Abstract
Objective: The study examines the relationship between moral distress and nurse leadership by identifying nurse leaders’ challenges in making ethical decisions. By employing empirically rotted theoretical frameworks and available literature, the research intends to explore how nurse leaders, positioned between frontline staff and organizational administration, experience moral distress and how this distress impacts their ethical decision-making processes. Methods: The paper presents a conceptual model that outlines leadership responsibility for the moral resilience of nursing practice. Consideration is given to individuals' moral distress, staff support in ethical dilemmas, creating an ethical practice environment, and developing leadership for a morally resilient domain (Miller, 2024). Results: Emphasize the ethical concerns within leadership roles, the structured ethical discourse, moral agency support, and resilience-building approaches to strengthen ethical decision-making in healthcare settings. Conclusion: Nursing leadership moral distress exceeds individual patient care moral dilemmas, including system-level ethical concerns affecting nurses and institutional policy. A multifaceted approach that includes strong ethical conversation, support for moral agency, and resilience practice is essential to reduce distress and promote ethical decision-making
References
Karlsson M, Karlsson C, Barbosa da Silva A, Berggren I, Söderlund M. Community nurses’ experiences of ethical problems in end-of-life care in the patient’s own home. Scand J Caring Sci. 2013; 27(4):831-838. https://doi.org/10.1111/j.1471-6712. 2012.01087.x
DeKeyser Ganz F, Berkovitz K. Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. J Adv Nurs. 2012;68(7):1516-1525. https://doi.org/10.1111/j.1365-2648.2011.05897.x
Epstein EG, Delgado S. Understanding and Addressing Moral Distress. Online J Issues Nurs. 2010;15(3). https://doi.org/10.3912/OJIN.Vol15No0 3Man01
Jameton A. Nursing practice: the ethical issues. Englewood Cliffs: Prentice-Hall; 1984.
Edmonson C. Moral Courage and the Nurse Leader. Online J Issues Nurs. 2010;15(3). https://doi.org/10. 3912/OJIN.Vol15No03Man05
Mitton C, Peacock S, Storch J, Smith N, Cornelissen E. Moral Distress among Healthcare Managers: Conditions, Consequences and Potential Responses. Healthcare policy (Online). 2010;6(2):99-112. https://doi.org/10.12927/hcpol.2010.22036
Storch J, Makaroff KS, Pauly B, Newton L. Take me to my leader: the importance of ethical leadership among formal nurse leaders. Nurs Ethics. 2013;20(2): 150-157. https://doi.org/10.1177/0969733012474291
Li H, Guo J, Ren Z, Bai D, Yang J, Wang W, et al. Moral courage level of nurses: a systematic review and meta-analysis. BMC Nurs. 2024;23:530. https:// doi.org/10.1186/s12912-024-02082-w
Miller PH, Epstein EG, Smith TB, Welch TD, Smith M, Bail JR. Moral distress among nurse leaders: A qualitative systematic review. Nurs Ethics. 2023;30 (7-8):939-959. https://doi.org/10.1177/09697330231 191279
Miller PH. Moral distress among nurse leaders: A conceptual framework. Nurs Ethics. 2025;32(7):2163 -2174. https://doi.org/10.1177/09697330251339420
Kalani Z, Barkhordari-Sharifabad M, Chehelmard N. Correlation between moral distress and clinical competence in COVID-19 ICU nurses. BMC Nurs. 2023;22(1):107. https://doi.org/10.1186/s12912-023-01277-x
Meng J, Guo X. The relationship between ethical leadership, moral sensitivity, and moral courage among head nurses. BMC Nurs. 2025;24(1):538. https://doi.org/10.1186/s12912-025-03170-1
Haghighinezhad G, Atashzadeh-Shoorideh F, Ashktorab T, Mohtashami J, Barkhordari-Sharifabad M. Relationship between perceived organizational justice and moral distress in intensive care unit nurses. Nurs Ethics. 2019;26(2):460-470. https://doi. org/10.1177/0969733017712082
Orgambídez A, Borrego Y, Alcalde FJ, Durán A. Moral Distress and Emotional Exhaustion in Healthcare Professionals: A Systematic Review and Meta-Analysis. Healthcare (Basel). 2025;13(4):393. https://doi.org/10.3390/healthcare13040393
Buchbinder M, Browne A, Berlinger N, Jenkins T, Buchbinder L. Moral Stress and Moral Distress: Confronting Challenges in Healthcare Systems under Pressure. Am J Bioeth. 2024;24(12):8-22. https://doi. org/10.1080/15265161.2023.2224270
Cheraghi R, Valizadeh L, Zamanzadeh V, Hassankhani H, Jafarzadeh A. Clarification of ethical principle of the beneficence in nursing care: an integrative review. BMC Nurs. 2023;22(1):89. https://doi.org/10.1186/s12912-023-01246-4
Storaker A, Heggestad AKT, Sæteren B. Ethical challenges and lack of ethical language in nurse leadership. Nurs Ethics. 2022;29(6):1372-1385. https://doi.org/10.1177/09697330211022415
Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009; 20(4):330-342. https://doi.org/10.1086/JCE2009204 06
Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics. 2002;9(6):636-650. https://doi.org/10.1191/0969733002ne557oa
Wilkinson JM. Moral distress in nursing practice: experience and effect. Nurs Forum. 1987;23(1):16-29. https://doi.org/10.1111/j.1744-6198.1987.tb0079 4.x
Pont J, Stöver H, Wolff H. Dual loyalty in prison health care. Am J Public Health. 2012;102(3):475-480. https://doi.org/10.2105/ajph.2011.300374
Thompson JE, Thompson HO. Bioethical decision making for nurses. Norwalk (CT): Appleton-Century-Crofts; 1985.
Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 7th ed. New York: McGraw-Hill; 2010.
Shapiro JP, Stefkovich JA. Ethical leadership and decision making in education: Applying theoretical perspectives to complex dilemmas. New York: Routledge; 2016.
Brown ME, Treviño LK, Harrison DA. Ethical leadership: A social learning perspective for construct development and testing. Organizational Behavior and Human Decision Processes. 2005;97(2):117-134. https://doi.org/10.1016/j.obhdp.2005.03.002
Rushton CH. Moral resilience: A capacity for navigating moral distress in critical care. AACN Adv Crit Care. 2016;27(1):111-119. https://doi.org/10.403 7/aacnacc2016275
Scott PA, Harvey C, Felzmann H, Suhonen R, Habermann M, Halvorsen K, et al. Resource allocation and rationing in nursing care: A discussion paper. Nurs Ethics. 2019;26(5):1528-1539. https:// doi.org/10.1177/0969733018759831
Haahr A, Norlyk A, Martinsen B, Dreyer P. Nurses experiences of ethical dilemmas: A review. Nurs Ethics. 2020;27(1):258-272. https://doi.org/10.1177/ 0969733019832941
Maunder RG, Heeney ND, Greenberg RA, Jeffs LP, Wiesenfeld LA, Johnstone J, et al. The relationship between moral distress, burnout, and considering leaving a hospital job during the COVID-19 pandemic: a longitudinal survey. BMC Nurs. 2023;22(1):243. https://doi.org/10.1186/s12912-023-01407-5
Andersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics. 2022;23(1):29. https://doi.org/10.1186/s12910-022-0 0766-z
Stucky CH, Wymer JA. Ethical Reasoning as a Core Nurse Leader Competency: Maximizing Strategic Decision-Making and Operational Outcomes. Nurse Lead. 2024;22(2):187-193. https://doi.org/10.1016/j. mnl.2023.09.009
Emam SM, Fakhry SF, Abdrabou HM. Leaders development program by 360 degree feedback: reflection on head nurses’ leadership practices. BMC Nurs. 2024;23(1):772. https://doi.org/10.1186/s1291 2-024-02395-w
Boeske J. Leadership towards Sustainability: A Review of Sustainable, Sustainability, and Environmental Leadership. Sustainability. 2023;15(16):12626. https:// doi.org/10.3390/su151612626
Lindberg C, Schneider M. Combating infections at Maine Medical Center: Insights into complexity-informed leadership from positive deviance. Leadership. 2013;9(2):229-253. https://doi.org/10.11 77/1742715012468784
Hargreaves J. Using patients: exploring the ethical dimension of reflective practice in nurse education. J Adv Nurs. 1997;25(2):223-228. https://doi.org/10.10 46/j.1365-2648.1997.1997025223.x
Crawford A, Eldardiri D, Leibecke A, Sloan R. Professional growth and development for nurse leaders [Internet]. Silver Spring (MD): American Nurses Association; 2019 Aug 13 [cited 2019 Jun 6]. Available from: https://www.myamericannurse.com/ professional-growth-and-development-for-nurse-lea ders/
Dell’Osso L, Lorenzi P, Nardi B, Carmassi C, Carpita B. Post Traumatic Growth (PTG) in the Frame of Traumatic Experiences. Clin Neuropsychiatry. 2022; 19(6):390-393. https://doi.org/10.36131/cnfioritiedit ore20220606

This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2025 Online Brazilian Journal of Nursing

