Ethical Conflict and Moral Distress of Intensive Care Nurses in End-of-Life Care: A Systematic Review and Strategies for Enhancing Ethical Decision- Making

Ethical Conflict and Moral Distress of Intensive Care Nurses in End-of-Life Care: A Systematic Review and Strategies for Enhancing Ethical Decision- Making | 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 Ethical Conflict and Moral Distress of Intensive Care Nurses in End-of-Life Care: A Systematic Review and Strategies for Enhancing Ethical Decision- Making MohammadReza Jokar, Maasoumeh Barkhordari-Sharifabad, Anahita Nooriyekta This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8319546/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background : Nurses, particularly those working in critical care and palliative settings, often encounter ethical conflicts when facing end-of-life (EoL) situations that involve complex clinical and moral considerations. Repeated exposure to such dilemmas can lead to moral distress. Ethical conflict and moral distress, although conceptually distinct, are closely interrelated phenomena that can significantly influence nurses’ ethical decision-making. Objective : This systematic review has a two-fold objective: (1) to identify and synthesize the principal drivers of ethical conflict and moral distress experienced by nurses in EoL care, and (2) to synthesize and critically evaluate evidence-based, multi-level strategies designed to mitigate moral distress and enhance ethical decision-making. Results : Thematic synthesis revealed three primary drivers: Conflict over Medical Futility, Family-Related Conflicts, and Systemic/Interprofessional Tensions. Synthesized strategies were categorized as Individual-Level (e.g., resilience training), Team-Level (e.g., formal ethics consultations), and Organizational-Level (e.g., transformational leadership). Conclusions : Ethical Conflict in EoL care is a systemic, relational, and organizational problem. While individual strategies offer coping mechanisms, the most effective interventions are systemic, focusing on creating an organizational "just culture," empowering nurses' voices in decision-making, and fostering interprofessional respect. Ethical Conflict Moral Distress End-of-Life Care Intensive Care Units Nursing Decision-Making Structural Empowerment Resilience 1. Introduction In contemporary healthcare, registered nurses are the professionals most intimately and consistently present with patients and families during the end-of-life (EoL) trajectory [1]. This proximity is particularly acute in settings of high technological saturation, such as the Intensive Care Unit (ICU), where approximately one in five Americans will die [2]. In this environment, the nurse stands at the nexus of technological possibility and humane limitation, tasked with reconciling the biomedical drive to sustain life with the ethical imperative to ensure comfort, relieve suffering, and facilitate a dignified death [3]. This role necessitates walking an "ethical tightrope," balancing competing values, managing complex family dynamics, and implementing intensive care plans, often under significant systemic pressure. ICU nurses often face ethical conflicts, balancing life-sustaining interventions with patients’ wishes and family expectations, and implementing intensive care plans, which places them at higher risk of moral distress. 1.1 Differentiating Ethical Conflict from Moral Distress [Times New Roman 10 pt, Justified] To analyze the challenges nurses face, it is imperative to distinguish between two fundamental concepts: ethical conflict and moral distress. An ethical conflict represents a state of uncertainty, arising from a clash between two or more equally justifiable, competing ethical principles [4]. In such a dilemma, no single "right" action is immediately apparent, and the process involves weighing principles like patient autonomy against beneficence [5]. Moral distress, conversely, is not a problem of uncertainty. As first defined in the seminal work of Jameton, moral distress is a profound psychological disequilibrium that arises when one knows the ethically appropriate action to take but is constrained from acting upon that judgment [6,21]. These constraints are typically external, including institutional policies, lack of administrative support, power imbalances, or interprofessional disagreement [7]. This distinction is critical: the pathology of moral distress is not a failure of the nurse's ethical reasoning but rather a failure of the system to permit ethically-grounded action. It is, at its core, a phenomenon of disempowerment [12]. 1.2 The Literature Gap and Review Objective The body of literature identifying moral distress and moral conflict as a significant problem for nurses has expanded exponentially since 2011 [8]. Countless descriptive and qualitative studies have meticulously documented its prevalence and causes[13]. However, a significant gap persists in the synthesis of clinically-actionable, evidence-based, and multi-level strategies to address it [14]. This review seeks to move beyond mere problem identification to a critical synthesis of solutions. This systematic review will address the identified gap by pursuing a two-fold objective: To identify and thematically synthesize the drivers of ethical conflict and moral distress for registered nurses in EoL care settings; and to synthesize and critically appraise the evidence for interventions—at the individual, team, and organizational levels—designed to mitigate moral distress and enhance ethical decision-making. 2. Methods A systematic search of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines[ 17 ]. Four electronic databases were comprehensively searched: PubMed (MEDLINE), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and PsycINFO [ 18 ]. The search was confined to articles published between January 1, 2015, and September 30, 2025, to ensure the review captures the contemporary landscape of clinical practice, ethical challenges, and interventional research. The search strategy utilized a robust combination of MeSH (Medical Subject Headings) terms and free-text keywords, adapted for the syntax of each database. The core search string was: (("Moral Distress" OR "Ethical Conflict*") OR "Moral Residue") AND ("Nurs*" OR "Nurse" OR "Nurses") AND (("End-of-Life Care" OR "Terminal Care" OR "Palliative Care" OR "Hospice Care") OR ("Critical Care" OR "Intensive Care Unit" OR "ICU")). 2.1. Inclusion and Exclusion Criter i Studies were selected based on pre-specified criteria. Inclusion Criteria: (1) Peer-reviewed, full-text original research (qualitative, quantitative, or mixed-methods) or systematic reviews; (2) Published in the English language; (3) Publication dates between 2015–2025; (4) The population of interest was Registered Nurses (RNs) or interprofessional teams including RNs; (5) The context of the study was end-of-life care, palliative care, critical care (ICU), or oncology. Exclusion Criteria: (1) Editorials, commentaries, letters, dissertations, abstracts, or case reports; (2) Studies not focused on nurses or EoL/critical care settings. Two reviewers independently screened all titles and abstracts. Articles deemed potentially eligible underwent a full-text review by both reviewers. 3. Results The thematic synthesis of the included articles revealed three dominant, interconnected themes that function as the primary drivers of ethical conflict and moral distress for registered nurses in EoL care settings. 3.1. Theme 1: The Weight of Futility This was the most frequently and intensely cited driver of moral distress, particularly in critical care environments. Nurses reported profound psychological distress from being the primary implementers of treatments they perceived as "futile," non-beneficial, or as merely "prolonging the dying process" [ 5 ]. This distress is rooted in the conflict between the nurse's ethical duty of beneficence and the institutional or physician-led mandate to continue aggressive interventions, such as ventilation, vasopressors, or dialysis, against a patient's perceived best interests [ 5 ]. This conflict is often exacerbated when healthcare providers believe further treatment is unlikely to provide benefit, yet family members request its continuation [ 19 ]. 3.2. Theme 2: Navigating Relational Tensions] This theme encompasses the distress arising from complex and often broken communication dynamics. Family-Related Conflicts : This category includes the stress of managing unrealistic family expectations about prognosis, mediating disagreements between family members and the healthcare team regarding care goals, and the inability to satisfy a patient's final requests [ 20 ]. Critically, nurses also reported distress from witnessing poor, incomplete, or delayed communication delivered to families by other members of the healthcare team [ 20 ]. Interprofessional Conflicts : Poor communication and collaboration between healthcare professionals were identified as pivotal factors in the development of moral conflict [ 10 ]. Differing opinions on care goals, value conflicts, and perceived disrespect between physicians and nurses create an environment ripe for ethical conflict and nurse distress. 3.3. Theme 3: The Systemic Architecture of Distress This theme moves beyond the immediate bedside encounter to the underlying context in which care is delivered. Evidence from qualitative studies highlights a crucial difference in the nature of distress: nurses' distress was overwhelmingly linked to "providing care without participation in decision-making" [ 22 ]. This sense of powerlessness within hierarchical team structures was a primary source of constraint [ 9 ]. Furthermore, systemic failures were identified as key drivers. Nurses reported moral distress caused by organizational factors that compromised their ability to provide the standard of care they felt was ethically required. These factors included inadequate staffing [ 23 ], a poor institutional "ethical climate" [ 25 ], a lack of administrative support [ 11 ], and conflicts over the allocation of scarce resources [ 5 ]. The inability to provide dignified care (e.g., adequate turning, comfort measures, presence) due to heavy workloads and time constraints was a potent and frequent source of moral distress [ 26 ]. 4. Discussion The second objective of this review was to synthesize and appraise interventions to mitigate moral distress. The strategies identified in the literature fall into three distinct, yet complementary, levels: individual, team, and organizational. 4.1. Individual-Level A large portion of the literature focuses on interventions aimed at "bolstering" the individual nurse. These strategies include Ethics Education designed to improve ethical reasoning and "moral agency" [ 27 ]; Resilience and Mindfulness Training (e.g., MBSR, yoga) to help nurses manage acute distress [ 15 , 18 ]; and Debriefing and Narrative Medicine to allow staff to process difficult cases [ 31 , 32 ]. While these strategies provide valuable coping tools, a critical analysis reveals they are profoundly insufficient on their own. Moral distress is often linked to "systems trauma" [ 29 ], and an exclusive focus on individual resilience creates a "blaming the victim" paradigm [ 16 ]. These interventions often treat the symptom but fail to address the pathology (external constraints). 4.2. Team-Level Interventions This set of strategies targets the relational and communication-based drivers of distress. Formal Ethics Consultation provides a mechanism for mediating value conflicts, particularly in disputes over medical futility [ 19 ]. However, barriers such as hierarchical intimidation often limit their use [ 35 ]. Structured Communication Protocols represent high-impact interventions. The literature highlights the value of proactive, structured interdisciplinary family meetings and ethics rounds [ 19 ]. Studies found that intensive communication structures flattened the "clinical hierarchy" and directly addressed disempowerment by ensuring nurses had input into the care plan [ 22 , 38 ]. 4.3. Organizational and Policy Interventions These strategies target the systemic drivers and represent the most effective solutions. As the core of moral distress is disempowerment [ 12 ], the effective antidote is structural empowerment [ 39 ]. This involves creating policies that provide nurses with autonomy and a voice in governance. Additionally, Transformational Leadership is a key antecedent, fostering a "just culture" and psychological safety that allows nurses to speak up without fear [ 36 , 40 ].A comprehensive synthesis of these evidence-based strategies, categorized by level of intervention, is presented in Table 1 . Table 1 Synthesis of Evidence-Based Strategies to Mitigate Moral Distress Level of Intervention Strategy/Intervention Type Mechanism of Action & Key Evidence Key Citations Individual Ethics Education & Competence Builds "moral agency" and ethical reasoning skills. [ 27 ] Resilience / Mindfulness Provides individual coping tools to buffer acute distress. Includes mindfulness, yoga, and somatic interventions. [ 28 , 29 , 30 ] Narrative Medicine / Debriefing Allows for processing of traumatic or distressing events. Reduces immediate negative psychological effects. [ 31 , 32 , 33 ] Team / Interprofessional Formal Ethics Consultation Provides a neutral, expert forum to mediate value conflicts. Particularly effective for futility and surrogate decision-making disputes. [ 19 , 34 , 37 ] Structured Interdisciplinary Communication Critically unifies the team's prognostic understanding. Flattens hierarchy by ensuring nurses have access to and input into care plan. [ 19 , 38 ] Organizational / Systemic Transformational / Supportive Leadership Fosters a "just culture" and psychological safety. Leaders' actions are a key mediator for nurse work environment and empowerment. [ 40 ] Structural Empowerment The organizational antidote to individual disempowerment. Involves policies that give nurses autonomy, resources, and a voice in governance. [ 39 ] Policy & Staffing Clear policies on EoL/DNR. Adequate staffing to ensure nurses can provide care they deem "dignified." [ 11 , 24 , 26 ] 5. Conclusions The moral distress of nurses in end-of-life care is not an inevitable "cost of caring." It is a clear and persistent signal of systemic, relational, and organizational dysfunction. The evidence synthesized in this review demonstrates that while the problem is often experienced by the individual nurse, its drivers—and therefore its solutions—are communal and systemic. Focusing on individual "resilience" is an inadequate response to the "systems trauma" [ 29 ] nurses experience. The path forward requires a multi-level approach, moving from individual coping to team-based communication and, ultimately, to organizational transformation. By fostering transformational leadership [ 40 ], structurally empowering nurses [ 39 ], and championing interprofessional collaboration [ 38 ], healthcare institutions can create the ethically-just environments necessary to uphold both the dignity of the patient and the moral integrity of the nurse. "Despite its contributions, this systematic review has certain limitations. The search was restricted to English-language studies, potentially overlooking relevant research in other languages. Additionally, the findings are primarily based on qualitative and descriptive evidence, which limits the ability to draw definitive causal conclusions about the effectiveness of the identified strategies. Future research should employ longitudinal or experimental designs to further validate these interventions across diverse clinical settings." Abbreviations ICU: Intensive Care Unit; EoL: End-of-Life; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RN: Registered Nurse; CINAHL: Cumulative Index to Nursing and Allied Health Literature. Declarations Ethics approval and consent to participate As this study is a systematic review of previously published data, it did not involve any human participants, human data, human tissue, or animals. Therefore, ethical approval and consent to participate were not applicable. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding The authors declare that no funds, grants, or other support were received from any organizations for the preparation of this manuscript. Authors' contributions MJ (MohammadReza Jokar) and MB-S (Maasoumeh Barkhordari-Sharifabad) conceived and designed the study. MJ and AN (Anahita Nooriyekta) performed the literature search and data extraction. MJ and MB-S conducted the thematic synthesis and analysis of the results. MJ drafted the manuscript, and MB-S and AN critically revised it for intellectual content. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Ethical considerations at the end-of-life care. PMC - NIH. https://pmc.ncbi.nlm.nih.gov/articles/PMC7958189/ Booth, A. T. Moral distress and moral residue among nurses working in the surgical setting. ThinkIR. https://ir.library.louisville.edu/etd/3490/ PriMera Scientific Medicine and Public Health (ISSN: 2833-5627). https://primerascientific.com/psmph/volume-4-issue-2 Moral Distress: The Struggle to Uphold Ethics in Healthcare. UR Medicine. https://www.urmc.rochester.edu/behavioral-health-partners/bhp-blog/january-2021/moral-distress-the-struggle-to-uphold-ethics-in-he A Brief Theory Critique: The Theory of Moral Reckoning. PMC - NIH. https://pmc.ncbi.nlm.nih.gov/articles/PMC9187298/ Jameton, A. What is 'moral distress'? A narrative synthesis of the literature. PMC - PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC6506903/ What Moral Distress in Nursing History Could Suggest about the Future of Health Care. Journal of Ethics. https://journalofethics.ama-assn.org/article/what-moral-distress-nursing-history-could-suggest-about-future-health-care/2017-06 Moral Distress, Health and Intention to Leave: Critical Care Nurses' Perceptions During COVID-19 Pandemic. PMC - NIH. https://pmc.ncbi.nlm.nih.gov/articles/PMC10116007/ Nurses' moral distress in palliative care: A systematic review of prevalence, contributing factors, and consequences. JNACS. https://www.jnacs.com/article_228011_e149fbb41e833988558149f242fab7ff.pdf Understanding and Addressing Moral Distress. The Online Journal of Issues in Nursing. https://ojin.nursingworld.org/table-of-contents/volume-15-2010/number-3-september-2010/understanding-moral-distress/ Moral Distress, Disempowerment, and Responsibility. Philosophy of Medicine. https://philmed.pitt.edu/philmed/article/view/210 Managing moral distress. NACNS - National Association of Clinical Nurse Specialists. https://nacns.org/managing-moral-distress/ The 2023–2026 Hospice and Palliative Nurses Association Research Agenda. PMC - NIH. Strategies to support the mental health and well-being of health and care workforce: a rapid review of reviews. Frontiers in Medicine. Self-care Strategies to Combat Burnout Among Pediatric Critical Care Nurses and Physicians. ResearchGate. Burnout in Hospital-Based Healthcare Workers during COVID-19. Science Table. Symposium of Student Scholars. Kennesaw State University. The Role of Ethics Consultation in Enhancing Family-Centered Care. ResearchGate. Nurses' moral distress in end-of-life care: A qualitative study. ResearchGate. Moral Distress Regarding End-of-Life Care Among Healthcare Personnel in Korean University Hospitals. NIH. Moral Distress. AACN. Hidden in Plain Sight: A Scoping Review of Professional Grief in Healthcare. NIH. Exploring the perceptions of dignity among patients and nurses in hospital and community settings. PubMed Central. Ethics Education for Nurses: Foundations for an Integrated Curriculum. Slack Journals. Resilience and Social Support Protect Nurses from Anxiety and Depressive Symptoms. PMC - NIH. Exploring the trauma experiences of people working in homelessness. BMJ Open. Workplace interventions to improve well-being and reduce burnout for nurses. PMC - NIH. Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. AACN Journals. Sounding Narrative Medicine. ResearchGate. The role of patients' stories in medicine: a systematic scoping review. ResearchGate. Utilization and Evaluation of Ethics Consultation Services in Neonatal Intensive Care. MDPI. Research Ethics Challenges, Controversies and Difficulties in Intensive Care Units. NIH. Ethics in the Intensive Care Unit. PMC - NIH. Best Case/Worst Case Communication Tool for Trauma Intensive Care Units. PMC - NIH. The Key Job Demands and Resources of Nursing Staff: An Integrative Review of Reviews. ResearchGate. The Impact of Transformational Leadership in the Nursing Work Environment and Patients' Outcomes. PMC. Occupational Burnout Symptoms and Its Relationship With Workload and Fear of the SARS-CoV-2 Pandemic. Frontiers. The effect of family boundary flexibility on employees' work engagement. Frontiers. International Nurses Day 2025: Caring for nurses strengthens economies. ICN. Transformational Leadership in Nursing. Systematic Review (Derived from text context). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 27 Jan, 2026 Reviews received at journal 21 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers invited by journal 13 Jan, 2026 Editor assigned by journal 12 Jan, 2026 Editor invited by journal 23 Dec, 2025 Submission checks completed at journal 22 Dec, 2025 First submitted to journal 22 Dec, 2025 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. We do this by developing innovative software and high quality services for the global research community. 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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-8319546","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":575130634,"identity":"00635335-6fc9-4563-a69d-a02847d2399e","order_by":0,"name":"MohammadReza 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Introduction","content":"\u003cp\u003eIn contemporary healthcare, registered nurses are the professionals most intimately and consistently present with patients and families during the end-of-life (EoL) trajectory [1]. This proximity is particularly acute in settings of high technological saturation, such as the Intensive Care Unit (ICU), where approximately one in five Americans will die [2]. In this environment, the nurse stands at the nexus of technological possibility and humane limitation, tasked with reconciling the biomedical drive to sustain life with the ethical imperative to ensure comfort, relieve suffering, and facilitate a dignified death [3]. This role necessitates walking an \u0026quot;ethical tightrope,\u0026quot; balancing competing values, managing complex family dynamics, and implementing intensive care plans, often under significant systemic pressure. ICU nurses often face ethical conflicts, balancing life-sustaining interventions with patients\u0026rsquo; wishes and family expectations, and implementing intensive care plans, which places them at higher risk of moral distress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.1 Differentiating Ethical Conflict from Moral Distress\u003c/strong\u003e \u003cstrong\u003e[Times New Roman 10 pt, Justified]\u003c/strong\u003e To analyze the challenges nurses face, it is imperative to distinguish between two fundamental concepts: ethical conflict and moral distress. An ethical conflict represents a state of uncertainty, arising from a clash between two or more equally justifiable, competing ethical principles [4]. In such a dilemma, no single \u0026quot;right\u0026quot; action is immediately apparent, and the process involves weighing principles like patient autonomy against beneficence [5]. Moral distress, conversely, is not a problem of uncertainty. As first defined in the seminal work of Jameton, moral distress is a profound psychological disequilibrium that arises when one knows the ethically appropriate action to take but is constrained from acting upon that judgment [6,21]. These constraints are typically external, including institutional policies, lack of administrative support, power imbalances, or interprofessional disagreement [7]. This distinction is critical: the pathology of moral distress is not a failure of the nurse\u0026apos;s ethical reasoning but rather a failure of the system to permit ethically-grounded action. It is, at its core, a phenomenon of disempowerment [12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 The Literature Gap and Review Objective\u003c/strong\u003e The body of literature identifying moral distress and moral conflict as a significant problem for nurses has expanded exponentially since 2011 [8]. Countless descriptive and qualitative studies have meticulously documented its prevalence and causes[13]. However, a significant gap persists in the synthesis of clinically-actionable, evidence-based, and multi-level strategies to address it [14]. This review seeks to move beyond mere problem identification to a critical synthesis of solutions. This systematic review will address the identified gap by pursuing a two-fold objective: To identify and thematically synthesize the drivers of ethical conflict and moral distress for registered nurses in EoL care settings; and to synthesize and critically appraise the evidence for interventions\u0026mdash;at the individual, team, and organizational levels\u0026mdash;designed to mitigate moral distress and enhance ethical decision-making.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eA systematic search of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Four electronic databases were comprehensively searched: PubMed (MEDLINE), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and PsycINFO [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The search was confined to articles published between January 1, 2015, and September 30, 2025, to ensure the review captures the contemporary landscape of clinical practice, ethical challenges, and interventional research. The search strategy utilized a robust combination of MeSH (Medical Subject Headings) terms and free-text keywords, adapted for the syntax of each database. The core search string was: ((\"Moral Distress\" OR \"Ethical Conflict*\") OR \"Moral Residue\") AND (\"Nurs*\" OR \"Nurse\" OR \"Nurses\") AND ((\"End-of-Life Care\" OR \"Terminal Care\" OR \"Palliative Care\" OR \"Hospice Care\") OR (\"Critical Care\" OR \"Intensive Care Unit\" OR \"ICU\")).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. \u003cb\u003eInclusion and Exclusion Criter\u003c/b\u003ei\u003c/h2\u003e \u003cp\u003eStudies were selected based on pre-specified criteria. Inclusion Criteria: (1) Peer-reviewed, full-text original research (qualitative, quantitative, or mixed-methods) or systematic reviews; (2) Published in the English language; (3) Publication dates between 2015\u0026ndash;2025; (4) The population of interest was Registered Nurses (RNs) or interprofessional teams including RNs; (5) The context of the study was end-of-life care, palliative care, critical care (ICU), or oncology. Exclusion Criteria: (1) Editorials, commentaries, letters, dissertations, abstracts, or case reports; (2) Studies not focused on nurses or EoL/critical care settings. Two reviewers independently screened all titles and abstracts. Articles deemed potentially eligible underwent a full-text review by both reviewers.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe thematic synthesis of the included articles revealed three dominant, interconnected themes that function as the primary drivers of ethical conflict and moral distress for registered nurses in EoL care settings.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Theme 1: The Weight of Futility\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis was the most frequently and intensely cited driver of moral distress, particularly in critical care environments. Nurses reported profound psychological distress from being the primary implementers of treatments they perceived as \"futile,\" non-beneficial, or as merely \"prolonging the dying process\" [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This distress is rooted in the conflict between the nurse's ethical duty of beneficence and the institutional or physician-led mandate to continue aggressive interventions, such as ventilation, vasopressors, or dialysis, against a patient's perceived best interests [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This conflict is often exacerbated when healthcare providers believe further treatment is unlikely to provide benefit, yet family members request its continuation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Theme 2: Navigating Relational Tensions]\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis theme encompasses the distress arising from complex and often broken communication dynamics. \u003cem\u003eFamily-Related Conflicts\u003c/em\u003e: This category includes the stress of managing unrealistic family expectations about prognosis, mediating disagreements between family members and the healthcare team regarding care goals, and the inability to satisfy a patient's final requests [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Critically, nurses also reported distress from witnessing poor, incomplete, or delayed communication delivered to families by other members of the healthcare team [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. \u003cem\u003eInterprofessional Conflicts\u003c/em\u003e: Poor communication and collaboration between healthcare professionals were identified as pivotal factors in the development of moral conflict [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Differing opinions on care goals, value conflicts, and perceived disrespect between physicians and nurses create an environment ripe for ethical conflict and nurse distress.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Theme 3: The Systemic Architecture of Distress\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis theme moves beyond the immediate bedside encounter to the underlying context in which care is delivered. Evidence from qualitative studies highlights a crucial difference in the nature of distress: nurses' distress was overwhelmingly linked to \"providing care without participation in decision-making\" [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This sense of powerlessness within hierarchical team structures was a primary source of constraint [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, systemic failures were identified as key drivers. Nurses reported moral distress caused by organizational factors that compromised their ability to provide the standard of care they felt was ethically required. These factors included inadequate staffing [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], a poor institutional \"ethical climate\" [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], a lack of administrative support [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and conflicts over the allocation of scarce resources [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The inability to provide dignified care (e.g., adequate turning, comfort measures, presence) due to heavy workloads and time constraints was a potent and frequent source of moral distress [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe second objective of this review was to synthesize and appraise interventions to mitigate moral distress. The strategies identified in the literature fall into three distinct, yet complementary, levels: individual, team, and organizational.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Individual-Level\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA large portion of the literature focuses on interventions aimed at \"bolstering\" the individual nurse. These strategies include Ethics Education designed to improve ethical reasoning and \"moral agency\" [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]; Resilience and Mindfulness Training (e.g., MBSR, yoga) to help nurses manage acute distress [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]; and Debriefing and Narrative Medicine to allow staff to process difficult cases [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. While these strategies provide valuable coping tools, a critical analysis reveals they are profoundly insufficient on their own. Moral distress is often linked to \"systems trauma\" [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], and an exclusive focus on individual resilience creates a \"blaming the victim\" paradigm [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These interventions often treat the symptom but fail to address the pathology (external constraints).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Team-Level Interventions\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis set of strategies targets the relational and communication-based drivers of distress. Formal Ethics Consultation provides a mechanism for mediating value conflicts, particularly in disputes over medical futility [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, barriers such as hierarchical intimidation often limit their use [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Structured Communication Protocols represent high-impact interventions. The literature highlights the value of proactive, structured interdisciplinary family meetings and ethics rounds [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Studies found that intensive communication structures flattened the \"clinical hierarchy\" and directly addressed disempowerment by ensuring nurses had input into the care plan [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Organizational and Policy Interventions\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThese strategies target the systemic drivers and represent the most effective solutions. As the core of moral distress is disempowerment [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], the effective antidote is structural empowerment [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This involves creating policies that provide nurses with autonomy and a voice in governance. Additionally, Transformational Leadership is a key antecedent, fostering a \"just culture\" and psychological safety that allows nurses to speak up without fear [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].A comprehensive synthesis of these evidence-based strategies, categorized by level of intervention, is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSynthesis of Evidence-Based Strategies to Mitigate Moral Distress\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrategy/Intervention Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMechanism of Action \u0026amp; Key Evidence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKey Citations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndividual\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthics Education \u0026amp; Competence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBuilds \"moral agency\" and ethical reasoning skills.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResilience / Mindfulness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProvides individual coping tools to buffer acute distress. Includes mindfulness, yoga, and somatic interventions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNarrative Medicine / Debriefing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAllows for processing of traumatic or distressing events. Reduces immediate negative psychological effects.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTeam / Interprofessional\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormal Ethics Consultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProvides a neutral, expert forum to mediate value conflicts. Particularly effective for futility and surrogate decision-making disputes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructured Interdisciplinary Communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCritically unifies the team's prognostic understanding. Flattens hierarchy by ensuring nurses have access to and input into care plan.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrganizational / Systemic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransformational / Supportive Leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFosters a \"just culture\" and psychological safety. Leaders' actions are a key mediator for nurse work environment and empowerment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructural Empowerment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe organizational antidote to individual disempowerment. Involves policies that give nurses autonomy, resources, and a voice in governance.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicy \u0026amp; Staffing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClear policies on EoL/DNR. Adequate staffing to ensure nurses can provide care they deem \"dignified.\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThe moral distress of nurses in end-of-life care is not an inevitable \"cost of caring.\" It is a clear and persistent signal of systemic, relational, and organizational dysfunction. The evidence synthesized in this review demonstrates that while the problem is often experienced by the individual nurse, its drivers\u0026mdash;and therefore its solutions\u0026mdash;are communal and systemic. Focusing on individual \"resilience\" is an inadequate response to the \"systems trauma\" [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] nurses experience. The path forward requires a multi-level approach, moving from individual coping to team-based communication and, ultimately, to organizational transformation. By fostering transformational leadership [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], structurally empowering nurses [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], and championing interprofessional collaboration [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], healthcare institutions can create the ethically-just environments necessary to uphold both the dignity of the patient and the moral integrity of the nurse.\u003c/p\u003e \u003cp\u003e\"Despite its contributions, this systematic review has certain limitations. The search was restricted to English-language studies, potentially overlooking relevant research in other languages. Additionally, the findings are primarily based on qualitative and descriptive evidence, which limits the ability to draw definitive causal conclusions about the effectiveness of the identified strategies. Future research should employ longitudinal or experimental designs to further validate these interventions across diverse clinical settings.\"\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eICU: Intensive Care Unit; EoL: End-of-Life; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RN: Registered Nurse; CINAHL: Cumulative Index to Nursing and Allied Health Literature.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate As this study is a systematic review of previously published data, it did not involve any human participants, human data, human tissue, or animals. Therefore, ethical approval and consent to participate were not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials All data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003eCompeting interests The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding The authors declare that no funds, grants, or other support were received from any organizations for the preparation of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions MJ (MohammadReza Jokar) and MB-S (Maasoumeh Barkhordari-Sharifabad) conceived and designed the study. MJ and AN (Anahita Nooriyekta) performed the literature search and data extraction. MJ and MB-S conducted the thematic synthesis and analysis of the results. MJ drafted the manuscript, and MB-S and AN critically revised it for intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEthical considerations at the end-of-life care. PMC - NIH. https://pmc.ncbi.nlm.nih.gov/articles/PMC7958189/ \u003c/li\u003e\n\u003cli\u003eBooth, A. T. Moral distress and moral residue among nurses working in the surgical setting. ThinkIR. https://ir.library.louisville.edu/etd/3490/ \u003c/li\u003e\n\u003cli\u003ePriMera Scientific Medicine and Public Health (ISSN: 2833-5627). https://primerascientific.com/psmph/volume-4-issue-2 \u003c/li\u003e\n\u003cli\u003eMoral Distress: The Struggle to Uphold Ethics in Healthcare. 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PMC - NIH. https://pmc.ncbi.nlm.nih.gov/articles/PMC10116007/\u003c/li\u003e\n\u003cli\u003eNurses\u0026apos; moral distress in palliative care: A systematic review of prevalence, contributing factors, and consequences. JNACS. https://www.jnacs.com/article_228011_e149fbb41e833988558149f242fab7ff.pdf\u003c/li\u003e\n\u003cli\u003eUnderstanding and Addressing Moral Distress. The Online Journal of Issues in Nursing. https://ojin.nursingworld.org/table-of-contents/volume-15-2010/number-3-september-2010/understanding-moral-distress/\u003c/li\u003e\n\u003cli\u003eMoral Distress, Disempowerment, and Responsibility. Philosophy of Medicine. https://philmed.pitt.edu/philmed/article/view/210\u003c/li\u003e\n\u003cli\u003eManaging moral distress. NACNS - National Association of Clinical Nurse Specialists. https://nacns.org/managing-moral-distress/\u003c/li\u003e\n\u003cli\u003eThe 2023\u0026ndash;2026 Hospice and Palliative Nurses Association Research Agenda. 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Frontiers.\u003c/li\u003e\n\u003cli\u003eThe effect of family boundary flexibility on employees\u0026apos; work engagement. Frontiers.\u003c/li\u003e\n\u003cli\u003eInternational Nurses Day 2025: Caring for nurses strengthens economies. ICN.\u003c/li\u003e\n\u003cli\u003eTransformational Leadership in Nursing. Systematic Review (Derived from text context). \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","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":"Ethical Conflict, Moral Distress, End-of-Life Care, Intensive Care Units, Nursing, Decision-Making, Structural Empowerment, Resilience","lastPublishedDoi":"10.21203/rs.3.rs-8319546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8319546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Nurses, particularly those working in critical care and palliative settings, often encounter ethical conflicts when facing end-of-life (EoL) situations that involve complex clinical and moral considerations. Repeated exposure to such dilemmas can lead to moral distress. Ethical conflict and moral distress, although conceptually distinct, are closely interrelated phenomena that can significantly influence nurses’ ethical decision-making.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: This systematic review has a two-fold objective: (1) to identify and synthesize the principal drivers of ethical conflict and moral distress experienced by nurses in EoL care, and (2) to synthesize and critically evaluate evidence-based, multi-level strategies designed to mitigate moral distress and enhance ethical decision-making.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Thematic synthesis revealed three primary drivers: Conflict over Medical Futility, Family-Related Conflicts, and Systemic/Interprofessional Tensions. Synthesized strategies were categorized as Individual-Level (e.g., resilience training), Team-Level (e.g., formal ethics consultations), and Organizational-Level (e.g., transformational leadership).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Ethical Conflict in EoL care is a systemic, relational, and organizational problem. While individual strategies offer coping mechanisms, the most effective interventions are systemic, focusing on creating an organizational \"just culture,\" empowering nurses' voices in decision-making, and fostering interprofessional respect.\u003c/p\u003e","manuscriptTitle":"Ethical Conflict and Moral Distress of Intensive Care Nurses in End-of-Life Care: A Systematic Review and Strategies for Enhancing Ethical Decision- Making","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 15:14:58","doi":"10.21203/rs.3.rs-8319546/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-27T10:01:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T15:30:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119101398750853082426887728745052156086","date":"2026-01-21T14:56:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34039374923822415044185765153721996756","date":"2026-01-20T17:05:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T11:46:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T02:53:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-23T06:15:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-22T09:13:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-12-22T09:00:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"43726384-5665-46fb-a8e7-795fc194c64a","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T15:14:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 15:14:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8319546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8319546","identity":"rs-8319546","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}