Nurses' moral distress and ethical climate: A systematic review and meta-analysis

BackgroundMoral distress is a pervasive challenge in nursing practice, adversely impacting nurses' well-being, career development, patient safety, and organizational performance. Ethical climate, as a modifiable organizational factor, plays a pivotal role in mitigating moral distress. Understanding the association between nurses' moral distress and ethical climate is critical for clinical practice, management, and policymaking.AimThe aim was to systematically assess the association between nurses' moral distress and ethical climate.MethodsA systematic review and meta-analysis was conducted based on a comprehensive search of ten databases (PubMed, Cochrane Library, Embase, Web of Science, CINAHL, PsycINFO, Scopus, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and WANFANG) from inception to December 27, 2024. Two reviewers independently screened studies, extracted data, and assessed methodological quality. Correlation coefficients were synthesized using random or fixed-effects models. Subgroup analyses and meta-regression were performed to explore sources of heterogeneity.Ethical considerationsEthical approval was not required as the review synthesized publicly available data.ResultsThirty-one studies involving 7635 nurses were included. Meta-analysis identified a moderate negative association between overall moral distress and ethical climate (r = -0.49, 95% CI: -0.59 to -0.38), and between moral distress frequency and ethical climate (r = -0.37, 95% CI: -0.45 to -0.28). Moderator analyses indicated that participant characteristics (gender composition, age, and work experience), study characteristics (sampling methods and ethical climate measurement tools), and working settings contributed to heterogeneity.ConclusionThis systematic review and meta-analysis demonstrated a moderate negative association between nurses' moral distress and ethical climate. Variations in participant demographics, study methodologies, and working settings partially accounted for the observed heterogeneity. Future research should employ larger, more diverse samples and longitudinal designs. Strengthening the ethical climate is essential for alleviating nurses' moral distress and enhancing organizational effectiveness.