Critical care nurses’ perspectives on moral distress: a qualitative study in a public sector tertiary care setting

BACKGROUND: Moral distress is a significant issue among critical care nurses who frequently encounter ethically complex situations that contradict their moral and professional values. In Pakistan, research on this phenomenon remains limited particularly regarding how nurses perceive and manage moral distress. OBJECTIVE: This qualitative study aimed to explore the perspectives of critical care nurses in a public sector tertiary care setting regarding the causes and psychological impact of moral distress, and the strategies employed to cope with it. METHODS: An exploratory-interpretive qualitative design was employed to explore moral distress among critical care nurses in a public sector tertiary care setting in Pakistan, a low- and middle-income country. This study was guided by Jameton's concept of moral distress, which describes the psychological and ethical conflict experienced when nurses are unable to act according to their professional and moral judgment due to various constraints. Employing purposive sampling techniques, 15 nurses working in Intensive Care Unit at a public sector tertiary care setting were interviewed based on their eligibility and availability. The data were transcribed, analyzed manually, and presented as themes and subthemes. RESULT: Three themes were extracted. Theme One: 'The Genesis of Moral Distress: A Conflict Between Ethics and Reality', theme two: 'The Pervasive Impact of Moral Distress: Psychological and Professional Toll' and theme three: 'Navigating the Aftermath: Coping in a Constrained Environment'. Findings suggest that moral distress arises from factors such as inadequate staffing, the hierarchical system in Pakistan which gives dominance to physician over nurses, systemic and resources constraint, consequences of moral distress; anxiety, emotional breakdown and reduced job satisfaction leading to burnout. Coping mechanism included avoidance and detachment, peer and family support and spiritual healing. There was a lack of organizational support for coping with moral distress, participants urged for structured and formal support from organization to mitigate moral distress. CONCLUSION: The study underscores urgent need for organizational support, ethical education and supportive leadership to address moral distress among critical care nurses which directly affect patients care.