Moral distress and demoralization experienced by nurses in emergency departments: A systematic review and meta-synthesis.

Abstract

ObjectiveTo explore moral distress and demoralization experienced by nurses in emergency departments.MethodsFollowing PRISMA guidelines, nine databases (PubMed, Scopus, Embase, Web of Science, MEDLINE, ScienceDirect, CINAHL, PsycINFO, and ProQuest) were searched up to September 2025. Eligible studies were primary qualitative or mixed-methods research focusing on moral distress and/or demoralization among ED nurses. Data were extracted, appraised using the CASP Qualitative Checklist, and synthesized through thematic and interpretive meta-synthesis.ResultsSix high-quality qualitative studies (CASP scores: 8-9/10) conducted in Spain, the United States, and Türkiye were included. Five meta-themes and sixteen subthemes emerged: (1) Structural and organizational drivers-including power imbalances, resource scarcity, and policy-imposed ethical barriers; (2) Ethical conflict at the bedside-such as futile care, dehumanization, and unrelieved suffering; (3) Emotional consequences and moral residue-manifesting as guilt, shame, and identity erosion; (4) Coping responses-ranging from emotional numbing to peer solidarity and moral advocacy; and (5) Moral resilience and ethical sustenance-fostered by experience, supportive leadership, and value alignment. Moral distress was conceptualized not as an individual weakness but as a systemic moral injury shaped by institutional constraints.ConclusionsAddressing moral distress requires organizational accountability, structured ethical reflection, and policies that protect nurses' moral agency.