{"paper_id":"266fb0c8-dfaf-41dd-abab-a60a08227249","body_text":"An Exploratory Descriptive Study of Critical Care Nurses' Perspectives on Moral Distress in Diverse Healthcare Settings: The Causes, the Psychological Impact, and the Coping Strategies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An Exploratory Descriptive Study of Critical Care Nurses' Perspectives on Moral Distress in Diverse Healthcare Settings: The Causes, the Psychological Impact, and the Coping Strategies khaleeq ur Rahman, Dr. Salma Rattani, Mehak Virani, Zulekha Saleem This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8706540/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Moral distress is a significant issue among critical care nurses who frequently encounter ethically complex situations that contradict their moral and professional values. In Pakistan, research on this phenomenon remains limited particularly regarding how nurses in different healthcare setting perceive and manage moral distress. Objective This study aimed to explore perspective of critical care nurses on the causes, psychological impact of moral distress and the strategy they use to deal with moral distress in diverse healthcare settings. Methods An exploratory descriptive qualitative design was used to evaluate the phenomenon, data was gathered through in-depth interviews with critical care nurses working in public sector tertiary care setting in Peshawar Pakistan. A purposive sampling technique was used to select participants with at least one year experience of working in an Intensive Care Unit. A total of 35 nurses volunteered to participate in the study. Among these 15 were interviewed based on their eligibility and availability. The data was transcribed and then analysed using a thematic analysis framework to identify themes and patterns. Result Three themes were extracted Theme One: ‘The Genesis of Moral Distress - A Conflict Between Ethics and Reality’, theme two: ‘the Pervasive Impact, the Psychological and Professional toll’ and theme three: ‘Navigating the Aftermath: Coping in a Constrained Environment’. Findings suggest that moral distress arises from factors such as inadequate staffing, the hierarchical system in Pakistan which gives dominance to physician over nurses, systemic and resources constraint, The cohort verbalizes the consequences of moral distress includes anxiety, emotional breakdown and reduced job satisfaction lead to burnout. Coping mechanism included avoidance and detachment, peer and family support and spiritual healing, there was a lack of organizational support for coping with moral distress, participants urged for a structure and formal support from organization to mitigate moral distress. Conclusion The study underscores urgent need for organizational support, ethical education and supportive leadership to address moral distress among critical care nurses which directly affect patients care. Moral distress psychological impact coping mechanism hierarchical barriers Introduction Moral distress is an increasingly recognized ethical and psychological challenge within the nursing profession, particularly among nurses working in critical care settings. Critical care nurses are frequently exposed to complex clinical situations involving life-sustaining treatments, end-of-life decisions, resource limitations, and hierarchical decision-making structures. These circumstances often place nurses in positions where they are acutely aware of the ethically appropriate course of action but are unable to act accordingly due to institutional, legal, or professional constraints. This inability to act in alignment with one’s moral and professional values generates moral distress, which can have profound consequences for nurses’ psychological well-being, professional integrity, and the quality of patient care delivered. The concept of moral distress was first introduced by Jameton, who defined it as the experience of knowing the ethically correct action to take while being constrained from taking that action by institutional barriers. This foundational definition has guided much of the early scholarship on moral distress in nursing. However, contemporary researchers argue that Jameton’s original conceptualization does not fully encompass the breadth and complexity of moral distress. The concept was expanded to suggest that moral distress may also arise from moral uncertainty, conflict, dilemmas, and tension, rather than solely from external constraints ( 1 ). This broader understanding reflects the dynamic and multifaceted ethical challenges faced by nurses, particularly in high-acuity settings such as intensive care units (ICUs). Empirical research has consistently demonstrated that moral distress adversely affects nurses’ emotional and psychological health. Studies report strong associations between moral distress and burnout, compassion fatigue, emotional exhaustion, job dissatisfaction, and increased intention to leave the profession ( 2 , 3 ). In a study conducted among hemodialysis nurses in South Korea, moral distress particularly distress arising from physicians’ ethically questionable decisions was found to be a significant predictor of turnover intention. Nurses described experiencing profound psychological discomfort when witnessing actions they perceived as unethical but felt powerless to challenge due to hierarchical structures and limited authority ( 2 ). Similarly, a national survey conducted in New Zealand revealed that nurses frequently experienced moral distress related to inadequate systemic support, managerial conflicts, workplace bullying, and witnessing poor or unsafe care practices. These unresolved experiences contributed to long-term psychological strain and professional dissatisfaction ( 4 ). Evidence further suggests that the intensity of moral distress varies across clinical settings. Inpatient and critical care nurses report higher levels of moral distress compared to outpatient nurses, largely due to their close involvement in end-of-life care, prolonged exposure to critically ill patients, and participation in ethically complex decision-making processes ( 5 ). Research conducted in intensive care units indicates that moderate to high levels of moral distress significantly impair nurses’ clinical judgment and decision-making capacity, potentially compromising patient safety and care quality ( 6 ).Additional factors influencing moral distress include years of clinical experience, leadership roles, family involvement in care decisions, and the quality of managerial and organizational support ( 7 ). Organizational and workplace characteristics also play a crucial role in the development of moral distress. High emotional demands, inadequate staffing, limited time for patient care, work–life conflict, insufficient social support, and minimal participation in decision-making have been identified as strong predictors of moral distress among nurses ( 8 ). When moral distress remains unaddressed, it often leads to burnout, deteriorating physical and mental health, and increased intentions to leave both the job and the nursing profession. Altogether, these outcomes pose serious implications for healthcare systems already struggling with nursing shortages and workforce instability ( 3 ). To cope with moral distress, nurses adopt a range of strategies that may be broadly categorized as adaptive or maladaptive. Adaptive strategies include seeking peer support, engaging in ethical discussions, participating in self-care activities, practising mindfulness, and finding meaning in patient care. A qualitative study conducted among ICU nurses in Iran highlighted that nurses commonly relied on physical activity, humour, social interaction, rest, and moral support groups to mitigate the emotional burden of distress ( 9 ). Conversely, maladaptive coping strategies such as emotional withdrawal, avoidance, normalization of unethical practices, and silence have also been reported, particularly in environments characterized by rigid hierarchies and fear of retaliation ( 9 ). The issue of moral distress is particularly pronounced in low-resource and developing healthcare settings, where systemic shortages of staff, equipment, and essential medical supplies intensify ethical challenges. Nurses in these contexts frequently face situations in which they are unable to provide adequate care despite their professional commitment and moral intentions ( 10 ). Early-career and novice nurses are especially vulnerable due to limited clinical experience, reduced ethical confidence, and lack of institutional support, making them more susceptible to moral distress and early career attrition ( 11 , 12 ). Despite the growing body of literature on moral distress, there remains a notable gap in research exploring its causes, psychological impact, and coping strategies among critical care nurses working in low-resource settings. Furthermore, limited empirical evidence exists regarding the effectiveness of coping mechanisms during large-scale crises such as pandemics, highlighting the urgent need for context-specific, evidence-based interventions ( 13 ). Addressing moral distress requires systemic approaches, including ethical education, supportive leadership, structured debriefing sessions, and the establishment of safe spaces for ethical dialogue ( 14 , 15 ). Therefore, this study aims to explore moral distress among critical care nurses, with a specific focus on its underlying causes, psychological and emotional impact, and the coping strategies nurses employ to sustain their professional roles. By examining moral distress within a low-resource healthcare context, this research seeks to contribute to the existing body of knowledge and inform the development of targeted interventions that support nurses’ well-being, enhance ethical practice, and ultimately improve patient care outcomes. Methodology This chapter outlines the methodological framework adopted to explore moral distress and coping strategies among critical care nurses working in intensive care units (ICUs) in Pakistan. It provides a detailed account of the research design, philosophical underpinnings, study setting, population, sampling strategy, data collection methods, data analysis, rigor, ethical considerations, and methodological limitations. The methodology was designed to capture nurses’ lived experiences within complex, resource-constrained clinical environments characteristic of low- and middle-income countries (LMICs). Research Design An Exploratory–Descriptive Qualitative Design (EDQ) was employed for this study. This design is particularly suited for investigating under-explored phenomena and gaining in-depth understanding of participants’ perspectives in their natural contexts ( 16 ). The study was guided by a constructivist–interpretivist paradigm, which assumes that reality is socially constructed and shaped by individual experiences and cultural contexts ( 17 ). From this perspective, moral distress is understood as a subjective and context-dependent experience rather than a uniform or measurable construct. Qualitative approaches are well suited to examining emotionally complex experiences such as moral distress, which cannot be adequately captured through quantitative measures alone ( 18 ). While surveys may quantify stress levels, they fail to reveal the ethical conflicts, emotional burden, and contextual pressures faced by ICU nurses. In contrast, qualitative inquiry allows exploration of the “how” and “why” of moral distress, providing rich narrative data grounded in participants’ own words (( 19 , 20 ). The exploratory component was essential due to the limited empirical literature on moral distress among critical care nurses in Pakistan. This design enabled the researcher to enter the field without predefined hypotheses and to remain open to discovering context-specific sources of moral distress ( 21 , 22 ). The descriptive component aimed to present a comprehensive and faithful account of participants’ experiences, staying close to the data and preserving the authenticity of nurses’ voices ( 23 ). Study Setting The study was conducted in the ICUs of a large public-sector tertiary care teaching hospital in Peshawar, Khyber Pakhtunkhwa, Pakistan. As a major referral center, the hospital receives critically ill patients from across the province and neighboring Afghanistan, resulting in high patient acuity, resource constraints, and constant ethical challenges. Such environments are known to intensify moral distress among healthcare professionals ( 24 , 25 ). Study Population and Sampling The study population comprised registered nurses (RNs) providing direct bedside care to adult ICU patients. These nurses were selected because of their continuous exposure to ethically challenging situations, making them particularly vulnerable to moral distress ( 26 ). A purposive sampling technique was used to recruit information-rich participants with relevant experience ( 27 ). Eligibility criteria included holding a valid Pakistan Nursing Council license, having at least one year of ICU experience, and being actively involved in direct patient care. Nurses in purely managerial roles or on temporary contracts were excluded to ensure contextual familiarity. Initially, 35 nurses volunteered; 25 met the inclusion criteria. Due to refusals and scheduling conflicts, 15 nurses ultimately participated. Data saturation was achieved when no new themes emerged from the interviews ( 28 ). Data Collection Data were collected through semi-structured, in-depth interviews, chosen for their balance of consistency and flexibility ( 29 ). An interview guide was developed following a literature review on moral distress ( 30 , 31 ). And was piloted prior to data collection. Minor revisions were made, and pilot data were excluded from final analysis. Interviews were conducted by the researcher, an ICU nurse fluent in English and Urdu, which facilitated rapport and trust. Interviews lasted 35–45 minutes, were audio-recorded with consent, and conducted in participants’ preferred language. Field notes capturing observational, contextual, and reflexive data were maintained to enrich interpretation ( 32 ). All data were securely stored and retained for seven years in accordance with AKU policy. Development of the Interview Guide The interview guide used in this study was developed specifically by the researcher for the purpose of this study and has not been previously published elsewhere. The development of the interview guide was informed by an extensive review of the relevant literature and aligned with the study objectives. To ensure content validity, clarity, and relevance, the interview guide was reviewed by six experts in the field (including experts in nursing ethics, qualitative research, and critical care). Based on their feedback, the interview questions were revised, reorganized, and refined to improve comprehensiveness and appropriateness. An English language version of the finalized interview guide has been uploaded as a supplementary file, and it has been appropriately cited in the main manuscript. Data Analysis Data analysis followed ( 33 ). Six-phase thematic analysis: familiarization, coding, theme development, theme review, naming themes, and reporting. Transcripts were analyzed inductively to ensure findings were grounded in participants’ narratives. Analysis was conducted manually, allowing deep engagement with the data. Rigor and Trustworthiness Study rigor was ensured using Lincoln and Guba’s framework of credibility, transferability, dependability, and confirmability ( 34 ). Credibility was enhanced through prolonged engagement, peer debriefing, triangulation, and member checking Birt, Scott ( 35 ). Transferability was supported through thick description of context and methods. Dependability and confirmability were ensured by maintaining a detailed audit trail and reflexive documentation ( 36 ). Ethical Considerations Ethical approval was obtained from the Aga Khan University Ethical Review Committee. The study adhered to the Declaration of Helsinki ( 37 ). Informed consent, confidentiality, anonymity, and participants’ emotional well-being were strictly maintained ( 38 , 39 ). Methodological Limitations As a single-site qualitative study with a purposive sample, findings are not statistically generalizable. However, this limitation aligns with the study’s aim of achieving depth and contextual understanding rather than generalization. Results This chapter presents the findings of the study exploring moral distress among critical care nurses working in a tertiary care hospital in Peshawar, Pakistan. Data were generated through in-depth interviews and analysed using Braun and Clarke’s thematic analysis framework. The analysis resulted in three overarching themes and eight subthemes, capturing the causes, psychological and professional impact, and coping responses related to moral distress. The findings are interpreted through Jameton’s model of moral distress (1984) to provide theoretical coherence. The chapter is organised into two sections: ( 1 ) demographic characteristics of the participants, and ( 2 ) thematic findings supported by verbatim excerpts from participants. Demographic Characteristics of the Participants The study sample consisted of 15 registered nurses working in adult Intensive Care Units (ICUs). All participants were directly involved in bedside patient care. Most participants were male (60%), aged between 25 and 35 years, and unmarried (73.3%). The majority held a Bachelor of Science in Nursing (86.7%), while a smaller proportion had a Master of Science in Nursing qualification. Most nurses had less than three years of ICU experience, reflecting an early-career workforce in a high-acuity environment. This homogeneity allowed for a focused exploration of shared ethical challenges within critical care. Thematic Analysis of In-Depth Interviews Using Braun and Clarke’s six-step approach, the data were coded and organised into three major themes: The Genesis of Moral Distress The Pervasive Impact Navigating the Aftermath These themes align closely with Jameton’s conceptualisation of moral distress as arising from institutional constraints that prevent morally appropriate action. Theme One: The Genesis of Moral Distress – A Conflict Between Ethics and Reality This theme describes the origins of moral distress, reflecting Jameton’s notion of constraint-based ethical conflict. Three subthemes emerged: hierarchical conflict, ethical dilemmas in patient care, and systemic resource constraints. Hierarchical and Interprofessional Conflict Participants repeatedly described feelings of powerlessness due to physician dominance and exclusion from decision-making. Nurses felt that their clinical knowledge was undervalued despite close patient contact. One participant stated, “Nurses are not allowed to make decisions… not allowing nurses to speak for themselves” (P1). Another added, “They keep us away from patient families… we are not allowed to explain the disease process” (P14). This hierarchical imbalance sometimes placed nurses at personal risk. A participant recalled, “In an HIV patient case, the consultant asked the nurse instead of the phlebotomist to take blood… I felt very bad” (P7). Such incidents intensified moral distress by forcing nurses to act against professional fairness and self-protection. Ethical Dilemmas in Patient Care Nurses described being compelled to provide futile care, particularly for terminally ill or brain-dead patients. One participant explained, “A brain-dead patient occupied the ventilator because of political influence… other patients suffered” (P10). Another described unsafe transfers: “I knew shifting the patient would worsen the condition… later the patient expired” (P2). These situations trapped nurses between ethical knowledge and institutional pressure. Systemic and Resource Constraints Resource scarcity was a pervasive trigger of moral distress. Unsafe nurse–patient ratios and inadequate equipment compromised care quality. One nurse stated, “Only two staff during CPR… if we had more staff, we could save the patient” (P9). Another highlighted, “At a 1:3 ratio, it becomes very difficult” (P7). The absence of formal end-of-life policies further intensified ethical uncertainty. Theme Two: The Pervasive Impact – Psychological and Professional Toll This theme captures the deep and cumulative effects of moral distress on nurses’ mental health, professional performance, and personal lives. Emotional and Psychological Fallout.Participants reported sleep disturbances, somatic symptoms, anxiety, and panic attacks. One nurse shared, “It affected us with headaches, frustration, and sleep problems” (P1). Another described emotional breakdowns: “Sometimes I have panic attacks… I feel like crying and isolate myself” (P4). These narratives reveal moral distress as a chronic psychological burden rather than isolated stress. Professional and Personal Consequences Moral distress impaired concentration and patient safety. One participant stated, “Anxiety and burnout increase chances of error” (P1). Another admitted, “Medication errors happened… I gave one patient’s medicine to another” (P10). These experiences intensified guilt and reinforced thoughts of leaving the profession: “I have thought about leaving my job multiple times” (P2). The distress extended into family life. One nurse shared, “It disturbs relationships… we start with anger and go into isolation” (P1). Another added, “At home, we fight… our sleep is disturbed” (P15). Moral distress thus permeated both professional and personal domains. Theme Three: Navigating the Aftermath – Coping in a Constrained Environment This theme explores how nurses cope with moral distress in the absence of institutional support. Individual Coping Mechanisms and Informal Support Nurses adopted avoidance, emotional withdrawal, and self-care as survival strategies. One participant explained, “I try to ignore what is happening… walking away to protect myself” (P1). Others relied on spirituality and relaxation: “I go for fresh air, do breathing exercises, and pray” (P2). In severe cases, professional help was required: “I went to a psychiatrist… he gave me medicine” (P15). Peer and family support emerged as essential coping resources. One participant noted, “Peer support is very fruitful” (P1), while another shared, “My roommate counsels me” (P9). The Critical Need for Organisational Support Participants expressed fear of retaliation for speaking up. One nurse stated, “Fear of losing my job… salary might be withheld” (P2). Contract-based employment intensified silence: “If the contract ends, they won’t renew” (P13). Administrative inaction further eroded trust, as noted by “They say ‘we will solve it’ but never do” (P1).Participants strongly advocated for ethics committees, leadership accountability, and regular ethics training. One nurse summarised, “Our responsibilities are high… we should be morally healthy” (P14). Theoretical Integration: Jameton’s Model Jameton’s (1984) model provides a coherent framework linking constraints (Theme One) to moral distress and residue (Theme Two), followed by coping responses and consequences (Theme Three ) . The findings illustrate a cyclical process where unresolved constraints perpetuate distress, leading nurses toward either resilience or burnout and exit Discussion This study explored moral distress among critical care nurses working in a tertiary care hospital in Peshawar, Pakistan, with a focus on its causes, psychological and professional consequences, and coping mechanisms. Guided primarily by Andrew Jameton’s (1984) theory of moral distress and extended through contemporary socio-cultural interpretations ( 30 ). the discussion integrates the study findings with existing literature while situating them within Pakistan’s healthcare realities. The findings demonstrate that moral distress among nurses is not solely an ethical phenomenon but a deeply institutional, cultural, and systemic issue. The Genesis of Moral Distress: Institutional and Societal Constraints Consistent with Jameton’s original conceptualisation, moral distress in this study emerged primarily from institutional constraints that prevented nurses from acting in accordance with their ethical judgment. Hierarchical dominance by physicians and exclusion of nurses from decision-making were central triggers. Participants described persistent marginalisation despite their close involvement in patient care, reinforcing a sense of powerlessness. These findings align with international literature identifying interprofessional conflict and organisational hierarchy as core drivers of moral distress ( 2 , 40 ). Within the Pakistani context, these hierarchical dynamics are intensified by patriarchal social structures and entrenched authority gradients. Although the sample included mostly male nurses, accounts of gender-based discrimination and societal expectations were evident, indicating that gender functions as a mediating factor in moral distress. This observation supports calls for culturally nuanced research examining how gender norms shape ethical experiences in healthcare settings ( 41 , 42 ). Expanded framework is particularly relevant here, as it captures not only constraint-based distress but also moral conflict, indecision, and injustice reflected in participants’ narratives. Ethical Dilemmas, Futile Care, and Resource Constraints Moral distress was most pronounced in situations involving futile care and end-of-life decision-making. Nurses reported being compelled to continue aggressive treatment for patients with no realistic chance of recovery, often influenced by political pressure or VIP culture. Such situations directly conflicted with their professional values and contributed to systemic inefficiencies, including delayed care for other critically ill patients. Similar findings have been widely documented among ICU nurses globally ( 14 , 43 ). These ethical challenges were further exacerbated by chronic resource shortages and the absence of formal institutional policies, particularly regarding do-not-resuscitate (DNR) orders and end-of-life care. In low- and middle-income countries like Pakistan, limited ICU capacity, inadequate staffing, and lack of ethical guidelines intensify moral conflict ( 44 ). Meta-analyses confirm a strong association between resource scarcity and moral distress, highlighting the urgent need for systemic reforms ( 45 ). The Pervasive Impact: Psychological and Professional Consequences The findings revealed that moral distress had profound psychological and physical consequences, including anxiety, sleep disturbances, headaches, panic attacks, and emotional exhaustion. These symptoms reflect the “crescendo effect” described by ( 46 ). Whereby repeated exposure to unresolved ethical conflicts accumulates as moral residue, progressively eroding psychological resilience. Participants’ descriptions of emotional withdrawal and loss of joy underscore the long-term mental health implications of moral distress. Consistent with international evidence, moral distress was closely linked to burnout, compassion fatigue, and reduced quality of life ( 47 ). Beyond individual suffering, participants reported impaired concentration and clinical judgment, increasing the risk of medication errors and compromising patient safety. These findings reinforce the view that moral distress is not merely a personal issue but a significant threat to healthcare quality and safety ( 48 ). Professional Disengagement and Spillover Effects Ongoing moral distress contributed to professional disengagement, reduced job satisfaction, and intentions to leave nursing. This aligns with previous studies identifying moral distress as a strong predictor of nurse turnover ( 2 , 49 ). In resource-limited settings like Pakistan, such attrition further exacerbates workforce shortages and undermines continuity of care. Importantly, moral distress extended beyond the workplace, affecting family relationships and social functioning. Participants described irritability, emotional withdrawal, and social isolation, findings echoed in global research on work–life imbalance among healthcare professionals ( 50 ). These spillover effects position moral distress as a broader public health concern rather than an isolated occupational issue. Coping Strategies in a Constrained Environment In the absence of robust organisational support, nurses relied heavily on individual coping strategies such as prayer, avoidance, emotional detachment, and peer support. While these strategies provided temporary relief, they were insufficient to address ongoing ethical stressors and, in some cases, led to psychiatric intervention. Similar patterns have been reported among ICU nurses internationally ( 9 , 51 ). Highlighting the limitations of individual resilience in the face of systemic problems. Peer and family support emerged as critical lifelines; however, overreliance on informal networks risks shifting institutional responsibility onto individuals. This finding aligns with moral community theory, which emphasises the need for collective and organisational responses to moral distress ( 52 ). Integrating and Extending Jameton’s Framework While Jameton’s (1984) framework effectively explains the core experience of moral distress as constrained moral agency, this study extends the theory by incorporating socio-cultural and systemic dimensions specific to Pakistan. Factors such as contract-based employment, VIP culture, gender norms, political influence, and weak regulatory structures shape how moral distress is experienced and sustained. These contextualised constraints demonstrate that moral distress is socially embedded and requires culturally responsive interventions. Strengths, Limitations, and Implications The study’s qualitative depth and focus on an underrepresented LMIC context are key strengths, offering culturally grounded insights into moral distress. However, limitations include its single-site design, small sample size, and reliance on self-reported data. Future multi-site and longitudinal studies are recommended. Overall, the findings highlight the urgent need for systemic reforms, including nursing-inclusive ethics committees, secure employment structures, mental health support within ICUs, and ethics education. Addressing moral distress through institutional, cultural, and policy-level interventions is essential to safeguarding nurse well-being and improving patient care in Pakistan. Conclusion This study explored moral distress among critical care nurses working in a tertiary care hospital in Peshawar, Pakistan, focusing on its causes, psychological and professional consequences, and coping mechanisms. Guided by Andrew Jameton’s (1984) theory of moral distress and its contemporary extensions, the study provides an in-depth understanding of how moral distress is experienced and sustained within a resource-limited and socio-culturally complex healthcare environment. The findings indicate that moral distress among critical care nurses is primarily driven by institutional and systemic constraints rather than individual inadequacies. Hierarchical dominance, exclusion from clinical decision-making, and restricted professional autonomy emerged as central contributors, preventing nurses from acting in accordance with their ethical judgment. While these findings align with Jameton’s concept of constrained moral agency, the study further demonstrates how local socio-cultural factors such as patriarchal norms, contract-based employment, political influence, and VIP culture intensify ethical conflict and reinforce nurses’ sense of powerlessness within the Pakistani healthcare system. Ethical dilemmas related to futile care, end-of-life decision-making, and inequitable allocation of scarce resources further exacerbated moral distress. The absence of formal institutional policies, including clear do-not-resuscitate guidelines, compelled nurses to provide care that conflicted with their professional values, transforming moral distress into a persistent and cumulative experience, particularly within a low- and middle-income country context. The consequences of moral distress were substantial, affecting both psychological well-being and professional performance. Participants reported anxiety, sleep disturbances, emotional exhaustion, and moral residue consistent with the “crescendo effect” described in the literature. Moral distress impaired clinical judgment, increased the risk of errors, contributed to burnout, and led to disengagement and intentions to leave the profession. Additionally, its impact extended beyond the workplace, negatively affecting family relationships and overall quality of life. In the absence of adequate organisational support, nurses relied on individual coping strategies, peer support, and spirituality, which provided limited relief. These findings highlight the urgent need for systemic interventions. Addressing moral distress requires ethical leadership, inclusive decision-making structures, supportive institutional policies, and prioritisation of nurses’ psychological well-being to ensure safe, ethical, and high-quality patient care in Pakistan’s critical care settings. Declarations Human Ethics and Consent to Participate This study involved human participants. Ethical approval was obtained prior to data collection, and all procedures were conducted in accordance with the ethical standards of the approving committee and the Declaration of Helsinki. Written informed consent was obtained from all participants before participation in the study Ethics Approval Ethical approval for this study was obtained from the Ethical Review Committee (ERC), Aga Khan University, Karachi, Pakistan (ERC approval number: 2025-11300-34507 ) Appendix A. In addition, formal permission (No Objection Certificate) was obtained from Hayatabad Medical Complex, Peshawar, where the data were collected. Competing Interests The author declares that there are no competing interests. Use of Artificial Intelligence or Writing Assistance Tools The unpaid (free) version of Grammarly was used solely for grammar correction and language editing during manuscript preparation. The tool did not generate content, influence the study design, data analysis, interpretation of results, or scientific conclusions. The authors take full responsibility for the content of the manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution Rahman conceptualized and designed the study, conducted data collection, performed data analysis, and drafted the original manuscript. Rattani provided overall supervision, contributed to the study design, guided data analysis and interpretation, and critically reviewed and revised the manuscript for important intellectual content. Virani contributed to data interpretation and assisted in manuscript drafting and critical revision. Saleem supported methodological rigor, contributed to data interpretation, and critically reviewed the manuscript. All authors read and approved the final version of the manuscript. 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Qualitative Res Sport Exerc Health. 2019;11(4):589–97. Amankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3). Birt L, Scott S, Cavers D, Campbell C, Walter F. Member Checking: A Tool to Enhance Trustworthiness or Merely a Nod to Validation? Qual Health Res. 2016;26(13):1802–11. Ahmed SK. The pillars of trustworthiness in qualitative research. J Med Surg Public Health. 2024;2:100051. Parums DV, Editorial. The 2024 Revision of the Declaration of Helsinki and its Continued Role as a Code of Ethics to Guide Medical Research. Med Sci Monit. 2024;30:e947428. Millum J, Bromwich D. Informed consent: What must be disclosed and what must be understood? Am J Bioeth. 2021;21(5):46–58. Hoft J. Anonymity and confidentiality. The Encyclopedia of Research Methods in Criminology and Criminal Justice. 2021;1:223-7. Ferguson H, Anderson J. Professional dominance and the oppression of the nurse: The health system hierarchy. Australian Nurs Midwifery J. 2021;27(4):30–1. Delgado-Ron JA, Tiwana MH, Murage A, Morgan R, Purewal S, Smith J. Moral distress, coping mechanisms, and turnover intent among healthcare providers in British Columbia: a race and gender-based analysis. BMC Health Serv Res. 2024;24(1):925. Morley G, Bradbury-Jones C, Ives J, REASONS TO REDEFINE MORAL. DISTRESS: A FEMINIST EMPIRICAL BIOETHICS ANALYSIS. Bioethics. 2021;35(1):61–71. Miller PH, Epstein EG, Smith TB, Welch TD, Smith M, Bail JR. Critical care nurse leaders addressing moral distress: A qualitative study. Nurs Crit Care. 2024;29(4):835–8. Svantesson M, Griffiths F, White C, Bassford C, Slowther A. Ethical conflicts during the process of deciding about ICU admission: an empirically driven ethical analysis. J Med Ethics. 2021;47(12):e87. Booth AT, Robinson KL. Factors influencing healthcare professionals' moral distress: A descriptive qualitative analysis. Nurs Ethics. 2025;32(5):1564–78. Epstein EG, Whitehead PB, Prompahakul C, Thacker LR, Hamric AB. Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals. AJOB Empir Bioeth. 2019;10(2):113–24. Orgambídez A, Borrego Y, Alcalde FJ, Durán A. Moral Distress and Emotional Exhaustion in Healthcare Professionals: A Systematic Review and Meta-Analysis. Healthc (Basel). 2025;13(4). Witton N, Goldsworthy S, Phillips LA. Moral distress: Does this impact on intent to stay among adult critical care nurses? Nurs Crit Care. 2023;28(2):211–7. Villagran CA, Dalmolin GL, Barlem ELD, Greco PBT, Lanes TC, Andolhe R. Association between Moral Distress and Burnout Syndrome in university-hospital nurses. Rev Lat Am Enfermagem. 2023;31:e3747. Malik A, Javaid F, Gardezi SBB. Impact of Job Stress on Mental Health and Work-Life Balance: Cross-Sectional Study. J Prof Appl Psychol. 2024;5(4):640–52. Almeida M, Lobão C, Coelho A, Parola V. Emotional Management Strategies in Prehospital Nurses: A Scoping Review. Nurs Rep. 2023;13(4):1524–38. Morley G, Sankary LR. Nurturing moral community: A novel moral distress peer support navigator tool. Nurs Ethics. 2024;31(5):980–91. Additional Declarations No competing interests reported. Supplementary Files Interviewguide.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviews received at journal 10 Mar, 2026 Reviewers agreed at journal 10 Mar, 2026 Reviewers agreed at journal 09 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviews received at journal 20 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers invited by journal 15 Feb, 2026 Editor invited by journal 12 Feb, 2026 Editor assigned by journal 09 Feb, 2026 Submission checks completed at journal 06 Feb, 2026 First submitted to journal 06 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8706540\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":594488559,\"identity\":\"64ce8ccd-dccb-4e84-9ae0-11625217a83a\",\"order_by\":0,\"name\":\"khaleeq ur Rahman\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"khaleeq\",\"middleName\":\"ur\",\"lastName\":\"Rahman\",\"suffix\":\"\"},{\"id\":594488560,\"identity\":\"9c2255c9-fa39-4032-9cf2-cd00ede95295\",\"order_by\":1,\"name\":\"Dr. Salma Rattani\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":false,\"prefix\":\"Dr.\",\"firstName\":\"Salma\",\"middleName\":\"\",\"lastName\":\"Rattani\",\"suffix\":\"\"},{\"id\":594488561,\"identity\":\"6404a3b8-4162-4b2c-b5e4-93f649f0d95a\",\"order_by\":2,\"name\":\"Mehak Virani\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mehak\",\"middleName\":\"\",\"lastName\":\"Virani\",\"suffix\":\"\"},{\"id\":594488563,\"identity\":\"62567916-f74c-4c83-807f-1ef70f0680f3\",\"order_by\":3,\"name\":\"Zulekha Saleem\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Aga Khan University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zulekha\",\"middleName\":\"\",\"lastName\":\"Saleem\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-01-27 06:38:19\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8706540/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8706540/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":103507065,\"identity\":\"7f281249-a986-4307-9ace-8700b04ddc9c\",\"added_by\":\"auto\",\"created_at\":\"2026-02-26 13:40:20\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1013495,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8706540/v1/41b1ccbd-185f-4465-8d51-7e54ded9c987.pdf\"},{\"id\":103383603,\"identity\":\"5b02dda8-ebef-4878-a853-599259ae33a7\",\"added_by\":\"auto\",\"created_at\":\"2026-02-25 06:16:07\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":17792,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Interviewguide.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8706540/v1/d130e0bc80c88d72148695a2.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"\\u003cp\\u003eAn Exploratory Descriptive Study of Critical Care Nurses' Perspectives on Moral Distress in Diverse Healthcare Settings: The Causes, the Psychological Impact, and the Coping Strategies\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eMoral distress is an increasingly recognized ethical and psychological challenge within the nursing profession, particularly among nurses working in critical care settings. Critical care nurses are frequently exposed to complex clinical situations involving life-sustaining treatments, end-of-life decisions, resource limitations, and hierarchical decision-making structures. These circumstances often place nurses in positions where they are acutely aware of the ethically appropriate course of action but are unable to act accordingly due to institutional, legal, or professional constraints. This inability to act in alignment with one\\u0026rsquo;s moral and professional values generates moral distress, which can have profound consequences for nurses\\u0026rsquo; psychological well-being, professional integrity, and the quality of patient care delivered.\\u003c/p\\u003e \\u003cp\\u003eThe concept of moral distress was first introduced by Jameton, who defined it as the experience of knowing the ethically correct action to take while being constrained from taking that action by institutional barriers. This foundational definition has guided much of the early scholarship on moral distress in nursing. However, contemporary researchers argue that Jameton\\u0026rsquo;s original conceptualization does not fully encompass the breadth and complexity of moral distress. The concept was expanded to suggest that moral distress may also arise from moral uncertainty, conflict, dilemmas, and tension, rather than solely from external constraints (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). This broader understanding reflects the dynamic and multifaceted ethical challenges faced by nurses, particularly in high-acuity settings such as intensive care units (ICUs).\\u003c/p\\u003e \\u003cp\\u003eEmpirical research has consistently demonstrated that moral distress adversely affects nurses\\u0026rsquo; emotional and psychological health. Studies report strong associations between moral distress and burnout, compassion fatigue, emotional exhaustion, job dissatisfaction, and increased intention to leave the profession (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). In a study conducted among hemodialysis nurses in South Korea, moral distress particularly distress arising from physicians\\u0026rsquo; ethically questionable decisions was found to be a significant predictor of turnover intention. Nurses described experiencing profound psychological discomfort when witnessing actions they perceived as unethical but felt powerless to challenge due to hierarchical structures and limited authority (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Similarly, a national survey conducted in New Zealand revealed that nurses frequently experienced moral distress related to inadequate systemic support, managerial conflicts, workplace bullying, and witnessing poor or unsafe care practices. These unresolved experiences contributed to long-term psychological strain and professional dissatisfaction (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eEvidence further suggests that the intensity of moral distress varies across clinical settings. Inpatient and critical care nurses report higher levels of moral distress compared to outpatient nurses, largely due to their close involvement in end-of-life care, prolonged exposure to critically ill patients, and participation in ethically complex decision-making processes (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). Research conducted in intensive care units indicates that moderate to high levels of moral distress significantly impair nurses\\u0026rsquo; clinical judgment and decision-making capacity, potentially compromising patient safety and care quality (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e).Additional factors influencing moral distress include years of clinical experience, leadership roles, family involvement in care decisions, and the quality of managerial and organizational support (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eOrganizational and workplace characteristics also play a crucial role in the development of moral distress. High emotional demands, inadequate staffing, limited time for patient care, work\\u0026ndash;life conflict, insufficient social support, and minimal participation in decision-making have been identified as strong predictors of moral distress among nurses (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). When moral distress remains unaddressed, it often leads to burnout, deteriorating physical and mental health, and increased intentions to leave both the job and the nursing profession. Altogether, these outcomes pose serious implications for healthcare systems already struggling with nursing shortages and workforce instability (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eTo cope with moral distress, nurses adopt a range of strategies that may be broadly categorized as adaptive or maladaptive. Adaptive strategies include seeking peer support, engaging in ethical discussions, participating in self-care activities, practising mindfulness, and finding meaning in patient care. A qualitative study conducted among ICU nurses in Iran highlighted that nurses commonly relied on physical activity, humour, social interaction, rest, and moral support groups to mitigate the emotional burden of distress (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Conversely, maladaptive coping strategies such as emotional withdrawal, avoidance, normalization of unethical practices, and silence have also been reported, particularly in environments characterized by rigid hierarchies and fear of retaliation (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe issue of moral distress is particularly pronounced in low-resource and developing healthcare settings, where systemic shortages of staff, equipment, and essential medical supplies intensify ethical challenges. Nurses in these contexts frequently face situations in which they are unable to provide adequate care despite their professional commitment and moral intentions (\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). Early-career and novice nurses are especially vulnerable due to limited clinical experience, reduced ethical confidence, and lack of institutional support, making them more susceptible to moral distress and early career attrition (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eDespite the growing body of literature on moral distress, there remains a notable gap in research exploring its causes, psychological impact, and coping strategies among critical care nurses working in low-resource settings. Furthermore, limited empirical evidence exists regarding the effectiveness of coping mechanisms during large-scale crises such as pandemics, highlighting the urgent need for context-specific, evidence-based interventions (\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Addressing moral distress requires systemic approaches, including ethical education, supportive leadership, structured debriefing sessions, and the establishment of safe spaces for ethical dialogue (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eTherefore, this study aims to explore moral distress among critical care nurses, with a specific focus on its underlying causes, psychological and emotional impact, and the coping strategies nurses employ to sustain their professional roles. By examining moral distress within a low-resource healthcare context, this research seeks to contribute to the existing body of knowledge and inform the development of targeted interventions that support nurses\\u0026rsquo; well-being, enhance ethical practice, and ultimately improve patient care outcomes.\\u003c/p\\u003e\"},{\"header\":\"Methodology\",\"content\":\"\\u003cp\\u003eThis chapter outlines the methodological framework adopted to explore moral distress and coping strategies among critical care nurses working in intensive care units (ICUs) in Pakistan. It provides a detailed account of the research design, philosophical underpinnings, study setting, population, sampling strategy, data collection methods, data analysis, rigor, ethical considerations, and methodological limitations. The methodology was designed to capture nurses\\u0026rsquo; lived experiences within complex, resource-constrained clinical environments characteristic of low- and middle-income countries (LMICs).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eResearch Design\\u003c/h2\\u003e \\u003cp\\u003eAn Exploratory\\u0026ndash;Descriptive Qualitative Design (EDQ) was employed for this study. This design is particularly suited for investigating under-explored phenomena and gaining in-depth understanding of participants\\u0026rsquo; perspectives in their natural contexts (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). The study was guided by a constructivist\\u0026ndash;interpretivist paradigm, which assumes that reality is socially constructed and shaped by individual experiences and cultural contexts (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). From this perspective, moral distress is understood as a subjective and context-dependent experience rather than a uniform or measurable construct.\\u003c/p\\u003e \\u003cp\\u003eQualitative approaches are well suited to examining emotionally complex experiences such as moral distress, which cannot be adequately captured through quantitative measures alone (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). While surveys may quantify stress levels, they fail to reveal the ethical conflicts, emotional burden, and contextual pressures faced by ICU nurses. In contrast, qualitative inquiry allows exploration of the \\u0026ldquo;how\\u0026rdquo; and \\u0026ldquo;why\\u0026rdquo; of moral distress, providing rich narrative data grounded in participants\\u0026rsquo; own words ((\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe exploratory component was essential due to the limited empirical literature on moral distress among critical care nurses in Pakistan. This design enabled the researcher to enter the field without predefined hypotheses and to remain open to discovering context-specific sources of moral distress (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). The descriptive component aimed to present a comprehensive and faithful account of participants\\u0026rsquo; experiences, staying close to the data and preserving the authenticity of nurses\\u0026rsquo; voices (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eStudy Setting\\u003c/h3\\u003e\\n\\u003cp\\u003e The study was conducted in the ICUs of a large public-sector tertiary care teaching hospital in Peshawar, Khyber Pakhtunkhwa, Pakistan. As a major referral center, the hospital receives critically ill patients from across the province and neighboring Afghanistan, resulting in high patient acuity, resource constraints, and constant ethical challenges. Such environments are known to intensify moral distress among healthcare professionals (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ch3\\u003eStudy Population and Sampling\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study population comprised registered nurses (RNs) providing direct bedside care to adult ICU patients. These nurses were selected because of their continuous exposure to ethically challenging situations, making them particularly vulnerable to moral distress (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eA purposive sampling technique was used to recruit information-rich participants with relevant experience (\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e). Eligibility criteria included holding a valid Pakistan Nursing Council license, having at least one year of ICU experience, and being actively involved in direct patient care. Nurses in purely managerial roles or on temporary contracts were excluded to ensure contextual familiarity.\\u003c/p\\u003e \\u003cp\\u003eInitially, 35 nurses volunteered; 25 met the inclusion criteria. Due to refusals and scheduling conflicts, 15 nurses ultimately participated. Data saturation was achieved when no new themes emerged from the interviews (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ch3\\u003eData Collection\\u003c/h3\\u003e\\n\\u003cp\\u003eData were collected through semi-structured, in-depth interviews, chosen for their balance of consistency and flexibility (\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e). An interview guide was developed following a literature review on moral distress (\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e). And was piloted prior to data collection. Minor revisions were made, and pilot data were excluded from final analysis.\\u003c/p\\u003e \\u003cp\\u003eInterviews were conducted by the researcher, an ICU nurse fluent in English and Urdu, which facilitated rapport and trust. Interviews lasted 35\\u0026ndash;45 minutes, were audio-recorded with consent, and conducted in participants\\u0026rsquo; preferred language. Field notes capturing observational, contextual, and reflexive data were maintained to enrich interpretation (\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e). All data were securely stored and retained for seven years in accordance with AKU policy.\\u003c/p\\u003e\\n\\u003ch3\\u003eDevelopment of the Interview Guide\\u003c/h3\\u003e\\n\\u003cp\\u003eThe interview guide used in this study was developed specifically by the researcher for the purpose of this study and has not been previously published elsewhere. The development of the interview guide was informed by an extensive review of the relevant literature and aligned with the study objectives. To ensure content validity, clarity, and relevance, the interview guide was reviewed by six experts in the field (including experts in nursing ethics, qualitative research, and critical care). Based on their feedback, the interview questions were revised, reorganized, and refined to improve comprehensiveness and appropriateness. An English language version of the finalized interview guide has been uploaded as a supplementary file, and it has been appropriately cited in the main manuscript.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData Analysis\\u003c/h2\\u003e \\u003cp\\u003eData analysis followed (\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e). Six-phase thematic analysis: familiarization, coding, theme development, theme review, naming themes, and reporting. Transcripts were analyzed inductively to ensure findings were grounded in participants\\u0026rsquo; narratives. Analysis was conducted manually, allowing deep engagement with the data.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eRigor and Trustworthiness\\u003c/h3\\u003e\\n\\u003cp\\u003eStudy rigor was ensured using Lincoln and Guba\\u0026rsquo;s framework of credibility, transferability, dependability, and confirmability (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e). Credibility was enhanced through prolonged engagement, peer debriefing, triangulation, and member checking Birt, Scott (\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e). Transferability was supported through thick description of context and methods. Dependability and confirmability were ensured by maintaining a detailed audit trail and reflexive documentation (\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ch3\\u003eEthical Considerations\\u003c/h3\\u003e\\n\\u003cp\\u003e \\u003cstrong\\u003eEthical approval\\u003c/strong\\u003e \\u003cp\\u003e was obtained from the Aga Khan University Ethical Review Committee. The study adhered to the Declaration of Helsinki (\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e). Informed consent, confidentiality, anonymity, and participants\\u0026rsquo; emotional well-being were strictly maintained (\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMethodological Limitations\\u003c/h2\\u003e \\u003cp\\u003eAs a single-site qualitative study with a purposive sample, findings are not statistically generalizable. However, this limitation aligns with the study\\u0026rsquo;s aim of achieving depth and contextual understanding rather than generalization.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eThis chapter presents the findings of the study exploring moral distress among critical care nurses working in a tertiary care hospital in Peshawar, Pakistan. Data were generated through in-depth interviews and analysed using Braun and Clarke\\u0026rsquo;s thematic analysis framework. The analysis resulted in three overarching themes and eight subthemes, capturing the causes, psychological and professional impact, and coping responses related to moral distress. The findings are interpreted through Jameton\\u0026rsquo;s model of moral distress (1984) to provide theoretical coherence.\\u003c/p\\u003e \\u003cp\\u003eThe chapter is organised into two sections: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) demographic characteristics of the participants, and (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) thematic findings supported by verbatim excerpts from participants.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDemographic Characteristics of the Participants\\u003c/h2\\u003e \\u003cp\\u003eThe study sample consisted of 15 registered nurses working in adult Intensive Care Units (ICUs). All participants were directly involved in bedside patient care. Most participants were male (60%), aged between 25 and 35 years, and unmarried (73.3%). The majority held a Bachelor of Science in Nursing (86.7%), while a smaller proportion had a Master of Science in Nursing qualification. Most nurses had less than three years of ICU experience, reflecting an early-career workforce in a high-acuity environment. This homogeneity allowed for a focused exploration of shared ethical challenges within critical care.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eThematic Analysis of In-Depth Interviews\\u003c/h2\\u003e \\u003cp\\u003eUsing Braun and Clarke\\u0026rsquo;s six-step approach, the data were coded and organised into three major themes:\\u003c/p\\u003e \\u003cp\\u003e \\u003col\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eThe Genesis of Moral Distress\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eThe Pervasive Impact\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eNavigating the Aftermath\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003eThese themes align closely with Jameton\\u0026rsquo;s conceptualisation of moral distress as arising from institutional constraints that prevent morally appropriate action.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eTheme One: The Genesis of Moral Distress \\u0026ndash; A Conflict Between Ethics and Reality\\u003c/h2\\u003e \\u003cp\\u003eThis theme describes the origins of moral distress, reflecting Jameton\\u0026rsquo;s notion of constraint-based ethical conflict. Three subthemes emerged: hierarchical conflict, ethical dilemmas in patient care, and systemic resource constraints.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eHierarchical and Interprofessional Conflict\\u003c/h2\\u003e \\u003cp\\u003eParticipants repeatedly described feelings of powerlessness due to physician dominance and exclusion from decision-making. Nurses felt that their clinical knowledge was undervalued despite close patient contact. One participant stated, \\u003cem\\u003e\\u0026ldquo;Nurses are not allowed to make decisions\\u0026hellip; not allowing nurses to speak for themselves\\u0026rdquo;\\u003c/em\\u003e (P1). Another added, \\u003cem\\u003e\\u0026ldquo;They keep us away from patient families\\u0026hellip; we are not allowed to explain the disease process\\u0026rdquo;\\u003c/em\\u003e (P14). This hierarchical imbalance sometimes placed nurses at personal risk. A participant recalled, \\u003cem\\u003e\\u0026ldquo;In an HIV patient case, the consultant asked the nurse instead of the phlebotomist to take blood\\u0026hellip; I felt very bad\\u0026rdquo;\\u003c/em\\u003e (P7). Such incidents intensified moral distress by forcing nurses to act against professional fairness and self-protection.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEthical Dilemmas in Patient Care\\u003c/h2\\u003e \\u003cp\\u003eNurses described being compelled to provide futile care, particularly for terminally ill or brain-dead patients. One participant explained, \\u003cem\\u003e\\u0026ldquo;A brain-dead patient occupied the ventilator because of political influence\\u0026hellip; other patients suffered\\u0026rdquo;\\u003c/em\\u003e (P10). Another described unsafe transfers: \\u003cem\\u003e\\u0026ldquo;I knew shifting the patient would worsen the condition\\u0026hellip; later the patient expired\\u0026rdquo;\\u003c/em\\u003e (P2). These situations trapped nurses between ethical knowledge and institutional pressure.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSystemic and Resource Constraints\\u003c/h2\\u003e \\u003cp\\u003eResource scarcity was a pervasive trigger of moral distress. Unsafe nurse\\u0026ndash;patient ratios and inadequate equipment compromised care quality. One nurse stated, \\u003cem\\u003e\\u0026ldquo;Only two staff during CPR\\u0026hellip; if we had more staff, we could save the patient\\u0026rdquo;\\u003c/em\\u003e (P9). Another highlighted, \\u003cem\\u003e\\u0026ldquo;At a 1:3 ratio, it becomes very difficult\\u0026rdquo;\\u003c/em\\u003e (P7). The absence of formal end-of-life policies further intensified ethical uncertainty.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eTheme Two: The Pervasive Impact \\u0026ndash; Psychological and Professional Toll\\u003c/h2\\u003e \\u003cp\\u003eThis theme captures the deep and cumulative effects of moral distress on nurses\\u0026rsquo; mental health, professional performance, and personal lives.\\u003c/p\\u003e \\u003cp\\u003eEmotional and Psychological Fallout.Participants reported sleep disturbances, somatic symptoms, anxiety, and panic attacks. One nurse shared, \\u003cem\\u003e\\u0026ldquo;It affected us with headaches, frustration, and sleep problems\\u0026rdquo;\\u003c/em\\u003e (P1). Another described emotional breakdowns: \\u003cem\\u003e\\u0026ldquo;Sometimes I have panic attacks\\u0026hellip; I feel like crying and isolate myself\\u0026rdquo;\\u003c/em\\u003e (P4). These narratives reveal moral distress as a chronic psychological burden rather than isolated stress.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eProfessional and Personal Consequences\\u003c/h2\\u003e \\u003cp\\u003eMoral distress impaired concentration and patient safety. One participant stated, \\u003cem\\u003e\\u0026ldquo;Anxiety and burnout increase chances of error\\u0026rdquo;\\u003c/em\\u003e (P1). Another admitted, \\u003cem\\u003e\\u0026ldquo;Medication errors happened\\u0026hellip; I gave one patient\\u0026rsquo;s medicine to another\\u0026rdquo;\\u003c/em\\u003e (P10). These experiences intensified guilt and reinforced thoughts of leaving the profession: \\u003cem\\u003e\\u0026ldquo;I have thought about leaving my job multiple times\\u0026rdquo;\\u003c/em\\u003e (P2).\\u003c/p\\u003e \\u003cp\\u003eThe distress extended into family life. One nurse shared, \\u003cem\\u003e\\u0026ldquo;It disturbs relationships\\u0026hellip; we start with anger and go into isolation\\u0026rdquo;\\u003c/em\\u003e (P1). Another added, \\u003cem\\u003e\\u0026ldquo;At home, we fight\\u0026hellip; our sleep is disturbed\\u0026rdquo;\\u003c/em\\u003e (P15). Moral distress thus permeated both professional and personal domains.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec21\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eTheme Three: Navigating the Aftermath \\u0026ndash; Coping in a Constrained Environment\\u003c/h2\\u003e \\u003cp\\u003eThis theme explores how nurses cope with moral distress in the absence of institutional support.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec22\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eIndividual Coping Mechanisms and Informal Support\\u003c/h2\\u003e \\u003cp\\u003eNurses adopted avoidance, emotional withdrawal, and self-care as survival strategies. One participant explained, \\u003cem\\u003e\\u0026ldquo;I try to ignore what is happening\\u0026hellip; walking away to protect myself\\u0026rdquo;\\u003c/em\\u003e (P1). Others relied on spirituality and relaxation: \\u003cem\\u003e\\u0026ldquo;I go for fresh air, do breathing exercises, and pray\\u0026rdquo;\\u003c/em\\u003e (P2). In severe cases, professional help was required: \\u003cem\\u003e\\u0026ldquo;I went to a psychiatrist\\u0026hellip; he gave me medicine\\u0026rdquo;\\u003c/em\\u003e (P15).\\u003c/p\\u003e \\u003cp\\u003ePeer and family support emerged as essential coping resources. One participant noted, \\u003cem\\u003e\\u0026ldquo;Peer support is very fruitful\\u0026rdquo;\\u003c/em\\u003e (P1), while another shared, \\u003cem\\u003e\\u0026ldquo;My roommate counsels me\\u0026rdquo;\\u003c/em\\u003e (P9).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec23\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eThe Critical Need for Organisational Support\\u003c/h2\\u003e \\u003cp\\u003e Participants expressed fear of retaliation for speaking up. One nurse stated, \\u003cem\\u003e\\u0026ldquo;Fear of losing my job\\u0026hellip; salary might be withheld\\u0026rdquo;\\u003c/em\\u003e (P2). Contract-based employment intensified silence: \\u003cem\\u003e\\u0026ldquo;If the contract ends, they won\\u0026rsquo;t renew\\u0026rdquo;\\u003c/em\\u003e (P13). Administrative inaction further eroded trust, as noted by \\u003cem\\u003e\\u0026ldquo;They say \\u0026lsquo;we will solve it\\u0026rsquo; but never do\\u0026rdquo;\\u003c/em\\u003e (P1).Participants strongly advocated for ethics committees, leadership accountability, and regular ethics training. One nurse summarised, \\u003cem\\u003e\\u0026ldquo;Our responsibilities are high\\u0026hellip; we should be morally healthy\\u0026rdquo;\\u003c/em\\u003e (P14).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec24\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eTheoretical Integration: Jameton\\u0026rsquo;s Model\\u003c/h2\\u003e \\u003cp\\u003eJameton\\u0026rsquo;s (1984) model provides a coherent framework linking constraints (Theme One) to moral distress and residue (Theme Two), followed by coping responses and consequences (Theme Three\\u003cb\\u003e)\\u003c/b\\u003e. The findings illustrate a cyclical process where unresolved constraints perpetuate distress, leading nurses toward either resilience or burnout and exit\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study explored moral distress among critical care nurses working in a tertiary care hospital in Peshawar, Pakistan, with a focus on its causes, psychological and professional consequences, and coping mechanisms. Guided primarily by Andrew Jameton\\u0026rsquo;s (1984) theory of moral distress and extended through contemporary socio-cultural interpretations (\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e). the discussion integrates the study findings with existing literature while situating them within Pakistan\\u0026rsquo;s healthcare realities. The findings demonstrate that moral distress among nurses is not solely an ethical phenomenon but a deeply institutional, cultural, and systemic issue.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec26\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eThe Genesis of Moral Distress: Institutional and Societal Constraints\\u003c/h2\\u003e \\u003cp\\u003e Consistent with Jameton\\u0026rsquo;s original conceptualisation, moral distress in this study emerged primarily from institutional constraints that prevented nurses from acting in accordance with their ethical judgment. Hierarchical dominance by physicians and exclusion of nurses from decision-making were central triggers. Participants described persistent marginalisation despite their close involvement in patient care, reinforcing a sense of powerlessness. These findings align with international literature identifying interprofessional conflict and organisational hierarchy as core drivers of moral distress (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWithin the Pakistani context, these hierarchical dynamics are intensified by patriarchal social structures and entrenched authority gradients. Although the sample included mostly male nurses, accounts of gender-based discrimination and societal expectations were evident, indicating that gender functions as a mediating factor in moral distress. This observation supports calls for culturally nuanced research examining how gender norms shape ethical experiences in healthcare settings (\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e). Expanded framework is particularly relevant here, as it captures not only constraint-based distress but also moral conflict, indecision, and injustice reflected in participants\\u0026rsquo; narratives.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec27\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEthical Dilemmas, Futile Care, and Resource Constraints\\u003c/h2\\u003e \\u003cp\\u003eMoral distress was most pronounced in situations involving futile care and end-of-life decision-making. Nurses reported being compelled to continue aggressive treatment for patients with no realistic chance of recovery, often influenced by political pressure or VIP culture. Such situations directly conflicted with their professional values and contributed to systemic inefficiencies, including delayed care for other critically ill patients. Similar findings have been widely documented among ICU nurses globally (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThese ethical challenges were further exacerbated by chronic resource shortages and the absence of formal institutional policies, particularly regarding do-not-resuscitate (DNR) orders and end-of-life care. In low- and middle-income countries like Pakistan, limited ICU capacity, inadequate staffing, and lack of ethical guidelines intensify moral conflict (\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e). Meta-analyses confirm a strong association between resource scarcity and moral distress, highlighting the urgent need for systemic reforms (\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec28\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eThe Pervasive Impact: Psychological and Professional Consequences\\u003c/h2\\u003e \\u003cp\\u003eThe findings revealed that moral distress had profound psychological and physical consequences, including anxiety, sleep disturbances, headaches, panic attacks, and emotional exhaustion. These symptoms reflect the \\u0026ldquo;crescendo effect\\u0026rdquo; described by (\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e). Whereby repeated exposure to unresolved ethical conflicts accumulates as moral residue, progressively eroding psychological resilience. Participants\\u0026rsquo; descriptions of emotional withdrawal and loss of joy underscore the long-term mental health implications of moral distress.\\u003c/p\\u003e \\u003cp\\u003eConsistent with international evidence, moral distress was closely linked to burnout, compassion fatigue, and reduced quality of life (\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e). Beyond individual suffering, participants reported impaired concentration and clinical judgment, increasing the risk of medication errors and compromising patient safety. These findings reinforce the view that moral distress is not merely a personal issue but a significant threat to healthcare quality and safety (\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec29\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eProfessional Disengagement and Spillover Effects\\u003c/h2\\u003e \\u003cp\\u003eOngoing moral distress contributed to professional disengagement, reduced job satisfaction, and intentions to leave nursing. This aligns with previous studies identifying moral distress as a strong predictor of nurse turnover (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e). In resource-limited settings like Pakistan, such attrition further exacerbates workforce shortages and undermines continuity of care.\\u003c/p\\u003e \\u003cp\\u003eImportantly, moral distress extended beyond the workplace, affecting family relationships and social functioning. Participants described irritability, emotional withdrawal, and social isolation, findings echoed in global research on work\\u0026ndash;life imbalance among healthcare professionals (\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e). These spillover effects position moral distress as a broader public health concern rather than an isolated occupational issue.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eCoping Strategies in a Constrained Environment\\u003c/h3\\u003e\\n\\u003cp\\u003eIn the absence of robust organisational support, nurses relied heavily on individual coping strategies such as prayer, avoidance, emotional detachment, and peer support. While these strategies provided temporary relief, they were insufficient to address ongoing ethical stressors and, in some cases, led to psychiatric intervention. Similar patterns have been reported among ICU nurses internationally (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e). Highlighting the limitations of individual resilience in the face of systemic problems.\\u003c/p\\u003e \\u003cp\\u003ePeer and family support emerged as critical lifelines; however, overreliance on informal networks risks shifting institutional responsibility onto individuals. This finding aligns with moral community theory, which emphasises the need for collective and organisational responses to moral distress (\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec31\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eIntegrating and Extending Jameton\\u0026rsquo;s Framework\\u003c/h2\\u003e \\u003cp\\u003eWhile Jameton\\u0026rsquo;s (1984) framework effectively explains the core experience of moral distress as constrained moral agency, this study extends the theory by incorporating socio-cultural and systemic dimensions specific to Pakistan. Factors such as contract-based employment, VIP culture, gender norms, political influence, and weak regulatory structures shape how moral distress is experienced and sustained. These contextualised constraints demonstrate that moral distress is socially embedded and requires culturally responsive interventions.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec32\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStrengths, Limitations, and Implications\\u003c/h2\\u003e \\u003cp\\u003eThe study\\u0026rsquo;s qualitative depth and focus on an underrepresented LMIC context are key strengths, offering culturally grounded insights into moral distress. However, limitations include its single-site design, small sample size, and reliance on self-reported data. Future multi-site and longitudinal studies are recommended.\\u003c/p\\u003e \\u003cp\\u003eOverall, the findings highlight the urgent need for systemic reforms, including nursing-inclusive ethics committees, secure employment structures, mental health support within ICUs, and ethics education. Addressing moral distress through institutional, cultural, and policy-level interventions is essential to safeguarding nurse well-being and improving patient care in Pakistan.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003e This study explored moral distress among critical care nurses working in a tertiary care hospital in Peshawar, Pakistan, focusing on its causes, psychological and professional consequences, and coping mechanisms. Guided by Andrew Jameton\\u0026rsquo;s (1984) theory of moral distress and its contemporary extensions, the study provides an in-depth understanding of how moral distress is experienced and sustained within a resource-limited and socio-culturally complex healthcare environment.\\u003c/p\\u003e \\u003cp\\u003eThe findings indicate that moral distress among critical care nurses is primarily driven by institutional and systemic constraints rather than individual inadequacies. Hierarchical dominance, exclusion from clinical decision-making, and restricted professional autonomy emerged as central contributors, preventing nurses from acting in accordance with their ethical judgment. While these findings align with Jameton\\u0026rsquo;s concept of constrained moral agency, the study further demonstrates how local socio-cultural factors such as patriarchal norms, contract-based employment, political influence, and VIP culture intensify ethical conflict and reinforce nurses\\u0026rsquo; sense of powerlessness within the Pakistani healthcare system.\\u003c/p\\u003e \\u003cp\\u003eEthical dilemmas related to futile care, end-of-life decision-making, and inequitable allocation of scarce resources further exacerbated moral distress. The absence of formal institutional policies, including clear do-not-resuscitate guidelines, compelled nurses to provide care that conflicted with their professional values, transforming moral distress into a persistent and cumulative experience, particularly within a low- and middle-income country context.\\u003c/p\\u003e \\u003cp\\u003eThe consequences of moral distress were substantial, affecting both psychological well-being and professional performance. Participants reported anxiety, sleep disturbances, emotional exhaustion, and moral residue consistent with the \\u0026ldquo;crescendo effect\\u0026rdquo; described in the literature. Moral distress impaired clinical judgment, increased the risk of errors, contributed to burnout, and led to disengagement and intentions to leave the profession. Additionally, its impact extended beyond the workplace, negatively affecting family relationships and overall quality of life.\\u003c/p\\u003e \\u003cp\\u003eIn the absence of adequate organisational support, nurses relied on individual coping strategies, peer support, and spirituality, which provided limited relief. These findings highlight the urgent need for systemic interventions. Addressing moral distress requires ethical leadership, inclusive decision-making structures, supportive institutional policies, and prioritisation of nurses\\u0026rsquo; psychological well-being to ensure safe, ethical, and high-quality patient care in Pakistan\\u0026rsquo;s critical care settings.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003cb\\u003eHuman Ethics and Consent to Participate\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003eThis study involved human participants. Ethical approval was obtained prior to data collection, and all procedures were conducted in accordance with the ethical standards of the approving committee and the Declaration of Helsinki. Written informed consent was obtained from all participants before participation in the study\\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eEthics Approval\\u003c/strong\\u003e \\u003cp\\u003eEthical approval for this study was obtained from the Ethical Review Committee (ERC), Aga Khan University, Karachi, Pakistan (ERC approval number: 2025-11300-34507\\u003cb\\u003e) Appendix A.\\u003c/b\\u003e In addition, formal permission (No Objection Certificate) was obtained from Hayatabad Medical Complex, Peshawar, where the data were collected.\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eCompeting Interests\\u003c/h2\\u003e \\u003cp\\u003eThe author declares that there are no competing interests.\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eUse of Artificial Intelligence or Writing Assistance Tools\\u003c/h2\\u003e \\u003cp\\u003eThe unpaid (free) version of Grammarly was used solely for grammar correction and language editing during manuscript preparation. The tool did not generate content, influence the study design, data analysis, interpretation of results, or scientific conclusions. The authors take full responsibility for the content of the manuscript.\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eFunding\\u003c/h2\\u003e \\u003cp\\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eRahman conceptualized and designed the study, conducted data collection, performed data analysis, and drafted the original manuscript. Rattani provided overall supervision, contributed to the study design, guided data analysis and interpretation, and critically reviewed and revised the manuscript for important intellectual content. Virani contributed to data interpretation and assisted in manuscript drafting and critical revision. Saleem supported methodological rigor, contributed to data interpretation, and critically reviewed the manuscript. All authors read and approved the final version of the manuscript.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to ethical considerations and participant confidentiality but are available from the corresponding author on reasonable request.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eMorley G, Bradbury-Jones C, Ives J. What is 'moral distress' in nursing? A feminist empirical bioethics study. Nurs Ethics. 2020;27(5):1297\\u0026ndash;314.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGiannetta N, Sergi R, Villa G, Pennestr\\u0026igrave; F, Sala R, Mordacci R et al. Levels of Moral Distress among Health Care Professionals Working in Hospital and Community Settings: A Cross Sectional Study. Healthc (Basel). 2021;9(12).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKim H, Kim H, Oh Y. Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study. BMC Nurs. 2023;22(1):55.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWoods M. Moral distress revisited: the viewpoints and responses of nurses. Int Nurs Rev. 2020;67(1):68\\u0026ndash;75.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMauro M, Grigoletto A, Zambon MC, Bettocchi M, Pegreffi F, Fimognari C, et al. The Evaluation of Physical Activity Habits in North Italian People before and during COVID-19 Quarantine: A Pilot Study. Int J Environ Res Public Health. 2022;19(3):1660.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAl-Turfi MK, Al-Jubouri MB. Effect of moral distress on decision making among nurses in intensive care units. Pakistan J Med Health Sci. 2022;16(03):915.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNordin A, Engstr\\u0026ouml;m \\u0026Aring;, Fredholm A, Persenius M, Andersson M. Measuring moral distress in Swedish intensive care: Psychometric and descriptive results. Intensive Crit Care Nurs. 2023;76:103376.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePetersen J, Melzer M. Predictors and consequences of moral distress in home-care nursing: A cross-sectional survey. Nurs Ethics. 2023;30(7\\u0026ndash;8):1199\\u0026ndash;216.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEsmaeili M, Navidhamidi M, Varasteh S. Coping strategies of intensive care unit nurses reducing moral distress: A content analysis study. Nurs Ethics. 2024;31(8):1586\\u0026ndash;99.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAfoko V, Hewison A, Newham R, Neilson S. Moral distress in nurses in developing economies: an integrative literature review. J Res Nurs. 2023;28(8):609\\u0026ndash;27.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVittone S, Sotomayor CR. Moral Distress Entangled: Patients and Providers in the COVID-19 Era. HEC Forum. 2021;33(4):415\\u0026ndash;23.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBecker RP. The Impact of Moral Distress on Staff and Novice Nurses. J Christ Nurs. 2024;41(1):50\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGhazanfari MJ, Esmaeili S, Emami Zeydi A, Karkhah S. Moral distress among nurses during COVID-19 pandemic: Challenges and coping strategies. Nurs Open. 2022;9(4):2227\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSalari N, Shohaimi S, Khaledi-Paveh B, Kazeminia M, Bazrafshan MR, Mohammadi M. The severity of moral distress in nurses: a systematic review and meta-analysis. Philos Ethics Humanit Med. 2022;17(1):13.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSilverman HJ, Kheirbek RE, Moscou-Jackson G, Day J. Moral distress in nurses caring for patients with Covid-19. Nurs Ethics. 2021;28(7\\u0026ndash;8):1137\\u0026ndash;64.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCreswell J. Qualitative Inquiry \\u0026amp; Research Design: Choosing Among Five Approaches. SAGE Publications. 2013;11.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTurin TC, Raihan M, Chowdhury N. Paradigms of approaches to research. Bangabandhu Sheikh Mujib Med Univ J. 2024;17(2):e73973\\u0026ndash;e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMoser A, Korstjens I, Series. Practical guidance to qualitative research. Part 1: Introduction. Eur J Gen Pract. 2017;23(1):271\\u0026ndash;3.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlmeida F, Faria D, Queir\\u0026oacute;s A. Strengths and Limitations of Qualitative and Quantitative Research Methods. Eur J Educ Stud. 2017;3:369\\u0026ndash;87.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRutledge P. In-Depth Interviews. 2020:1\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSaka R, Chinagozi O, Joe O. Exploratory Research Design in Management Science: A Review of Literature on Conduct and Application. Int J Res Innov Social Sci. 2023;VII:1384\\u0026ndash;95.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSwaraj A. Exploratory research: Purpose and process. Parisheelan J. 2019;15(2):665\\u0026ndash;70.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGrove SK, Gray JR. Understanding nursing research: First South Asia Edition, E-Book: building an evidence-based practice. Elsevier Health Sciences; 2019.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSasidharan S, Dhillon HS. Intensive care unit stress and burnout among health-care workers: The wake-up call is blaring! Indian J Psychiatry. 2021;63(6):606\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eXavier T, Hittle BM, Rojas-Guyler L, Lee RC. Resilience in Intensive Care Unit Nurses: An Integrative Review. Crit Care Nurse. 2024;44(6):52\\u0026ndash;63.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSalas-Berg\\u0026uuml;\\u0026eacute;s V, Pereira-S\\u0026aacute;nchez M, Mart\\u0026iacute;n-Mart\\u0026iacute;n J, Olano-Lizarraga M. Development of burnout and moral distress in intensive care nurses: An integrative literature review. Enferm Intensiva (Engl Ed). 2024;35(4):376\\u0026ndash;409.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTajik O, Golzar J, Noor S. Purposive Sampl. 2024;2:1\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eStratton SJ. Purposeful Sampling: Advantages and Pitfalls. Prehosp Disaster Med. 2024;39(2):121\\u0026ndash;2.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKallio H, Pietil\\u0026auml; AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016;72(12):2954\\u0026ndash;65.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMorley G, Ives J, Bradbury-Jones C, Irvine F. What is 'moral distress'? A narrative synthesis of the literature. Nurs Ethics. 2019;26(3):646\\u0026ndash;62.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJameton A. Nursing practice: The ethical issues. 1984.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePhillippi J, Lauderdale J. A Guide to Field Notes for Qualitative Research: Context and Conversation. Qual Health Res. 2018;28:381\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBraun V. Reflecting on reflexive thematic analysis. Qualitative Res Sport Exerc Health. 2019;11(4):589\\u0026ndash;97.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAmankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBirt L, Scott S, Cavers D, Campbell C, Walter F. Member Checking: A Tool to Enhance Trustworthiness or Merely a Nod to Validation? Qual Health Res. 2016;26(13):1802\\u0026ndash;11.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAhmed SK. The pillars of trustworthiness in qualitative research. J Med Surg Public Health. 2024;2:100051.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eParums DV, Editorial. The 2024 Revision of the Declaration of Helsinki and its Continued Role as a Code of Ethics to Guide Medical Research. Med Sci Monit. 2024;30:e947428.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMillum J, Bromwich D. Informed consent: What must be disclosed and what must be understood? Am J Bioeth. 2021;21(5):46\\u0026ndash;58.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHoft J. Anonymity and confidentiality. The Encyclopedia of Research Methods in Criminology and Criminal Justice. 2021;1:223-7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFerguson H, Anderson J. Professional dominance and the oppression of the nurse: The health system hierarchy. Australian Nurs Midwifery J. 2021;27(4):30\\u0026ndash;1.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDelgado-Ron JA, Tiwana MH, Murage A, Morgan R, Purewal S, Smith J. Moral distress, coping mechanisms, and turnover intent among healthcare providers in British Columbia: a race and gender-based analysis. BMC Health Serv Res. 2024;24(1):925.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMorley G, Bradbury-Jones C, Ives J, REASONS TO REDEFINE MORAL. DISTRESS: A FEMINIST EMPIRICAL BIOETHICS ANALYSIS. Bioethics. 2021;35(1):61\\u0026ndash;71.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMiller PH, Epstein EG, Smith TB, Welch TD, Smith M, Bail JR. Critical care nurse leaders addressing moral distress: A qualitative study. Nurs Crit Care. 2024;29(4):835\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSvantesson M, Griffiths F, White C, Bassford C, Slowther A. Ethical conflicts during the process of deciding about ICU admission: an empirically driven ethical analysis. J Med Ethics. 2021;47(12):e87.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBooth AT, Robinson KL. Factors influencing healthcare professionals' moral distress: A descriptive qualitative analysis. Nurs Ethics. 2025;32(5):1564\\u0026ndash;78.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEpstein EG, Whitehead PB, Prompahakul C, Thacker LR, Hamric AB. Enhancing Understanding of Moral Distress: The Measure of Moral Distress for Health Care Professionals. AJOB Empir Bioeth. 2019;10(2):113\\u0026ndash;24.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOrgamb\\u0026iacute;dez A, Borrego Y, Alcalde FJ, Dur\\u0026aacute;n A. Moral Distress and Emotional Exhaustion in Healthcare Professionals: A Systematic Review and Meta-Analysis. Healthc (Basel). 2025;13(4).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWitton N, Goldsworthy S, Phillips LA. Moral distress: Does this impact on intent to stay among adult critical care nurses? Nurs Crit Care. 2023;28(2):211\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eVillagran CA, Dalmolin GL, Barlem ELD, Greco PBT, Lanes TC, Andolhe R. Association between Moral Distress and Burnout Syndrome in university-hospital nurses. Rev Lat Am Enfermagem. 2023;31:e3747.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMalik A, Javaid F, Gardezi SBB. Impact of Job Stress on Mental Health and Work-Life Balance: Cross-Sectional Study. J Prof Appl Psychol. 2024;5(4):640\\u0026ndash;52.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlmeida M, Lob\\u0026atilde;o C, Coelho A, Parola V. Emotional Management Strategies in Prehospital Nurses: A Scoping Review. Nurs Rep. 2023;13(4):1524\\u0026ndash;38.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMorley G, Sankary LR. Nurturing moral community: A novel moral distress peer support navigator tool. Nurs Ethics. 2024;31(5):980\\u0026ndash;91.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":true,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-nursing\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"nurs\",\"sideBox\":\"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/nurs/default.aspx\",\"title\":\"BMC Nursing\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Moral distress, psychological impact, coping mechanism, hierarchical barriers\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8706540/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8706540/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eBackground\\u003cbr\\u003e\\nMoral distress is a significant issue among critical care nurses who frequently encounter ethically complex situations that contradict their moral and professional values. In Pakistan, research on this phenomenon remains limited particularly regarding how nurses in different healthcare setting perceive and manage moral distress.\\u003cbr\\u003e\\nObjective\\u003cbr\\u003e\\nThis study aimed to explore perspective of critical care nurses on the causes, psychological impact of moral distress and the strategy they use to deal with moral distress in diverse healthcare settings.\\u003cbr\\u003e\\n Methods\\u003cbr\\u003e\\nAn exploratory descriptive qualitative design was used to evaluate the phenomenon, data was gathered through in-depth interviews with critical care nurses working in public sector tertiary care setting in Peshawar Pakistan. A purposive sampling technique was used to select participants with at least one year experience of working in an Intensive Care Unit. A total of 35 nurses volunteered to participate in the study. Among these 15 were interviewed based on their eligibility and availability. The data was transcribed and then analysed using a thematic analysis framework to identify themes and patterns.\\u003cbr\\u003e\\n Result\\u003cbr\\u003e\\nThree themes were extracted Theme One: ‘The Genesis of Moral Distress - A Conflict Between Ethics and Reality’, theme two: ‘the Pervasive Impact, the Psychological and Professional toll’ and theme three: ‘Navigating the Aftermath: Coping in a Constrained Environment’.\\u003cbr\\u003e\\nFindings suggest that moral distress arises from factors such as inadequate staffing, the hierarchical system in Pakistan which gives dominance to physician over nurses, systemic and resources constraint, The cohort verbalizes the consequences of moral distress includes anxiety, emotional breakdown and reduced job satisfaction lead to burnout. Coping mechanism included avoidance and detachment, peer and family support and spiritual healing, there was a lack of organizational support for coping with moral distress, participants urged for a structure and formal support from organization to mitigate moral distress.\\u003c/p\\u003e\\n\\u003cp\\u003eConclusion\\u003cbr\\u003e\\nThe study underscores urgent need for organizational support, ethical education and supportive leadership to address moral distress among critical care nurses which directly affect patients care.\\u003c/p\\u003e\",\"manuscriptTitle\":\"An Exploratory Descriptive Study of Critical Care Nurses' Perspectives on Moral Distress in Diverse Healthcare Settings: The Causes, the Psychological Impact, and the Coping Strategies\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-25 06:16:02\",\"doi\":\"10.21203/rs.3.rs-8706540/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-03-17T05:04:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"203970808723147751837269520091243742470\",\"date\":\"2026-03-10T15:20:12+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-03-10T08:15:33+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"191373612044532462627293447804866360531\",\"date\":\"2026-03-10T06:05:49+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"256347525638852535343159548600625154667\",\"date\":\"2026-03-09T06:30:05+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"315247324247124312917512448886064156676\",\"date\":\"2026-03-08T16:12:31+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-20T13:46:56+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"176282680939583326392855385096136814782\",\"date\":\"2026-02-15T15:59:01+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-15T14:06:01+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-02-12T07:16:21+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-02-09T07:00:21+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-02-06T12:04:39+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Nursing\",\"date\":\"2026-02-06T11:28:17+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-nursing\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"nurs\",\"sideBox\":\"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/nurs/default.aspx\",\"title\":\"BMC Nursing\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"75a260e8-b736-418b-8240-0d9fd1838a73\",\"owner\":[],\"postedDate\":\"February 25th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-22T07:10:14+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-02-25 06:16:02\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8706540\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8706540\",\"identity\":\"rs-8706540\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}