Moral distress among neonatal and pediatric intensive care nurses before and during COVID-19: A systematic review

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This review synthesizes evidence on the prevalence, contributing factors, and consequences of moral distress among Neonatal Intensive Care Unit (NICU) and Pediatric Intensive Care Unit (PICU) nurses before and during the COVID-19 pandemic. Methods A systematic scoping review was conducted in accordance with PRISMA-ScR guidelines. Literature was searched across five databases (MEDLINE, PubMed, ProQuest, ScienceDirect, Web of Science) and Google Scholar between August and October 2024. Only quantitative studies using validated moral distress instruments were included. Risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies. Results A total of 23 studies met the inclusion criteria, 15 from the pre-pandemic period and 8 from the COVID-19 period, encompassing 6,197 participants across diverse healthcare settings. Most studies used cross-sectional designs and tools like the Moral Distress Scale (MDS). Findings showed consistently high moral distress before the pandemic, which intensified during COVID-19 due to new stressors such as PPE shortages, restricted visitation, and triage-related ethical conflicts. Pandemic-era studies reported higher burnout, emotional exhaustion, and intention to leave the profession. Conclusion Moral distress among NICU and PICU nurses is an ongoing concern that was significantly exacerbated during the COVID-19 pandemic. Addressing it requires systemic interventions including staff support, clear ethical guidelines, and structured decision-making frameworks. Future studies should explore long-term impacts and develop targeted mitigation strategies. Moral distress Neonatal intensive care Pediatric intensive care COVID-19 pandemic Nurses Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Moral distress is a psychological burden experienced by nurses who recognize the ethically appropriate action but are unable to pursue it due to organizational or situational barriers [1]. It is quantified by frequency and intensity scores derived from the Moral Distress Scale (MDS) or comparable instruments [2]. High scores indicate significant distress, which can correlate with adverse mental health outcomes [3], compromised job performance [4], reduced patient care quality [3], diminished nurse well-being [5], and higher turnover rates in intensive care settings [6]. Moral distress is especially prevalent in high-stress environments such as neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs), where nurses often face ethically questionable or futile interventions [7]. Research highlights a direct connection between moral distress and professional dissatisfaction, emotional exhaustion, and reduced quality of care [8]. Studies consistently show that moral distress triggers emotional responses such as frustration and anger [9,10,11], leading to increased risk of errors and impairing nurses' effectiveness and well-being [12]. Sustained moral distress, if unaddressed, can lead to emotional fatigue, burnout, and intentions to leave the profession, thereby threatening workforce resilience [13,14,15,16]. The COVID-19 pandemic has significantly amplified these challenges. Nurses in both NICU and PICU settings faced unprecedented resource shortages [17], staff constraints [18], heightened safety protocols [19], and complex ethical dilemmas [20]. Care rationing, overwhelming patient loads, and restrictions on individualized patient-centered care intensified moral distress in pediatric critical care environments [21]. These pressures resulted in emotional exhaustion, disengagement, and compromised patient care quality, further emphasizing the need for strong organizational support [4,22]. Sustained moral distress during the pandemic has had profound implications for nurse retention and healthcare system stability [13]. Studies show that chronic moral distress increases turnover intentions, particularly in regions with already fragile healthcare infrastructures, such as Latvia [14,15,16]. Consequently, there is an urgent need to implement supportive frameworks, including ethics consultations, peer support programs, and structured reflection opportunities, to mitigate ethical burdens on nurses [23]. Addressing moral distress in NICUs and PICUs is critical to sustaining nurse well-being and ensuring high-quality patient care [6,24]. The pandemic introduced additional ethical constraints that further limited nurses’ autonomy and decision-making capacity [25]. Implementing targeted strategies, including ethical resilience training and strengthening organizational support systems, is essential to buffer the lasting impacts of moral distress [26]. Proactive measures that encourage ethical deliberation, peer engagement, and interdisciplinary collaboration are vital for building a resilient nursing workforce capable of navigating ethical complexities in neonatal and pediatric intensive care settings [27]. Despite a growing of research on moral distress among intensive care nurses [2,8,9,10,11], significant gaps remain. Most existing studies have focused primarily on adult ICUs, with limited systematic exploration of NICU and PICU nurses’ experiences. Moreover, few studies have compared moral distress before and during the COVID-19 pandemic systematically [13,14,15,16]. This systematic scoping review aims to address these gaps by synthesizing available evidence on the prevalence, contributing factors, and consequences of moral distress among NICU and PICU nurses before and during the pandemic. Our objective is to provide a comprehensive understanding of how moral distress evolved during this period and to identify organizational and individual factors that may help mitigate its impact. his study was conducted as a systematic scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines [28]. To the best of our knowledge, this is the first systematic scoping review that exclusively compares moral distress among NICU and PICU nurses across pre-pandemic and pandemic periods, providing targeted insights for non-adult critical care environments. 2. Materials and Methods The study protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024592661. The primary aim of the review was to map and synthesize evidence on moral distress among NICU and PICU nurses before and during the COVID-19 pandemic. Given the anticipated variability in design, outcomes, and measurement tools among studies, a scoping review methodology was selected over a traditional systematic review, and no meta-analysis was planned. However, quality assessment of included studies was still conducted to ensure transparency and rigor. The main outcome of the review is the level of moral distress experienced by NICU and PICU nurses, assessed using validated tools like the MDS or similar instruments. Secondary outcome: burnout. Measured with tools like the Maslach Burnout Inventory (MBI), focusing on aspects such as emotional exhaustion and depersonalization [29]. Moral distress can contribute to high turnover rates and absenteeism, which disrupts the patient care environment and places additional strain on remaining staff [30]. It can be a tertiary outcome. Nurse retention and reliable staffing are critical for consistent patient care in NICU and PICU settings. 2.1. Identifying the Research Question To explore the moral distress among neonatal and pediatric intensive care nurses before and during COVID-19, five research questions were formulated: How has the intensity and experience of moral distress among NICU and PICU nurses changed before and during the COVID-19 pandemic? What specific factors have contributed to the levels of moral distress experienced by NICU and PICU nurses during the pre-pandemic period compared to during the COVID-19 pandemic? How has moral distress impacted the mental health, job satisfaction, and retention rates of NICU and PICU nurses before and during the pandemic? What role do work environment factors (e.g., PPE availability, ethical climate, organizational support) play in influencing moral distress levels? What ethical challenges, especially around life-sustaining treatments and end-of-life care, have heightened moral distress? 2.2. Inclusion and Exclusion Criteria Inclusion and exclusion criteria were clearly defined, according to which relevant studies were selected. Studies were included, if: Quantitative or mixed-method studies in which moral distress was a primary outcome measured using a validated instrument (e.g., MDS, MDS-R); Studies involving NICU and/or PICU nurses; Peer-reviewed journal articles published in English; Publications from January 1, 2015, to October 17, 2024. Studies were excluded, if: Studies not focused on NICU or PICU nurses; Studies without moral distress as a primary outcome; Studies published in languages other than English; Non-peer-reviewed literature (e.g., opinion pieces, book chapters, conference abstracts); Purely qualitative or experimental studies without quantifiable moral distress outcomes. Importantly, the inclusion of pandemic-period studies was not limited to the early 2020 phase. The search covered literature published up to October 17, 2024, ensuring that studies addressing all phases of the pandemic, including its prolonged effects, were included. The participants being studied in this systematic review are NICU and PICU nurses working in ICUs. 2.3. Selecting a Study Figure 1 and Figure 2 illustrate the process of study selection for systematic scoping review. All articles were imported into NoteExpress software for deduplication. Titles and abstracts were screened independently by two reviewers (O.C-B. and A.P.) based on eligibility criteria. Full texts of relevant studies were reviewed for final inclusion. Discrepancies were resolved through consensus discussions. 2.4. Study Search Strategy We conducted a literature search of 5 electronic research databases: MEDLINE (1); PubMed (2); ProQuest (3); Science Direct (4); Web of Science (5). Database searches were conducted between August 3 and October 17, 2024. A manual search of Google Scholar was also completed to ensure that all relevant studies were captured. Articles for the period before COVID-19 were retrieved with the use of the following Medical Subject Headings terms (MeSH Terms). Search Syntax (Pre-COVID): (moral distress) AND (nurse OR nurses OR nursing) AND (neonatal OR pediatric OR NICU OR PICU nursing OR nurses) AND (intensive OR critical care). Articles for the period during COVID-19 were retrieved with the use of the following MeSH Terms. Search Syntax (During COVID-19): (moral distress) AND (nurse OR nurses OR nursing) AND (neonatal OR pediatric OR NICU OR PICU nursing OR nurses) AND (intensive OR critical care) AND (covid-19 OR coronavirus OR 2019-ncov OR sars-cov-2 OR cov-19)). Also, the search strategy used a combination of keywords connected with AND, OR, and NOT to refine the search results. Figure 3 illustrates the search strategies and outcomes before COVID-19. Figure 4 illustrates the search strategies and outcomes during COVID-19. In addition, references to the included literature were hand-searched. The Cochrane Database of Systematic Review and Systematic Scoping Review was checked to establish registered reviews of a similar subject, and no systematic reviews addressing moral distress in PICU on NICU nurses were identified. 2.5. Data Extraction and Quality Assessment Data were extracted using a standardized form including key variables such as author, country, publication year, study design, research objectives, healthcare setting, coping strategies, interventions, limitations, recommendations, and other relevant information. Two reviewers (O.C-B. and A.P.) conducted the data extraction independently. After verifying the full-text eligibility of each study, data extraction proceeded. The extracted data were then cross-checked to ensure consistency and accuracy. Consensus on study inclusion and extracted data was achieved through discussion. In the case of discrepancies, joint resolution was reached by the two reviewers. To assess methodological quality, the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies [31] was applied to all included quantitative studies. While a meta-analysis was not feasible due to heterogeneity in study design and outcomes, risk of bias and methodological limitations were documented and considered in the synthesis process. 3. Results 3.1. Study Selection and Risk of Bias Assessment The selection process is presented in Figures 1 and 2, which illustrate the flow of studies identified, screened, and included for both the pre-pandemic and pandemic periods. Initially, 2,964 records were retrieved. After deduplication and screening, 23 studies met the inclusion criteria. Quality appraisal was conducted using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies [31]. The majority of included studies demonstrated clear objectives and appropriate statistical analysis. However, common limitations across studies included small sample sizes and lack of longitudinal follow-up. Risk of bias varied, with some studies lacking detailed reporting on sampling methods and ethical approval. 3.2. Study Characteristics A total of 23 studies were included in this systematic scoping review: 15 conducted before the COVID-19 pandemic and 8 conducted during the pandemic. This systematic scoping review included 15 articles from the pre-COVID-19 period. These studies were conducted in various countries, including the USA (5) [32,33,34,35,36], Iran (3) [37,38,39], Canada (2) [40,41], Italy (2) [42,43], Belgium (1) [44], the Netherlands (1) [45], and the UK (1) [46]. The sample sizes ranged from 13 [35] to 1,814 [41], with a combined total of 5,171 participants. Table 1 and Table 2 summarizes the key characteristics of these studies. The tables are added at the beginning of the main document. Eight studies were multidisciplinary [33,34,35,40,41,44,45,46], involving professionals from at least two different fields. For the COVID-19 period, 8 articles were included in the review. These studies were conducted in Australia (2) [47,48], Iran (2) [49,50], Italy (2) [51,52], Canada (1) [53], and China (1) [54]. Sample sizes ranged from 26 [54] to 240 [53], with a total of 1,026 participants. Table 2 summarizes the characteristics of these studies. Five of the studies [47,51,52,53,54] were multidisciplinary, involving professionals from at least two different fields. Cross-sectional studies were the most common approach both before [33,37,38,40,42,43] and during [48,49,50,51,53,54] the pandemic, utilizing tools like the MDS and its adaptations (e.g., Pediatric MDS-R). During the pandemic, online surveys [51,52,53] were widely employed to reach broader respondents. 3.3. Moral Distress Before COVID-19 Pre-pandemic moral distress among NICU and PICU nurses often stemmed from ethical dilemmas like end-of-life [40,41,42,43,46] care, perceived unnecessary treatments [35,36,42], limited decision-making autonomy [34,37,43], and inadequate end-of-life support [32,40,41,42,43,46]. Moral distress scores ranged from 59.54 [36] to 106.41 [38] with two studies identifying high levels of distress [35,45]. While the numerical range appears broad, interpretation depends on the scaling of the specific version of the MDS used, studies defined distress levels as moderate or high based on internal cut-offs or comparison to baseline norms. Nurses frequently reported emotional and ethical conflicts related to delivering care perceived as non-beneficial. Poor team collaboration [45] and organizational constraints also contributed to elevated distress levels. 3.4. Moral Distress During COVID-19 During the pandemic, distress levels increased significantly from 44.42 [32] to 102 [54] and two studies [52,54] reporting high levels, driven by resource shortages, intensified workloads, and fears of virus transmission. Although the lower bound appears reduced compared to pre-pandemic scores, this is due to variation in measurement tools and sample characteristics, not a true reduction. Several studies highlighted increased emotional burden despite fluctuating numerical ranges. Nurses faced new stressors such as PPE shortages [50,52], increased workload, resource-driven triage, and fear of virus transmission to family members [50,52]. Ethical dilemmas intensified around end-of-life decision-making and providing life-sustaining interventions with uncertain outcomes [33,35,48,49,50,51,54]. This trend highlights the deepening of moral distress in nursing. Additionally, organizational factors such as limited support systems [53] and lack of ethical consultation contributed to the emotional burden. A sense of powerlessness emerged due to institutional constraints and emotionally taxing decisions, including situations where patients died alone [48,49,50,51,54]. 3.5. Burnout, Turnover, and Psychological Impacts Pre-pandemic studies linked moral distress with moderate burnout [34,36,40,41,44,46], reduced job satisfaction [43], and career change considerations [35,38]. During the pandemic, psychological effects worsened: one study reported 50% experiencing severe burnout [52], and others highlighted increased depression and anxiety [51,54]. Notably, over 50% of nurses considered leaving their jobs during the pandemic [52], compared to 25% pre-pandemic [46]. 3.6. Contributing Factors and Protective Mechanisms Before the pandemic, factors such as restricted professional autonomy [34,37,44], ethical dilemmas related to life-sustaining treatments [33,35], poor team collaboration [45], and inadequate end-of-life support [32,40,41,42,43,46] contributed to moral distress. However, a supportive work environment, clear guidelines, and effective collaboration were found to reduce distress [35,45]. During the pandemic, those mitigating elements often disappeared. Resource shortages, disorganized working conditions, and lack of institutional support exacerbated the situation [47,49,52,54]. Emotional strain increased, as nurses had to navigate ethical conflicts while coping with isolation, uncertainty, and an overwhelmed system. The emotional toll was amplified when nurses had to make or witness decisions influenced by resource scarcity and patients dying without family present [48,49,50,51,54]. 4. Discussion This systematic scoping review aimed to explore the experience and contributing factors of moral distress among NICU and PICU nurses before and during the COVID-19 pandemic. The results offer an integrative perspective on the nature, sources, and consequences of moral distress, while also identifying potential mitigation strategies. The studies included in this review originated from various countries, including the USA, Canada, Italy, Iran, Australia, China, and the UK, providing a diverse international context for understanding this phenomenon. Across all included studies, moral distress was consistently associated with ethical conflicts in care provision, particularly in end-of-life situations or when nurses felt compelled to participate in treatment plans they deemed futile or harmful [34,35,40,41,42,44,46]. These ethical tensions often involved decisions about prolonging life at the expense of suffering [35,36,37,42], lack of participation in decision-making, or conflicts between the values of the nurse, the patient, and the institution [32,33,43,45]. Notably, the intensity of moral distress was high both before and during the pandemic. However, during COVID-19, additional stressors emerged, including resource scarcity [48], visitor restrictions [47,49,54], and rapid changes in clinical protocols [48,53]. These heightened the moral burden on nurses, as they were often forced to prioritize care [55,56] in ways that contradicted their professional ethics. The absence of family members, especially in pediatric and neonatal settings, created further emotional strain [50,51,54]. While pre-pandemic moral distress was frequently related to structural issues [33,34,36], such as insufficient support in end-of-life care [35,37], poor communication with physicians [32,43], and perceived low autonomy [38,45], pandemic-related distress arose from both similar and new factors, including inadequate PPE, fear of infection, and working in understaffed and emotionally volatile environments [48,53,57,58]. The findings of this review align with existing evidence suggesting that moral distress is not only a persistent problem in intensive care settings but one that significantly intensified during the pandemic. Previous research has identified similar themes, including role conflict [35,37,44,45,52], team dynamics [42,45,50,54], and the emotional burden of futile care decisions [34,44,51]. However, this review expands upon prior work by synthesizing data across both time periods and emphasizing the unique dynamics of pediatric and neonatal care, where family involvement and developmental considerations add complexity to ethical decision-making [32,43,53]. Several included studies also reported that nurses experienced distress when their professional expertise was overlooked by physicians or management [47,54], echoing findings from studies on adult ICUs. This lack of voice in decision-making processes has been repeatedly shown to increase emotional exhaustion and decrease job satisfaction [59,60,61]. In contrast to many earlier studies, this review sheds light on the gender and role-specific elements [33,35,38,40,44] of moral distress, although more research is still needed in this area. The female-dominated nursing profession often intersects with hierarchical healthcare structures, potentially compounding moral injury in emotionally charged scenarios. The data highlight an urgent need for healthcare organizations to address the root causes of moral distress through structural and organizational reforms. One key recommendation is the promotion of shared decision-making practices [47,49,54], where nurses’ ethical concerns are acknowledged and incorporated into treatment planning. Multidisciplinary team meetings [48], ethical debriefings [48,49,50,54], and regular communication forums [34,46,47,48] can help to prevent moral residue [62] and reduce the likelihood of long-term burnout [63]. The review also emphasizes the importance of staffing adequacy [64] and workload regulation. Moral distress often arose when nurses were required to make ethically complex decisions under time pressure or with insufficient support [47,54]. Providing adequate PPE and ensuring fair shift distribution is vital not only for physical safety but also for emotional well-being [51,52,53]. Psychological support systems, such as peer support groups, professional counseling, and stress resilience training [33,36,39,49,51], are essential components in mitigating moral distress. Furthermore, institutional transparency, particularly during health crises, can help reduce feelings of powerlessness and strengthen trust between staff and management [65,66]. Professional autonomy, particularly in ethically sensitive domains like end-of-life care, should be reinforced [36,38,42,44]. When nurses are involved in shaping care plans and policies, they are more likely to feel empowered and less likely to experience moral distress [67]. Despite the valuable insights obtained, several limitations must be acknowledged. Many of the included studies had small sample sizes [32,33,34,35,36,37,38,39,40,43,47,48,49,50,51,52] and were conducted within a single country or healthcare institution, reducing generalizability [33,35,37,38,39,40,42,43,48,49,50,51,52]. Moreover, most data were cross-sectional, limiting the ability to assess the evolution of moral distress over time. Studies often focused on female participants, reflecting the gender imbalance in nursing, yet limiting exploration of how moral distress may manifest differently among male or non-binary healthcare providers. Additionally, few studies examined variations in distress based on years of experience, ICU role (e.g., charge nurse vs bedside nurse), or institutional type (e.g., academic vs community hospital). Pandemic-era studies tended to focus on early COVID-19 phases, potentially omitting long-term effects on workforce sustainability and psychological recovery [49,51,53]. Finally, although some studies involved interprofessional samples [47,51,52,53,54], most concentrated solely on nurses [48,49,50], without adequately analyzing how moral distress interacts with team dynamics. Future studies should prioritize longitudinal designs to better understand the development and resolution of moral distress over time. Comparative studies between different ICU types (adult vs pediatric vs neonatal) may also help clarify setting-specific dynamics. There is also a need to investigate organizational cultures that successfully buffer moral distress and to develop interventions grounded in ethical resilience and communication theory. Quantitative research should be complemented by qualitative insights to capture the emotional and contextual subtleties of moral suffering. Researchers should also ensure that instruments used to measure moral distress are sensitive to current challenges, including those introduced by public health emergencies. This scoping review has illustrated that moral distress among NICU and PICU nurses is a serious, complex, and multifaceted issue that has only grown more acute during the COVID-19 pandemic. The review highlights how ethical conflict, emotional overload, and systemic limitations intersect to affect nurses’ mental health, job satisfaction, and care quality. It also underscores the role of leadership, communication, and institutional culture in shaping the moral climate of intensive care units. Addressing moral distress is not only a matter of individual coping, but a shared responsibility that requires systemic action and sustained investment from healthcare organizations and policymakers alike. 5. Conclusions This systematic scoping review highlights the complex and multifaceted nature of moral distress experienced by NICU and PICU nurses before and during the COVID-19 pandemic. The findings reveal that the intensity and frequency of moral distress were moderate before the pandemic, driven by challenging ethical dilemmas such as life-sustaining treatments perceived as prolonging suffering and end-of-life care decisions. During the pandemic, these levels significantly increased, exacerbated by resource shortages, heightened workloads, and organizational constraints. The results underscore the critical role of workplace factors, such as team dynamics, communication, and ethical climate, in shaping the levels of moral distress. A supportive organizational culture, characterized by clear ethical guidelines and adequate resources, was found to mitigate distress, while its absence amplified emotional and professional strain. The pandemic introduced new ethical challenges, such as triage decisions and restricted family access, further intensifying moral distress. Nurses often experienced feelings of powerlessness and frustration due to limited professional autonomy and insufficient involvement in decision-making processes. The emotional toll, compounded by personal safety concerns and the risk of infection, led to increased burnout and a significant proportion of nurses considering leaving their profession. The findings emphasize the need for targeted interventions to reduce moral distress, particularly in high-stress settings like NICUs and PICUs. These include improving communication within teams, fostering collaborative decision-making, and providing regular debriefing and psychological support sessions. Training programs focusing on ethical resilience and emotional coping strategies are vital to equip nurses to navigate ethically challenging situations effectively. Finally, the review highlights the importance of addressing systemic issues such as staffing levels, resource allocation, and organizational support structures. A proactive approach to managing moral distress will not only enhance nurse well-being but also improve patient care quality and workforce retention, ensuring the sustainability of healthcare systems during future crises. 6. Limitations This review has several limitations that should be acknowledged. First, despite applying a comprehensive search strategy across multiple databases, it is possible that some relevant studies were missed, particularly unpublished or non-indexed literature, which may have led to publication bias. The inclusion of only studies published in English may have excluded important research conducted in other languages, especially from regions where NICU and PICU services differ structurally or culturally. Second, we limited the review to studies published from 2015 onwards to ensure relevance to current clinical contexts. However, this decision may have excluded earlier yet potentially significant work on moral distress. Additionally, our focus on open-access and peer-reviewed literature may have inadvertently excluded studies published in subscription-based journals. Third, the review included only quantitative and mixed-methods studies that used validated instruments, which may have limited the diversity of perspectives captured, particularly rich qualitative insights. Furthermore, we did not conduct a meta-analysis due to heterogeneity in study designs and outcome measures, which restricts the ability to provide pooled effect estimates. Fourth, while we assessed the methodological quality of included studies, the use of cross-sectional designs and self-reported instruments across most studies may introduce inherent bias, such as social desirability or recall bias. Finally, the review synthesized evidence up to October 2024, and developments in the literature after this period were not captured. Despite these limitations, this systematic scoping review provides a timely and comprehensive overview of moral distress among NICU and PICU nurses before and during the COVID-19 pandemic. It highlights important trends, knowledge gaps, and directions for future research, offering practical implications for policy and healthcare practice. Declarations Funding: The APC was funded by Riga Stradiņš University. Institutional Review Board Statement: The study was conducted in accordance with the Declara-tion of Helsinki, and approved by the Ethics Committee of Riga Stradiņš University (protocol code 2-PĒK-4/416/2023 09.05.2023). Informed Consent Statement: Not applicable. Data Availability Statement: The datasets produced and examined in this study can be obtained from the corresponding author upon a reasonable request. All data generated or analyzed during this study are provided within the published article. The data utilized in this study is confidential. Conflicts of Interest: The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Declarations of interest: none. 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Cohen, Catherine, Silvia Pignata, Eva Bezak, Mark Tie, and Jessie Childs. 2023. “Workplace Interventions to Improve Well-Being and Reduce Burnout for Nurses, Physicians and Allied Healthcare Professionals: A Systematic Review.” BMJ Open 13 (6): e071203. https://doi.org/10.1136/bmjopen-2022-071203. Mabona, Jean F., Dalena Van Rooyen, and Wilma Ten Ham-Baloyi. 2022. “Best Practice Recommendations for Healthy Work Environments for Nurses: An Integrative Literature Review.” Health SA Gesondheid 27 (April). https://doi.org/10.4102/hsag.v27i0.1788. Vatn, Line, and Berit Misund Dahl. 2022. “Interprofessional Collaboration between Nurses and Doctors for Treating Patients in Surgical Wards.” Journal of Interprofessional Care 36 (2): 186–94. https://doi.org/10.1080/13561820.2021.1890703. Aggrawal, Sakhi, and Alejandra J. Magana. 2024. “Teamwork Conflict Management Training and Conflict Resolution Practice via Large Language Models.” Future Internet 16 (5): 177. https://doi.org/10.3390/fi16050177. Skegg, Emma, Canice McElroy, Mercedes Mudgway, and James Hamill. 2023. “Debriefing to Improve Interprofessional Teamwork in the Operating Room: A Systematic Review.” Journal of Nursing Scholarship 55 (6): 1179–88. https://doi.org/10.1111/jnu.12924. Tables Tables 1, 3 and 4 are available in the Supplementary Files section. Table 2. Search Strategy, Outcome, and Data Sources during COVID-19 MeSH Terms Database Count Results (moral distress or moral problems or moral issues or ethical distress) AND (nurse or nurses or nursing) AND (neonatal or pediatric or NICU or PICU nursing or nurses) AND (intensive or critical care) AND (covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19)) MEDLINE 7 (moral distress or moral problems or moral issues or ethical distress) AND (nurse or nurses or nursing) AND (neonatal or pediatric or NICU or PICU nursing or nurses) AND (intensive or critical care) AND (covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19)) PubMed 58 (moral distress or moral problems or moral issues or ethical distress) AND nurses AND (nicu AND nursing) AND (picu AND nursing) AND (intensive AND critical care) AND (COVID-19) ProQuest 32 (moral distress or moral problems or moral issues or ethical distress) AND nurses AND (nicu AND nursing) AND (picu AND nursing) AND (intensive AND critical care) AND (COVID-19) Science Direct 25 (moral distress or moral problems or moral issues or ethical distress) AND (nurse or nurses or nursing) AND (neonatal or pediatric or NICU or PICU nursing or nurses) AND (intensive or critical care) AND (COVID-19) Web of Sciences 52 Total 5 174 Additional Declarations No competing interests reported. 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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-5604685","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":507928251,"identity":"40391336-c6f1-4571-9215-a0a83dc658b1","order_by":0,"name":"Olga Cerela-Boltunova","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYLCCB0DMx8DACKJ5+IjSkgDEbAwMzAYgLWykaGGTYIAw8AP+9t6HDxJqGOTY+Bc/q/yaYyfDxsD88NENPFokzhw3Nkg4xmDMJvHM7LbstmSgw9iMjXPwaDGQSGOTSGBjSGyTOGB2W3IbM1ALD5s0Xi3yz9h/JPwDaTn+rVhyWz0RWiTYQFYAEX+PGePHbYcJa5E4k8YskdgnAfQLT7E047bjPGzMBPzC336M8cOHbzZy/PzHN378ua3anp+9+eFjfFpglgFRAgMzD4jNTFg5zL4DDIw/iFY9CkbBKBgFIwkAAPiwPcNA/8tpAAAAAElFTkSuQmCC","orcid":"","institution":"Riga Stradiņš University","correspondingAuthor":true,"prefix":"","firstName":"Olga","middleName":"","lastName":"Cerela-Boltunova","suffix":""},{"id":507928252,"identity":"2f1cd24b-7ae3-4f8f-8d7f-8210381a9e57","order_by":1,"name":"Anna Paskova","email":"","orcid":"","institution":"University of Zaragoza","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Paskova","suffix":""}],"badges":[],"createdAt":"2024-12-08 21:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5604685/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5604685/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90896979,"identity":"3bdb8774-7c3e-4c08-9218-d441a6a992f3","added_by":"auto","created_at":"2025-09-09 11:39:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47986,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePicture 1. \u003c/strong\u003eIdentification of Studies via Databases before COVID-19.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5604685/v1/5dad9f003c2fce420a1a3664.png"},{"id":90896976,"identity":"e0e7c0b8-9be3-4adb-aa88-2be738e67cb2","added_by":"auto","created_at":"2025-09-09 11:39:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":48901,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePicture 2. \u003c/strong\u003eIdentification of Studies via Databases during COVID-19.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5604685/v1/a703360bd217ae474a9d6e10.png"},{"id":90896981,"identity":"f4cb3379-3a9e-4caa-a473-70e4281c312a","added_by":"auto","created_at":"2025-09-09 11:39:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":134313,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5604685/v1/044532cf8fab60a0d7b356f9.png"},{"id":90896971,"identity":"70bcb486-7197-4328-995b-3afc289882dd","added_by":"auto","created_at":"2025-09-09 11:39:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":156373,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5604685/v1/201a0183477a8ed436332126.png"},{"id":90897641,"identity":"8c3b7fc1-f4d5-42b4-8cc2-62c8b5cb27a4","added_by":"auto","created_at":"2025-09-09 11:47:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1022817,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5604685/v1/22c703ef-7c19-4b13-aa1f-b86bdb422961.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Moral distress among neonatal and pediatric intensive care nurses before and during COVID-19: A systematic review","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eMoral distress is a psychological burden experienced by nurses who recognize the ethically appropriate action but are unable to pursue it due to organizational or situational barriers [1]. It is quantified by frequency and intensity scores derived from the Moral Distress Scale (MDS) or comparable instruments [2]. High scores indicate significant distress, which can correlate with adverse mental health outcomes [3], compromised job performance [4], reduced patient care quality [3], diminished nurse well-being [5], and higher turnover rates in intensive care settings [6].\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoral distress is especially prevalent in high-stress environments such as neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs), where nurses often face ethically questionable or futile interventions [7]. Research highlights a direct connection between moral distress and professional dissatisfaction, emotional exhaustion, and reduced quality of care [8]. Studies consistently show that moral distress triggers emotional responses such as frustration and anger [9,10,11], leading to increased risk of errors and impairing nurses\u0026apos; effectiveness and well-being [12]. Sustained moral distress, if unaddressed, can lead to emotional fatigue, burnout, and intentions to leave the profession, thereby threatening workforce resilience [13,14,15,16].\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic has significantly amplified these challenges. Nurses in both NICU and PICU settings faced unprecedented resource shortages [17], staff constraints [18], heightened safety protocols [19], and complex ethical dilemmas [20]. Care rationing, overwhelming patient loads, and restrictions on individualized patient-centered care intensified moral distress in pediatric critical care environments [21]. These pressures resulted in emotional exhaustion, disengagement, and compromised patient care quality, further emphasizing the need for strong organizational support [4,22].\u003c/p\u003e\n\u003cp\u003eSustained moral distress during the pandemic has had profound implications for nurse retention and healthcare system stability [13]. Studies show that chronic moral distress increases turnover intentions, particularly in regions with already fragile healthcare infrastructures, such as Latvia [14,15,16]. Consequently, there is an urgent need to implement supportive frameworks, including ethics consultations, peer support programs, and structured reflection opportunities, to mitigate ethical burdens on nurses [23].\u003c/p\u003e\n\u003cp\u003eAddressing moral distress in NICUs and PICUs is critical to sustaining nurse well-being and ensuring high-quality patient care [6,24]. The pandemic introduced additional ethical constraints that further limited nurses\u0026rsquo; autonomy and decision-making capacity [25]. Implementing targeted strategies, including ethical resilience training and strengthening organizational support systems, is essential to buffer the lasting impacts of moral distress [26]. Proactive measures that encourage ethical deliberation, peer engagement, and interdisciplinary collaboration are vital for building a resilient nursing workforce capable of navigating ethical complexities in neonatal and pediatric intensive care settings [27].\u003c/p\u003e\n\u003cp\u003eDespite a growing of research on moral distress among intensive care nurses [2,8,9,10,11], significant gaps remain. Most existing studies have focused primarily on adult ICUs, with limited systematic exploration of NICU and PICU nurses\u0026rsquo; experiences. Moreover, few studies have compared moral distress before and during the COVID-19 pandemic systematically [13,14,15,16]. This systematic scoping review aims to address these gaps by synthesizing available evidence on the prevalence, contributing factors, and consequences of moral distress among NICU and PICU nurses before and during the pandemic. Our objective is to provide a comprehensive understanding of how moral distress evolved during this period and to identify organizational and individual factors that may help mitigate its impact. his study was conducted as a systematic scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines [28]. To the best of our knowledge, this is the first systematic scoping review that exclusively compares moral distress among NICU and PICU nurses across pre-pandemic and pandemic periods, providing targeted insights for non-adult critical care environments.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eThe study protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024592661. The primary aim of the review was to map and synthesize evidence on moral distress among NICU and PICU nurses before and during the COVID-19 pandemic. Given the anticipated variability in design, outcomes, and measurement tools among studies, a scoping review methodology was selected over a traditional systematic review, and no meta-analysis was planned. However, quality assessment of included studies was still conducted to ensure transparency and rigor.\u003c/p\u003e\n\u003cp\u003eThe main outcome of the review is the level of moral distress experienced by NICU and PICU nurses, assessed using validated tools like the MDS or similar instruments.\u003c/p\u003e\n\u003cp\u003eSecondary outcome: burnout. Measured with tools like the Maslach Burnout Inventory (MBI), focusing on aspects such as emotional exhaustion and depersonalization [29].\u003c/p\u003e\n\u003cp\u003eMoral distress can contribute to high turnover rates and absenteeism, which disrupts the patient care environment and places additional strain on remaining staff [30]. It can be a tertiary outcome. Nurse retention and reliable staffing are critical for consistent patient care in NICU and PICU settings.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.1. Identifying the Research Question\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo explore the moral distress among neonatal and pediatric intensive care nurses before and during COVID-19, five research questions were formulated:\u003c/p\u003e\n\u003col class=\"decimal_type\"\u003e\n \u003cli\u003eHow has the intensity and experience of moral distress among NICU and PICU nurses changed before and during the COVID-19 pandemic?\u003c/li\u003e\n \u003cli\u003eWhat specific factors have contributed to the levels of moral distress experienced by NICU and PICU nurses during the pre-pandemic period compared to during the COVID-19 pandemic?\u003c/li\u003e\n \u003cli\u003eHow has moral distress impacted the mental health, job satisfaction, and retention rates of NICU and PICU nurses before and during the pandemic?\u003c/li\u003e\n \u003cli\u003eWhat role do work environment factors (e.g., PPE availability, ethical climate, organizational support) play in influencing moral distress levels?\u003c/li\u003e\n \u003cli\u003eWhat ethical challenges, especially around life-sustaining treatments and end-of-life care, have heightened moral distress?\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cem\u003e2.2. Inclusion and Exclusion Criteria\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInclusion and exclusion criteria were clearly defined, according to which relevant studies were selected. Studies were included, if:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eQuantitative or mixed-method studies in which moral distress was a primary outcome measured using a validated instrument (e.g., MDS, MDS-R);\u003c/li\u003e\n \u003cli\u003eStudies involving NICU and/or PICU nurses;\u003c/li\u003e\n \u003cli\u003ePeer-reviewed journal articles published in English;\u003c/li\u003e\n \u003cli\u003ePublications from January 1, 2015, to October 17, 2024.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eStudies were excluded, if:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eStudies not focused on NICU or PICU nurses;\u003c/li\u003e\n \u003cli\u003eStudies without moral distress as a primary outcome;\u003c/li\u003e\n \u003cli\u003eStudies published in languages other than English;\u003c/li\u003e\n \u003cli\u003eNon-peer-reviewed literature (e.g., opinion pieces, book chapters, conference abstracts);\u003c/li\u003e\n \u003cli\u003ePurely qualitative or experimental studies without quantifiable moral distress outcomes.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eImportantly, the inclusion of pandemic-period studies was not limited to the early 2020 phase. The search covered literature published up to October 17, 2024, ensuring that studies addressing all phases of the pandemic, including its prolonged effects, were included. The participants being studied in this systematic review are NICU and PICU nurses working in ICUs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3. Selecting a Study\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 and Figure 2 illustrate the process of study selection for systematic scoping review. \u0026nbsp;All articles were imported into NoteExpress software for deduplication. Titles and abstracts were screened independently by two reviewers (O.C-B. and A.P.) based on eligibility criteria. Full texts of relevant studies were reviewed for final inclusion. Discrepancies were resolved through consensus discussions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4. \u0026nbsp;Study Search Strategy\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a literature search of 5 electronic research databases: MEDLINE (1); PubMed (2); ProQuest (3); Science Direct (4); Web of Science (5). Database searches were conducted between August 3 and October 17, 2024. A manual search of Google Scholar was also completed to ensure that all relevant studies were captured.\u003c/p\u003e\n\u003cp\u003eArticles for the period before COVID-19 were retrieved with the use of the following Medical Subject Headings terms (MeSH Terms). Search Syntax (Pre-COVID): (moral distress) AND (nurse OR nurses OR nursing) AND (neonatal OR pediatric OR NICU OR PICU nursing OR nurses) AND (intensive OR critical care).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eArticles for the period during COVID-19 were retrieved with the use of the following MeSH Terms. Search Syntax (During COVID-19): (moral distress) AND (nurse OR nurses OR nursing) AND (neonatal OR pediatric OR NICU OR PICU nursing OR nurses) AND (intensive OR critical care) AND (covid-19 OR coronavirus OR 2019-ncov OR sars-cov-2 OR cov-19)). Also, the search strategy used a combination of keywords connected with AND, OR, and NOT to refine the search results.\u003c/p\u003e\n\u003cp\u003eFigure 3 illustrates the search strategies and outcomes before COVID-19. Figure 4 illustrates the search strategies and outcomes during COVID-19.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, references to the included literature were hand-searched. The Cochrane Database of Systematic Review and Systematic Scoping Review was checked to establish registered reviews of a similar subject, and no systematic reviews addressing moral distress in PICU on NICU nurses were identified.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.5. Data Extraction and Quality Assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were extracted using a standardized form including key variables such as author, country, publication year, study design, research objectives, healthcare setting, coping strategies, interventions, limitations, recommendations, and other relevant information. Two reviewers (O.C-B. and A.P.) conducted the data extraction independently. After verifying the full-text eligibility of each study, data extraction proceeded. The extracted data were then cross-checked to ensure consistency and accuracy. Consensus on study inclusion and extracted data was achieved through discussion. In the case of discrepancies, joint resolution was reached by the two reviewers.\u003c/p\u003e\n\u003cp\u003eTo assess methodological quality, the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies [31] was applied to all included quantitative studies. While a meta-analysis was not feasible due to heterogeneity in study design and outcomes, risk of bias and methodological limitations were documented and considered in the synthesis process.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cem\u003e3.1. Study Selection and Risk of Bias Assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe selection process is presented in Figures 1 and 2, which illustrate the flow of studies identified, screened, and included for both the pre-pandemic and pandemic periods. Initially, 2,964 records were retrieved. After deduplication and screening, 23 studies met the inclusion criteria.\u003c/p\u003e\n\u003cp\u003eQuality appraisal was conducted using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies [31]. The majority of included studies demonstrated clear objectives and appropriate statistical analysis. However, common limitations across studies included small sample sizes and lack of longitudinal follow-up. Risk of bias varied, with some studies lacking detailed reporting on sampling methods and ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.2. Study Characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of 23 studies were included in this systematic scoping review: 15 conducted before the COVID-19 pandemic and 8 conducted during the pandemic.\u003c/p\u003e\n\u003cp\u003eThis systematic scoping review included 15 articles from the pre-COVID-19 period. These studies were conducted in various countries, including the USA (5) [32,33,34,35,36],\u0026nbsp;Iran (3) [37,38,39], Canada (2) [40,41], Italy (2) [42,43],\u0026nbsp;Belgium (1) [44], the Netherlands (1) [45], and the UK (1) [46]. The sample sizes ranged from 13 [35] to 1,814 [41], with a combined total of 5,171 participants. Table 1 and Table 2 summarizes the key characteristics of these studies. The tables are added at the beginning of the main document. Eight studies were multidisciplinary [33,34,35,40,41,44,45,46], involving professionals from at least two different fields.\u003c/p\u003e\n\u003cp\u003eFor the COVID-19 period, 8 articles were included in the review. These studies were conducted in Australia (2) [47,48], Iran (2) [49,50], Italy (2) [51,52], Canada (1) [53], and China (1) [54]. Sample sizes ranged from 26 [54] to 240 [53], with a total of 1,026 participants. Table 2 summarizes the characteristics of these studies. Five of the studies [47,51,52,53,54] were multidisciplinary, involving professionals from at least two different fields.\u003c/p\u003e\n\u003cp\u003eCross-sectional studies were the most common approach both before [33,37,38,40,42,43]\u0026nbsp;and during [48,49,50,51,53,54] the pandemic, utilizing tools like the MDS and its adaptations (e.g., Pediatric MDS-R). During the pandemic, online surveys [51,52,53] were widely employed to reach broader respondents.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.3. Moral Distress Before COVID-19\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePre-pandemic moral distress among NICU and PICU nurses often stemmed from ethical dilemmas like end-of-life [40,41,42,43,46] care, perceived unnecessary treatments [35,36,42], limited decision-making autonomy [34,37,43], and inadequate end-of-life support [32,40,41,42,43,46]. Moral distress scores ranged from 59.54 [36] to 106.41 [38] with two studies identifying high levels of distress [35,45]. While the numerical range appears broad, interpretation depends on the scaling of the specific version of the MDS used, studies defined distress levels as moderate or high based on internal cut-offs or comparison to baseline norms.\u003c/p\u003e\n\u003cp\u003eNurses frequently reported emotional and ethical conflicts related to delivering care perceived as non-beneficial. Poor team collaboration [45] and organizational constraints also contributed to elevated distress levels.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.4. Moral Distress During COVID-19\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring the pandemic, distress levels increased significantly from 44.42 [32] to 102 [54] and two studies [52,54] reporting high levels, driven by resource shortages, intensified workloads, and fears of virus transmission. Although the lower bound appears reduced compared to pre-pandemic scores, this is due to variation in measurement tools and sample characteristics, not a true reduction. Several studies highlighted increased emotional burden despite fluctuating numerical ranges. Nurses faced new stressors such as PPE shortages [50,52], increased workload, resource-driven triage, and fear of virus transmission to family members [50,52].\u003c/p\u003e\n\u003cp\u003eEthical dilemmas intensified around end-of-life decision-making and providing life-sustaining interventions with uncertain outcomes [33,35,48,49,50,51,54]. This trend highlights the deepening of moral distress in nursing.\u003c/p\u003e\n\u003cp\u003eAdditionally, organizational factors such as limited support systems [53] and lack of ethical consultation contributed to the emotional burden. A sense of powerlessness emerged due to institutional constraints and emotionally taxing decisions, including situations where patients died alone [48,49,50,51,54].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.5. Burnout, Turnover, and Psychological Impacts\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePre-pandemic studies linked moral distress with moderate burnout [34,36,40,41,44,46], reduced job satisfaction [43], and career change considerations [35,38].\u003c/p\u003e\n\u003cp\u003eDuring the pandemic, psychological effects worsened: one study reported 50% experiencing severe burnout [52], and others highlighted increased depression and anxiety [51,54]. Notably, over 50% of nurses considered leaving their jobs during the pandemic [52], compared to 25% pre-pandemic [46].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.6. Contributing Factors and Protective Mechanisms\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBefore the pandemic, factors such as restricted professional autonomy [34,37,44], ethical dilemmas related to life-sustaining treatments [33,35], poor team collaboration [45], and inadequate end-of-life support [32,40,41,42,43,46] contributed to moral distress. However, a supportive work environment, clear guidelines, and effective collaboration were found to reduce distress [35,45].\u003c/p\u003e\n\u003cp\u003eDuring the pandemic, those mitigating elements often disappeared. Resource shortages, disorganized working conditions, and lack of institutional support exacerbated the situation [47,49,52,54]. Emotional strain increased, as nurses had to navigate ethical conflicts while coping with isolation, uncertainty, and an overwhelmed system. The emotional toll was amplified when nurses had to make or witness decisions influenced by resource scarcity and patients dying without family present [48,49,50,51,54].\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis systematic scoping review aimed to explore the experience and contributing factors of moral distress among NICU and PICU nurses before and during the COVID-19 pandemic. The results offer an integrative perspective on the nature, sources, and consequences of moral distress, while also identifying potential mitigation strategies. The studies included in this review originated from various countries, including the USA, Canada, Italy, Iran, Australia, China, and the UK, providing a diverse international context for understanding this phenomenon.\u003c/p\u003e\n\u003cp\u003eAcross all included studies, moral distress was consistently associated with ethical conflicts in care provision, particularly in end-of-life situations or when nurses felt compelled to participate in treatment plans they deemed futile or harmful [34,35,40,41,42,44,46]. These ethical tensions often involved decisions about prolonging life at the expense of suffering [35,36,37,42], lack of participation in decision-making, or conflicts between the values of the nurse, the patient, and the institution [32,33,43,45].\u003c/p\u003e\n\u003cp\u003eNotably, the intensity of moral distress was high both before and during the pandemic. However, during COVID-19, additional stressors emerged, including resource scarcity [48], visitor restrictions [47,49,54], and rapid changes in clinical protocols [48,53]. These heightened the moral burden on nurses, as they were often forced to prioritize care [55,56] in ways that contradicted their professional ethics. The absence of family members, especially in pediatric and neonatal settings, created further emotional strain [50,51,54].\u003c/p\u003e\n\u003cp\u003eWhile pre-pandemic moral distress was frequently related to structural issues [33,34,36], such as insufficient support in end-of-life care [35,37], poor communication with physicians [32,43], and perceived low autonomy [38,45], pandemic-related distress arose from both similar and new factors, including inadequate PPE, fear of infection, and working in understaffed and emotionally volatile environments [48,53,57,58].\u003c/p\u003e\n\u003cp\u003eThe findings of this review align with existing evidence suggesting that moral distress is not only a persistent problem in intensive care settings but one that significantly intensified during the pandemic. Previous research has identified similar themes, including role conflict [35,37,44,45,52], team dynamics [42,45,50,54], and the emotional burden of futile care decisions [34,44,51]. However, this review expands upon prior work by synthesizing data across both time periods and emphasizing the unique dynamics of pediatric and neonatal care, where family involvement and developmental considerations add complexity to ethical decision-making [32,43,53].\u003c/p\u003e\n\u003cp\u003eSeveral included studies also reported that nurses experienced distress when their professional expertise was overlooked by physicians or management [47,54], echoing findings from studies on adult ICUs. This lack of voice in decision-making processes has been repeatedly shown to increase emotional exhaustion and decrease job satisfaction [59,60,61].\u003c/p\u003e\n\u003cp\u003eIn contrast to many earlier studies, this review sheds light on the gender and role-specific elements [33,35,38,40,44] of moral distress, although more research is still needed in this area. The female-dominated nursing profession often intersects with hierarchical healthcare structures, potentially compounding moral injury in emotionally charged scenarios.\u003c/p\u003e\n\u003cp\u003eThe data highlight an urgent need for healthcare organizations to address the root causes of moral distress through structural and organizational reforms. One key recommendation is the promotion of shared decision-making practices [47,49,54], where nurses\u0026rsquo; ethical concerns are acknowledged and incorporated into treatment planning. Multidisciplinary team meetings [48], ethical debriefings [48,49,50,54], and regular communication forums [34,46,47,48] can help to prevent moral residue [62] and reduce the likelihood of long-term burnout [63].\u003c/p\u003e\n\u003cp\u003eThe review also emphasizes the importance of staffing adequacy [64] and workload regulation. Moral distress often arose when nurses were required to make ethically complex decisions under time pressure or with insufficient support [47,54]. Providing adequate PPE and ensuring fair shift distribution is vital not only for physical safety but also for emotional well-being [51,52,53].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePsychological support systems, such as peer support groups, professional counseling, and stress resilience training [33,36,39,49,51], are essential components in mitigating moral distress. Furthermore, institutional transparency, particularly during health crises, can help reduce feelings of powerlessness and strengthen trust between staff and management [65,66].\u003c/p\u003e\n\u003cp\u003eProfessional autonomy, particularly in ethically sensitive domains like end-of-life care, should be reinforced [36,38,42,44]. When nurses are involved in shaping care plans and policies, they are more likely to feel empowered and less likely to experience moral distress [67].\u003c/p\u003e\n\u003cp\u003eDespite the valuable insights obtained, several limitations must be acknowledged. Many of the included studies had small sample sizes [32,33,34,35,36,37,38,39,40,43,47,48,49,50,51,52] and were conducted within a single country or healthcare institution, reducing generalizability [33,35,37,38,39,40,42,43,48,49,50,51,52]. Moreover, most data were cross-sectional, limiting the ability to assess the evolution of moral distress over time.\u003c/p\u003e\n\u003cp\u003eStudies often focused on female participants, reflecting the gender imbalance in nursing, yet limiting exploration of how moral distress may manifest differently among male or non-binary healthcare providers. Additionally, few studies examined variations in distress based on years of experience, ICU role (e.g., charge nurse vs bedside nurse), or institutional type (e.g., academic vs community hospital).\u003c/p\u003e\n\u003cp\u003ePandemic-era studies tended to focus on early COVID-19 phases, potentially omitting long-term effects on workforce sustainability and psychological recovery [49,51,53]. Finally, although some studies involved interprofessional samples [47,51,52,53,54], most concentrated solely on nurses [48,49,50], without adequately analyzing how moral distress interacts with team dynamics.\u003c/p\u003e\n\u003cp\u003eFuture studies should prioritize longitudinal designs to better understand the development and resolution of moral distress over time. Comparative studies between different ICU types (adult vs pediatric vs neonatal) may also help clarify setting-specific dynamics. There is also a need to investigate organizational cultures that successfully buffer moral distress and to develop interventions grounded in ethical resilience and communication theory.\u003c/p\u003e\n\u003cp\u003eQuantitative research should be complemented by qualitative insights to capture the emotional and contextual subtleties of moral suffering. Researchers should also ensure that instruments used to measure moral distress are sensitive to current challenges, including those introduced by public health emergencies.\u003c/p\u003e\n\u003cp\u003eThis scoping review has illustrated that moral distress among NICU and PICU nurses is a serious, complex, and multifaceted issue that has only grown more acute during the COVID-19 pandemic. The review highlights how ethical conflict, emotional overload, and systemic limitations intersect to affect nurses\u0026rsquo; mental health, job satisfaction, and care quality. It also underscores the role of leadership, communication, and institutional culture in shaping the moral climate of intensive care units. Addressing moral distress is not only a matter of individual coping, but a shared responsibility that requires systemic action and sustained investment from healthcare organizations and policymakers alike.\u0026nbsp;\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis systematic scoping review highlights the complex and multifaceted nature of moral distress experienced by NICU and PICU nurses before and during the COVID-19 pandemic. The findings reveal that the intensity and frequency of moral distress were moderate before the pandemic, driven by challenging ethical dilemmas such as life-sustaining treatments perceived as prolonging suffering and end-of-life care decisions. During the pandemic, these levels significantly increased, exacerbated by resource shortages, heightened workloads, and organizational constraints.\u003c/p\u003e\n\u003cp\u003eThe results underscore the critical role of workplace factors, such as team dynamics, communication, and ethical climate, in shaping the levels of moral distress. A supportive organizational culture, characterized by clear ethical guidelines and adequate resources, was found to mitigate distress, while its absence amplified emotional and professional strain.\u003c/p\u003e\n\u003cp\u003eThe pandemic introduced new ethical challenges, such as triage decisions and restricted family access, further intensifying moral distress. Nurses often experienced feelings of powerlessness and frustration due to limited professional autonomy and insufficient involvement in decision-making processes. The emotional toll, compounded by personal safety concerns and the risk of infection, led to increased burnout and a significant proportion of nurses considering leaving their profession.\u003c/p\u003e\n\u003cp\u003eThe findings emphasize the need for targeted interventions to reduce moral distress, particularly in high-stress settings like NICUs and PICUs. These include improving communication within teams, fostering collaborative decision-making, and providing regular debriefing and psychological support sessions. Training programs focusing on ethical resilience and emotional coping strategies are vital to equip nurses to navigate ethically challenging situations effectively.\u003c/p\u003e\n\u003cp\u003eFinally, the review highlights the importance of addressing systemic issues such as staffing levels, resource allocation, and organizational support structures. A proactive approach to managing moral distress will not only enhance nurse well-being but also improve patient care quality and workforce retention, ensuring the sustainability of healthcare systems during future crises.\u003c/p\u003e"},{"header":"6. Limitations","content":"\u003cp\u003eThis review has several limitations that should be acknowledged. First, despite applying a comprehensive search strategy across multiple databases, it is possible that some relevant studies were missed, particularly unpublished or non-indexed literature, which may have led to publication bias. The inclusion of only studies published in English may have excluded important research conducted in other languages, especially from regions where NICU and PICU services differ structurally or culturally.\u003c/p\u003e\n\u003cp\u003eSecond, we limited the review to studies published from 2015 onwards to ensure relevance to current clinical contexts. However, this decision may have excluded earlier yet potentially significant work on moral distress. Additionally, our focus on open-access and peer-reviewed literature may have inadvertently excluded studies published in subscription-based journals.\u003c/p\u003e\n\u003cp\u003eThird, the review included only quantitative and mixed-methods studies that used validated instruments, which may have limited the diversity of perspectives captured, particularly rich qualitative insights. Furthermore, we did not conduct a meta-analysis due to heterogeneity in study designs and outcome measures, which restricts the ability to provide pooled effect estimates.\u003c/p\u003e\n\u003cp\u003eFourth, while we assessed the methodological quality of included studies, the use of cross-sectional designs and self-reported instruments across most studies may introduce inherent bias, such as social desirability or recall bias. Finally, the review synthesized evidence up to October 2024, and developments in the literature after this period were not captured.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, this systematic scoping review provides a timely and comprehensive overview of moral distress among NICU and PICU nurses before and during the COVID-19 pandemic. It highlights important trends, knowledge gaps, and directions for future research, offering practical implications for policy and healthcare practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The APC was funded by Riga Stradiņ\u0026scaron; University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u003c/strong\u003e The study was conducted in accordance with the Declara-tion of Helsinki, and approved by the Ethics Committee of Riga Stradiņ\u0026scaron; University (protocol code 2-PĒK-4/416/2023 09.05.2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The datasets produced and examined in this study can be obtained from the corresponding author upon a reasonable request. All data generated or analyzed during this study are provided within the published article. The data utilized in this study is confidential.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003eDeclarations of interest: none.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e: Before the implementation of the practical part of the study, the permission of the ethical committee of Riga Stradiņ\u0026scaron; University to conduct the study was obtained (Document nr. 2-PEK-4/45/2021).\u003c/p\u003e\n\u003cp\u003eAcknowledgement: no.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAljabery, Mohannad, Isabel Coetzee-Prinsloo, Annatjie Van Der Wath, and Nathira Al-Hmaimat. 2024. \u0026ldquo;Characteristics of Moral Distress from Nurses\u0026rsquo; Perspectives: An Integrative Review.\u0026rdquo; \u003cem\u003eInternational Journal of Nursing Sciences\u003c/em\u003e, October, S2352013224001042. https://doi.org/10.1016/j.ijnss.2024.10.005.\u003c/li\u003e\n\u003cli\u003eTian, Xu, Yanfei Jin, Hui Chen, and Mar\u0026iacute;a F. 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Davis. 2021. \u0026ldquo;Moral Distress in Neonatology.\u0026rdquo; \u003cem\u003ePediatrics\u003c/em\u003e 148 (2): e2020031864. https://doi.org/10.1542/peds.2020-031864.\u003c/li\u003e\n\u003cli\u003eBarr, Peter. 2024. \u0026ldquo;Moral Foundations, Moral Emotions, and Moral Distress in NICU Nurses.\u0026rdquo; \u003cem\u003eNursing Ethics\u003c/em\u003e, June, 09697330241262468. https://doi.org/10.1177/09697330241262468.\u003c/li\u003e\n\u003cli\u003eRezaei, Zeinab, Monirsadat Nematollahi, and Neda Asadi. 2023. \u0026ldquo;The Relationship between Moral Distress, Ethical Climate, and Attitudes towards Care of a Dying Neonate among NICU Nurses.\u0026rdquo; \u003cem\u003eBMC Nursing\u003c/em\u003e 22 (1): 303. https://doi.org/10.1186/s12912-023-01459-7.\u003c/li\u003e\n\u003cli\u003eAlipour, Zeinab, Monir Nobahar, Raheb Ghorbani, and Elahe Jahan. 2024. \u0026ldquo;The Relationship between Teamwork and Moral Distress among NICU Nurses.\u0026rdquo; \u003cem\u003eBMC Nursing\u003c/em\u003e 23 (1): 790. https://doi.org/10.1186/s12912-024-02437-3.\u003c/li\u003e\n\u003cli\u003eCarletto, Sara, Maria Chiara Ariotti, Giulia Garelli, Ludovica Di Noto, Paola Berchialla, Francesca Malandrone, Roberta Guardione, et al. 2022. \u0026ldquo;Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy.\u0026rdquo; \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e 19 (14): 8526. https://doi.org/10.3390/ijerph19148526.\u003c/li\u003e\n\u003cli\u003eGrasso, Chiara, Davide Massidda, Karolina Zaneta Maslak, Cinzia Favara-Scacco, Francesco Antonio Grasso, Carmela Bencivenga, Valerio Confalone, et al. 2022. \u0026ldquo;Moral Distress in Healthcare Providers Who Take Care of Critical Pediatric Patients throughout Italy\u0026mdash;Cultural Adaptation and Validation of the Italian Pediatric Instrument.\u0026rdquo; \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e 19 (7): 3880. https://doi.org/10.3390/ijerph19073880.\u003c/li\u003e\n\u003cli\u003eFoster, Jennifer R., Laurie A. Lee, Jamie A. Seabrook, Molly Ryan, Corey Slumkoski, Martha Walls, Laura J. Betts, et al. 2023. \u0026ldquo;A Survey of Pediatric Intensive Care Unit Clinician Experience with Restricted Family Presence during COVID-19.\u0026rdquo; \u003cem\u003eCanadian Journal of Anesthesia/Journal Canadien d\u0026rsquo;anesth\u0026eacute;sie\u003c/em\u003e 70 (10): 1669\u0026ndash;81. https://doi.org/10.1007/s12630-023-02547-7.\u003c/li\u003e\n\u003cli\u003eCheung, Wl, Kl Hon, Karen Ky Leung, Wf Hui, Judith Jm Wong, Jh Lee, Sc Kwok, and Patrick Ip. 2023. \u0026ldquo;Moral Distress and Psychological Status among Healthcare Workers in a Newly Established Paediatric Intensive Care Unit.\u0026rdquo; \u003cem\u003eHong Kong Medical Journal\u003c/em\u003e, December. https://doi.org/10.12809/hkmj209246.\u003c/li\u003e\n\u003cli\u003eKirkpatrick, James N., Sarah C. Hull, Savitri Fedson, Brendan Mullen, and Sarah J. Goodlin. 2020. \u0026ldquo;Scarce-Resource Allocation and Patient Triage During the COVID-19 Pandemic.\u0026rdquo; \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e 76 (1): 85\u0026ndash;92. https://doi.org/10.1016/j.jacc.2020.05.006.\u003c/li\u003e\n\u003cli\u003eRobert, Ren\u0026eacute;, Nancy Kentish-Barnes, Alexandre Boyer, Alexandra Laurent, Elie Azoulay, and Jean Reignier. 2020. \u0026ldquo;Ethical Dilemmas Due to the Covid-19 Pandemic.\u0026rdquo; \u003cem\u003eAnnals of Intensive Care\u003c/em\u003e 10 (1): 84. https://doi.org/10.1186/s13613-020-00702-7.\u003c/li\u003e\n\u003cli\u003eCohen, Jennifer, and Yana van der Meulen Rodgers. 2020. \u0026ldquo;Contributing Factors to Personal Protective Equipment Shortages during the COVID-19 Pandemic.\u0026rdquo; \u003cem\u003ePreventive Medicine\u003c/em\u003e 141 (December):106263. https://doi.org/10.1016/j.ypmed.2020.106263.\u003c/li\u003e\n\u003cli\u003eLake, Eileen T., Aliza M. Narva, Sara Holland, Jessica G. Smith, Emily Cramer, Kathleen E. Fitzpatrick Rosenbaum, Rachel French, Rebecca R. S. Clark, and Jeannette A. Rogowski. 2022. \u0026ldquo;Hospital Nurses\u0026rsquo; Moral Distress and Mental Health during COVID-19.\u0026rdquo; \u003cem\u003eJournal of Advanced Nursing\u003c/em\u003e 78 (3): 799\u0026ndash;809. https://doi.org/10.1111/jan.15013.\u003c/li\u003e\n\u003cli\u003eRicciardelli, Rosemary, Matthew S. Johnston, Brittany Bennett, Andrea M. Stelnicki, and R. Nicholas Carleton. 2022. \u0026ldquo;\u0026lsquo;It Is Difficult to Always Be an Antagonist\u0026rsquo;: Ethical, Professional, and Moral Dilemmas as Potentially Psychologically Traumatic Events among Nurses in Canada.\u0026rdquo; \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e 19 (3): 1454. https://doi.org/10.3390/ijerph19031454.\u003c/li\u003e\n\u003cli\u003eEngstr\u0026ouml;m, \u0026Aring;sa, Angelica Fredholm, Anna Nordin, and Maria Andersson. 2022. \u0026ldquo;Institutional Constraints as an Obstacle for Prioritizing Nursing Interventions During the COVID-19 Pandemic\u0026mdash;Critical Care Nurses\u0026rsquo; Experiences.\u0026rdquo; \u003cem\u003eSAGE Open Nursing\u003c/em\u003e 8 (January):23779608221133656. https://doi.org/10.1177/23779608221133656.\u003c/li\u003e\n\u003cli\u003eBringedal, Berit H., Karin Isaksson R\u0026oslash;, Fredrik B\u0026aring;\u0026aring;the, Ingrid Miljeteig, and Morten Magelssen. 2022. \u0026ldquo;Guidelines and Clinical Priority Setting during the COVID-19 Pandemic \u0026ndash; Norwegian Doctors\u0026rsquo; Experiences.\u0026rdquo; \u003cem\u003eBMC Health Services Research\u003c/em\u003e 22 (1): 1192. https://doi.org/10.1186/s12913-022-08582-2.\u003c/li\u003e\n\u003cli\u003eWanigasekara, Assel, and Julie Freeborn. 2023. \u0026ldquo;Moral Distress among Healthcare Professionals during the Covid-19 Pandemic: Report of an Institution-Wide Survey.\u0026rdquo; \u003cem\u003ePsyPag Quarterly\u003c/em\u003e 1 (124): 43\u0026ndash;54. https://doi.org/10.53841/bpspag.2023.1.124.43.\u003c/li\u003e\n\u003cli\u003eCohen, Catherine, Silvia Pignata, Eva Bezak, Mark Tie, and Jessie Childs. 2023. \u0026ldquo;Workplace Interventions to Improve Well-Being and Reduce Burnout for Nurses, Physicians and Allied Healthcare Professionals: A Systematic Review.\u0026rdquo; \u003cem\u003eBMJ Open\u003c/em\u003e 13 (6): e071203. https://doi.org/10.1136/bmjopen-2022-071203.\u003c/li\u003e\n\u003cli\u003eMabona, Jean F., Dalena Van Rooyen, and Wilma Ten Ham-Baloyi. 2022. \u0026ldquo;Best Practice Recommendations for Healthy Work Environments for Nurses: An Integrative Literature Review.\u0026rdquo; \u003cem\u003eHealth SA Gesondheid\u003c/em\u003e 27 (April). https://doi.org/10.4102/hsag.v27i0.1788.\u003c/li\u003e\n\u003cli\u003eVatn, Line, and Berit Misund Dahl. 2022. \u0026ldquo;Interprofessional Collaboration between Nurses and Doctors for Treating Patients in Surgical Wards.\u0026rdquo; \u003cem\u003eJournal of Interprofessional Care\u003c/em\u003e 36 (2): 186\u0026ndash;94. https://doi.org/10.1080/13561820.2021.1890703.\u003c/li\u003e\n\u003cli\u003eAggrawal, Sakhi, and Alejandra J. Magana. 2024. \u0026ldquo;Teamwork Conflict Management Training and Conflict Resolution Practice via Large Language Models.\u0026rdquo; \u003cem\u003eFuture Internet\u003c/em\u003e 16 (5): 177. https://doi.org/10.3390/fi16050177.\u003c/li\u003e\n\u003cli\u003eSkegg, Emma, Canice McElroy, Mercedes Mudgway, and James Hamill. 2023. \u0026ldquo;Debriefing to Improve Interprofessional Teamwork in the Operating Room: A Systematic Review.\u0026rdquo; \u003cem\u003eJournal of Nursing Scholarship\u003c/em\u003e 55 (6): 1179\u0026ndash;88. https://doi.org/10.1111/jnu.12924.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cb\u003eTables 1, 3 and 4 are available in the Supplementary Files section.\u003c/b\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Search Strategy, Outcome, and Data Sources during COVID-19\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71.0031%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeSH Terms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9655%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDatabase Count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0313%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71.0031%;\"\u003e\n \u003cp\u003e(moral distress or moral problems or moral issues or ethical distress) AND (nurse or nurses or nursing) AND (neonatal or pediatric or NICU or PICU nursing or nurses) AND (intensive or critical care) AND (covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9655%;\"\u003e\n \u003cp\u003eMEDLINE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0313%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71.0031%;\"\u003e\n \u003cp\u003e(moral distress or moral problems or moral issues or ethical distress) AND (nurse or nurses or nursing) AND (neonatal or pediatric or NICU or PICU nursing or nurses) AND (intensive or critical care) AND (covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9655%;\"\u003e\n \u003cp\u003ePubMed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0313%;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71.0031%;\"\u003e\n \u003cp\u003e(moral distress or moral problems or moral issues or ethical distress) AND nurses AND (nicu AND nursing) AND (picu AND nursing) AND (intensive AND critical care) AND (COVID-19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9655%;\"\u003e\n \u003cp\u003eProQuest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0313%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71.0031%;\"\u003e\n \u003cp\u003e(moral distress or moral problems or moral issues or ethical distress) AND nurses AND (nicu AND nursing) AND (picu AND nursing) AND (intensive AND critical care) AND (COVID-19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9655%;\"\u003e\n \u003cp\u003eScience Direct\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0313%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71.0031%;\"\u003e\n \u003cp\u003e(moral distress or moral problems or moral issues or ethical distress) AND (nurse or nurses or nursing) AND (neonatal or pediatric or NICU or PICU nursing or nurses) AND (intensive or critical care) AND (COVID-19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9655%;\"\u003e\n \u003cp\u003eWeb of Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0313%;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71.0031%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.9655%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.0313%;\"\u003e\n \u003cp\u003e174\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Moral distress, Neonatal intensive care, Pediatric intensive care, COVID-19 pandemic, Nurses","lastPublishedDoi":"10.21203/rs.3.rs-5604685/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5604685/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMoral distress occurs when nurses are constrained from acting in accordance with their ethical beliefs. This review synthesizes evidence on the prevalence, contributing factors, and consequences of moral distress among Neonatal Intensive Care Unit (NICU) and Pediatric Intensive Care Unit (PICU) nurses before and during the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA systematic scoping review was conducted in accordance with PRISMA-ScR guidelines. Literature was searched across five databases (MEDLINE, PubMed, ProQuest, ScienceDirect, Web of Science) and Google Scholar between August and October 2024. Only quantitative studies using validated moral distress instruments were included. Risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 23 studies met the inclusion criteria, 15 from the pre-pandemic period and 8 from the COVID-19 period, encompassing 6,197 participants across diverse healthcare settings. Most studies used cross-sectional designs and tools like the Moral Distress Scale (MDS). Findings showed consistently high moral distress before the pandemic, which intensified during COVID-19 due to new stressors such as PPE shortages, restricted visitation, and triage-related ethical conflicts. Pandemic-era studies reported higher burnout, emotional exhaustion, and intention to leave the profession.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMoral distress among NICU and PICU nurses is an ongoing concern that was significantly exacerbated during the COVID-19 pandemic. Addressing it requires systemic interventions including staff support, clear ethical guidelines, and structured decision-making frameworks. Future studies should explore long-term impacts and develop targeted mitigation strategies.\u003c/p\u003e","manuscriptTitle":"Moral distress among neonatal and pediatric intensive care nurses before and during COVID-19: A systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 11:38:41","doi":"10.21203/rs.3.rs-5604685/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1d86645d-869c-4fc1-b947-dc1b420027bc","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-09T11:38:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 11:38:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5604685","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5604685","identity":"rs-5604685","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}