Moral distress among healthcare students: an integrative review




Students, Health Occupations; Ethics; Moral; Moral distress.


Objective: to identify the scientific production about moral distress among healthcare students. Method: an integrative review that included original articles indexed in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases and in the PUBMED portal without time and language restrictions. The analysis of the results occurred in a descriptive way, in three analytical categories. Results: 32 articles were selected, published in international journals, the largest number was in the journal Nursing Ethics. Regarding the level of evidence, 22 qualitative and descriptive studies were in evidence stratum IV and 10 articles between reports of experiences and articles of reflection at level of evidence V. After analysis, three thematic categories were elaborated: Moral distress in the training environment of Health area; Coping with Moral distress: possible repercussions; Academic training: future directions for facing Moral distress. Conclusion: the articles portray that Moral Suffering occurs throughout the career of health professionals, including among students. Situations that cause Moral distress in students must be faced by all undergraduate courses in order to maintain the well-being of students and ensure quality academic education in health. 


Berger, J. T. (2014) Moral Distress in Medical Education and Training. J Gen Intern Med, 29 (2), 395–398.

Brasil. Ministério Da Saúde (2012). Diretrizes metodológicas: elaboração de revisão sistemática e metanálise de ensaios clínicos randomizados. Recuperado de

Bordignon, S. S., Lunardi, V. L., Barlem, E. L., Silveira, R., Ramos, F. R., Dalmolin, G. L., & Barlem, J. (2018). Nursing students facing moral distress: strategies of resistance. Revista brasileira de enfermagem, 71(suppl 4), 1663–1670.

Carlotto, M. S., & Câmara, S. G. (2008). Preditores da síndrome de burnout em estudantes universitários. Pensamiento Psicológico, 4 (10), 101-109. Recuperado de

Comrie, R. W. (2012). An analysis of undergraduate and graduate student nurses ‟moral sensitivity. Nursing Ethics, London, 19 (1), 116-127. https://doi: 10.1177/0969733011411399.

Curtis, K. (2014). Learning the requirements for compassionate practice: Student vulnerability and courage. Nursing Ethics, 21(2): 210–223. https://doi: 10.1177/0969733013478307.

Escolar Chua, R. L., & Magpantay, J. C. J. (2019). Sofrimento moral de estudantes de graduação em enfermagem em enfermagem em saúde comunitária. Nursing Ethics, 26 (7-8), 2340-2350. 10.1177 / 0969733018819130

Escolar-Chua, R. L. (2018). Moral sensitivity, moral distress, and moral courage among baccalaureate Filipino nursing students. Nursing Ethics, 25 (4), 458–469.

Ganske, K. M. (2010). Moral Distress in Academia. The Online Journal of Issues in Nursing, 15 (3), 1-10.

Garity, J. (2009). Fostering nursing students‟ use of ethical theory and decision-making models: teaching strategies. Learn Health SocCare, 8 (2), 114–22.

Grady, A. (2014). Experiencing moral distress as a student nurse. Imprint. 61(2), 40- 42. Recuperado de from: .br/pubmed/24707639

Grant, B.M., Giddings, L. S., & Beale, J. (2005) Vulnerable Bodies: Competing Discourses of Intimate Bodily Care. Journal of Nursing Education, 44 (11), 498-504.

Ham, K. (2004). Principled thinking: A comparison of nursing students and experienced nurses. Journal of Continuing Education in Nursing. 35 (2), 66–73.

Hilliard, R., Harrison, C., & Madden, S. (2007). Ethical conflicts and moral distress experienced by paediatric residents during their training. Paediatr Child Health. 12(1), 29-35.

Jameton, A. (1984). Nursing Practice: The Ethical Issues. Prentice-Hall: Englewood Cliffs.

Jameton, A. (2013). A reflection of moral distress in nursing together with a current application of the concept. Bioethical Inquiry, 10(3), 297–308. Recuperado de

Kelly, E., & Nisker, J. (2009). Increasing bioethics education in preclinical medical curricula: what ethical dilemmas do clinical clerks experience? Acad Med, 84 (4), 498- 504.

Kim, Y. S., Parque, J. H. & Han, S. S. (2007). Differences in moral judgment between nursing students and qualified nurses. Nursing Ethics, 14 (3), 309- 319.

Knifed, E., Goyal, A. & Bernstein, M. (2010). Moral angst for surgical residents: a qualitative study. The American Journal of Surgery, 199 (4), 571-6.

Kopala, B., & Burkhart, L. (2005). Ethical dilemma and moral distress: proposed new NANDA diagnoses. Intern Journal of Nursing Terminologies and Classifications, 16 (1), 3-13.

Lomis, K. D., Carpenter, R. O. & Miller, B. M. (2009). Moral distress in the third year of medical school; a descriptive review of student case reflections. The American Journal of Surgery, 197 (1), 107-112.

Lunardi, V. L., et al. (2009). Sofrimento moral e a dimensão ética no trabalho da enfermagem. Revista Brasileira de Enfermagem, 62 (4), 599-603.

Lunardi, V. L. (2013). Moral distress: An innovative and important subject of study in Brazil. Journal of Bioethical Inquiry, 10 (3), 309–312.

Martinez, W., & Lo, B. (2008). Medical students‟ experiences with medical errors: an analysis of medical studentes says. Medical education, 42 (7), 733–741.

Mehdipour Rabori, R., Dehghan, M., & Nematollahi, M. (2019). Desafios éticos dos estudantes de enfermagem no ambiente clínico: um estudo de métodos mistos. Nursing Ethics, 26 (7–8), 1983–1991. 10.1177 / 0969733018810766

Melnyk B. M., & Fineout-Overholt H. (2005). Evidence-based practice in nursing and healthcare: a guide to best practice. Philadelphia: Lippincott Williams & Wilkins.

Miller B. M. (2017). How Should Resident Physicians Respond to Patients' Discomfort and Students' Moral Distress When Learning Procedures in Academic Medical Settings?. AMA journal of ethics, 19(6), 537–543. https://doi-org/10.1001/journalofethics.2017.19.6.ecas1-1706

Monrouxe, L., Shaw, M., & Rees, C. (2017). Antecedents and Consequences of Medical Students' Moral Decision Making during Professionalism Dilemmas. AMA journal of ethics, 19(6), 568–577.

Monrouxe, L. V., Rees, C. E., Dennis, I., & Wells, S. E. (2015). Professionalism dilemmas, moral distress and the healthcare student: insights from two online UK-wide questionnaire studies. BMJ open, 5(5), e007518.

Monteverde, S. (2016). Cuidando da força de trabalho de amanhã: resiliência moral e educação ética em saúde. Ética em enfermagem, 23 (1), 104-116. / 0969733014557140

Oliveira, R. A. & Ciampone, M. H. T. (2006). A Universidade como espaço promotor de qualidade de vida: vivências e expressões dos alunos de enfermagem. Texto & Contexto Enfermagem,15 (2), 254-261.

Penny, N.H. & You, D. (2011). Preparing Occupational Therapy Students to Make Moral Decisions. Occupational Therapy in Health Care, 25(2/3), 150-63.

Peter, E., Mohammed, S. & Simmonds, A. (2013). Narratives of Aggressive Care: Knowledge, time, and responsibility. Nursing Ethics, 21(4), 461- 472.

Theobald, A. (2013). Moral Distress in Baccalaureate Nursing Students. Ky Nurse, 61(2), 5-6. Recuperado de /pdfviewer?vid=7&sid=1cc67a23-88a2-49e8-9548-360cb49f5234%40sessionmgr103

Range, L. M., & Rotherham, A. L. (2010) Moral distress among nursing and non-nursing students. Nursing Ethics, 17 (2), 225-232.

Reader, R. L. (2015). Students’ experiences in associate degree nursing programs: A qualitative study looking at moral distress. Teaching & Learning in Nursing, 10(3), 118–123.

Rees, C. E., Monrouxe, L. V., & Mcdonald, L. A. (2013) Narrative, emotion and action: analysing "most memorable‟ professionalism dilemmas. Med Educ, 47, 80–96.

Rees, C. E., Monrouxe, L. V., & Mcdonald, L. A. (2015). My mentor kicked a dying woman‟ sbed…‟ Analysing UK nursing students‟ "most memorable‟ professionalism dilemmas. Journal of Advanced Nursing, 71 (1), 169–80.

Rennó, H. M. S., Ramos, F. R. S., & Brito, M. J. M. (2018). Sofrimento moral de graduandos de enfermagem: mito ou realidade? Ética em enfermagem, 25 (3), 304–312. / 0969733016643862

Rosenthal, M. S., & Clay, M. (2017). Initiatives for Responding to Medical Trainees' Moral Distress about End-of-Life Cases. AMA journal of ethics, 19(6), 585–594. 10.1001/journalofethics.2017.19.6.stas1-1706

Rubashkin, N., & Minckas, N. (2018). How Should Trainees Respond in Situations of Obstetric Violence? AMA journal of ethics, 20(1), 238–246.

Souza M., Silva M. & Carvalho R. (2010) Revisão integrativa: o que é e como fazer. Einstein, 8(1), 102- 106.

Yoes, T. (2012) Addressing Moral Distress: Challenge and Strategies for Nursing Faculty. The oklahoma Nurse, 57 (2), 14. Recuperado de ation/230628505_Addressing_moral_distress_challenge_and_strategies_for_nursing_faculty

Weber, E., & Gray, S. (2017). How Should Integrity Preservation and Professional Growth Be Balanced during Trainees' Professionalization? AMA journal of ethics, 19(6), 544–549.

Wiggleton, C., et al. (2010) Medical Students‟ Experiences of Moral Distress: Development of a Web-Based Survey. Academic Medicine, 85 (1), 111-117. 097/ACM.0b013e3181c4782b.

Wojtowicz, B., Hagen, B., & Daalen-smith, C. V. (2014) No place to turn: Nursing students‟ experiences of moral distress in mental health settings. International Journal of Mental Health Nursing, 23 (3), 257–264.

Wojtowicz, B., & Hagen B. (2014) A guest in the house: nursing instructors' experiences of the moral distress felt by students during inpatient psychiatric clinical rotations. Int J Nurs Educ Scholarsh, 11, 121-128.



How to Cite

Bordignon, S. S., Lunardi, V. L., Barlem, E. L. D., Silveira, R. S. da, Castanheira, J. S., & Carvalho, D. P. de . (2020). Moral distress among healthcare students: an integrative review . Research, Society and Development, 9(11), e2829119655.



Review Article