Nurses, Moral Distress, and COVID-19 in a Global Perspective – An Integrative Review

Published: 8 August 2022| Version 4 | DOI: 10.17632/yrvtz3zryv.4


ABSTRACT Aim This integrative review aims to synthesize the current literature on moral distress in nurses during the COVID-19 in healthcare. The objectives are: 1. To review empirical data on the impacts of moral distress nurses experience during the COVID-19 in healthcare. 2. To explore the current literature for strategies to EASE (Equip, Alleviate, Support, and Educate) nurses' moral distress during a pandemic. Design/Method An integrative review guided by the Whittemore and Knafl (2005) method. Results Of the 299 studies identified, six published met inclusion criteria. Greece, Iran, Romania, Switzerland, and United States were among the countries with nurses suffering from moral distress due to COVID-19. Three overarching concepts were identified: impact of moral distress on nurses, factors for moral distress, and improved quality of work conditions as an intervention for moral distress. Strategies to EASE (Equip, Alleviate, Support, and Educate) nurses' moral distress during a pandemic were explored. Keywords Moral Distress, COVID-19, Pandemic, Nurse, Mental health, Integrative Review, Healthcare, COVID-19 Pandemic


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An integrative review was conducted using the Knalf (2005) method. The Mixed Methods Assessment Tool (MMAT) version 2018 (Hong et al., 2018) was used to assess the quality of the papers. The objectives, inclusion criteria, exclusion criteria, and methodology directed the review's focus. ScienceDirect, ProQuest, Medline, Cumulative Index to Nursing and Allied Health (CINAHL), and PubMed electronic databases searched for peer-reviewed articles between 2020 and 2022 from February 18 to 26, 2022, and April 2, 2022. Search terms and keywords are "moral distress", "nurse", "nursing", "covid-19", and "covid-19 pandemic." If published in English, Papers were included and reported nurses' moral distress in any country during COVID-19. Non-English, editorials, commentaries, meta-analyses, systematic reviews, data not acquired during the COVID-19 pandemic, and populations other than nurses were excluded. There were 299 articles retrieved at the initial search of keywords. The publication date was narrowed from 2020 to 2022 to account for moral distress issues among nurses during the COVID-19 pandemic. References were tracked using PDFs with result counts, time stamps, and search terms documented for future retrieval. Abstracts were saved to a cloud-based Box folder for collaboration and imported into RefWorks's reference database application. The articles were then screened for duplicates (n=31), reducing the articles to 268. Further screening of articles applying the inclusion criteria by title and abstract review (n=207) decreased the remaining papers to 61. A brief study of full articles excluded 45 more articles. The remaining 16 articles were left for final selection, and exclusion criteria resulted in four articles. There were six articles retrieved from other related work and references. They were screened using the same inclusion and exclusion criteria. Only two of six articles were left after a full review and analysis of the abstract. After a focused review, six articles remained for a full review, analysis, and synthesis of the nurses' moral distress during COVID-19 globally. The PRISMA flow diagram (Page et al., 2021) was used to present the review's search, screening, and selection process in the data extraction phase. The article was peer-reviewed by two nurse researchers and an author, nurse researcher, and expert cunsultant.


Mental Health, Trauma, Moral Dilemmas, COVID-19, Pandemic