Effectiveness of interventions to address moral distress in nursing students: An integrative review

Abstract

Moral distress is an increasing concern in nursing education, with evidence that it may undermine learning, ethical confidence, and early professional identity formation. Although the literature includes strategies to address moral distress among nurses, less is known about effective strategies to mitigate it among nursing students. This integrative review examined the available evidence regarding interventions designed to reduce moral distress during prelicensure education. A systematic search of CINAHL, Health Source Nursing, MEDLINE, PubMed, PsycInfo, Web of Science, ProQuest Central, and ProQuest Dissertations & Theses Global was conducted for studies published between 2014 and 2024, supplemented by searches using AI-assisted tools (Connected Papers, Elicit, Scite, and Consensus). Eligible studies included an intervention explicitly aimed at addressing moral distress among nursing students. Two reviewers independently screened titles, abstracts, and full texts; discrepancies were resolved through consultation with a third reviewer. Study quality was assessed using the Johns Hopkins Evidence-Based Practice tool. Findings were synthesized using thematic analysis. Five studies met inclusion criteria, representing interventions incorporating structured ethics content, simulation-based learning, reflective dialogue, instructor facilitation, and self-compassion practices. Across studies, improvements were reported in moral sensitivity, ethical reasoning, indicators of moral resilience, and emotional regulation. Instructor support emerged as a central mechanism that enabled psychological safety and facilitated deeper ethical reflection. Contextual factors, including age, prior exposure to moral adversity, and demographic characteristics, appeared to shape responsiveness. Evidence remains limited by modest samples, heterogeneous intervention designs, and reliance on short-term outcomes. Restricting the review to English-language studies may have resulted in missing relevant research. Findings suggest that multimodal, developmentally informed approaches may have the potential to strengthen nursing students’ ethical and emotional capacities while mitigating moral distress, yet larger, rigorous, and longitudinal studies are needed. Early integration of these strategies throughout prelicensure curricula may contribute to more resilient professional identity formation. No review protocol was registered, and no external funding was received.