How healthcare workers experience moral distress while navigating ethical complexity: a qualitative study

<title>Abstract</title> <p> <bold>Background</bold> Moral distress is a well-documented phenomenon among healthcare workers (HCWs) and is associated with negative psychological outcomes and detrimental impact on patient care, staff wellbeing and health system sustainability. This study presents a secondary analysis of qualitative data collected to explore HCWs’ experiences of ethical encounters, in which moral distress emerged as a prominent, unprompted theme. <bold>Methods</bold> Data were drawn from four focus groups (n=26), conducted with registered health professionals at an Australian teaching hospital. Participants reflected on a progressively complex fictional patient case study. Although the primary study did not set out to investigate moral distress specifically, its prominence across the focus groups warranted secondary analysis. Using a combined inductive and deductive coding approach, an a-priori code of “moral distress” was applied. Codes were iteratively developed into themes and are presented in a descriptive framework. This study is reported in line with Consolidated Criteria for Reporting Qualitative Research (COREQ). <bold>Results</bold> Participants described moral distress arising from three interrelated drivers: (1) Constrained agency and voice, where an inability to raise ethical concerns, not being heard or acknowledged or having to enact others’ decisions. (2) Systemic constraints, including organisational hierarchy, resource and logistical limitations and the sense of being overwhelmed by structural and societal factors. (3) Finally, deficits in preparedness and understanding, including a lack of ethical deliberative frameworks, insufficient training and shouldering an unreasonable ethical burden in decision making was described. Participants also identified protective factors contributing to what we term “moral safety”; cultivating shared understanding through dialogue and support, camaraderie and collaboration among colleagues. <bold>Conclusion</bold> Moral distress among HCWs is experienced through a cumulative interplay of personal, relational and institutional factors. Our findings demonstrate that this distress is experienced as they navigate the ethical complexity embedded in clinical practice. Interventions focused on individual resilience risk mislocating responsibility for what is a systemic issue. Our findings highlight the need for structural responses: procedural frameworks for ethical deliberation, organisational cultures that reduce hierarchical barriers to voice, and formal spaces for collective processing of morally difficult experiences. Our conceptual framework offers a foundation for future research and targeted institutional interventions. <bold>Trial Registration</bold> Not Applicable. </p>