Abstract
Introduction: Moral distress arises when nurses cannot act in accordance with their ethical values due to institutional or resource constraints. Though well-studied in Western settings, evidence from Sub-Saharan Africa remains scarce. This review synthesises and quantifies moral distress among nurses in the region.
Methods: A PRISMA-guided systematic review and meta-analysis was conducted. Two databases: PubMed, and African Journals Online, plus a grey literature source, Google Scholar were searched from January 2005 to March 2025. Eligible studies reported quantitative moral distress measures among nurses in Sub-Saharan Africa. Quality was appraised using Joanna Briggs Institute checklists; no study attained high methodological quality. A random-effects model pooled mean scores; subgroup and meta-regression analyses explored heterogeneity. Publication bias was assessed via funnel plots, Egger’s test, and trim-and-fill.
Results: Seven studies (n=1,704 nurses; Ethiopia, Ghana, South Africa) met the inclusion criteria. The pooled mean moral distress score, standardised to a 1–10 scale, was 2.46 (95% CI: 2.33–2.58), indicating low overall distress; however, extreme heterogeneity (I²=100%) precludes definitive conclusions. Subgroup analyses revealed notably higher distress among Ethiopian nurses (pooled mean 4.97) compared to Ghanaian (0.07) and South African nurses (0.36), and among nurses in ICU, surgical, and medical units relative to operating theatre nurses.
Conclusion: This review provides the first region-specific evidence on moral distress among nurses in Sub-Saharan Africa. Findings highlight low but heterogeneous levels of distress. Enhancing organisational ethics, fostering supportive leadership, and implementing context-specific interventions could alleviate moral distress and improve the well-being of nurses.