions to address moral distress.

Several supportive and educational offerings, such as moral distress consultations, ethical group debriefings, facilitated discussions, and specialist consultations, have been described in the literature to address moral distress [32]. Based on our findings, we suggest that a debriefing model incorporating both ethical and psychological competencies could be the most effective approach to support HPs in coping with moral distress. Such an integrated debriefing model may help HPs not only to draw from behavioral strategies but also from cognitive or emotion-focused strategies.

Interestingly, our findings showed that HPs employed more than one strategy to cope with moral distress. We know from the literature that the exclusive use of one type of strategy, especially the emotion-focused strategies (such as avoidance), does not promote psychological and physical well-being on the long term [33–35]. It is possible that having more than one strategy available within one’s repertoire to draw upon as needed over time could allow HPs to select the one that best fits the context, therefore leading to overall better management of moral distress. HPs also reported that some strategies evolved and matured over time thanks to professional experience, personal growth, and psychological support. For example, some HPs reported that they learned to be less aggressive and more assertive in voicing their moral concerns. Others recounted that they acquired the capacity to reinterpret the situations they encountered thanks to sharing with colleagues or by engaging in psychological support. Similarly, Forozeiya et al. [22] found that coping strategies varied with nurses’ levels of experience. In their study novice nurses leaned more frequently on problem-focused coping strategies whereas experienced nurses employed positive re-appraisal, focusing on personal growth. These findings suggest that moral coping strategies can be learned and therefore training or specific support may be offered to HPs to broaden their range of personal coping strategies.

Our study identified strategies that may echo those found in existing literature on psychological coping. Trying to modify the situation, for example, was similar to what Folkman et colleagues [19] described as planful problem-solving, limiting one’s own involvement was consistent with avoidance strategies and reframing the situation was similar to what has been called positive reappraisal or positive cognitive restructuring. However, it is crucial to highlight that the strategies we identified were distinctly characterized by a moral dimension and content. Additionally, searching for alternative actions and meeting and sharing with colleagues are strategies specifically identified to cope with moral distress [36]. These findings suggest that coping strategies for moral distress are distinct from those used for emotional distress. It is important for future research to continue to explore the interface and possible distinctions between general coping and moral coping, as they may not overlap. The results of this study may offer a qualitative base for the future development and validation of a specific questionnaire measuring moral coping strategies. It was not the aim of this study to explore the situations that generated moral distress or the efficacy of the different strategies described by HPs. Future quantitative research could assess what strategies or cluster of strategies are most effective to reduce moral distress or are more frequently associated with certain morally distressing situations.

Our study has several limitations. As the aim was to identify strategies used to manage moral distress, the approach was qualitative. The results are not statistically generalizable but analytic generalization of the strategies identified to other contexts can be assessed [37]. A selection bias in the sample may exist because we adopted a purposeful sample of HPs. As our sample was composed of quite experienced clinicians, it is possible that the breadth and the type of strategies identified were influenced by the personal and professional growth of the participants. Finally, we are aware that we explored only coping strategies that were conscious and could be recalled and reported by HPs. Defense mechanisms, that are unconscious and that may have been used by HPs to protect them from moral distress, were not able to be explored with our methodology. Additionally, differences in coping strategies across professions or years of experience were not assessed.

Conclusions

This research focused on a fundamental resource- moral coping- that needs to be understood and supported among HPs as they face moral distress in everyday clinical practice. In our study we identified eight strategies used to cope with moral distress. These strategies seemed partially distinct from those used to cope with emotional distress. In the future, identifying strategies associated with different levels of moral distress could inform and guide the implementation of preventive interventions for HPs. Given that the effectiveness of individual coping strategies is also influenced by broader environmental characteristics and responses [38], it is essential that healthcare institutions assume responsibility to cultivate ethically attentive environments and continuously advance efforts to report, discuss, and learn from morally distressing situations.

Electronic supplementary material

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Abbreviations

HPs

Healthcare Professionals

Author contributions

G.L., L.B. and E.V. conceptually designed the study. G.L., C.L.B. and M.M. contributed to data collection and analysis. G.L. and M.M. drafted the manuscript. L.B., E.C.M and E.V. revised and edited the manuscript. All authors reviewed and approved the manuscript.

Funding

The study was funded by the Università degli Studi di Milano, with grant number “PSR2023_DIP_013_LAMIANI”.

Data availability

The qualitative data that support the findings are in Italian and cannot be shared openly to protect study participants’ privacy. Restrictions apply to the availability of these data, which were used for the current study and so are not publicly available. The data are, however, available from the authors upon reasonable request.

Declarations

Ethical approval

The project was conducted in accordance with the Declaration of Helsinki and was reviewed and approved by the Ethical Committee of the University of Milan (Comitato Etico, Università degli Studi di Milano, reference number 48/22).

Consent for publication

All participants provided informed consent to participate in the study and to use their sociodemographic data and interviews for research purposes and for publication.

Competing interests

The authors declare no competing interests.