Nurses' moral distress in palliative care: A systematic review of prevalence, contributing factors, and consequences

Moral distress (MD) is defined as the emotional suffering experienced when a healthcare professional identifies the ethically correct action but is hindered by institutional or professional constraints. This systematic review aims to investigate the primary causes, consequences, and potential improvements of interventions for MD, with a focus on palliative care and the physician-nurse professional dynamic. A comprehensive literature search was conducted across major databases (PubMed, Embase, and CINAHL), including quantitative, qualitative, and mixed-methods studies. The selection process, documented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, resulted in 12 relevant articles. MD is prevalent among nurses, with rates reaching 79% in some studies. The intensive care unit (ICU) is the most frequently associated clinical setting. The study population consisted of 1,223 nurses and 257 physicians. Contributing factors include advanced age, extensive work experience, and postgraduate degrees. Ineffective physician-nurse collaboration, characterized by limited nurse influence in clinical decisions and forced implementation of aggressive/futile treatments, is a significant factor, often due to poor communication. MD correlates with administrative policies that undervalue staff and limit the utilization of palliative care services. Consequences include anger, depression, frustration, and burnout, leading to professional abandonment. Patients experience suffering, prolonged death, and treatment delays, while families face emotional distress, financial burdens, and guilt. MD is a common emotional experience among nurses, particularly in ICUs, with severe professional and patient repercussions. Physician-nurse collaboration is pivotal in the development of MDs, influenced by differing opinions, goals, and responsibilities. Targeted training can prevent MD and foster a favorable ethical climate. Administrative recognition of emotional and professional burdens is crucial for effective management of MDs.