Institutional Constraints, Nursing Autonomy, and Moral Distress: A Narrative Review

Authors: Jennifer L. Brosseau MSN MPH RN, Janet Reed PhD RN CMSRN CNE

Corresponding Author: Jennifer L. Brosseau, jbrossea@kent.edu

Abstract

Background: Healthcare systems increasingly recognize moral distress as an important contributor to workforce instability, though it is often viewed as a personal lack of resilience rather than a reaction to the organizational conditions from which it arises. The consequences of unresolved moral distress extend beyond individual psychological well-being. Studies have associated moral distress and moral injury with anxiety, depression, emotional exhaustion, diminished professional satisfaction, reduced psychosocial functioning, turnover intention, and career abandonment.

Methods: A narrative review methodology was selected to integrate qualitative, quantitative, and mixed-methods evidence examining relationships among nursing sensitive indicators, autonomy, and moral distress of nurses within the past 10 years. Because conceptual ambiguity exists between moral distress and moral injury, both terms were included in the search strategy.

Results: Nurses described moral distress as arising when systemic or organizational constraints prevented them from providing the quality of care they believe patients deserve. Five interrelated themes characterized these constraints. No term was identified in the literature to describe the ethical obligations inherent in the dynamic relationship between an institution and its members. Therefore, the authors introduce a new term, “Institutional Relational Morality”, defined as an institution’s ability to successfully develop and maintain ethical relationships with its members.

Conclusions: New strategies, such as professional governance, hold promise for increasing nurses’ control over their practice, thus reducing their moral distress, improving nurse well-being, and supporting high-quality patient care.

Introduction

Nursing practice sits at the intersection of professional ethical obligations and the systemic constraints of modern healthcare. Nurses enter the profession committed to providing safe, quality care guided by personal and professional ethical principles. Yet inadequate resources, financial pressures, regulatory requirements, insufficient institutional support, and interpersonal conflict frequently prevent nurses from delivering the care they believe patients deserve. This conflict between professional values and systemic realities creates moral distress, defined as the psychological suffering experienced when individuals know the morally correct action but are unable to carry it out (Safari et al., 2024). Although healthcare systems increasingly recognize moral distress as an important contributor to workforce instability, it is often viewed as a personal lack of resilience, rather than a reaction to the organizational conditions from which it arises. Efforts to ameliorate moral distress focus on individual education and coping strategies because these are far simpler to address than larger systemic issues (Buchbinder et al., 2024).

Background

Moral distress is conceptually related to, but different from, moral injury and burnout. Moral distress was first described within the nursing ethics literature by Andrew Jameton (1984) and refers to situations in which nurses recognize the ethically appropriate action yet are prevented from acting because of institutional constraints. In contrast, moral injury emerged from military psychology and describes the profound psychological, emotional, and spiritual consequences of perpetrating, witnessing, or failing to prevent actions that violate deeply held moral beliefs (Griffin et al., 2019; Litz et al., 2009). Although the concepts overlap, moral injury generally reflects a more enduring disruption of one’s moral identity, whereas moral distress often results from repeated workplace experiences that conflict with professional values (Heitzmann et al., 2025; Vanderloo et al., 2025; Williamson et al., 2023). Conversely, burnout refers to the emotional exhaustion, depersonalization, cynicism, and decreased job performance that results from work-related frustrations in a high-pressure environment (Maslach, 1982). Thus, both moral distress and moral injury differ from burnout because their development requires the presence of a moral or ethical conflict rather than chronic occupational stress alone. Because considerable conceptual overlap exists within the nursing literature, both moral distress and moral injury were considered during this review.

The consequences of unresolved moral distress extend beyond individual psychological well-being. Studies have associated moral distress and moral injury with anxiety, depression, emotional exhaustion, diminished professional satisfaction, reduced psychosocial functioning, turnover intention, and career abandonment (Safari et al., 2024; Sert-Ozen & Kalaycioglu, 2023; Smallwood et al., 2021; Williamson et al., 2023). These outcomes can negatively affect healthcare organizations through increased absenteeism, decreased retention, and workforce shortages while also threatening patient safety and quality of care (Janatolmakan & Khatony, 2022). Understanding systemic factors that influence moral distress therefore represents an important priority for both workforce sustainability and healthcare quality.

Healthcare quality has increasingly been evaluated using nursing-sensitive indicators (NSIs), measures intended to reflect nursing’s contribution to patient care. NSIs can be defined as structural, process, or outcome criteria for change in a person’s health status that can be influenced by nursing care (Oner et al., 2021). This definition builds upon previous conceptualizations while recognizing that patient outcomes result from complex interactions among multiple healthcare disciplines, with nursing representing a substantial, although not exclusive, influence. Choi (2024) acknowledges that nurses are not solely responsible for patient outcomes due to shared responsibilities with other providers and the institution. Consistent with the Donabedian framework (1966), NSIs can be classified as one of three types. First, structural indicators describe the environment in which care is delivered, including staffing, turnover, level of nursing education, skill mix, and organizational resources. Second, process indicators evaluate the delivery of nursing care through assessment, surveillance, communication, patient education, and evidence-based interventions. Finally, outcome indicators include both patient-focused outcomes, such as falls, hospital-acquired infections, pressure injuries, mortality, and restraint use, and nurse-focused outcomes, including job satisfaction, turnover intention, and psychological well-being (Gormley et al., 2024).

Although NSIs were developed to evaluate the quality of nursing care, debate continues regarding which measures are truly nursing-sensitive and the degree to which they isolate nursing’s contribution to patient outcomes (Gormley et al., 2024). Nevertheless, healthcare organizations increasingly use these indicators to guide quality improvement initiatives, accreditation standards, public reporting, and reimbursement programs. As organizations become accountable for achieving quality benchmarks, responsibility for meeting these expectations is often transferred to bedside nurses who may have limited authority over the organizational conditions required to achieve them. Consequently, nurses are held accountable for patient outcomes despite lacking the autonomy needed to influence the structural conditions that shape those outcomes.

Professional nursing autonomy, therefore, provides a useful framework for understanding this disconnect. Autonomy extends beyond independent decision-making and encompasses the professional competence, authority, and organizational support necessary for nurses to exercise clinical judgment and advocate for patients (Rouhi-Balasi et al., 2020). When nurses possess sufficient autonomy, they are better able to implement evidence-based interventions, collaborate effectively with interdisciplinary teams, and adapt care to meet patient needs. Conversely, institutional constraints that limit nurses’ ability to exercise professional judgment reduce their perceived ability to provide high-quality care, increasing the likelihood of moral distress. The Demand-Control Model (DCM) of occupational stress by Karasek (1979) provides theoretical support for this relationship.

According to the DCM model, psychological strain results when employees experience high job demands but have limited control over how their work is performed (Van Der Doef & Maes, 1999). Nursing is generally a high-demand profession characterized by high patient acuity, staffing shortages, regulatory requirements, and competing organizational priorities. When nurses simultaneously experience diminished autonomy because of institutional constraints, the combination of high demands and low control creates conditions conducive to psychological strain, including moral distress. Increasing nurses’ professional autonomy may therefore represent an important organizational strategy for mitigating moral distress without reducing the inherent demands of nursing practice.

Although relationships among staffing, work environment, patient outcomes, and nurse outcomes have been extensively investigated (Oner et al., 2021), less attention has been given to how nurses’ perceived ability to achieve nursing-sensitive patient outcomes contributes to moral distress. Accordingly, this review synthesizes current evidence to explain how institutional constraints on nursing autonomy contribute to moral distress by limiting their perceived ability to achieve nursing-sensitive patient outcomes. This narrative review addressed the following research question: What is known from the existing literature regarding the relationship between nurses’ perceived ability to provide nursing care that achieves nursing-sensitive patient outcomes and moral distress?

Methods

A narrative review methodology was selected to integrate qualitative, quantitative, and mixed-methods evidence examining relationships among nursing sensitive indicators, autonomy, and moral distress of nurses within the past 10 years. Electronic database searches were conducted in CINAHL, MEDLINE, and PsycINFO using combinations of keywords related to moral distress, moral injury, patient safety, quality of care, and nursing-sensitive indicators. Because conceptual ambiguity exists between moral distress and moral injury, both terms were included in the search strategy. Following removal of duplicate citations, titles and abstracts were independently screened for relevance. Full-text review identified studies examining institutional, environmental, or professional factors associated with nurses’ perceived ability to provide safe, high-quality care and their relationship to moral distress or moral injury. Studies representing diverse methodologies were retained to provide a comprehensive understanding of the phenomenon. Data were extracted and synthesized narratively according to recurring conceptual themes rather than methodological design. Throughout the review, findings were interpreted through the lens of the Demand-Control Model (DCM) by Karasek (1979). The DCM served as the theoretical framework to develop an integrated explanation of how institutional constraints and lack of professional autonomy contribute to moral distress and moral injury.

Results

The literature search was originally designed to identify studies examining the relationship between nurses’ perceived ability to achieve nursing-sensitive patient outcomes and moral distress. However, relatively few studies were found that explicitly examined and objectively measured NSIs, specifically patient outcome indicators. Of the 18 studies we included, one study focused on missed nursing care, three examined restraint usage, and one addressed medication errors. The remaining studies described compromised patient care more broadly, including nurses’ moral distress related to inability to provide safe, timely, and ethical nursing care. No studies directly examined relationships between moral distress and objectively measured patient-focused nursing-sensitive outcome indicators, such as falls, hospital-acquired infections, pressure injuries, or mortality.

Despite this limitation, a consistent pattern emerged through the literature: Nurses described moral distress as arising when systemic or organizational constraints prevented them from providing the quality of care they believe patients deserve. Five interrelated themes characterized these constraints: inadequate resources, financial pressures, legislative and organizational policies, insufficient institutional support, and ineffective interpersonal relationships.

Inadequate Resources

Resource limitations were the most consistently reported source of compromised nursing care leading to the development of moral distress and moral injury. Across healthcare settings, nurses described shortages of personnel as a barrier to delivering safe, high-quality care. Insufficient staffing was one of the most frequently cited contributors to moral distress and moral injury. Staffing shortages prevented nurses from providing thorough assessments, timely interventions, and individualized patient care while increasing concerns about patient safety (Beil-Hildebrand et al., 2024; Booth et al., 2024; Larsman et al., 2024). Similarly, mental health nurses identified inadequate staffing as the leading contributor to compromised patient care (Thompson et al., 2024). Furthermore, during the COVID-19 pandemic, nurses reported experiencing their highest levels of moral distress when assigned unsafe numbers of patients (Lee et al., 2024).

Beyond caring for unsafe numbers of patients with limited staff, nurses emphasized concerns regarding inappropriate skill mix and inadequate clinical expertise. Increased reliance on less-qualified personnel created ethical concerns regarding patient safety among nurse leaders (Beil-Hildebrand et al., 2024; Bergman et al., 2025). Home healthcare nurses also expressed discomfort delegating complex clinical responsibilities that required ongoing assessment and management (Narayan, 2024). Nurses practicing in long-term care described feelings of isolation and professional inadequacy when functioning without experienced colleagues for consultation (Finnbakk et al., 2020).

Heavy workloads and limited time further reduced nurses’ ability to provide the standard of care they want to provide. Excessive workloads made nurses feel unable to perform competently, forcing them to prioritize competing responsibilities while sacrificing aspects of care they considered essential (Finnbakk et al., 2020). Furthermore, missed nursing care caused a reduction in quality of care, endangering patient safety and prolonging hospital stays (Janatolmakan & Khatony, 2022). Similarly, home health nurses described inadequate visit lengths and documentation demands from Medicare that prevented patient-centered care, resulting in frustration, guilt, emotional exhaustion, and feelings of personal ineffectiveness (Narayan, 2024). Nurses frequently reported missing breaks, extending work hours, and compromising personal well-being to maintain acceptable standards of care (Thompson et al., 2024). Resource limitations, especially inadequate staff, skill mix and time, prevented nurses from practicing independently and according to their values, reducing perceived ability to achieve NSIs and creating moral distress.

Financial Pressures

Financial priorities within healthcare organizations frequently conflict with nurses’ perceptions of quality patient care. Several studies described tension between organizational efficiency, cost containment, and nurses’ ethical obligation to provide individualized, patient-centered care. Nurse leaders reported that financial goals often superseded patient care quality and staff safety, resulting in moral distress and moral injury (Beil-Hildebrand et al., 2024; Bergman et al., 2025). Similarly, bedside nurses felt perceived pressure from administrators and insurers to reduce costs even when doing so compromised patient care (Oldenmenger et al., 2024). In addition, home health nurses described agencies as increasingly business-oriented, emphasizing productivity and reimbursement rather than patient needs (Narayan, 2024). In psychiatric settings, nurses described conflict between initiatives to reduce mechanical restraint use and organizational unwillingness to provide additional staffing necessary to implement alternative interventions (Jansen et al., 2022). These competing priorities forced nurses to balance organizational financial expectations against patient safety concerns, contributing to moral distress and moral injury

Legislative and Organizational Policies

Healthcare legislation, regulatory requirements, and institutional policies frequently create ethical conflicts when nurses perceived mandated practices to be inconsistent with quality patient care. Several studies described situations in which policies designed to improve safety inadvertently restricted nurses’ ability to respond to patient needs. For example, changes to medication titration standards intended to improve patient safety were perceived as delaying treatment, limiting nursing practice, and increasing frustration for nurses (Davidson et al., 2021). Similarly, psychiatric nurses described moral conflict arising from legislation and institutional policies governing involuntary treatment and mechanical restraint. Although nurses supported reducing restraint use, they reported inadequate staffing and limited alternative resources to achieve this goal safely (Jansen et al., 2022; Pérez‐Toribio et al., 2022; Salehi et al., 2020). Likewise, home health nurses described Medicare regulations, documentation requirements, and reimbursement policies as limiting opportunities to provide individualized, patient-centered care (Narayan, 2024). Thus, policies intended to improve quality or efficiency may often create unintended ethical challenges when implementation occurs without sufficient organizational resources.

Insufficient Institutional Support

While moral distress and moral injury are often framed as problems with an individual’s characteristics, many studies emphasized the importance of organizational culture and leadership in shaping nurses’ experiences of moral distress. Importantly, Cohen et al. (2025) found that personal accountability was not protective in the relationship between workload and moral distress, emphasizing the importance of institutional support. Furthermore, nurses consistently reported greater distress when they perceived organizational leaders to be unresponsive to concerns regarding compromised patient care. Nurses described feeling unsupported when concerns regarding staffing, safety, or ethical conflicts were dismissed or inadequately addressed by leadership (Booth et al., 2024; Thompson et al., 2024). Conversely, supportive leadership and healthy practice environments were associated with lower levels of moral distress (Hiler et al., 2018). Organizational support also facilitated nurses’ ability to address ethical conflicts constructively (Larsman et al., 2024). In fact, many nurses expressed a desire for stronger institutional ethics resources. Nurses identified limited access to ethics committees, uncertainty regarding consultation processes, and inadequate ethics education as barriers to resolving ethically challenging situations (Afenigus & Sinshaw, 2025; Bergman et al., 2025). Nurse leaders similarly highlighted a need for greater preparation in ethical leadership and moral decision-making (Beil-Hildebrand et al., 2024).

Ineffective Interpersonal Relationships

Interpersonal relationships within healthcare teams substantially influenced nurses’ experiences of moral distress and perceived ability to achieve NSIs. Collaborative communication and mutual respect facilitated ethical decision-making, whereas hierarchical relationships, poor communication, and unprofessional behaviors intensified moral distress and moral injury. Interdisciplinary collaboration enabled shared decision-making and distributed responsibility during ethically challenging situations, reducing the emotional burden experienced by individual nurses (Afenigus & Sinshaw, 2025). In contrast, ineffective communication and poor teamwork contributed to compromised patient care and increased moral distress (Oldenmenger et al., 2024). Relationships between physicians and nurses can further complicate ethical decision-making. Several studies described organizational cultures in which physicians maintain authority over nursing-related decisions despite nurses possessing greater expertise regarding bedside care (Beil-Hildebrand et al., 2024; Bergman et al., 2025). Conversely, collegial relationships between nurses and physicians were associated with lower moral distress (Hiler et al., 2018).

Professional integrity in the face of others’ unethical actions also emerged as an important theme. Nurses described moral distress and moral injury arising both from witnessing unethical behaviors and from organizational cultures that discouraged reporting patient safety concerns. Individuals who reported witnessed medical errors experienced retaliation, whereas remaining silent generated moral conflict because nurses believed patients could be harmed (Namadi et al., 2024). Concerns regarding incivility, bullying, dishonesty, and lack of accountability were reported as contributing to ethically compromised work environments (Beil-Hildebrand et al., 2024).

Summary

Overall, the literature consistently demonstrated that moral distress and moral injury arise when nurses perceive themselves as unable to provide the quality of care they believe patients deserve because of organizational, structural, or interpersonal barriers. Although few studies directly evaluated nursing-sensitive patient outcome indicators, the evidence consistently linked compromised nursing care with moral distress across diverse clinical settings and healthcare systems.

Discussion

Institutional Relational Morality

This narrative review sought to explain how institutional constraints on nursing autonomy contribute to moral distress among nurses by limiting their perceived ability to achieve nursing-sensitive patient outcomes. We found that although moral distress has traditionally been described as arising from personal moral conflicts, nearly every cause identified in the literature synthesis reflected the role of institutional constraints that prevent nurses from acting congruently with their personal and professional values. Despite this, nurses can and often do develop trusting relationships with healthcare organizations, confidence that the organization will provide for their psychological safety, and the expectation of mutually respectful ethical behavior (Brewer, 2021). No term was identified in the literature to describe the ethical obligations inherent in the dynamic relationship between an institution and its members; in this case, healthcare organizations and nurses. Therefore, the authors introduce a new term, ‘Institutional Relational Morality’, defined as an institution’s ability to successfully develop and maintain ethical relationships with its members, congruent with shared societal and professional values. One important component of institutional relational morality is the provision of professional autonomy. For example, one study in this review showed that inflexible physician orders for medication titration made nurses feel that their competence was being questioned, which made them feel devalued and unappreciated (Thompson et al., 2024). The nurses no longer felt the organization trusted their judgment, which damaged the moral relationship between the nurse and the organization, decreasing institutional relational morality.

The findings of this review further support the relevance of institutional relational morality by demonstrating that moral distress arises not primarily from difficult clinical situations themselves, but from organizational constraints. Although our original research question focused on NSIs, the literature revealed remarkably few studies which objectively examined patient-focused outcomes, such as falls, hospital-acquired infections and pressure injuries, in relation to moral distress and moral injury. Instead, the literature consistently demonstrated that nurses experience moral distress when organizational or systemic barriers prevent them from providing the high-quality care patients deserve. Across diverse healthcare settings and countries, these barriers reflected a common underlying construct: constraints on professional nursing autonomy for their practice.

Professional Autonomy

Autonomy is an essential component of institutional relational morality. Professional autonomy has been defined as a developmental achievement based on professional competence, self-reliance, professional decision-making, and effective interactions with other members of the healthcare team (Rouhi-Balasi et al., 2020). Viewed through this framework, the five themes identified in this literature review each represent different mechanisms through which institutional constraints reduce nurses’ ability to practice autonomously. Our findings support the proposition that moral distress is fundamentally associated with nurses’ inability to practice according to their personal and professional values because institutional conditions limit autonomous practice. Rather than representing isolated organizational problems, inadequate staffing, insufficient resources, financial constraints, restrictive policies, and ineffective collaboration appear to function as interconnected barriers that reduce nurses’ control over patient care. Failure to address these constraints on autonomy causes nurses to feel devalued, unsupported and mistrusted, impairing the development and maintenance of ethical relationships between healthcare organizations and nurses.

These findings also support the Demand-Control Model (DCM) that posits psychological strain is greatest when employees experience high job demands but limited control over how their work is performed (Karasek, 1979). ​​Nursing has long been recognized as a profession characterized by exceptionally high physical, cognitive, emotional, and ethical demands. The present review suggests that these demands alone are insufficient to explain moral distress. Instead, moral distress appears to emerge when high demands are combined with limited professional control. Nurses are expected to achieve increasingly complex patient care outcomes while simultaneously experiencing reduced influence over staffing decisions, resource allocation, organizational policies, and clinical decision-making. Institutional relational morality requires organizations to take action to address harm, including moral distress, to their members. However, holding a narrow definition of moral distress that only links it to institutional constraints may fail to capture the complexity of moral distress essential for informing targeted interventions and support for nurses (Maffoni et al., 2026).

Future Implications

Many current interventions in the literature emphasize helping nurses adapt to morally distressing situations through individual debriefing, reflection, and education (Moverley et al., 2023). Although these approaches may improve individual coping, this review suggests that they do little to address the broader organizational conditions which trigger moral distress. Organizational ​​interventions that strengthen professional autonomy, such as inclusion in decision-making, may be more effective in reducing moral distress because they address the underlying issue. Moral distress is exacerbated when nurses are not involved in decision making or are forced to adhere to treatment plans they find morally objectionable (Aljabery et al., 2024). Thus, healthcare organizations have an ethical responsibility inherent in institutional relational morality to mitigate these conditions and support professional autonomy.

Shared governance has been one way that nurses have traditionally provided input, although ultimately decisions are usually made by leadership. Conversely, newer emerging professional governance models grant nurses complete ownership and accountability for their decisions. A study of one hospital system that transitioned from shared governance to professional governance found that the latter improved nurses’ perception of control over their own practice (Partridge et al., 2026). However, rigorous evidence evaluating organizational interventions to reduce moral distress remains limited (Bolton et al., 2025). Future research should move beyond descriptive studies to test evidence-based organizational interventions, including leadership practices, staffing models, ethical work environments, and policies that strengthen nursing autonomy as potential mitigators of moral distress among nurses. Longitudinal and interventional studies are needed to determine which institutional strategies most effectively reduce moral distress while improving nurse retention, professional well-being, and patient outcomes.

These findings also have implications for defining nursing-sensitive indicators. Traditionally, nurse-focused nursing-sensitive indicators have included outcomes such as job satisfaction, turnover intention, and burnout. The consistent relationship observed between compromised patient care and moral distress suggests that moral distress should also be considered an important nurse-focused nursing-sensitive outcome. Future research should examine whether improvements in structural and process nursing-sensitive indicators produce measurable reductions in moral distress, thereby validating current conceptual models linking nursing practice environments with nurse psychological wellbeing.

This study was limited by the lack of publications directly answering the research question. Study methods may have contributed to this lack, as only three databases were searched for relevant literature. However, given the extensive nature of the databases searched, it is more likely that there is a gap in understanding of how patient-focused nursing sensitive outcomes impact moral distress. Furthermore, few of the studies used quantitative methods, decreasing the total quality of the evidence available for review.

Conclusion

Constraints on nursing autonomy contribute to moral distress by limiting nurses’ perceived ability to achieve nursing-sensitive patient outcomes. Insufficient professional autonomy can exacerbate the conflict between nurses’ personal and professional values and the organizational barriers that prevent them from acting according to those values. These conflicts can damage trust between the nurse and the organization, harming their reciprocal moral relationship, and diminishing institutional relational morality. This review identified five institutional constraints that restrict nurses’ autonomy over their practice contributing to moral distress: inadequate resources, financial pressures, legislative and organizational policy, insufficient institutional support, and ineffective interpersonal relationships. Current approaches for increasing professional autonomy, such as shared governance, do too little to give nurses ownership and accountability in clinical decision making. New strategies, such as professional governance, hold promise for increasing nurses’ control over their practice, thus reducing their moral distress. Future research should prioritize the development and rigorous evaluation of organizational interventions that strengthen professional autonomy and institutional relational morality, thereby reducing moral distress, improving nurse well-being, and supporting high-quality patient care.

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