The level of moral sensitivity among nurses: a systematic review and meta-analysis

Moral distress was originally defined as the experience of individuals in the workforce knowing or believing in an ethically appropriate course of action yet feeling unable to pursue it because of organizational or other external constraints [1]. As frontline healthcare workers, nurses face heavy workloads and are constrained by the decisions of others in the clinical decision-making process [2]. Compared to other healthcare professionals, they are particularly vulnerable to moral distress [3, 4]. Moral distress has been a significant issue in nursing practice for many decades [5]. Research has demonstrated that moral distress ultimately diminishes nurses’ professional performance, negatively impacting nurses, patients, and healthcare organizations [6]. For nurses, moral distress leads to feelings of guilt and anguish [3], even causing mental health issues [7]. For patients, nurses facing moral distress cannot provide high-quality care, consequently jeopardizing the quality of care, safety, and satisfaction [8‐10]. For healthcare organizations, moral distress can increase nurses’ intentions to leave the profession [11‐13]. Therefore, measures must be taken to mitigate this negative impact.

Moral sensitivity (MS) has been recognized as both a prerequisite and a foundational component for nurses to make moral decisions and engage in moral behaviors that align with their professional responsibilities [14‐16]. Research suggests that enhancing MS is a key strategy for promoting moral behavior and reducing moral distress [9, 12, 17]. According to Lützén et al., MS involves an intuitive understanding of the vulnerable situations of patients by nurses and an awareness of the moral consequences of decisions made on their behalf [18]. Studies have demonstrated that nurses with higher MS levels are more adept at identifying moral issues, making sound moral decisions [19], and exhibiting moral behavior [20]. Consequently, they can not only deliver high-quality, human-centered care to patients, thereby enhancing patient outcomes [21], but also depict greater respect for colleagues, foster a positive work environment, and improve professional identity and job satisfaction [21]. However, nurses with poor MS are less likely to identify moral issues and make appropriate decisions, eventually leading to a vicious cycle of low MS and high moral distress. Previous studies have demonstrated a direct and significant effect of MS on relieving nurses from moral distress [22]. Khaghanizadeh et al. conducted moral decision-making training for nurses, and the results also demonstrated that improving MS through effective training can reduce moral distress in nurses [23‐25]. In conclusion, enhancing MS is an effective strategy to reduce moral distress.

To effectively improve MS in nurses, the first step is to accurately assess the MS level and provide targeted measures. Many scholars have devoted themselves to studying the current MS levels among nurses. For instance, Khodaveisi et al. [26] suggested that MS remained at a high level in nurses caring for patients with coronavirus 2019. Huang et al. [27] surveyed 331 nurses and found that the MS among nurses was at a relatively moderate-to-high level. However, Chen et al. [28] discovered that MS among nurses was at a low-to-moderate level. Current studies on MS levels among nurses demonstrate significant discrepancies, which may be related to factors such as department, gender, education level, work experience, and learning experience in MS [29‐31]. Although current studies have depicted varying results, it is encouraging that the level of MS among nurses has garnered the attention it deserves. A high MS level not only alleviates moral distress and benefits the professional development of nurses, but also improves the quality of patient care and satisfaction [32]. Consequently, it is important to identify the overall level of MS among nurses to provide evidence for targeted intervention measures. Meta-analysis is a robust method for objectively synthesizing the findings of multiple studies and offers a comprehensive approach to assess the overall effect or trend within a given research domain [33]. However, to date, we have not found any meta-analyses of MS levels among nurses. Consequently, this review aimed to assess the level of MS among nurses, provide evidence-based insights in this area, and facilitate moral practice.

The review was registered in PROSPERO (CRD42024573221) and was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines [34, 35]. As this was a meta-analysis, ethical approval was not required.

This review included 99 cross-sectional studies [13, 20, 24‐27, 29, 31, 42‐132], all of which were evaluated using the JBI Critical Appraisal Tool. The quality of included studies ranged from moderate to high. All studies clearly defined their subjects, inclusion criteria, measurement methods, statistical analyses, and outcomes. However, 61 studies [13, 20, 24, 26, 27, 29, 31, 44‐48, 52, 54, 57, 58, 60‐62, 64‐67, 69, 72‐74, 77, 80‐83, 85, 87‐91, 93‐98, 100, 101, 103, 104, 106, 109, 110, 112, 114, 120, 122‐124, 127‐129, 131] were rated as moderate quality due to limitations in their research design. Specifically, these studies failed to adequately account for potential confounding factors in their measurements and analyses, which might have influenced their results. The absence of proper control for these confounders could lead to over- or underestimation of the relationships between the key variables, thereby diminishing the reliability of the findings. To enhance the quality of future research, it is crucial to address these confounding factors properly.

To the best of our knowledge, this is the first meta-analysis to assess MS levels among nurses. The results of this review indicated that the level of MS among nurses was moderate. However, considerable heterogeneity was observed in this meta-analysis. To further explore the sources of heterogeneity, meta-regression and subgroup analyses were performed, considering factors such as country, department, assessment instrument, gender, education level, work experience, learning experience in MS, publication year, and sample size. Furthermore, sensitivity analysis was conducted to assess the robustness of the results.

Our results demonstrated that the pooled mean score for MS among nurses was 4.49 [95% CI (4.29, 4.70)], which represents a moderate level and is consistent with the results of previous studies [43, 53, 85, 133]. This finding suggests that nurses can identify moral issues and reduce ethical distress. However, the clinical scenarios faced by nurses are much more complex than we might imagine, and there remains room to improve the MS level. As an important form of moral awareness, MS plays a crucial role in promoting ethical conduct among nurses. Nursing managers and educators must prioritize the enhancement of MS levels among nurses.

Meta-regression results demonstrated that the assessment instrument, country, and department were statistically significant. This finding suggests that substantial variation in assessment instrument across studies may be a significant contributor to the observed heterogeneity. Another potential source of heterogeneity could be the fact that the studies involved nurses from different countries, each with unique cultural, ethnic, social, and economic contexts. Furthermore, the differences in departments where nurses are employed may also serve as an important source of heterogeneity, given the variations in work intensity and organizational climate across departments. Although meta-regression analyses were conducted to explore the sources of heterogeneity, the limited number of included studies may have reduced the statistical power of the meta-regression in identifying these sources.

Subgroup analysis revealed significant differences in the pooled mean scores of nurses’ MS across countries, and assessment instrument. At the first place, subgroup analysis revealed notable differences between countries, which may be strongly linked to cultural variation. While nursing practices share commonalities worldwide, the MS level among nurses varies and is influenced by distinct cultural contexts in each country [134]. Additionally, institutional policies and societal expectations further contribute to these variations, resulting in differing MS levels across nations [135]. Lastly, the meta-analysis included studies that used five different MS assessment instruments. The pooled mean score reported using the various assessment instruments varied widely, ranging from 5.46 (the MSQ-R scale) to 3.57 (the MSQ scale). All included studies assessed the level of MS among nurses using the MSQ scale or its adapted versions, which differed in the number of items compared to the original version following its translation and adaptation. This may have contributed to the discrepancies observed [136]. Furthermore, objective assessment of MS level remains limited, as it primarily relies on individual reports and self-reported rating scales, which may exacerbate these discrepancies [14].

Although the results of the meta-subgroup analysis indicated no statistically significant differences in terms of country, gender, education level, work experience and whether nurses had undergone MS training, we still consider it necessary to further discuss these factors. First, the level of MS among nurses varied significantly depending on the department in which they worked. The meta-analysis revealed that the operating room nurses exhibited the pooled mean score of 5.24 [95% CI (4.07, 6.41)], while ICU nurses presented the pooled mean score of 3.26 [95% CI (2.01, 4.51)], which indicates a relatively high level and moderate-low level of MS among nurses. ICU nurses often experience high work demands and long working hours, leading to burnout and fatigue, which may diminish their MS levels [137, 138]. It is well-documented that the emergency department is characterized by high pressure, frequent demands, and rapid decision-making, all of which contribute to a significant prevalence of nurse burnout and a heightened incidence of moral distress, thereby weakening the MS level [139‐141]. Therefore, to improve MS levels, the strategic allocation of human resources and the provision of emotional and psychological support for nurses should be emphasized, as this will help address both the ethical and emotional challenges faced by nurses in high-pressure environments, such as the emergency and ICU departments. Secondly, the pooled mean score for females was 4.11[95% CI (3.76, 4.77)], and for males, it was 4.07 [95% CI (3.74, 4.39)], without significant differences. However, previous studies have revealed differences between genders at the MS level [75, 134, 142]. The following factors may account for the observed differences in MS between males and females across various studies: MS was positively correlated with empathy, and female nurses, who possess more delicate emotions, a stronger capacity for empathy, and greater sensitivity to moral issues, tend to exhibit higher MS level [143, 144]. Nonetheless, existing literature indicates that females are more susceptible to moral distress, which can result in empathy fatigue and adversely affect their MS levels [17, 145]. We contend that it is essential to develop and implement ethical training programs considering gender differences. Thirdly, our results depicted that nurses with a bachelor’s degree or lower had a pooled mean score of 4.08 [95% CI (3.78, 4.37)], while those with a master’s degree or higher had a pooled mean score of 4.44 [95% CI (4.05, 4.83)]. Previous studies have indicated that individuals with a master’s degree generally possess better critical thinking skills and enhanced ability to manage clinical problems, which subsequently leads to a higher MS level and less moral distress [146‐149]. Accordingly, we suggest strengthening MS training for nurses with lower academic qualifications. Fourthly, the results revealed that the pooled mean scores of nurses with work experience of ≤ 5 years, 6–10 years, and ≥ 10 years were 3.78 [95% CI (3.32, 4.23)], 4.51 [95% CI (3.80, 5.23)], and 4.40 [95% CI (4.03, 4.78)], respectively. With the accumulation of clinical experience, nurses become more experienced in caring for patients and are more likely to recognize and address moral issues. This is consistent with the findings of Yildirim et al. [54] and Hognestadet et al. [150], who revealed that the richer the clinical experience of nurses, the higher their MS. However, Arslan et al. [78] stated that, as the number of working years increased, moral sensitivities decreased in the holistic approach subscale. This is related to compassion fatigue. Peters et al. [151] posited that, with an increase in the number of working years, the incidence of compassion fatigue increases, which exerts a reverse impact on MS. Consequently, we recommend that nursing managers develop training programs at different levels to meet the needs of nurses with varying seniority levels. Finally, the results indicated that nurses who underwent moral training exhibited a pooled mean score of 4.65 [95% CI (4.21, 5.10)], compared to a pooled mean score of 4.48 [95% CI (4.09, 4.87)] for those who did not participate in moral training. Multiple studies have demonstrated that nurses who participated in moral training scored higher on MS than those who did not [43, 55, 152]. Besides, several studies have confirmed that moral training effectively improves the MS level and serves as a robust strategy for alleviating moral distress [60, 153‐155]. Nurses with moral training can identify and resolve ethical issues effectively. Consequently, we advocate that nurses continue to learn about and strengthen their moral education.

Overall, our review found that the level of MS among nurses was moderate, indicating the need for further improvement. The results from current studies clearly depict that MS is influenced by various factors. Based on this, the following recommendations can be made to enhance MS. First, given cultural differences between countries, it is essential to implement ethics training programs tailored to the specific cultural context of each nation. Second, it is of paramount importance for nursing administrators to prioritize ethics training in departments with relatively low MS levels, such as ICU and emergency departments. Third, nursing educators and administrators should design and deliver personalized ethics training that considers the individual characteristics of nurses, including gender and years of experience, to mitigate moral dilemmas and enhance MS. Finally, both the accumulation of clinical experience and higher education levels were found to positively influence MS. As such, we advocate for a commitment to lifelong learning, with nurses actively engaging in ongoing moral education throughout their professional careers.

In summary, our review aimed to systematically assess MS levels. The results indicated that, while nurses generally demonstrate moderate MS, there is potential for further improvement. As the largest group of healthcare service providers, nurses need to exhibit an adequate MS level that supports their role in providing quality care. Accordingly, implementing moral training programs could help to enhance MS among nurses. When designing and implementing such programs, it is essential to consider factors such as national cultural differences, departmental variations, and individual characteristics, including gender and educational experience, to ensure focused and effective improvement of MS among nurses.