Moral distress among neonatal and pediatric intensive care nurses before and during COVID-19: A systematic review

Background Moral distress occurs when nurses are constrained from acting in accordance with their ethical beliefs. This review synthesizes evidence on the prevalence, contributing factors, and consequences of moral distress among Neonatal Intensive Care Unit (NICU) and Pediatric Intensive Care Unit (PICU) nurses before and during the COVID-19 pandemic. Methods A systematic scoping review was conducted in accordance with PRISMA-ScR guidelines. Literature was searched across five databases (MEDLINE, PubMed, ProQuest, ScienceDirect, Web of Science) and Google Scholar between August and October 2024. Only quantitative studies using validated moral distress instruments were included. Risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies. Results A total of 23 studies met the inclusion criteria, 15 from the pre-pandemic period and 8 from the COVID-19 period, encompassing 6,197 participants across diverse healthcare settings. Most studies used cross-sectional designs and tools like the Moral Distress Scale (MDS). Findings showed consistently high moral distress before the pandemic, which intensified during COVID-19 due to new stressors such as PPE shortages, restricted visitation, and triage-related ethical conflicts. Pandemic-era studies reported higher burnout, emotional exhaustion, and intention to leave the profession. Conclusion Moral distress among NICU and PICU nurses is an ongoing concern that was significantly exacerbated during the COVID-19 pandemic. Addressing it requires systemic interventions including staff support, clear ethical guidelines, and structured decision-making frameworks. Future studies should explore long-term impacts and develop targeted mitigation strategies.