Moral distress among nursing students during clinical practice: A qualitative systematic review and meta-synthesis

Moral distress arises when nursing students recognize the ethically appropriate action but are constrained from acting due to institutional or interpersonal barriers. During clinical placements, they frequently encounter unethical practices, hierarchical dynamics, and value dissonance that evoke emotional strain and ethical disillusionment. Such experiences can undermine moral competence and hinder professional identity formation. Although moral distress among students has gained increasing scholarly attention, prior reviews often lacked conceptual coherence, cultural inclusiveness, and methodological rigor.

To systematically synthesize and interpret qualitative evidence on nursing students' experiences of moral distress during clinical practice.

A qualitative systematic review and meta-synthesis was conducted following Joanna Briggs Institute methodology and reported in accordance with PRISMA and ENTREQ guidelines. Ten databases-PubMed, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Cochrane Library, CNKI, CBM, and WanFang-plus Google Scholar were searched from inception to November 2024 (updated October 3, 2025). Studies were appraised using the JBI Critical Appraisal Checklist, and data were analyzed thematically using NVivo 14. Confidence in the synthesized findings was assessed via the JBI ConQual process.

Nine studies from eight countries were included. Six overarching themes and 17 subthemes were identified, highlighting moral distress triggered by unethical conduct, limited autonomy, and inadequate supervision. Students often responded with silence or avoidance, whereas access to peer or faculty support promoted moral resilience. ConQual assessment rated two themes as high confidence, one as moderate, and three as low.

Moral distress among nursing students is a culturally embedded, multifactorial experience shaped by systemic, relational, and personal influences. Integrating reflective mentorship and ethics-focused education may transform moral adversity into resilience and support the ethical development of future nurses.