Moral distress among nurse leaders: A conceptual framework

Moral distress among nurses has been well examined within the literature since the concept's introduction in 1984. Moral distress occurs when constraints result in an individual being unable to act or compelled to act against their professional moral obligations, resulting in a sense of complicity and wrongdoing. Extensive research has explored the experience and consequences of moral distress, particularly among bedside nurses. Despite an abundance of articles regarding moral distress in nursing, few examine the concept among nurse leaders. Leadership roles within nursing can be at the patient care, unit, middle, and executive levels. Existing evidence suggests that nurse leaders experience moral distress similarly to other nursing populations; however, their leadership roles introduce unique challenges and experiences. The purpose of this paper is to present a framework for understanding moral distress among nurse leaders grounded in existing theory and evidence. The Moral Distress Theory, Crescendo Effect, and Ecological Systems Theory served as theoretical frameworks. The conceptual framework was developed from 2022 to 2024 following literature review, empirical (qualitative) validation, and content expert review and validation (n = 5). The Conceptual Framework of Moral Distress Among Nurse Leaders consists of four primary elements: (1) nurse leaders as moral agents within a moral ecology, (2) antecedents of moral distress among nurse leaders, (3) physiological, psychological, and emotional effects of moral distress among nurse leaders, and (4) responsive action(s) versus inaction. This proposed conceptual framework may serve as a foundational understanding of moral distress experienced by nurse leaders and a guide for future moral distress research among nurse leaders.