How professional nurses working in hospital environments experience moral distress: a systematic review

Jameton who first conceptualized moral distress, described it as arising when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. The phenomenon of moral distress is well documented in the nursing literature but no systematic review exists. The plethora of literature on moral distress would suggest that attention to this phenomenon is deemed noteworthy by the profession. A synthesized understanding of how nurses experience the phenomenon of moral distress is presented.

The overall objective of this review was to appraise and synthesize the best available evidence on how professional nurses working in hospital environments experience ethical/moral distress.

This review considered qualitative research including descriptive/exploratory studies whose participants were professional nurses working in hospital environments and experienced either moral or ethical distress as a result of their patient care responsibilities. Studies were included that described participant's own experience of moral distress.

The search strategy sought to find both published and unpublished research studies. This review was limited to papers in English. An initial limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of text words contained in the title and abstract, and of index terms used to describe the article. A second extensive search was then undertaken using all identified key words and index terms.

Each paper was assessed by two independent reviewers for methodological quality prior to inclusion in the review using the Qualitative Assessment and Review Instrument (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third party reviewer.

Information was extracted by two reviewers from each paper using the Qualitative Assessment and Review data extraction tool (QARI) developed by the Joanna Briggs Institute. Disagreements were resolved through consultation with a third reviewer.

Data synthesis aimed to portray an accurate interpretation and synthesis of themes arising from the selected participant's experience of moral distress.

A total of 50 studies were identified and of those 39 were included in the review. These qualitative studies examined how professional nurses working in hospital environments experienced moral/ethical distress. Findings were analyzed using the JBI-QARI tool. The process of meta-synthesis using this program involved categorizing findings and developing synthesized topics from the categories. Four syntheses were developed related to the experience of moral distress: human reactivity, institutional culpability, patient pain and suffering, and unequal power hierarchies.

Nurses who experience moral distress respond with a myriad of biological, psychological and stress reactions. Moral distress is experienced when nurses feel the need to advocate for patients well-being, while coping with institutional constraints. The perception of patient pain and suffering as a result of medical decisions of which the nurse has little power to influence also contributed to the experience. Unequal power structure prevalent in institutions exacerbates the problem.

In order to mitigate the effects of moral distress institutions need to design structures of support for nurses that provide education on the effects of moral distress, give nurses authentic voice in expressing ethical concerns and allow them to practice nursing in a way that does not violate their core professional values.

Further research is needed on the effectiveness of interventions designed to decrease the effect of moral distress on the workplace environment. Additionally, measuring the effectiveness of strategies designed to provide nurses a platform to openly express their ethical concerns and provide them an authentic voice would inform the profession. Research on the hierarchical structures of the nurse-physician relationship within the hospital environment and its effect on patient care outcomes would enrich the literature.