BACKGROUND:
Moral distress (MD) is the psychological discomfort experienced when an individual knows the ethically correct action to take but is constrained from doing so. This study examined the ethical dilemmas and the prevalence and predictors of MD experienced by critical care nurses during the COVID-19 pandemic.

METHODS:
During 2023, a cross-sectional study was conducted in the four central hospitals of the Gauteng province of South Africa. The self-administered questionnaire included an adapted Moral Distress of Health Professionals Scale to measure the frequency and severity of MD amongst other sections. We grouped the ethical dilemmas into three dimensions of patient care, teamwork and interprofessional collaboration, and health system, and calculated the MD score for each dimension. We fitted separate multiple linear regression models for each dimension to compare the mean scores.

RESULTS:
We obtained a response rate of 88.2%, with 180 participating nurses. The mean age of the nurses was 45.2 years [SD= 9.78], the majority were professional nurses (88.9%), and female (91.1%). The predictors of MD associated with patient care included training in infection prevention and control (p = 0.01) and collegial stigmatisation (p < 0.0001). MD related to teamwork, predictors were age (p = 0.01), access to personal protective equipment (PPE) (p = 0.01), and collegial stigmatisation (p < 0.0001). The MD predictors in relation to the health system were age (p = 0.03), collegial stigmatisation (p = 0.01) and access to PPE (p < 0.0001). The hospital of employment impacted on MD related to teamwork (p = 0.03) and health systems (p = 0.02).

CONCLUSIONS:
The study underscores the critical role of positive practice environments and the need for investment in nurses’ health and well-being.