Moral distress and moral resilience in nurses during the COVID-19 pandemic: A narrative review

Article Type : Reviews


1 Department of Medical-Surgical Nursing, Kashan University of Medical Sciences, Kashan, Iran

2 Department of Medical-Surgical, Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran

3 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran


COVID-19 has resulted in devastating economic, social, and psychological effects on a global scale due to its unstoppable and disastrous nature. There is a paucity of literature examining the interconnection between moral distress (MD) and resilience among nurses in the context of the pandemic. We have undertaken a narrative review of the available research on nurses' MD and resilience during the COVID-19 outbreak. A narrative review was performed through an extensive search in databases, such as PubMed, Web of Science, and Scopus, from December 1, 2020, to March 29, 2023. Keywords included "COVID-19", "2019-nCoV disease", "2019 novel coronavirus infection", "nurses", "moral distress", and "moral resilience". English-language published articles that matched the inclusion criteria were evaluated and included. Inclusion criteria included review and all descriptive studies evaluating MD and resilience in nurses during the COVID-19 pandemic. Gray literature and letters were excluded from the search results. The study results showed that nurses suffered from MD during the COVID-19 pandemic. Moral resilience is the opposite of MD, which can be reduced by using strategies such as developing the abilities of healthcare workers, strengthening honesty, and reducing their stress and anxiety. On the other hand, strengthening moral resilience by fostering self-regulation capacities, accountability and flexibility, recognizing the boundaries of honesty, and exercising conscientious objections can effectively promote their moral resilience. Considering the challenging conditions among healthcare professionals, especially nurses, in the era of COVID-19, this causes increased MD, which can cause mental and emotional risks for nurses. So, considering the relationship between MD and moral resilience (considered a protective factor) and the inverse relationship between them, it is suggested that by increasing moral resilience, we should reduce MD to survive the difficult period of COVID-19. Protect ourselves from moral and psychological problems and improve patient care quality by following the tips.


1 Introduction

COVID-19 has resulted in devastating economic, social, and psychological effects on a global scale due to its unstoppable and disastrous nature [1-5]. Healthcare workers are at risk of exposure to COVID-19 when providing direct care to patients affected by the virus, with the possibility of experiencing adverse physical and psychological health outcomes [6-8]. Nurses are essential members of health workers, and the disease has resulted in moral challenges for them [9-11]. Amid the COVID-19 pandemic, new insight about moral distress (MD) has been ‎gained during COVID-19 [12, 13]. In this regard, in a research study conducted by Berhie et al., MD was identified in 83% of the nursing staff. Also, the prevalence of MD is higher among nurses in developed nations, and conversely, it is more frequently encountered by women than men [14]. Additionally, a study has shown that 60% of nursing staff suffering from MD in medical center [15]. MD arises when a disparity between an individual's fundamental values and actions leads to ethical uncertainty or unease. [16, 17]. Jameton first coined the term MD about nurses feeling distressed when forced to act in ways that contradict their beliefs due to institutional constraints [18]. According to a qualitative study, healthcare professionals, specifically nurses, who offer medical assistance to patients affected by COVID-19 may be experiencing MD for the following reasons: a) the inability to recognize and treat a newly diagnosed disease due to a lack of knowledge and uncertainty, b) assuaging from the depths and breadths of COVID-19, c) suboptimal care due to apprehension about being exposed to the virus, d) the adoption of a nursing care model that emphasized teamwork gave rise to disagreements among healthcare staff, generating tensions within the profession and other associated challenges [19].

In contrast to MD, "moral resilience" is turn to one's integrity in moral challenges. Moral resilience is characterized by its focus on three key elements: 1) recognizing the moral dimension of human experience, 2) acknowledging the intricacy of moral judgments, responsibilities, and connections, and 3) accepting the presence of inevitable obstacles to conscience, ethical ambiguity, and MD [20]. By utilizing moral resilience, clinicians can respond to complex, often intractable, ethical problems in the COVID-19 pandemic [21, 22]. To handle heightened levels of MD, nurses necessitate a trustworthy source of assistance to turn to. Hence, the development of moral resilience can serve to alleviate the unfavorable impacts of MD [23].

Scant literature exists on the correlation between MD and resilience among nurses amid the COVID-19 pandemic. The investigation carried out by Spilg et al., sought to explore the interrelationships between MD, moral resilience, and mental health among healthcare professionals in the context of the COVID-19 pandemic. The results of their study suggest that moral resilience can act as a buffer against exposure to potentially distressing moral circumstances [24]. Qualitative research assessed critical care nurses' encounters with ethical dilemmas, MD, and resilience amid the COVID-19 pandemic. The study characterized the relationship between MD and resilience as "iterative and fluid” [25].

In the current study, the authors aim to conduct a narrative review of the experiences of MD and moral resilience among nurses in the context of the COVID-19 pandemic. The findings of this review will guide future research efforts in identifying areas of research gaps during this critical period.


2 Methods

In this review, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist as our methodological framework [26]. It's worth noting that this review was not registered in the International Prospective Register of systematic reviews (PROSPERO) database. An in-depth search of databases was undertaken to perform a narrative review, such as PubMed, Web of Science, and Scopus, from December 1, 2020, to March 29, 2023. The search process was carried out utilizing the subsequent search terms and Boolean operators and keywords included "COVID-19", "2019-nCoV disease", "2019 novel coronavirus infection", "nurses", "moral distress", and "moral resilience". Two independent authors searched English-language published articles that matched the inclusion criteria and were evaluated and included. Inclusion criteria included review and all descriptive studies evaluating MD and resilience in nurses during the COVID-19 pandemic. Gray literature and letters were excluded from the search results. In addition, commonalities found among websites were also disregarded in the research. Two authors searched independently to confirm the dependability and credibility of the narrative review. Search results were managed through the EndNote 20X software. Initially, a whole of 632 articles was received using database searches. The initial database searches yielded a total of 632 articles. After screening the titles, abstracts, and full texts and eliminating duplicate studies, 24 articles were selected for this review, and further data were identified for analysis [15]. In instances where mutual consensus was not readily achieved, the intervention of a third researcher was solicited to mediate and expedite resolution (Figure 1).


3 Results

3.1 MD in nurses during the COVID-19 pandemic

Complex nursing practice's intense and stressful atmosphere can cause MD [28]. Staff shortages, financial constraints, and greater patient orientation are some of the indicators of MD [29]. Low self-esteem, a decline in job satisfaction, lower years of experience, and the work environment all contributed to some MD in nursing during the COVID-19 pandemic [30-32]. Experiencing a higher risk of infection, arguing with patients and families about untrue and excessive precautions (false safety), having a limited supply of personal protective equipment, and lacking hospital support and communication such as (honesty and deception) [33] during COVID were some of the MD factors in this epidemic condition [34].

Figure 1. Flow diagram of study selection.


3.2 Moral resilience in nurses during the COVID-19 pandemic

Moral resilience pertains to an individual's capability to uphold or restore ethical principles when faced with moral intricacy, uncertainty, hardship, or setbacks [35]. The Rushton Moral Resilience Scale was created to provide a quantitative evaluation of moral resilience, emphasizing four key areas: individual integrity, interpersonal integrity, moral efficacy, and the ability to respond to moral adversity [36, 37]. The upsurge in COVID-19 cases at the height of the pandemic, an overwhelming work burden, a shortage of personal protective equipment, media attention, insufficiency of particular medications, and a feeling of being under supported have all been correlated with psychological strain among healthcare workers, particularly nurses who directly interact with patients suffering from COVID-19 [38]. In this circumstance, nurses can improve moral resilience by scheduling self-care (such as acupuncture, yoga, or massage therapy), practicing deep breathing, cultivating gratitude, and rewarding communities of practice [39, 40]. Some dimensions support moral resilience, as shown in Table 1.


Table 1. Dimensions to support moral resilience in nurses.

Knowing who you are and what you stand for in life

Moral conscientiousness refers to continue exploring and refine one's values, ideals, and points of view.

Cultivating self-regulatory capacities

Being responsive and flexible in complex ethical situations

Capability to discern the boundaries of integrity, including the exercise of conscientious objections

The ability to be resolute and courageous in one's moral action despite resistance or obstacles


3.3 Relationship between MD and moral resilience in nurses during the COVID-19 pandemic

Through the cultivation of moral resilience, nurses can shift their narrative from one of distress and exhaustion to one of potential solutions and opportunities. Moral resilience is currently understood as a personal capability to uphold, restore, or advance ethical principles when confronted with situations involving moral complexity, uncertainty, hardship, or setbacks [35, 41]. MD can be recognized by reflecting on and questioning the ethical aspects of clinical situations, reconnecting with their original intention and purpose as a nurse, committing to their well-being, supporting and restoring moral integrity, and developing ethical competence. Some strategies can provide a starting point for those seeking moral agency and resilience in the face of MD. [42, 43]. Strengthening the capabilities that enable healthcare workers to stay committed to their roles amidst challenging circumstances can reinforce their moral resilience [44]. Malatesta utilized the constructs of integrity, buoyancy, moral efficacy, self-regulation, self-stewardship, and self-perception to define the constituent parts of moral resilience. The interconnection between MD and resilience was fluid and iterative [25]. Spilg's study revealed that higher levels of moral resilience were associated with lower levels of MD, depression, stress, and anxiety among healthcare workers during the COVID-19 pandemic [24].


4 Limitations

It is important to acknowledge number of limitations of the study. Firstly, it only considered English sources for inclusion, which may have led to a lack of diversity in perspectives and findings. Secondly, the study did not evaluate the quality of the articles obtained, which could impact the reliability of the conclusions. Moreover, the results obtained may be subject to bias due to various factors such as publication bias and selection bias. Recognizing these limitations is crucial for a comprehensive understanding of the study's findings and their potential implications.


5 Clinical implications to nursing practice

The COVID-19 pandemic has resulted in heightened MD among healthcare workers, particularly nurses. This has significant implications for nursing practice, including the urgent need to prioritize the development of moral resilience training programs. Nurses also require psychological support to alleviate the strain they face and resources for ethical decision-making. An emphasis on self-care and well-being education for nurses is also crucial, along with an overarching aim to improve the quality of nursing care by fostering emotional and moral resilience. These implications highlight the importance of addressing MD and promoting the well-being of healthcare professionals, especially in challenging circumstances like those presented by the ongoing pandemic.


6 Recommendations for future research

The COVID-19 pandemic has led to heightened MD experienced by healthcare workers, especially nurses. To address this issue, nursing research should focus on developing evidence-based interventions that enhance moral resilience. Longitudinal research is essential to understand the enduring impact of MD on healthcare workers' mental health. Addressing MD is critical to improving patient outcomes, satisfaction, and care quality. Implementing strategies to mitigate MD and enhance healthcare workers' resilience is urgent.


7 Conclusions

Given the difficult circumstances faced by healthcare workers, particularly nurses, amid the COVID-19 pandemic, the heightened MD they experience can lead to mental and emotional risks for these professionals. So, considering the relationship between MD and moral resilience (considered a protective factor) and the inverse correlation between them, it is suggested that by increasing moral resilience, we should reduce MD to survive the difficult period of COVID-19. Protect ourselves from moral and psychological problems and improve patient care quality by following the tips.



Not applicable.


Authors’ contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: ZA, MHG, AZK, MJG; Drafting the work or revising it critically for important intellectual content: ZA, MHG, AZK, MJG; Final approval of the version to be published: ZA, MHG, AZK, MJG; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: ZA, MHG, AZK, MJG.





Ethics approval and consent to participate

Not applicable.


Competing interests

We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.


Availability of data and materials

The datasets used during the current study are available from the corresponding author on request.


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© 2023 The Author(s).

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Volume 2, Issue 1
January 2024
Pages 32-37
  • Receive Date: 23 April 2023
  • Revise Date: 25 October 2023
  • Accept Date: 02 November 2023
  • First Publish Date: 03 November 2023
  • Publish Date: 03 November 2023