Abstract
Critical care nursing shortage has become a crisis worldwide due to rising turnover and prevalence of burnout. Although there is plenty of literature on the issues including workload, staffing ratio and pandemic-related challenges in relation to critical care nurses, another factor which still needs considerable attention is moral distress. An integrative review published by Ananzeh and Miller (2025) entitled ‘Consequences of moral distress among critical care nursing: an integrative review’ comes at an ideal time, as it presents a comprehensive evaluation of the existing research on this widespread problem. As this systematic integration of nine empirical papers conducted within various geographical settings and using different research methods reveals, the key point of this review is not just listing adverse consequences of moral distress but, more importantly, transforming the concept into a predictable outcome of systemic and organisational failures. It is only through understanding moral distress as a system-based preventable problem that effective interventions may be developed.
Summary of the paper
This systematically executed integrative review conducted according to the Whittemore and Knafl (2005) model involved the analysis of data from nine papers that were published within the period of 2010 to 2024, comprising six cross-sectional, two qualitative and one mixed-methods designs. The search process employed the three main online databases, namely PubMed, CINAHL and PsycINFO, which provided a total of 366 papers at the outset; however, nine fulfilled strict selection criteria and were rated as Level III (good quality).
The findings from the content analysis of the review’s literature pointed to three main themes that have far-reaching implications. The first one pertained to the influence of moral distress on the well-being and job satisfaction of nurses. According to many studies, there were notable associations between moral distress and anxiety, depression, post-traumatic stress disorder (PTSD) and emotional exhaustion. The nurses used strong words to describe their experiences such as horror, devastation, anger and ‘the worst thing that could happen’ (Guttormson et al., 2022; Maiden et al., 2011; Wiegand and Funk, 2012).
Secondly, impact on patient care revealed how morally distressed nurses struggled to advocate effectively, became emotionally withdrawn and reported distraction that could lead to clinical oversights or medication errors. As one participant poignantly stated, ‘Even on rounds you experience this moral distress. . . you’re not in the right mind frame to do your job effectively. . . you may just be forgetting something, not noticing something that is a danger to that patient’ (Henrich et al., 2017: e54). Notably, Maiden et al. (2011) identified a positive correlation between moral distress and perceived reasons for medication errors and non-reporting, directly linking ethical distress to patient safety outcomes.
Thirdly, the effect on the intention to turn over and burnout indicated that those individuals who experienced a higher degree of moral distress showed lower intention to continue working and higher intention to leave. As stated by alarming statistics, 8.5% of nurses have already quit their job because of moral distress, and 16.9% have decided to leave their current workplace (Asgari et al., 2019). Moreover, researchers claim that the level of leaving the profession for nurses with a high moral distress is three times higher than that of other nurses, and the cost of nurse turnover per year for a single hospital varies between $3.9 million and $5.7 million (Laurs et al., 2020; Nursing Solutions Inc., 2025).
Connection to nursing theory, practice and research
From a theoretical standpoint, this review powerfully operationalises the concept of structural and systemic determinants of nurse well-being, aligning with Jameton’s (1984) foundational work defining moral distress as suffering that occurs when institutional or systemic barriers prevent ethical action. The findings empirically validate that moral distress is not primarily a function of individual moral sensitivity or weakness but rather a predictable response to organisational constraints, inadequate staffing, ineffective teamwork, powerlessness, resource limitations and unsupportive practice environments (Atashzadeh-Shoorideh et al., 2020; Prompahakul et al., 2021).
These implications have significant bearing on how responsibility for addressing the issue can be understood. In a paradigm where moral distress is considered an individual issue, responsibility lies with nurses’ ability to cope or build their resilience to work with dysfunctional systems. Yet, in a paradigm where it is viewed as a system failure, responsibility lies with organisational and political actors, rather than nurses. From my previous discussion about nursing leadership and patient safety, it is important to make a distinction between formal and informal authority. Nurses may be equipped with clinical knowledge and ethical perspective, yet lack the structural capacity to use them in practice (Aqtam et al., 2026a). The current review demonstrates the absence of theoretical foundations among reviewed papers; as such, only one out of nine studies was built using a theoretical framework (McAndrew et al., 2011, combining Corley’s moral distress theory and the Nursing Worklife Model). Further study will require grounding studies in well-established theories of structural empowerment (Kanter 1977), ethical climate and organisational justice.
Drawing from my practical experience working with nurses in such stressful situations as operating within environments of systemic violence and resource shortages, there are clear similarities (Aqtam et al., 2026b). Nurses witnessing the unnecessary suffering of patients and realising what the proper way is but unable to do anything because of circumstances out of their hands are going through a specific kind of moral pain which makes them lose not only their sense of professional identity but also personal integrity. The findings of the qualitative review of nurses’ testimonies, where they voice their dissatisfaction, say that they are ‘not true to themselves’ and doubt their professional value, seem to be very much related to cases of moral injury among nurses in conflict environments.
Although I anticipated seeing negative consequences consistently, what surprised me the most was the lack of even one study that reported either neutral or positive consequences of nurses’ experiences of moral distress. The lack of variability in this sense is unusual in nursing research, and it should be considered a clarion call. As the review shows, it does not matter whether the study was performed in a different geographical area or employed a different research design: all studies found nothing but harm as a consequence of nurses’ moral distress. Moreover, the recognition by the authors of this review that one study (Guttormson et al., 2022) was performed amid the coronavirus pandemic, when moral distress was particularly prevalent, only raises questions about whether it occurred at lower levels before.
Practical implications: who can benefit from this research?
The implications of this review are direct, actionable and relevant to multiple stakeholder groups across healthcare systems.
For nurse leaders, managers and hospital administrators
This review is the scientific basis for considering moral distress as a matter of quality and safety rather than simply a wellness concern. Nurse administrators should go beyond providing individual interventions and address the systemic level by implementing ethics debriefing programmes, systems for incorporating frontline perspectives in resource allocation and end-of-life decisions and promoting collaboration in decision-making. The study by Hiler et al. (2018) showing the association between positive practice environments such as sufficient staffing, effective leadership and collegiality with lower moral distress offers clear guidelines. Moral distress assessment, along with traditional indicators such as turnover rates and patient satisfaction, should be conducted regularly and assessed with validated tools, such as the Moral Distress Scale-Revised. The economic perspective is clear, as annual costs per hospital related to turnover can amount to millions of dollars. Thus, addressing moral distress systematically would be both morally right and financially sensible.
For nursing educators and researchers
This review constitutes a key teaching tool for graduate programmes in nursing ethics, leadership and healthcare systems. The review highlights the effectiveness of the integrative literature review approach in synthesising diverse data and drawing conclusions. For scholars conducting further research on moral distress, the review provides several critical gaps: firstly, there is no longitudinal study to identify cause-and-effect relationships; secondly, the high number of cross-sectional studies makes it difficult to establish temporal sequences and thirdly, no experimental studies have evaluated interventions, which poses an evidentiary gap. In my earlier research on evidence-based practice implementation, I have stressed the gap between knowing how something works and its systematic application (Ejheisheh et al., 2025). Future researchers must focus on randomised control trials of interventions such as ethics rounds, moral resilience training with organisational change and shared governance to identify successful strategies against moral distress. Furthermore, the inconsistency in instruments used to measure moral distress (MDS, MDS-R, MMD-HP and IMDS) hampers comparisons across studies.
For health policymakers and professional associations
On a systemic level, nurse shortages represent a strategic crisis that demands structural remedies. This literature review equips policymakers with an observable construct, that of moral distress, which may be included in national nursing work force policies, hospital accreditation requirements and funding formulas. Professional organisations need to lobby for laws that demand a conducive environment for ethical practices such as proper staffing ratios, ethics consultations and debriefing periods. From the findings of this literature review, moral distress does not appear to be culture-bound but rather universal among critical care nurses across the globe, thus providing an even stronger rationale for adopting an international standard in this regard. From my analysis on prioritising nursing research in the Eastern Mediterranean Region, local customisation of best practices is necessary without compromising basic tenets (Nashwan et al., 2024).
For frontline critical care nurses
In the end, however, those who benefit from this study are the nurses themselves and their patients. Understanding the concept of moral distress in its systemic context, not its individualistic one, allows nurses to push for change without being hard on themselves. By focusing on the qualitative findings of this study, nurses can bring to light issues that many of them silently endure, such as frustration, anger, hopelessness and disappointment. Using this data, nurses can make informed demands for ethical support, become active members of shared governance models and discuss moral distress in the same way as any other aspect of workplace safety. My research on nursing students and decision-making in nursing practice suggests that self-efficacy and self-concept as a profession are essential defences against occupational stress (Aboalrob et al., 2025; Toqan et al., 2026).
In summary, this commentary highlights the significant contribution that the integrative review carried out by Ananzeh and Miller (2025) has made in proving the negative effects of moral distress on all three domains of well-being, patient care and nurse workforce stability. In redefining the moral distress experienced by critical care nurses from something that is psychologically devastating for the individuals involved into something that can be prevented, the authors have shifted the responsibility from personal resiliency to the organisation. The message is loud and clear, moral distress is not something that needs to remain an issue; rather, it is a modifiable system problem that must be fixed urgently.
Footnotes
Acknowledgements
The author wishes to acknowledge the critical care nurses worldwide who silently endure moral distress while striving to provide ethical, compassionate care in dysfunctional systems – and to thank Tharaa Ananzeh and Dr. Elaine Miller for their important integrative review that inspired this commentary.
Author contribution
Ibrahim Aqtam: Conceptualisation, Writing – Original Draft, Writing – Review & Editing, Project Administration, Correspondence. The author approved the final manuscript.
Data availability statement
No datasets were generated or analysed during the current commentary.
