ICU nurses’ moral distress in decisions to implement physical restraints

Abstract

Background

Use of physical restraints in intensive care units (ICUs) creates ethical challenges for nurses and often causes moral distress as they balance patient safety with autonomy and dignity.

Research aim

To explore Iranian ICU nurses’ experiences of moral distress related to decisions about PR use.

Research design

An exploratory qualitative approach was used.

Participants and research context

Twenty Persian-speaking ICU nurses with at least two years’ clinical experience were purposively recruited from hospitals affiliated with Shahid Beheshti University of Medical Sciences between September 10 and November 14, 2025. In-depth semi-structured interviews were audio-recorded, transcribed verbatim, and analyzed using Elo and Kyngäs’s three-phase content analysis. Trustworthiness was ensured via Lincoln and Guba’s criteria of credibility, dependability, confirmability, and transferability.

Ethical considerations

Approved by the Medical Ethics and Law Research Center of Shahid Beheshti University of Medical Sciences (IR.SBMU.RETECH.REC.1404.397). Written informed consent and reconfirmed verbal consent were obtained.

Results

Analysis generated 323 initial codes; 201 remained after refinement. Two principal categories emerged: (1) Moral suffering in clinical decision-making—ethical conflicts, negative emotions, consequences for the patient, and for nurses; and (2) Adaptation and efforts to reduce moral distress—contextual factors, coping strategies, and suggestions for reducing moral distress. Participants described emotional exhaustion, guilt, reduced motivation, and compromised quality of care. Key contributing factors included staff shortages, workload pressure, and unilateral physician orders. Coping strategies comprised peer support, temporary distancing from the situation, and spiritual or self-soothing practices. Suggestions for reducing moral distress emphasized education on restraint alternatives, clear clinical guidelines, and strengthened interprofessional decision-making.

Conclusion

Moral distress related to PR use among ICU nurses stems from tensions between patient safety and dignity and is shaped by organizational and contextual factors. While nurses described individual strategies to cope, organizational support, clearer guidance, and collaborative decision-making may reduce ethical burden. Further research should examine applicability in other clinical and cultural contexts.