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

Abstract

Background

This study aims to assess the level of ethical distress experienced by intensive care unit (ICU) nurses in their work, thereby providing a theoretical basis for the development of evidence-based interventions.

Methods

The review was registered in PROSPERO (CRD42025637436) and was conducted following the PRISMA guidelines. A comprehensive search was conducted across multiple databases, including PubMed, Embase, the Cochrane Library, Web of Science, and ClinicalTrials.gov, to identify original studies published up to January 2025 that explore the experiences of moral distress among ICU nurses. The methodological quality of the included studies was rigorously assessed using the 2018 version of the Mixed Methods Appraisal Tool (MMAT).

Results

This systematic review encompasses a total of 34 articles, involving 6,461 participants from 13 countries. The results showed that the weighted mean difference (WMD) based on the revised Moral Distress Scale (MDS-R) score was 49.98 (95% CI 38.02–61.94, p < 0.001), and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) score was 88.32 (weighted MD [WMD] 88.32, 95% CI 54.13–122.51, p < 0.001), indicating that ICU nurses are experiencing moderate levels of moral distress. Subgroup analysis of MDS-R scores by gender did not show significant differences (MD 3.49, 95% CI 5.74–12.72, p = 0.46, I² = 62%), indicating no association between the intensity of moral distress among ICU nurses and gender.

Conclusion

ICU nurses are experiencing moderate moral distress. Nursing administrators should prioritize the distressing experiences induced by moral distress among ICU nurses and adopt a multifaceted intervention strategy to proactively address these challenges, thereby mitigating the intensity of moral distress faced by ICU nurses and enhancing the quality of nursing care services.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-04274-4.

Introduction

Moral distress refers to the psychological anguish or imbalance experienced when an individual recognizes the ethically appropriate course of action but is constrained from implementing it due to internal or external barriers, thereby influencing behavior and potentially leading to long-term consequences [1]. Nursing is a profession frequently confronted with common ethical challenges [2]. Due to their close involvement in patient care and decision-making, nurses often encounter more frequent moral distress compared to other healthcare providers [3].

The Intensive Care Unit (ICU), as a critical center for treating severely ill patients, presents a high-pressure, closed environment where nursing staff face intense workloads, significant occupational stress, and pronounced ethical issues. This distress typically arises when ICU nurses encounter ethical problems lacking morally satisfactory solutions, preventing them from acting in accordance with their internal values and perceived duties [4]. ICU nurses also face additional challenges that exacerbate moral distress, such as high mortality rates, limited resources, and restricted family visitation [5].

The field of critical care is rife with ethical distress. Studies indicate that over 50% of ICU nurses have experienced moral distress [6]. Prolonged exposure to such distress can lead not only to physical discomfort but also to negative outcomes including diminished care quality, professional burnout, compassion fatigue, breakdowns in nurse-patient relationships, and even extreme consequences such as assisting in patient suicide. These effects severely compromise the safety and quality of nursing care [7–9]. In recent years, the experience of moral distress among ICU nurses has garnered increasing research attention, resulting in a growing body of related studies. However, findings from individual qualitative studies cannot fully capture the complete reality of this experience. Furthermore, due to differences in cultural values and nursing education, ICU nurses may experience moral distress in ways that differ from those reported in previous studies. Insights into resolving moral distress among critical care nurses remain contentious, with related evidence being fragmented and insufficient. This variability in findings underscores the necessity for a comprehensive systematic review.

This systematic review aims to synthesize current evidence on the prevalence, sources, and consequences of moral distress among ICU nurses, and to evaluate strategies for its mitigation.

Methods

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [10]. The protocol for this review was registered and published in PROSPERO (CRD42025637436, https://www.crd.york.ac.uk/PROSPERO/view/CRD42025637436).

Search strategy

A systematic search was conducted across PubMed, Embase, the Cochrane Library, Web of Science, and ClinicalTrials.gov to identify relevant literature. To maximize retrieval scope while enhancing precision, a refined search strategy incorporating both keywords and subject headings was employed. Briefly, the initial search strategy focused on core terms such as “intensive care unit,” “nurse,” and “moral distress,” which were selected based on Cochrane’s highly sensitive search approach. Search terms deemed conceptually similar were initially combined using the Boolean operator “OR”; subsequently, the results from three distinct conceptual categories were integrated using the “AND” operator. The comprehensive search strategy is detailed in Supplementary Material 1. Additionally, to maximize the potential regional applicability of the findings, no restrictions were imposed regarding the country of publication. Studies for which the full text could not be obtained after contacting the corresponding author were strictly excluded. The search execution and screening process were independently conducted by two reviewers, with any discrepancies resolved through consultation with a third senior analyst.

Eligibility criteria

The initial screening procedure was conducted as follows: Titles were screened to identify potentially relevant articles, followed by a detailed review of abstracts for further refinement. Ultimately, full texts were screened to establish a candidate list based on compliance with inclusion criteria and thematic relevance. The inclusion criteria were: (a) participants in the study must be full-time nurses in the ICU who are not part-time; (b) quantitative studies (descriptive and analytical designs), qualitative studies, and mixed-methods research; and (c) only high-quality literature assessed as Level A or B according to the Joanna Briggs Institute (JBI) critical appraisal tools. Studies meeting any of the following criteria, however, were excluded: (a) reviews, brief communications, letters to the editor, etc.; (b) articles published in languages other than English; or (c) articles for which the full text cannot be obtained even after contacting the corresponding author.

Data extraction

Two reviewers independently screened titles and abstracts using identical criteria. Subsequently, data were extracted from potentially relevant studies by the same two reviewers utilizing a predefined inclusion criteria checklist in Microsoft Excel. Disagreements between reviewers regarding eligibility were resolved through re-examination and discussion with a third, senior independent reviewer until consensus was achieved. Following the exclusion of irrelevant and duplicate articles, a flowchart illustrating the data extraction strategy was developed in accordance with PRISMA guidelines. Briefly, the following information was extracted from studies included in the systematic review: first author and publication year, country, sample size, age (reported as median or mean ± standard deviation), study objective, instrument type, moral distress severity, moral distress experience, and coping strategies for moral distress. Furthermore, this study employed the most recent methodological guidance from the Joanna Briggs Institute (JBI) for Evidence-Based Healthcare to conduct a mixed-methods systematic review [11]. A convergent integrated approach was adopted for data synthesis. This approach encompasses the integration of all data extracted from both quantitative and qualitative studies, primarily through a process known as data transformation. In the present study, the conversion of quantitative findings into qualitative data was performed independently by two authors, aiming to provide a narrative interpretation of the quantitative results. All synthesized qualitative data were then collated and ultimately categorized by the review team based on the similarity and relevance of the findings. During this phase, factors influencing moral distress among intensive care unit nurses were identified.

Risk of bias assessments

The quality of the included literature was evaluated using the 2016 Joanna Briggs Institute (JBI) Evidence-Based Health Care Center Qualitative Research Quality Evaluation Tool [11]. The JBI (Joanna Briggs Institute) guidelines are recognized as one of the core methodological frameworks within evidence-based healthcare. They provide a suite of comprehensive and rigorous critical appraisal tools tailored to different study designs, which are widely utilized for systematic reviews, evidence synthesis, and informing clinical practice. Additionally, two authors independently assessed literature quality using the Mixed Methods Assessment Tool (MMAT) 2018 version [12]. The MMAT is a reliable and comprehensive tool designed to assess the quality of mixed-methods research, including qualitative, quantitative, or mixed-methods designs. It includes two screening questions for different types of studies and five questions for each possible study design to assess the overall quality of the study. It is important to note that in the latest version of the MMAT 2018, the calculation of the total score based on the scoring of each criterion is discouraged. Instead, it is recommended to present the ratings for each criterion in more detail to better understand the quality of the included studies. Moreover, the risk of bias for each included study was meticulously evaluated using the Cochrane Risk of Bias Assessment Tool, a well-established and extensively utilized instrument for quality appraisal in meta-analyses.

Statistical analysis

After screening and data extraction, a meta-analysis was conducted using Review Manager (version 5.3; Cochrane Collaboration, London, UK). Eligible data were pooled. The results for moral distress intensity—measured using the MDS-R or MMD-HP scale and presented as mean ± standard deviation in all original studies—were synthesized and reported as the Mean Difference (MD) with a corresponding 95% confidence interval (95% CI) in the meta-analysis. Heterogeneity among the included studies was quantified using the I² statistic, with thresholds of 25%, 50%, and 75% or higher interpreted as indicative of low, moderate, and high heterogeneity, respectively. Publication bias was assessed using funnel plots generated in RevMan and Egger’s regression test, and a random-effects model was selected to account for potential variations in effect sizes across studies. Subgroup analyses were conducted for MDS-R score outcomes based on different genders using the same data processing strategy as described above.

Results

Studies selection

The initial search yielded 2,059 articles published between 6 August 2006 and 1 January 2025, of which 788 duplicate articles were removed, followed by an eligibility assessment of 112 full-text articles. After screening titles and abstracts, 43 articles were eligible for full-text evaluation and were included in further evaluation. After an in-depth screening of articles to find those that met the inclusion criteria for ICU nurses and moral distress, 34 eligible articles were finalized [13–46]. Fig. 1 shows a PRISMA flowchart detailing the study extraction process. The PRISMA flow diagram detailing the study extraction process is presented in Fig. 1.

Fig. 1.

PRISMA flow diagram of the systematic review selection process

Characteristics of the included articles

A total of 6,461 participants from 34 studies were included in this systematic review according to the eligibility criteria, with the main characteristics being 92.6% female and 7.4% male participants. In addition, the published articles originated from 13 countries, including the United States, the United Kingdom, China, Iran, Israel, the Netherlands, Canada, Switzerland, Spain, Turkey, Italy, South Korea, and the Czech Republic. Twenty-eight articles introduced statistical scale analysis data, with the most cited being the Moral Distress Scale-Revised (MDS-R) and adopting a cross-sectional design. In contrast, 10 articles used qualitative methods such as descriptive content analysis and phenomenology to investigate the moral distress experienced by ICU nurses, and another 16 studies used mixed methods. The results of the quality assessment of all qualitative studies are presented in Table 1, the results of the MMAT assessment of the quality of all included studies are presented in Supplementary Material 2, and the baseline characteristics of the included high-quality studies are shown in Table 2.

Table 1.

Quality assessment results of the included qualitative studies

Study & Year of publication	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Literature quality ratings
Neda, et al., 2021	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Grade A
Michelle, et al., 2021	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Grade A
Virginia, et al., 2014	Yes	Yes	Yes	Yes	Yes	NO	Yes	Yes	NR	Yes	Grade B
Sophie T, et al., 2021	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Grade A
Zahra, et al., 2019	Yes	Yes	Yes	Yes	Yes	NO	Yes	Yes	NR	Yes	Grade B
Foroozan, et al., 2012	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Grade A
Florence J, et al., 2006	Yes	Yes	Yes	Yes	Yes	Yes	NO	Yes	NR	Yes	Grade B
Adam, et al., 2023	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Grade A
Ellen H, et al., 2013	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Grade A
Soojeong, et al., 2022	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Grade A

Abbreviations: NR = Unclear or unavailable. Criteria for the critical appraisal of qualitative evidence: Q1 = Is there congruity between the stated philosophical perspective and the research methodology? Q2 = Is there congruity between the research methodology and the research question or objectives? Q3 = Is there congruity between the research methodology and the methods used to collect data? Q4 = Is there congruity between the research methodology and the representation and analysis of data? Q5 = Is there congruity between the research methodology and the interpretation of results? Q6 = Is there a statement locating the researcher culturally or theoretically? Q7 = Is the influence of the researcher on the research, and vice-versa, addressed? Q8 = Are participants, and their voices, adequately represented? Q9 = Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body? Q10 = Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

Table 2.

Baseline characteristics of the included studies

First Author & Year published	Country	Sample size	Age (years)	Methodology	Scales	Intensity of MD (Mean ± SE)	Moral dilemma outcomes
							experience	Causes	Solutions
Jeanie M, et al., 2013	USA	13	Median 18	Cross-sectional survey	MDS-R	/	Stress, isolation, tendency to quit	Personal abilities	Organize debriefing, case discussion
GA Colville, et al., 2018	UK	171	36.4 ± 9.2	Cross-sectional survey	MDS-R	70.2 ± 39.6	Futility, stress, depression, anxiety, tendency to quit	Scarcity of resources, work environment, poor communication with families, hospice care	/
Neda, et al., 2022	Iran	140	35.1 ± 7.43	Descriptive analytics	MDS-R	33.80 ± 11.60	Fatigue, sleep disturbances	Excessive work intensity, lack of personal competence and experience, moral sensitivity	/
Jacoba, et al., 2015	Netherlands	87	38.2 ± 10.0	Cross-sectional survey	MDS-R	52.70 ± 20.07	Tendency to quit	Inappropriate care, overtreatment, poor communication, shortage of human resources, lack of moral atmosphere	palliative care planning and promoting ethical dialogue
Neda, et al., 2021	Iran	14	34.0 ± 6.46	Semi-structured interviews	MMD-HP	/	Weakness, stress	Occupational conflicts, occupational hierarchy and role limitations, internal decision-making conflicts among nurses, trade-offs between patients’ interests and self-interests, incompatibility between professional responsibilities and organizational expectations, conflicts of religious beliefs, lack of facilities and equipment, and shortage of human resources	/
Michelle, et al., 2021	Canada	7	/	Semi-structured interviews	/	/	Exhaustion, weakness, complaining, feelings of failure, self-blame, pain and relief	Occupational hierarchy or role limitations, knowledge burden, neglect of the dignity of the deceased patient, family abandonment of care, timing of death decision announcement, family wishes, team disagreements, insufficient human resources	/
Paige, et al., 2024	Canada	40	28.4 ± 6.2	Interpretive description	MMD-HP	139.4 ± 58.23	Tendency to quit, delayed emotional responses, personality changes, negative irritability, cynicism, decreased interpersonal activity, depression and sadness, burnout, low self-esteem, shame and guilt, frustration, self-doubt, decreased sense of security, fatigue, attrition, irritability, arrhythmia, sleep disturbance, anxiety, doubt in faith	The level of power, the level of administrative support, the intensity of work, the lack of human resources	Positive self-adjustment, distraction, medical advocacy behaviors, seeking increased benefits packages, employee assistance programs, on-site counseling services, formal presentations, unit gatherings, open leadership forums, and quality improvement plans
Arefeh, et al., 2024	Iran	198	/	Cross-sectional survey	MDS-R	92.2 ± 23.61	/	Personal experience and competence in nurse clinical decision-making	Preparation of training programs, nurse seminars
Virginia M, et al., 2014	USA	26	24.8 ± 4.77	Descriptive analytics	MDS-R	/	Burnout, compassion fatigue, weakness, changes in medical and nursing values, decreased job satisfaction, and post-traumatic stress disorder	Violence in the ICU, limitations in professional roles, insufficient human resources, and insufficient nursing experience	Introspection, sharing painful experiences with others, and material resource support
Jill, et al., 2022	USA	488	28.2 ± 9.45	Descriptive analytics	MMD-HP	106.5 ± 34.6	Occupational burnout, depression and anxiety, post-traumatic stress disorder, turnover tendencies	Lack of equipment, lack of administrative support from management	Administrative support has increased, resource allocation has increased, vocational training has been increased, and psychological counseling has been provided
Maria, et al., 2022	Sweden	71	34.5 ± 6.19	Cross-sectional survey	MDS-R	31.85 ± 10.16	Tendency to quit	Ineffective and incompetent care, performing tests or treatments that the individual deems unnecessary, medical mistakes made by co-workers that are not reported, family members asking to participate in nursing behaviors, hierarchical medical authority limitations, false hope for family members or patients, poor teamwork	/
Dominik, et al., 2023	Germany	173	/	Cross-sectional survey	MDS-R	/	Emotional exhaustion, decreased job satisfaction, stress	Insufficient human resources, inadequate capacity for colleague care, operational and financial pressures, lack of continuity in the treatment team, and improper prescribing	Professional support for the organization to foster team spirit
Sophie T, et al., 2021	USA	16	/	Semi-structured interviews	MDS-R	/	Worry, fear, stress, feeling isolated and alienated, worrying about infection	Lack of professional competence and high work intensity	/
Zahra, et al., 2019	Iran	17	37.5 ± 7.07	Semi-structured interviews	/	/	Sadness, sadness, guilt, pity, choice contradictions	Restrain the patient’s body	/
Emilio, et al., 2022	Spain	1260	39.6 ± 12.8	Cross-sectional study	MMD-HP	61.5 ± 35.6	Tendency to quit, stress	Lack of continuity of care, inadequate human resources and equipment, lack of administrative support, inadequate capacity of colleagues in care, poor teamwork, execution of treatment deemed inappropriate or unnecessary by the individual, administrative control over the cost of care, excessive record-keeping taking up of care time	Increase system training, increase resource allocation, and increase administrative support
Meryem T, et al., 2021	Turkey	128	28.7 ± 5.4	Cross-sectional survey	MDS-R	79.2 ± 46.4	Willingness to leave jobs, change in professional values, burnout, decreased job satisfaction	Lack of human resources, inappropriate care, reduced quality of care due to cost control by managers, painful surgeries performed on patients just to improve their skills, performing tests or treatments that individuals consider unnecessary, and medical staff giving false hope to patients	Participate in focus group discussions and trainings to supplement human resources
Foroozan, et al., 2012	Iran	28	Median 38.5	Semi-structured interviews	/	/	Fatigue and burnout, stress, reduced efficiency and quality of care, dissatisfaction, reduced motivation to work	Neglect and institutional inequity of nurses, occupational or role hierarchical limitations, heavy financial burden on patients, poor communication, inability to communicate leading to inability to implement nursing behavior, ineffective nursing, colleague malfeasance, medical/nursing errors, concealment or justification of treatment errors, negligence and irresponsibility of the treatment team, misallocation of duties, misallocation of resources and caregiver capacity, neglect of patient and family autonomy	/
Florence J, et al., 2006	Netherlands	15	/	Semi-structured interviews	MMD-HP	/	Insomnia, choice contradictions	Terminate the treatment that has already begun, witnessing the pain of the patient as he suffers from the disease	/
E. Rodriguez, et al., 2021	Spain	608	/	Cross-sectional study	MMD-HP	61.0 ± 41.7	Tendency to quit	Lack of continuity of care, inadequate human resources and equipment, active treatment of the dying, involvement of family members in treatment decisions, execution of tests or treatments deemed unnecessary by the individual, lack of administrative support, poor team communication, and inadequate colleague capacity	/
Adam, et al., 2023	UK	227	38.1 ± 10.3	Semi-structured interviews	MMD-HP	117.0 ± 65.5	Resignation tendencies, avoidance tendencies, frustration, anger	Ineffective nursing, perception of nursing as a violation of patient autonomy, inadequate human resources and equipment, medical grade limitations, lack of administrative support, abusive by the patient or family, performance of nursing actions deemed not in the best interest of the patient	Personal reflections, informal discussions with colleagues, conversations with friends/family, and more formal debriefing sessions
MAURA, et al., 2016	Italy	283	Median 40.2	Cross-sectional study	MDS-R	38.1 ± 21.06	Turnover tendency, burnout, decreased satisfaction	Providing active treatment to the dying, performing tests or treatments that the individual deems unnecessary, believing that care is ineffective, colleague malfeasance and inadequate competence, reducing the quality of care due to cost control, family involvement in the clinical decision-making of the dying patient, and neglecting the patient’s autonomy	/
By Leah, et al., 2016	Canada	169	Median 35.6	Cross-sectional study	MBI-HSS MDS-R	80.8 ± 56.4	Burnout, decreased job satisfaction, decreased job happiness, propensity to leave the job	Providing active end-of-life care to terminally ill patients, poor communication, false hope for patients or families, and lack of continuity of care	/
Peter, et al., 2022	Australia	142	Median 37.5	Cross-sectional study	MDS-R	/	Burnout, decreased motivation at work	Ineffective nursing, dishonest nursing, compromising nursing	/
Moniek A, et al., 2021	Netherlands	345	36.7 ± 12.6	Cross-sectional study	MMD-HP	88.2 ± 42.3	Burnout, tendency to leave a job	Inadequate human resources and equipment, inadequate capacity of colleagues, occupational or role limitations, inadequate emotional support for patients and their families, inability to say goodbye with dignity for patients, fear of infection, administrative burden, purposeless care	Provide professional & psychological support (e.g. psychologists, social workers, spiritual counselors, peer supporters, and other mental health support team members), administrative support or appreciation, informal reporting, financial investment to improve the work environment
WL Cheng, et al., 2023	China	46	30.6 ± 8.8	Cross-sectional study	MDS-R	71.0 ± 24.2	Depression, anxiety, stress, turnover tendencies	Providing end-of-life care that is not in the best interest of the patient, performing tests or treatments deemed unnecessary, miscommunication, providing false hope for the patient or family	/
MARIA, et al., 2014	Italy	566	38.2 ± 8.2	Cross-sectional study	MDS-R	57.9 ± 15.6	Tendency to leave the job, lower job satisfaction	Assisting incompetent colleagues, deeming care ineffective, performing tests or treatments that the individual deems unnecessary or ineffective, inadequate co-worker’s capacity	/
Maria, et al., 2023	Sweden	220	46.5 ± 10.76	Cross-sectional study	MDS-R	41.73 ± 23.46	Tendency to leave a job, emotional instability or irritability, physical weakness, exhaustion, and decreased well-being	Ineffective care, poor teamwork, performing tests or treatments that the individual deems unnecessary or ineffective, providing false hope for patients or families	/
Terri A, et al., 2010	USA	94	36.1 ± 12.37	Cross-sectional study	MDS-R	/	Tendency to leave the job and lower job satisfaction	Performing tests or treatments that the individual considers unnecessary or ineffective, inadequate co-worker capacity, family intervention in nursing behavior (fear of lawsuits), performing ineffective, active care with no apparent benefit, inadequate human resources and equipment	/
Charles, et al., 2017	Canada	159	29.6 ± 13.2	Cross-sectional study	MDS-R	96.5 ± 27.4	Burnout, lack of support, increased uncertainty	Performing ineffective, active care with no apparent benefit, poor team communication, giving false hope to patients or families, inadequate co-workers, performing tests or treatments that the individual deems unnecessary or ineffective	/
Patrizio, et al., 2019	Italy	136	38.0 ± 8.6	Cross-sectional study	MDS-R	/	Tendency to quit	Performing ineffective, unappreciable active care, performing tests or treatments that the individual considers unnecessary or ineffective, poor team communication, inadequate co-workers, giving false hope to patients or families	/
Serife, et al., 2015	Turkey	200	27.19 ± 5.11	Descriptive analytics	MDS-R	70.81 ± 48.23	Tendency to quit	Poor team communication, working with incompetent colleagues, futile and ineffective care, ineffective execution of active care with no apparent benefit	/
Ellen H, et al., 2013	USA	28	29.5 ± 7.6	Descriptive analytics	MDS-R	/	Decreased job satisfaction, tendency to quit, depression, anxiety, nervousness, stress, cynicism, suspicion, lack of enthusiasm, powerlessness, feelings of hopelessness, lack of support	Performing ineffective, active care with no apparent benefit, performing tests or treatments that the individual considers unnecessary or ineffective, inadequate capacity of colleagues, family intervention in nursing behavior (fear of lawsuits), inadequate human resources and equipment, and lack of respect for patient privacy by colleagues	Share and discuss with older family members
Soojeong, et al., 2022	Korea	20	Median 38.0	Descriptive analytics	/	/	Burnout, sadness, lack of confidence, apathy, guilt and self-blame	Lack of personal capacity, lack of experience or professional training, inadequate human resources or equipment, family indifference to the deceased patient, religious beliefs of the patient’s family, family involvement in the treatment process, cramped working environment, continuity of care (shift system), distrust of the patient’s family, improper communication by the patient’s family	/
Tereza, et al., 2022	Czech Republic	313	Median 42.0	Cross-sectional study	/		/	Improper care, neglect of patient dignity, team communication	/

ICU nurses’ degree of moral distress

Among all quantitative studies utilizing scales, three studies reported a high level of moral distress, ten studies indicated a moderate level of moral distress, and eight studies found a low level of moral distress. Additionally, thirteen studies did not assess the degree of moral distress. As shown in Fig. 2, the meta-analysis results based on MDS-R scores indicate that the MDS-R score for ICU nurses was 49.98 (weighted mean difference [WMD] 49.98, 95% confidence interval [CI] 38.02–61.94, p < 0.001); The non-significance of the chi-square value and high I² statistic (Chi² = 13.64, df = 12, I² = 12%, p = 0.32) indicates low heterogeneity among the studies. As shown in Fig. 3, the meta-analysis results based on the MMD-HP score showed that the MMD-HP score for ICU nurses was 88.32 (weighted mean difference [WMD] 88.32, 95% CI 54.13–122.51, p < 0.001); The non-significant chi-square value and high I² statistic (Chi² = 2.23, df = 5, I² = 0%, p = 0.82) indicate extremely low heterogeneity among studies. As shown in Fig. 4, Subgroup analysis of MDS-R scores by gender showed no significant differences (MD 3.49, 95% CI 5.74–12.72, p = 0.46, I² = 62%). Additionally, the results of the Cochrane Risk of Bias Assessment Tool indicated that the quality of the relevant studies was acceptable, and funnel plots showed no obvious publication bias (see Figs. 5, 6, 7 and 8).

Fig. 2.

Forest plot summarizing the degree of moral distress among ICU nurses based on MDS-R

Fig. 3.

Forest plot summarizing the degree of moral distress among ICU nurses based on MMD-HP

Fig. 4.

Forest plot summarizing gender differences in the severity of moral distress among ICU nurses (based on MDS-R)

Fig. 5.

A summary of authors’ assessments of risk of bias in each study included with MDS-R as the outcome

Fig. 6.

A summary of authors’ assessments of risk of bias in each study included with MMD-HP as the outcome

Fig. 7.

Funnel plot of overall publication bias for articles evaluating outcomes using the MDS-R

Fig. 8.

Funnel plot of overall publication bias for articles evaluating outcomes using the MMD-HP

ICU nurses’ experiences of moral distress

Our systematic review reveals that the experiences of moral distress among ICU nurses predominantly manifest as adverse physiological, psychological, and cognitive-behavioral responses. The demanding and intricate nature of ICU nursing work engenders negative physiological experiences, including loss of appetite [13], fatigue and burnout [14–25], physical debilitation [23], alterations in personality [13], cardiac arrhythmias [13], sleep disturbances [14, 19, 26], and delayed emotional reactions [13]. These adverse physiological experiences significantly impair the quality of nursing care and work efficiency.

Similarly, moral distress also engenders a multitude of negative psychological experiences among ICU nurses, such as stress and social withdrawal [17, 19, 27–32], sadness and guilt [13, 25, 33, 34], feelings of powerlessness and frustration [13, 15, 28, 30, 31, 33], sorrow and compassion [15, 34], anger and despondency [13, 23, 35], a sense of depletion [13], perceived lack of support [24, 30], negativity and complaints [13, 19, 33], suspicion [30], lack of self-confidence [25], numbness and apathy [25, 30], feelings of inferiority and shame [13], fear and worry [30, 31], diminished sense of security and well-being [13, 23], reduced work motivation and job satisfaction [15, 17–21, 30, 36–38], and experiences of pain and relief [33]. In severe cases, these experiences can lead to secondary mental health issues among ICU nurses, including anxiety, depression [13, 16, 30, 32, 39], and stress-related disorders [15, 16].

Furthermore, moral distress also imposes negative cognitive and behavioral experiences on ICU nurses, not only rendering them feeling powerless and physically as well as mentally exhausted but also influencing their cognitive and behavioral perspectives. These include cynicism [13, 30], reduced interpersonal activities [13], professional burnout [13, 36], skepticism towards beliefs [13], alterations in medical and nursing values [15, 18], ambivalence in decision-making [26, 34], tendencies towards avoidance [35], and intentions to leave the profession [13, 16, 18, 20–23, 27, 29, 30, 32, 35, 37–44].

Factors of moral distress among ICU nurses

The factors influencing moral distress among ICU nurses are multifaceted and, based on recent empirical research, can be systematically categorized into four dimensions: individual factors, healthcare-related factors, organizational factors, and other environmental factors. Personal characteristics significantly shape nurses’ perceptions and reactions to moral distress. We have identified individual factors (such as being female [14, 39], single [14, 45], age [43, 45], work experience [14, 15, 45], personal competence [14, 17, 19, 20, 22, 24, 25, 27, 29–31, 33, 37, 38, 40, 43, 45], and moral sensitivity [14]) as fundamental contributors to moral distress, with insufficient work experience being the primary individual cause. Furthermore, due to inadequate training in moral decision-making, younger nurses and those with limited clinical experience are more susceptible to moral distress.

Inadequate teamwork within healthcare settings [23, 29, 33, 42], execution of treatment and end-of-life decisions [19, 26, 33, 45], poor communication [19, 21, 24, 25, 32, 40, 41, 43, 46], inappropriate care [18, 21, 22, 24, 30, 35, 38, 40, 41, 44, 46], compromised care [36], neglect of nurses [19], execution of unnecessary tests or treatments [18, 20, 23, 24, 29, 30, 32, 37, 38, 40–43], inappropriate prescriptions [17], lack of continuity in care [17, 21, 25, 29, 43], balancing patient and self-interests [28], disregard for patient dignity and family autonomy [19, 20, 22, 30, 33, 35, 46], lack of emotional support for patients and their families [22], witnessing the suffering of critically ill patients during treatment [26], excessive financial burden on patients [19], family abandonment of care [25, 33], high family expectations [33], providing false hope to patients or families [18, 21, 23, 24, 32, 40, 42], physical restraint of patients [34], incompetent colleagues [19, 20, 37, 42, 44], concealment of medical or nursing errors [19, 36, 42], family interference or involvement in care [20, 25, 30, 38, 42, 43], among other healthcare-related factors, also play significant roles in the occurrence of moral distress among ICU nurses.

The existing healthcare prioritization system, which often imposes professional role constraints, has a pivotal impact on the manifestation of moral distress. Hierarchical medical structures frequently suppress the moral voices of nurses, particularly when challenging physicians’ decisions regarding life-sustaining treatments, a viewpoint substantiated by eight studies [13, 15, 19, 22, 28, 33, 35, 42]. The moral climate within teams emerges as a crucial moderating factor, with units exhibiting poor conflict resolution mechanisms reporting a 2.3 times higher prevalence of distress [41]. Furthermore, ten studies indicate that end-of-life care and futile care exacerbate nurses’ psychological barriers, constituting the most significant causes of moral distress among nurses [19, 20, 23, 32, 35–37, 42, 44].

Moreover, structural constraints originating from organizations represent the most enduring stressors. Increased workloads due to chronic shortages of equipment and staff (patient-to-nurse ratios > 2:1) [13–19, 22, 25, 28–30, 35, 38, 39, 43] are associated with a heightened likelihood of severe moral distress caused by the compulsory allocation of humane care [31, 33, 41]. Prioritizing financial metrics over moral requirements engenders systemic value conflicts, particularly in the context of non-beneficial intensive treatments [18, 20, 29]Additionally, the lack of organizational administrative support [13, 16, 22, 29, 35, 43] and excessively high organizational expectations [28] frequently engender feelings of powerlessness and frustration, leading to decreased work motivation and increased turnover rates. On the other hand, macro-level forces often produce compounded effects. Environmental factors such as fear of viral infection [22, 39], ICU violence [15, 35], ineffective pain management [20, 23, 30, 40], conflicts in religious beliefs [25, 28], and cramped workspaces [25] also induce moral distress among ICU nurses. Notably, epidemics, by restricting visitation rights, undermine patient-centered care and significantly increase the prevalence of distress.

Solutions to moral distress among ICU nurses

Moral distress exerts numerous negative impacts on the self-efficacy of intensive care unit (ICU) nurses, with coping strategies for moral distress primarily categorized into two types. Firstly, individual self-coping strategies, influenced by personality, values, communication skills, and empathy, vary significantly among nurses. Some ICU nurses opt for passive acceptance, while others engage in self-regulation practices such as introspection [15, 35] and diverting their attention through activities like exercise and social gatherings [13]. Secondly, seeking external support is another approach, where ICU nurses may turn to faith [17, 21], peer support [15], mutual assistance [35], and particularly seek advice from senior colleagues and positive feedback from leadership to alleviate moral distress [13, 30]. It is noteworthy that an inappropriate feedback mechanism within the medical hierarchy compels some nurses to attribute decision-making authority entirely to physicians, attempting to shift conflicts, which may exacerbate tensions between healthcare providers [26, 30].

Furthermore, the findings also indicate that institutional support from organizations, aimed at increasing resource allocation [13, 16, 18, 22, 29] or providing psychological counseling services [16, 22], establishing online open forums for leadership [13] or offering on-site consulting services [13], conducting appropriate skills and team collaboration training [13, 18, 45], organizing informal reporting and case discussions [13, 18, 22, 27, 35, 45], formulating palliative care plans to facilitate moral dialogues [27], engaging in medical advocacy [13], enhancing interdisciplinary communication in intensive care units [18], and developing employee assistance programs to improve welfare benefits [13, 15], can assist nurses in managing moral distress.

Discussion

This systematic review shows that the meta-analysis results based on the MDS-R score indicate a weighted mean difference (WMD) of 49.98 (95% CI 38.02–61.94, p < 0.00001), and the MMD-HP score was 88.32 (weighted MD [WMD] 88.32, 95% CI 54.13–122.51, p < 0.00001), indicating that ICU nurses are experiencing moderate levels of moral distress. Subgroup analysis of MDS-R scores by gender did not show significant differences (MD 3.49, 95% CI 5.74–12.72, p = 0.46, I² = 62%), indicating no association between the intensity of moral distress among ICU nurses and gender, which is inconsistent with the conclusions of most studies. Moral distress bring about negative physiological, psychological, and cognitive-behavioral experiences for ICU nurses, thereby affecting the quality of nursing care and work efficiency. Among these, fatigue and burnout, stress and social withdrawal, feelings of powerlessness and frustration, anxiety and depression, decreased work motivation and satisfaction, and the intention to leave are the most significant experiences of moral distress.

The intensive care environment is characterized by its ever-evolving structure in response to advancements in science and technology, the uncertainty of the lifeline between life and death, challenges in the equitable distribution of limited resources, close contact with severe cases of COVID-19, individual involvement in medical decision-making, and witnessing the suffering of personal experiences. These characteristics influence the degree of moral distress [47]. In fact, due to nurses constituting the largest proportion of the treatment team and frequently interacting with diverse individuals, they are more susceptible to communication issues than other members of the treatment team [2]. Moreover, the longer ICU nurses work, the more their experience of moral distress diminishes, rooted in the profound and lasting impact of unresolved moral distress on ICU nurses. More seriously, moral distress do not disappear over time but continue to subtly exacerbate their sense of moral unease, known as moral residue [48].

The emergence of moral distress is the result of the interplay of multiple factors. The level of psychological empowerment among nurses directly influences their capacity to cope with such distress [49]. Dimensions of psychological empowerment, such as “self-efficacy” and “impact at work,” are positively correlated with moral courage, whereas nurses who lack autonomous decision-making authority are more susceptible to passivity [50]. Moreover, professional experience is associated with moral sensitivity, and newly recruited nurses are more prone to anxiety [51] due to moral conflicts because of their insufficient clinical experience. Our research also confirms that personal experience and competence are the primary factors in avoiding moral distress. Conflicts arising from the levels of physicians, nurses, and patients are often the direct causes of moral distress. This study also found that intra-team inconsistency is a major source of distress across all healthcare disciplines. Respondents identified two scenarios where intra-team inconsistency causes moral distress: first, situations involving the initiation or continuation of futile life-sustaining treatments, and second, situations involving inadequate disclosure of interventions. Additionally, when different team members respond asynchronously to the same case—nurses becoming more emotionally involved while physicians become more detached—communication gaps are likely to occur at critical moments of moral distress. The existing medical hierarchy and role limitation system play a surprisingly significant role in moral distress. It is well recognized that nurses play roles in clinical decision-making such as decision coaching, integration coordination, and time facilitation. However, in specific environments, physicians can easily amplify this “assistive” implication, resulting in nurses having less voice in clinical decision-making [52].

Another significant influencing factor is the lack of confidence within the nursing team. Many participants expressed feelings of inadequacy during patient treatment—perceiving their care as ineffective—and often felt powerless in end-of-life care, although some acknowledged that this sense of powerlessness sometimes stemmed from the existing medical hierarchy. When intensive care units chronically experience shortages of staff or equipment, the lack of administrative support makes them more susceptible to moral distress. Additionally, disregarding patient dignity and autonomy, providing false hope to patients, and encountering colleague misconduct or deceptive communication are other frequent direct factors contributing to moral distress. In morals, patient and family autonomy have been heavily emphasized. A lack of attention to patient requests and making decisions for patients without their or their families’ knowledge can cause significant moral distress among nurses. The moral climate of a hospital is a core variable, as a positive moral climate can significantly reduce the incidence of moral distress [53]. Conversely, rigid bureaucratic systems, unfair resource allocation, or insufficient team collaboration can exacerbate conflicts. Differences in healthcare policies and cultural values across regions are notable. For instance, in regions with strong religious influences, nurses may face more complex moral challenges due to conflicts between their beliefs and medical practices, such as the termination of life support. Our research also indicates that in the Middle East, where religious culture is prominent, religious beliefs can both exacerbate the occurrence of moral distress and alleviate psychological stress through religious culture, although this effect is not significant in other regions. Another issue that cannot be overlooked is the fear of viral infection. Approximately one-fifth of the included studies reported significantly increased moral distress scale scores among ICU nurses during the COVID-19 pandemic.

While individual coping strategies play a positive role in addressing moral distress, we emphasize the necessity of external support. This is because we found that some participants frequently mentioned alleviating the experience of moral distress by shifting conflicts, which only exacerbates internal friction and increases uncertainty. In reality, the existing medical hierarchy is difficult to dismantle, and a strong collaborative relationship between healthcare providers is the cornerstone of ensuring the quality of nursing care. With the continuous development of the nursing profession and the increasing inclusion of advanced practice nurses, nurses should actively participate in clinical decision-making in the future, creating the best interests for patients from their own perspective. Finally, our findings also indicate that organizational institutional support, such as increasing resource allocation, providing psychological counseling services, conducting appropriate skills and team collaboration training, organizing informal debriefings and case discussions, and implementing employee assistance programs to enhance welfare, can effectively help nurses cope with moral distress. This partially aligns with a previous report recommending flexible interventions [54] This systematic review demonstrates that enhancing the personal capabilities of ICU nurses and increasing the allocation of ICU nurses or equipment through administrative means are the most promising approaches to alleviating moral distress.

In recent years, the moral distress faced by ICU nurses have gradually garnered widespread attention from researchers. However, individual study results cannot fully reflect the comprehensive picture of ICU nurses’ experiences with moral distress. A previous study primarily focused on the experiences of pediatric ICU nurses with moral distress, but it provided limited analysis of the causes of moral distress [55] Our study not only addresses this gap but also offers a comprehensive evaluation of coping strategies for moral distress. Additionally, due to differences in cultural values and nursing education, ICU nurses may experience moral distress that differs from that reported in previous studies. There remains considerable controversy over the approaches to addressing moral distress among ICU nurses, and this variability in outcomes underscores the necessity for a comprehensive systematic review. This systematic review aims to incorporate high-quality clinical evidence to thoroughly assess the experiences, influencing factors, and coping methods of ICU nurses at the current stage, providing evidence-based guidance for nursing administrators to develop interventions related to moral distress. This study has several limitations that cannot be ignored. First, a small portion of the literature included in this study had limited sample sources, which may introduce uncertainty in the results. Second, the included literature rarely mentioned the influence of the researchers’ own values on the study, which could affect the accuracy of the findings. Third, due to the lack of some important baseline data, it was not possible to perform subgroup analyses for all potential risk factors. Fourth, this study lacks sensitivity analysis data.

Conclusion

In conclusion, ICU nurses are experiencing moderate moral distress. Professional associations in critical care, hospitals, and other stakeholders have a responsibility to acknowledge the existence of moral distress and to develop strategies to identify it among their members and staff. These groups should encourage more clinical trials to study interventions aimed at alleviating moral distress among ICU nurses. Future research should further explore differentiated strategies across cultural contexts and promote systemic support at the policy level.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

QKY, YPF, ZJQ, WYH.: Search for articles, extraction of data, writing the text of the article; WYH, ZDJ.: Search for articles, extraction of data, writing the text of the article; HHJ.: Quality assessment, writing the text of the article; ZDJ, ZYC, LHJ.: Quality assessment, writing the text of the article; ZJQ, CH: Review and approval of the draft of the article.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.