Moral Distress and Burnout among Critical Care Nurses in Low- and Middle- Income Countries: A Mini-Review

Abstract

Critical care nurses work in highly demanding environments characterized by severe patient illness, rapid clinical deterioration, complex treatment decisions, advanced technologies, and frequent exposure to death and suffering. These conditions may contribute to moral distress and occupational burnout. Moral distress occurs when nurses identify an ethically appropriate course of action but encounter constraints that prevent them from acting accordingly. Burnout is an occupational phenomenon associated with chronic workplace stress that has not been successfully managed and is characterised by exhaustion, increased mental distance from work or negativism, and reduced professional efficacy. Although distinct, these experiences may overlap when ethically challenging situations recur in demanding work environments. The issue is particularly relevant in low- and middle-income countries (LMICs), although these countries differ substantially in workforce availability, resources, professional autonomy, and healthcare structures. Recent international evidence indicates that moral distress remains an important concern among intensive care unit (ICU) nurses. The literature describes end-of-life decision-making, perceived non-beneficial treatment, inadequate resources, poor teamwork, hierarchical relationships, and limited professional autonomy as key factors. Burnout may be associated with overlapping organizational and occupational conditions. Addressing these challenges requires more than individual coping strategies. Supportive leadership, adequate staffing, effective interprofessional communication, ethical consultation, nurse participation in decision-making, psychological support, and appropriate end-of-life care processes may help strengthen professional well- being. An author-proposed “Empower–Engage–Enable” framework is presented as a practical, multilevel approach for consideration and future testing. Context-specific research is needed to establish its feasibility, acceptability, and effectiveness in LMIC settings.