Table 1.

Summary of findings.

Author(s)	Title	Design of Study	Aim	Sample	Main Measures of MD	Main Findings
Schaefer, R.; Zoboli, E.L.C.P.; Vieira, M.M. (2019)	Psychometric evaluation of the Moral Distress Risk Scale: A methodological study	Validation study	To psychometrically test the Moral Distress Risk Scale.	268 nurses. Of these, 97 working in primary healthcare services.	Moral Distress Risk Scale (MDRS)	“The Moral Distress Risk Scale is composed of 7 factors and 30 items; it shows evidence of acceptable reliability and validity with a Cronbach’s a = 0.913, a total variance explained of 59%, a Kaiser–Meyer–Olkin = 0.896, and a significant Bartlett <0.001”
Porr, C.; Gaudine, A.; Woo, K.; Smith-Young, J.; Green, C. (2019)	How Community Nurses Manage Ethical Conflicts: A Grounded Theory Study	Qualitative study	To uncover the process of behaviors enacted by community nurses when experiencing ethical conflicts	24 community health (as home nurses or public health nurses)	Interviews	“Moral Compassing comprises processes that resolve this main concern by providing community nurses with the means to attain the moral agency necessary to decide to act or to decide not to act. The processes are undergoing a visceral reaction, self-talk, seeking validation, and mobilizing support for action or inaction. [The authors] also discovered that community nurses may experience continuing distress that we labeled moral residue”.
Barth, P.O.; Ramos, F.R.S.; Barlem, E.L.D.; Rennó, H.M.S.; Brehmer, L.C.F.; Rocha, J.M. (2019)	Generating situations of Moral Distress in Primary Care Nurses	Qualitative study	To analyze the situations generating Moral Distress in Primary Care nurses from different regions of Brazil.	13 nurses of primary health care	Semi-structured interviews	Causes of moral distress in primary care settings are related to the professional’s everyday life, such as lack of conditions and organization of the work process, conflicts in interpersonal relationships (user, community, health professionals) and conflicts related to management of services and the health system
Gágyor, I.; Heßling, A.; Heim, S.; Frewer, A.; Nauck, F.; Himmel, W. (2018)	Ethical challenges in primary care: A focus group study with general practitioners, nurses and informal caregivers	Qualitative study	To describe ethical problems from the perspective of these three groups and to investigate whether there is a common experience of ethical issues in primary care.	7 nurses	Focus groups	“Nurses were concerned about bureaucratic and other barriers to professional care and about dual loyalty if they had to consider the conflicting interests of patients and family members. They often felt powerless and unable to act according to their professional standards. Informal caregivers reported problems that resulted from role strain and being both a family member and a caregiver. GPs, nurses and informal caregivers sometimes perceived the other parties as a source of ethical problems”
Barth, P.O.; Ramos, F.R.S.; Barlem, E.L.D.; Dalmolin, G.L.; Schneider, D.G. (2018)	Validation of a moral distress instrument in nurses of primary health care	Validation study	To validate an instrument to identify situations that trigger moral distress in relation to intensity and frequency in primary health care nurses.	433 nurses	Brazilian Scale of Moral Distress in Nurses	“There were 46 questions validated divided into six constructs: Health Policies, Working Conditions, Nurse Autonomy, Professional ethics, Disrespect to patient autonomy and Work Overload. The instrument had satisfactory internal consistency, with Cronbach’s alpha 0.98 for the instrument, and between 0.96 and 0.88 for the constructs.”
Burston, A.; Eley, R.; Parker, D.; Tuckett, A. (2017)	Validation of an instrument to measure moral distress within the Australian residential and community care environments	Validation study	To gain insight into the experience of moral distress within the aged care workforce. To use and validate an existing instrument to measure moral distress within the aged care setting.	106 nurses	Moral Distress Scale- Revised	“The frequency component of the instrument demon- strated an alpha of 0.89, the intensity component 0.95 and the instrument as a whole 0.94. Three factors were identified and labelled as: Quality of Care, Capacity of Team and Professional Practice. Mean scores indicate a low occurrence of moral distress, but this distress, when experienced, was felt with a moderate level of intensity. Primary causes of moral distress were insufficient staff competency levels, poor quality care because of poor communication and delays in implementing palliation.”
Nora, C.R.; Zoboli, E.L.; Vieira, M.M. (2017)	Moral sensitivity in Primary Health Care nurses	Quantitative study	To characterize the profi le and describe the moral sensitivity of primary health care nurses.	100 nurses	Moral Sensitivity Questionnaire	“the nurses had an average moral sensitivity of 4.5 (out of 7). The dimensions with the greatest moral sensitivity were: interpersonal orientation, professional knowledge, moral confl ict and moral meaning.”
Siqueira-Batista, R.; Gomes, A.P.; Motta, L.C.S.; Rennó, L.; Lopes, T.C.; Miyadahira, R.; Vidal, S.V.; Cotta, R.M.M. (2015)	(Bio)ethics and family health strategy: Mapping problems	Qualitative study	To outline the main (bio)ethical problems identified by members of the Family Health Strategy (FHS) teams in the town of Viçosa, Minas Gerais, Brazil.	73 nurses	Interviews	“It was possible to categorize five major groups of (bio)ethical issues experienced by teams: those related to unequal access to health services; those related to the teaching-work-community relation; those related to secrecy and confidentiality; those related to conflicts between team and users; and those related to conflicts between team members.”
Nora, C.R.; Zoboli, E.L.; Vieira, M. (2015)	Ethical problems experienced by nurses in primary health care: integrative literature review	Integrative review	To identify ethical problems experienced by nurses in primary health care and resources for coping based on publications on the subject	-	-	“This analysis resulted in four categories: ethical problems in the relationship between team members, ethical problems in the relationship with the user, ethical problems in health services management and resources for coping with ethical problems. Results showed that nurses need to be prepared to face ethical problems, emphasizing the importance of ethics education during the education process before and during professional practice to enhance the development of ethical sensitivity and competence for problem resolution”
Schaefer, R.; Junges, J.R. (2014)	The construction of ethical competence in the perception of primary care nurses	Qualitative study	To understand the per-ception of nurses of Primary Care Services about the construction of ethical compe-tence on their formation and practices.	10 nurses	Interviews	“The results showed that the interviewed professionals had already experienced situations with ethical conflicts and knew what ethical competen-ce means. The central themes point out three fundamental issues in the construc-tion of the ethical competence: personal values, education and practice. Taking into account that ethical competence is in per-manent construction, the study shows the importance to promote organizational and educational activities in a transversal man-ner, as a tool to cope the moral stress and contribute in improving the quality of care in the primary health attention”
Karlsson, M.; Karlsson, C.; Barbosa da Silva, A.; Berggren, I.; Söderlund, M. (2013)	Community nurses’ experiences of ethical problems in end-of-life care in the patient’s own home	Qualitative study	To gain a deeper understanding of community nurses’ experiences of ethical problems in end-of-life care in the patient′s own home	10 nurses	Inteviews	“In the first step of interpretation, two themes emerged: Uncomfortable feelings and Lack of cooperation and in the second step, one theme Lack of security emerged. Finally, the overall interpretation revealed the theme Feelings of loss of control in end-of-life care in the patient’s own home.”
Kadioǧlu, F.G.; Can, R.; Nazik, S.; Kadioǧlu, S. (2013)	Ethical problems in geriatrics: Views of Turkish primary healthcare professionals	Quantitative study	To determine the frequency rates of various geriatric ethical problems and to evaluate the importance given to these problems in primary healthcare.	36 nurse	Questionnaire	“Based on the results, the most frequently encountered ethical issues were on “decision-making competency” and these issues respectively were “decision-making with relatives instead of elder patients”, “not informing elders due to the lack of tolerance” and “not informing elders due to the lack of comprehending”. The most important geriatric ethical issues were “ignoring respect for privacy”, “ignoring patient’s complaints” and “rejecting detailed examination or treatment because of age”.
De Veer, A.J.E.; Francke, A.L.; Struijs, A.; Willems, D.L. (2013)	Determinants of moral distress in daily nursing practice: A cross sectional correlational questionnaire survey	Quantitative study	To identify individual and job characteristics associated with moral distress in nursing staff	365 nurses	Moral distress questionnaire and MAS-GZ	“Nursing staff in nursing homes had the highest scores and this was statistically significantly higher than those in home care, which had the lowest mean.
Kayser, J.W.; Nault, D.; Ostiguy, G. (2012)	Resolving moral distress when caring for patients who smoke while using home oxygen therapy	Case study	To describe this distress, then to propose a 3-step process of taking concrete actions to resolve the distress	-	-	“Three steps to resolve the moral distress described in this case scenario are proposed. Step 1 entails better understanding the competing moral principles that cause the distress. Step 2 entails better understanding what care options are available for the patient in question. And Step 3 involves taking action.”
Karlsson, M.; Roxberg, A.; Da Silva, A.B.; Berggren, I. (2010)	Community nurses’ experiences of ethical dilemmas in palliative care: A Swedish study	Qualitative study	To highlight community nurses’ experiences of ethical dilemmas in palliative care	7 nurses	Inteviews	“The core themes that emerged were: powerlessness, frustration, and concern in relation to ethical dilemmas in palliative care. The nurses were motivated and felt responsibility for their patients’ end of life, and their relatives, and took their duties seriously. They wanted to satisfy all parties; the patient, the relatives and other palliative care professionals.”