Tharaa AnanzehpersName, Caroline F. MorrisonpersName, Elaine L. MillerpersName, Natalie KreitzerpersName, Tamilyn BakaspersName (2026date). “Moral Distress Among Family Caregivers: A Concept Analysis..” Journal of Advanced Nursingtitle·j.
Object of study — moral distressterm·dom among family caregiversterm·dom
Research question — what moral distressterm·dom means in family caregiving: its attributes, antecedentsterm·mth and consequencesterm·mth
Contribution — a conceptual definition of moral distressterm·dom in family caregiversterm·dom, resting on three defining attributesterm·mth: self-directed negative emotionsterm·dom, internal conflictterm·dom, and powerlessness and helplessnessterm·dom
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | family caregivers pushed into decisions that go against their own values — “Moral distress occurs when family caregivers are forced to make decisions that conflict with their ethical beliefs and values due to a number of reasons, such as lack of resources, support, knowledge or time” | |
| claim-type | existence — “For this concept analysis of moral distress among family caregivers, three main defining attributes or characteristics were identified based on a comprehensive review of the literature: internal conflict, self‐directed negative emotions and feelings of powerlessness and helplessness” | |
| method — evidence | — “This study was guided by Walker and Avant's concept analysis framework” | |
| object of study — evidence | — “To examine and define the concept of moral distress among family caregivers by identifying its key attributes, antecedents and consequences” | |
| research question — evidence | — “Thus, the purpose of this paper is to rigorously examine and define the concept of moral distress among family caregivers by identifying its key attributes, antecedents and consequences” | |
| contribution — evidence | — “Three defining attributes of moral distress in family caregivers were identified: self‐directed negative emotions, internal conflict and feelings of powerlessness and helplessness” | |
| mechanism | illness uncertainty Not knowing how the illness will progress makes caregivers' decisions harder and more painful. — “Uncertainty surrounding the illness trajectory leaves family caregivers unsure of how their loved one's condition will progress, making decisions even more complex and emotionally difficult” | mechanisms[0] |
| mechanism | multiple roles Juggling several roles strains caregivers' time, costing some their jobs or social ties. — “These multiple roles make it difficult for them to manage and balance their time effectively (Gágyor et al. 2019 ; Koenig 2004 ; Rozo et al. 2025 ; Ullrich et al. 2020 ; Vachon et al. 2023 ). As a result, some family caregivers lose their jobs, while others become socially isolated due to these multiple roles and responsibilities” | mechanisms[1] |
| builds-on | Walker and Avant (2019), concept analysis method — “This concept analysis follows Walker and Avant's ( 2019 ) method, which provides a structured and systematic approach to clarifying and defining moral distress in the context of family caregiving” | claim_relations[0] |
| sense | moral distress (Jameton) - knowing the right action but being kept from it by constraints — “The concept of moral distress was first introduced in nursing by Jameton ( 1984 ), who defined it as the distress that occurs when individuals recognise the ethically right course of action to take but are unable to act due to various constraints” | senses[0] |
| sense | moral distress (Wilkinson) - disequilibrium after a decision that goes against one's values — “Building on this, Wilkinson ( 1987 ) described it as the psychological disequilibrium and negative feeling the person experiences when they make a moral decision that does not align with their values and beliefs” | senses[1] |
| sense | moral distress (Barlem and Ramos) - a powerlessness that blocks morally appropriate action — “More recently, Barlem and Ramos ( 2015 ) defined moral distress as a sense of powerlessness that prevents individuals from taking morally appropriate actions leading to physical, psychological and behavioural consequences” | senses[2] |
| relation | family caregivers —same-as→ informal caregivers — Family caregivers, also called informal caregivers, are individuals who provide regular care and assistance to friends, neighbours or family members with health conditions requiring support — “Family caregivers, also called informal caregivers, are individuals who provide regular care and assistance to friends, neighbours or family members with health conditions requiring support” | concept_edges[0] |
| weight | family caregivers —same-as→ informal caregivers — 0.9 — “Family caregivers, also called informal caregivers, are individuals who provide regular care and assistance to friends, neighbours or family members with health conditions requiring support” | concept_edges[0] |
| relation | self-directed negative emotions —is-a→ moral emotions — Self‐directed negative emotions are feelings, such as guilt, shame, regret and self‐blame, that arise from individuals' self‐evaluations when they believe they have violated their own moral or ethical standards. These emotions are often classified as moral emotions — “Self‐directed negative emotions are feelings, such as guilt, shame, regret and self‐blame, that arise from individuals' self‐evaluations when they believe they have violated their own moral or ethical standards. These emotions are often classified as moral emotions” | concept_edges[1] |
| weight | self-directed negative emotions —is-a→ moral emotions — 0.75 — “Self‐directed negative emotions are feelings, such as guilt, shame, regret and self‐blame, that arise from individuals' self‐evaluations when they believe they have violated their own moral or ethical standards. These emotions are often classified as moral emotions” | concept_edges[1] |
| relation | moral distress —causes→ burnout — Family caregivers experience two aspects of burnout as a result of moral distress — “Family caregivers experience two aspects of burnout as a result of moral distress” | concept_edges[2] |
| weight | moral distress —causes→ burnout — 0.65 — “Family caregivers experience two aspects of burnout as a result of moral distress” | concept_edges[2] |
| replication | not-applicable | |
| limitation | The included papers were qualitative or theoretical, limiting generalizability. — “First, nine of the included articles were qualitative studies, and the remaining three were theoretical and perspective papers, which limit the generalizability of the results” | limitations[0] |
| limitation | Only five articles explicitly addressed moral distress in family caregivers. — “Second, only five articles explicitly discussed moral distress among family caregivers. The other seven articles primarily discussed ethical decision‐making challenges and ethical dilemmas” | limitations[1] |
| limitation | None of the explicit articles concerned caregivers of stroke survivors. — “Third, the articles that explicitly discuss moral distress involve family caregivers of individuals with cancer, dementia and Alzheimer's. Notably, none of these articles refer to family caregivers of stroke survivors who face significant caregiving burdens” | limitations[2] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | No instrument exists to measure moral distress in family caregivers quantitatively. — “Perhaps the reason for the exclusive focus on qualitative papers is that no instrument is available to measure moral distress among family caregivers quantitatively” | content_tags.findings[0] |
| finding | Social isolation is a consequence found mainly in family caregivers rather than professionals. — “Social isolation is a distinct consequence that is primarily associated with family caregivers” | content_tags.findings[1] |
| quantity | 986; 12 — — “The initial search returned a total of 986 articles. Of these, 128 articles were in PubMed, 257 were in PsycINFO, 158 were in Scopus and 443 were in CINAHL. After removing duplicates and applying the eligibility criteria, 12 articles met the inclusion criteria” | content_tags.quantities[0] |
| quantity | 53 million (24%) — — “In 2020, the National Alliance for Caregiving (NAC) and AARP reported that approximately 53 million Americans (24%) served as family caregivers, which has risen significantly from 43.5 million (18%) in 2015” | content_tags.quantities[1] |
| key-terms | moral distress, family caregivers, ethical dilemmas, internal conflict, caregiving burden, concept analysis |
| concept | moral distress — The emotional and psychological turmoil that arises when family caregivers experience ethically challenging and complex decision‐making situations that prevent them from acting according to their moral values and beliefs is characterised by self‐directed negative feelings and emotions, internal conflicts, and feelings of powerlessness and helplessness — “a conceptual definition of moral distress in the context of family caregiving is described as follows: The emotional and psychological turmoil that arises when family caregivers experience ethically challenging and complex decision‐making situations that prevent them from acting according to their moral values and beliefs” | concepts[0] |
| concept | family caregivers — individuals who provide regular care and assistance to friends, neighbours or family members with health conditions requiring support — “Family caregivers, also called informal caregivers, are individuals who provide regular care and assistance to friends, neighbours or family members with health conditions requiring support” | concepts[1] |
| concept | informal caregivers — not defined in this paper's own words; another name for family caregivers — “Family caregivers, also called informal caregivers, are individuals who provide regular care and assistance to friends, neighbours or family members with health conditions requiring support” | concepts[2] |
| concept | internal conflict — occurs among family caregivers when they experience tension between their personal values, beliefs and caregiving responsibilities — “Internal conflict occurs among family caregivers when they experience tension between their personal values, beliefs and caregiving responsibilities” | concepts[3] |
| concept | self-directed negative emotions — feelings, such as guilt, shame, regret and self‐blame, that arise from individuals' self‐evaluations when they believe they have violated their own moral or ethical standards — “Self‐directed negative emotions are feelings, such as guilt, shame, regret and self‐blame, that arise from individuals' self‐evaluations when they believe they have violated their own moral or ethical standards” | concepts[4] |
| concept | moral emotions — not defined in this paper's own words; emotions bound up with judging one's own conduct against moral standards — “Self‐directed negative emotions are feelings, such as guilt, shame, regret and self‐blame, that arise from individuals' self‐evaluations when they believe they have violated their own moral or ethical standards. These emotions are often classified as moral emotions” | concepts[5] |
| concept | helplessness — emerges when family caregivers cannot provide the optimal care they want for their loved one, particularly in situations where they face financial restraints and a lack of resources — “Helplessness emerges when family caregivers cannot provide the optimal care they want for their loved one, particularly in situations where they face financial restraints and a lack of resources” | concepts[6] |
| concept | moral residue — unresolved and prolonged distress, known as moral residue — “When they make a decision that conflicts with their moral values and beliefs over an extended period of time, they may experience unresolved and prolonged distress, known as moral residue” | concepts[7] |
| concept | burnout — not defined in this paper's own words; exhaustion from caregiving, or having to cut back on or leave work — “Family caregivers experience two aspects of burnout as a result of moral distress” | concepts[8] |
| concept | role conflict — not defined in this paper's own words; the strain of caregiving held alongside roles as parent, spouse and employee — “This ongoing role conflict creates significant pressure, particularly when caregivers feel they have not met expectations in their roles as caregivers” | concepts[9] |
| concept | ethical dilemma — not defined in this paper's own words; a situation with no entirely right choice, where principles such as autonomy and protection clash — “Family caregivers experience many morally undesirable situations when they feel that there is no choice that is entirely correct” | concepts[10] |
| concept | defining attributes — the essential cluster of characteristics of a concept that consistently and frequently appear in the literature — “Defining attributes are the essential cluster of characteristics of a concept that consistently and frequently appear in the literature” | concepts[11] |
| concept | antecedents — events that occur prior to the occurrence of the concept, and they are required for the concept to exist — “Antecedents are events that occur prior to the occurrence of the concept, and they are required for the concept to exist” | concepts[12] |
| concept | consequences — the events that happen as a result or outcome of the concept — “Consequences are the events that happen as a result or outcome of the concept” | concepts[13] |
| concept | contrary cases — The cases that do not reflect the defining attributes are called contrary cases — “The cases that do not reflect the defining attributes are called contrary cases” | concepts[14] |
| concept | borderline cases — The cases that contain most of the defining attributes but not all of them are called borderline cases — “The cases that contain most of the defining attributes but not all of them are called borderline cases” | concepts[15] |
Full text — tagged
Moral Distressterm·dom Among Family Caregiversterm·dom: A Concept Analysisterm·key.
Abstract To examine and define the concept of moral distressterm·dom among family caregiversterm·dom by identifying its key attributes, antecedentsterm·mth and consequencesterm·mth.
This study was guided by Walker and Avant's concept analysisterm·key framework. A comprehensive literature search was conducted to identify relevant studies, with 12 articles included in this analysis.
PubMed, CINAHL, Scopus and PsycINFO databases were searched for articles published between February 2000 and May 2025.
Three defining attributesterm·mth of moral distressterm·dom in family caregiversterm·dom were identified: self‐directed negative emotionsterm·dom, internal conflictterm·dom and feelings of powerlessness and helplessnessterm·dom. Antecedentsterm·mth included caregiving burdenterm·key, role conflictterm·dom, ethical dilemmasterm·key, complex decision‐making and internal and external constraints. Consequencesterm·mth encompassed long‐term health effects, social withdrawal, burnoutterm·dom and moral residueterm·dom. These findings led to a conceptual definition of moral distressterm·dom in family caregiversterm·dom.
Moral distressterm·dom in family caregiversterm·dom is a significant and underrecognised issue that affects caregiver well‐being and the quality of care they provide. This concept analysisterm·key offers a clear conceptual definition, providing a foundation for developing research instruments and interventions.
Healthcare professionals should recognise moral distressterm·dom in family caregiversterm·dom as a key factor impacting both caregiver well‐being and patient care. Support through education, counselling and peer groups can reduce moral distressterm·dom and foster more ethical, collaborative care environments.
This study addressed the lack of clarity surrounding moral distressterm·dom in family caregiversterm·dom. It identified key attributes, antecedentsterm·mth, and consequencesterm·mth, and developed a clear conceptual definition. These insights will inform research, practice and policy. The findings will benefit caregivers, improve patient care and support healthcare teams.
This study followed Walker and Avant's framework and employed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines in article selection.
No patient or public involvement.
Keywords: caregiving burdenterm·key, decision‐making, ethical dilemmasterm·key, family caregiversterm·dom, internal conflictterm·dom, moral distressterm·dom Introduction Family caregiversterm·dom, also called informal caregiversterm·dom, are individuals who provide regular care and assistance to friends, neighbours or family members with health conditions requiring support (Centers for Disease Control and Prevention 2018 ). According to the Family Caregiverterm·dom Alliance, there are two types of family caregiversterm·dom, primary or secondary, depending on their level of involvement in caregiving responsibilities. Both primary and secondary caregivers can live with or separately from the person they assist (Family Caregiverterm·dom Alliance, n.d. ). In 2020, the National Alliance for Caregiving (NAC) and AARP reported that approximately 53 million Americans (24%) served as family caregiversterm·dom, which has risen significantly from 43.5 million (18%) in 2015. Additionally, 61% of these caregivers were employed while providing care. Globally, the International Alliance of Carer Organisations estimates that there are over 63 million family carers worldwide (International Alliance of Carer Organisations 2018 ). Family caregiving is also increasingly recognised as a significant global health concern. In 2025, the World Health Organisation signed a partnership to strengthen support for family caregiversterm·dom worldwide, underscoring the essential but often overlooked role of families in health systems (World Health Organisation 2025 ).
Family caregiversterm·dom work as an extension to the health care institutions, performing complex medical tasks and providing care based on the specific needs of the illness (American Psychological Association 2011 ). They support individuals with acute and chronic conditions, including Alzheimer's, stroke, heart disease, cancer, mental health disorders, developmental disabilities and mobility issues (AARP and National Alliance for Caregiving 2020 ). Among the many caregiving populations, those caring for patients with dementia and Alzheimer's disease often face additional challenges due to the complex symptoms of the disease (Lindeza et al. 2024 ). They assist with instrumental activities of daily living, personal activities of daily living, medication management and adherence and managing behavioural symptoms such as aggression and depression (Alzheimer's Association 2024 ). Those taking care of stroke survivors face unique challenges as well (Martin et al. 2024 ). The caregiving role of stroke survivors involves many tasks, including providing physical and personal support, administering medication, managing follow‐up appointments, ensuring safety and providing both emotional and financial support (American Stroke Association 2023 ). In contrast to stroke caregiving, caring for cancer patients presents its own unique set of challenges (Schulz and Eden 2016 ). One of these challenges is caring for a person with cancer at the end‐of‐life while facing low mental and physical health (National Cancer Institute 2024 ). This includes managing severe pain, coordinating palliative care and dealing with anticipatory grief (Bilić et al. 2022 ).
As a result of these responsibilities, caregivers often experience significant burdens (Jaracz et al. 2024 ; Sheehan et al. 2021 ). These include emotional distress (McCurley et al. 2019 ; Sugawara et al. 2023 ), stress (Lewandowska 2022 ; Sajwani‐Merchant et al. 2023 ; Vu et al. 2022 ), depression (Gurley Nettles 2024 ; Sheehan et al. 2021 ) and role conflictterm·dom distress (MacKenzie 2024 ). Moreover, they may experience physical health problems (Sugawara et al. 2023 ; Vu et al. 2022 ), and feelings of frustration, guilt, and powerlessness are also common (McCurley et al. 2019 ; Shewangizaw et al. 2023 ). These burdens create internal conflictsterm·dom, decision‐making challenges (Lawson 2022 ) and ethical dilemmasterm·key among family caregiversterm·dom (Koenig 2004 ; Lafrance et al. 2022 ; Stork et al. 2018 ). Unlike healthcare professionals, family caregiversterm·dom often lack sufficient education and training in caregiving, and this makes it challenging for them to deal with difficult situations (Lobo et al. 2021 ). All these challenges, burdens, feelings and ethical dilemmasterm·key make it difficult for caregivers to make decisions that align with their moral values and beliefs (James 2021 ).
Background Moral distressterm·dom occurs when family caregiversterm·dom are forced to make decisions that conflict with their ethical beliefs and values due to a number of reasons, such as lack of resources, support, knowledge or time (Ullrich et al. 2020 ). As a result of the difficult decisions, family caregiversterm·dom often experience negative emotional, physical and psychological effects, including guilt, frustration, powerlessness, stress, regret and disturbed sleep (Ullrich et al. 2020 ). The concept of moral distressterm·dom was first introduced in nursing by Jameton ( 1984 ), who defined it as the distress that occurs when individuals recognise the ethically right course of action to take but are unable to act due to various constraints. Moral distressterm·dom has been frequently examined among healthcare professionals, particularly nurses, who face institutional barriers that prevent them from providing optimal patient care (Epstein and Hamric 2009 ). There is agreement that moral distressterm·dom is a fluid and context‐dependent experience (Hardingham 2004 ; Wilkinson 1987 ). The variability in its attributes across different contexts highlights its dynamic nature and fluidity (Epstein and Hamric 2009 ). As every community has its unique context and characteristics, it is important to study this concept in different communities, such as family caregiversterm·dom.
Before studies can be conducted on moral distressterm·dom among family caregiversterm·dom, a clear definition of moral distressterm·dom in the context of family caregiving is needed. Without a clear conceptual definition, researchers cannot effectively measure, study, or develop interventions to support family caregiversterm·dom experiencing moral distressterm·dom. The conceptual definition will facilitate the identification of the operational definition of moral distressterm·dom, features and key elements among family caregiversterm·dom. As a result, this contributes to the advancement of general knowledge and a more comprehensive understanding of the concept of moral distressterm·dom. A comprehensive review of the literature reveals that the concept of moral distressterm·dom among family caregiversterm·dom has not been thoroughly examined or conceptualised. Thus, the purpose of this paper is to rigorously examine and define the concept of moral distressterm·dom among family caregiversterm·dom by identifying its key attributes, antecedentsterm·mth and consequencesterm·mth.
Methods (Data Sources) Design This concept analysisterm·key follows Walker and Avant's ( 2019 ) method, which provides a structured and systematic approach to clarifying and defining moral distressterm·dom in the context of family caregiving. The results of the concept analysisterm·key provide comprehensive, clear, and precise definitions and give a basic understanding of the concept's characteristics and underlying attributes. Additionally, the findings can help researchers develop new research instruments, improve existing tools and refine interview questions (Walker and Avant 2019 ).
Walker and Avant's concept analysisterm·key method is an updated version of Wilson's ( 1963 ) classic concept analysisterm·key. Walker and Avant's method has eight iterative steps: (1) selecting a concept, (2) determining the aim of the analysis, (3) identifying the uses of the concept, and (4) defining its key attributes. The process continues with (5) developing a model case, (6) presenting a borderline and contrary caseterm·mth, (7) identifying antecedentsterm·mth and consequencesterm·mth and (8) concluding with empirical referents. Figure 1 represents the concept analysisterm·key process, adapted from Walker and Avant ( 2019 ).
Conceptual model of moral distressterm·dom in family caregiversterm·dom, adapted from Walker and Avant ( 2019 ).
Literature Search A comprehensive literature search was conducted across four databases: PubMed, CINAHL, Scopus and PsycINFO. The search used both MeSH terms and keywords to identify articles relevant to this concept analysisterm·key. Keywords include family caregiverterm·dom, informal caregiverterm·dom, morality, non‐professional caregiver, moral distressterm·dom, ethical dilemmaterm·dom, caregiver guilt, powerlessness, ethical conflict, decision‐making and home care. The Boolean operators ‘AND’ and ‘OR’ were used to refine the search strategy. As most research on moral distressterm·dom has focused on healthcare professionals, we employed a comprehensive and multi‐database strategy to capture the full scope of evidence and to strengthen methodological rigour.
The search was limited to articles published between February 2000 and May 2025 to ensure a comprehensive review of research on moral distressterm·dom in family caregiversterm·dom. The complete search strings for each database are presented in Table 1 . The inclusion criteria for this concept analysisterm·key focused on studies that (1) examined family caregiversterm·dom, informal caregiversterm·dom, or non‐professional caregivers, (2) addressed moral distressterm·dom within the context of family caregiving for individuals with acute and chronic illnesses (e.g., stroke, brain injury, dementia, cancer and Alzheimer's), (3) included discussions of ethical dilemmasterm·key, guilt, powerlessness, or related concepts; and (4) are published in peer‐reviewed journals. Articles that focused on health care professionals (e.g., nurses, physicians) or were not published in English were excluded.
Search strategy.
The initial search returned a total of 986 articles. Of these, 128 articles were in PubMed, 257 were in PsycINFO, 158 were in Scopus and 443 were in CINAHL. After removing duplicates and applying the eligibility criteria, 12 articles met the inclusion criteria and were included in this concept analysisterm·key. The article selection process was presented following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines (Moher et al. 2009 ; Page et al. 2021 ) to ensure transparency and rigour, as illustrated in Figure 2 .
PRISMA flow chart illustrating the study selection process, adapted from Moher et al. ( 2009 ) and Page et al. ( 2021 ).
We systematically reviewed these studies using Walker and Avant's framework. Specifically, the content of these articles informed the identification of defining attributesterm·mth, antecedentsterm·mth, consequencesterm·mth and empirical referents of moral distressterm·dom in family caregiving. The results of these steps then guided the development of the model, contrary casesterm·mth and borderline casesterm·mth. Collectively, these steps informed the final definition of moral distressterm·dom among family caregiversterm·dom. A summary of the included articles is presented in Table 2 .
Summary of the included articles.
Overview of the Concept The Uses of the Concept The concept of moral distressterm·dom was initially explored among healthcare professionals, especially nurses (Epstein and Hamric 2009 ). It was initially defined by Jameton ( 1984 ) as knowing the right course of action but not being able to do it due to institutional constraints. Building on this, Wilkinson ( 1987 ) described it as the psychological disequilibrium and negative feeling the person experiences when they make a moral decision that does not align with their values and beliefs. Corley et al. ( 2001 ) expanded this definition to include the painful feeling that results from recognising ethically correct behaviours but not doing them due to a lack of time, legal considerations and institutions' policies. More recently, Barlem and Ramos ( 2015 ) defined moral distressterm·dom as a sense of powerlessness that prevents individuals from taking morally appropriate actions leading to physical, psychological and behavioural consequencesterm·mth.
Beyond nursing, moral distressterm·dom has been studied among physicians (Miljeteig et al. 2023 ) and students, including both medical and nursing students (Ong et al. 2022 ). Additionally, the concept of moral distressterm·dom has been explored among social workers, with institutional rules identified as the primary reason for their moral distressterm·dom (Jaskela et al. 2018 ). Furthermore, research has applied and studied this concept in other contexts and populations, including schoolteachers (Thumvichit 2023 ). School teachers face a lot of ethical dilemmasterm·key and complex decision‐making situations, making them more susceptible to experiencing moral distressterm·dom, which negatively affects their well‐being and job satisfaction (Váchová 2019 ).
Family caregiversterm·dom are one of these populations that face numerous ethical and decision‐making challenges (Kristanti and Effendy 2021 ; Rozo et al. 2025 ; Vachon et al. 2023 ). Moral distressterm·dom has been studied among family caregiverterm·dom populations, including those who care for cancer patients (Paidipati et al. 2023 ; Rozo et al. 2025 ), and individuals with dementia and Alzheimer's disease (James 2021 ).
Determining the Defining Attributesterm·mth Defining attributesterm·mth are the essential cluster of characteristics of a concept that consistently and frequently appear in the literature (Walker and Avant 2019 ). These attributes help distinguish a concept from other similar or related concepts. For this concept analysisterm·key of moral distressterm·dom among family caregiversterm·dom, three main defining attributesterm·mth or characteristics were identified based on a comprehensive review of the literature: internal conflictterm·dom, self‐directed negative emotionsterm·dom and feelings of powerlessness and helplessnessterm·dom.
Attributes Internal Conflictterm·dom Internal conflictterm·dom occurs among family caregiversterm·dom when they experience tension between their personal values, beliefs and caregiving responsibilities. Many family caregiversterm·dom feel they need to hide their true emotions and show that they are positive, supportive and happy while they are feeling physically and mentally overwhelmed (Kristanti and Effendy 2021 ; MacKenzie 2024 ). Situations where there is no clear right or wrong, combined with a lack of confidence in their decisions, further intensify this conflict (Hosseini et al. 2024 ; Rozo et al. 2025 ). For example, during the COVID‐19 pandemic, family caregiversterm·dom felt torn between staying with their loved ones during hospitalisation or leaving them alone, according to institutional policies (Vachon et al. 2023 ). They face a conflict between staying and increasing the risk of spreading the virus to family and society, or leaving them alone in this challenging condition for the safety of others (Vachon et al. 2023 ). Another example of internal conflictterm·dom is when family caregiversterm·dom struggle with decisions regarding autonomy and safety, such as whether to intervene or not in situations like driving. They feel conflict between intervening and preventing their loved ones from driving to ensure safety, or not intervening and respecting their autonomy and independence (Lafrance et al. 2022 ).
Self‐Directed Negative Emotionsterm·dom Self‐directed negative emotionsterm·dom are feelings, such as guilt, shame, regret and self‐blame, that arise from individuals' self‐evaluations when they believe they have violated their own moral or ethical standards. These emotions are often classified as moral emotionsterm·dom, as they are closely tied to individuals' evaluations of their behaviour in relation to internalised moral standards (Tangney et al. 2007 ). Family caregiversterm·dom frequently face negative self‐directed emotions due to ethically complex and challenging decision‐making processes (Hosseini et al. 2024 ; Rozo et al. 2025 ; Ullrich et al. 2020 ). They often experience feelings of failure and frustration when they are unable to provide the optimal care they want for their loved ones (Shewangizaw et al. 2023 ). Additionally, feelings of guilt, anger and low self‐esteem arise when caregivers find themselves in situations where they have no choice or control (Koenig 2004 ; Rozo et al. 2025 ). When they believe they have made the wrong decision, they experience fear, regret, self‐blame, confusion and self‐doubt (Rozo et al. 2025 ; Shewangizaw et al. 2023 ; Ullrich et al. 2020 ). The challenging situations and difficult caregiving decisions lead to emotions of anger, denial, shock, fear and endless grief (Hosseini et al. 2024 ). Moreover, the inability to balance multiple caregiving roles often results in feelings of inadequacy and frustration (Rozo et al. 2025 ).
Powerlessness and Helplessnessterm·dom Moral distressterm·dom occurs when individuals have no power to act according to their moral and ethical beliefs (Jameton 1984 ). They experience situations where they face a lack of control and are forced to act in ways that conflict with their values (Ullrich et al. 2020 ). Additionally, they often feel powerless when they cannot help their loved ones get better or when they face a difficult decision‐making process (Gágyor et al. 2019 ; Paidipati et al. 2023 ). Helplessnessterm·dom emerges when family caregiversterm·dom cannot provide the optimal care they want for their loved one, particularly in situations where they face financial restraints and a lack of resources (Rozo et al. 2025 ; Ullrich et al. 2020 ).
Antecedentsterm·mth Antecedentsterm·mth are events that occur prior to the occurrence of the concept, and they are required for the concept to exist (Walker and Avant 2019 ). In this concept analysisterm·key, after reviewing the included articles, six antecedentsterm·mth occur before the occurrence of moral distressterm·dom among family caregiversterm·dom: caregiver burden, role conflictterm·dom, complex decision‐making process, ethical dilemmaterm·dom and internal and external constraints.
Caregiver Burden To experience the challenges and burdens of caregiving, an individual must first take on the role of a family caregiverterm·dom for someone with an acute or chronic condition. The sudden caregiving responsibilities expose them to physical, emotional and psychological burdens (Hosseini et al. 2024 ; Vachon et al. 2023 ). Caregivers must assist with activities of daily living, including bathing, feeding and mobility, which add to their physical strain (MacKenzie 2024 ). Moreover, they are responsible for coordinating health care appointments and managing medications and treatments, all of which contribute to stress and emotional burdens (MacKenzie 2024 ; Rozo et al. 2025 ).
Role Conflictterm·dom Family caregiversterm·dom face a lot of responsibilities, including their roles as parents, friends, spouses, family members and employees (Rozo et al. 2025 ; Ullrich et al. 2020 ; Vachon et al. 2023 ). These multiple roles make it difficult for them to manage and balance their time effectively (Gágyor et al. 2019 ; Koenig 2004 ; Rozo et al. 2025 ; Ullrich et al. 2020 ; Vachon et al. 2023 ). As a result, some family caregiversterm·dom lose their jobs, while others become socially isolated due to these multiple roles and responsibilities (Shewangizaw et al. 2023 ). This ongoing role conflictterm·dom creates significant pressure, particularly when caregivers feel they have not met expectations in their roles as caregivers (Vachon et al. 2023 ). MacKenzie ( 2024 ) emphasises that role conflictterm·dom may also occur within the caregiving relationship itself, as caregivers often feel torn between performing physically and emotionally demanding caregiving tasks and preserving their identity as a loving spouse or family member. MacKenzie provides an example of this tension, describing a caregiver who refused to administer her partner's heparin injection because she could not bear to cause him pain. Although the task was medically necessary, the caregiver felt that performing it conflicted with her identity as a loving partner.
Complex Decision‐Making Process Family caregiversterm·dom are often responsible for making critical care decisions for their loved ones, especially when they are entirely dependent and unable to decide for themselves (Ullrich et al. 2020 ; Weigel 2019 ). Common decisions include choosing between home care and nursing home placement, as well as making palliative care and resuscitation decisions (Hosseini et al. 2024 ; Koenig 2004 ; Kristanti and Effendy 2021 ). In addition, daily care‐related decisions, particularly those regarding when to seek help, further increase the complexity of decision‐making (Rozo et al. 2025 ). Uncertainty surrounding the illness trajectory leaves family caregiversterm·dom unsure of how their loved one's condition will progress, making decisions even more complex and emotionally difficult (Rozo et al. 2025 ). The fear of making wrong decisions combined with a lack of confidence is overwhelming, especially since most caregivers do not have adequate knowledge and guidance (Hosseini et al. 2024 ; Kristanti and Effendy 2021 ; Ullrich et al. 2020 ).
Ethical Dilemmaterm·dom Family caregiversterm·dom experience many morally undesirable situations when they feel that there is no choice that is entirely correct (Vachon et al. 2023 ). These situations involve conflicting ethical principles, such as autonomy versus protection, forcing caregivers to make choices and decisions that challenge their personal and moral values and beliefs (Hosseini et al. 2024 ; Koenig 2004 ; Vachon et al. 2023 ; Weigel 2019 ). End‐of‐life care is one of these situations where caregivers feel confused about the choices, whether to continue life‐prolonging treatment or transition to palliative care (Hosseini et al. 2024 ). Choosing between a peaceful death, human dignity, and the best interest of the person they care for is challenging (Hosseini et al. 2024 ).
Internal Constraints These include the challenges that arise within the caregivers and make them feel inadequate, overwhelmed and conflicted (Ullrich et al. 2020 ). One of these challenges is insufficient knowledge and inadequate information (Ullrich et al. 2020 ). Most family caregiversterm·dom have suddenly found themselves responsible for complex tasks and responsibilities without sufficient training and support (Ullrich et al. 2020 ). Furthermore, time constraints further exacerbate the distress (MacKenzie 2024 ; Shewangizaw et al. 2023 ; Ullrich et al. 2020 ).
External Constraints These include financial barriers, such as increased medical costs and limited insurance coverage, which create significant stress (Koenig 2004 ; Rozo et al. 2025 ; Shewangizaw et al. 2023 ). As a result of these barriers, caregivers experience negative self‐directed feelings when they cannot afford the cost of providing their loved one with the perfect care and treatment they desire (Shewangizaw et al. 2023 ). Moreover, institutional rules and policies also serve as barriers for caregivers to do what they believe is morally right (Vachon et al. 2023 ). During the COVID‐19 pandemic, many caregivers were prohibited from visiting their loved ones due to institutional policies, and these situations intensified their emotional burdens (Vachon et al. 2023 ). In addition, limited access to healthcare services, inadequate resources, a shortage of formal care facilities, and the high cost of nursing homes, palliative care, and hospice leave caregivers with few options (Koenig 2004 ; Rozo et al. 2025 ).
Consequencesterm·mth Consequencesterm·mth are the events that happen as a result or outcome of the concept (Walker and Avant 2019 ). In this analysis, four main consequencesterm·mth were identified after reviewing the included articles: long‐term health effects, social withdrawal and isolation, burnoutterm·dom and moral residueterm·dom.
Long‐Term Health Effects (Physical and Psychological) Family caregiversterm·dom experiencing prolonged or unresolved moral distressterm·dom may develop significant long‐term physical and psychological health effects (Rozo et al. 2025 ). The physical impact includes chronic fatigue, exhaustion and sleep disturbances due to prolonged stress (Voultsos et al. 2024 ). Many caregivers, as a result of the ongoing caregiving burdenterm·key and unresolved ethical dilemmasterm·key, experience heightened levels of anxiety and persistent sadness (Rozo et al. 2025 ; Voultsos et al. 2024 ).
Social Withdrawal and Isolation Family caregiversterm·dom manage multiple responsibilities and roles, and morally distressing situations. Many struggle to balance these roles with their social lives (Koenig 2004 ; Ullrich et al. 2020 ). Due to increased caregiving demands, many caregivers find it challenging to maintain their social relationships as they did in the past (Rozo et al. 2025 ). Those caring for ageing parents often prioritise caregiving responsibilities over their social and familial connections. This leads to significant disruptions in personal relationships, including marital conflict and divorce (Rozo et al. 2025 ).
Burnoutterm·dom Family caregiversterm·dom experience two aspects of burnoutterm·dom as a result of moral distressterm·dom. The first occurs when the caregiver becomes emotionally and physically exhausted, drained, and unable to tolerate the demands of caregiving. In this case, they may feel unable to continue their caregiving role and seek alternative care options such as home nurses, institutional care or hospice (Weigel 2019 ). The second aspect of burnoutterm·dom occurs when caregivers need to adjust their work due to a conflict between caregiving responsibilities and work obligations (Rozo et al. 2025 ). These adjustments include changing shifts, reducing work hours, asking for unpaid leave or even leaving their jobs (Rozo et al. 2025 ). Many family caregiversterm·dom struggle to balance the complex demands of caregiving, family and work, leading them to leave their jobs (Gágyor et al. 2019 ; Koenig 2004 ; Ullrich et al. 2020 ; Vachon et al. 2023 ).
Moral Residueterm·dom Some family caregiversterm·dom repeatedly face morally challenging situations and difficult decisions (Ullrich et al. 2020 ). When they make a decision that conflicts with their moral values and beliefs over an extended period of time, they may experience unresolved and prolonged distress, known as moral residueterm·dom (Ullrich et al. 2020 ). This enduring psychological distress results from the prolonged persistence of self‐directed negative emotionsterm·dom such as guilt, regret or shame that remain long after a morally distressing situation has passed (Shewangizaw et al. 2023 ; Ullrich et al. 2020 ).
Empirical Referents The empirical referents are directly related to the means of recognising and measuring the attributes and characteristics of moral distressterm·dom among family caregiversterm·dom. Determining the existence of moral distressterm·dom in the real world involves identifying several observable characteristics. These referents or characteristics manifest through verbal expressions of distress, behavioural changes and physiological responses. Common indicators include negative self‐directed emotions such as feelings of guilt, anger, low self‐esteem, frustration, fear, regret, self‐blame, anxiety, sadness, confusion, self‐doubts and sleep problems (Rozo et al. 2025 ; Shewangizaw et al. 2023 ; Ullrich et al. 2020 ). Additionally, powerlessness and helplessnessterm·dom can arise due to ethical dilemmasterm·key, complex decision‐making processes and internal conflictsterm·dom (Gágyor et al. 2019 ; MacKenzie 2024 ; Paidipati et al. 2023 ). Caregivers may also exhibit social withdrawal due to the difficulty of balancing their multiple roles and caregiving responsibilities and even the loss of their jobs (Koenig 2004 ; Ullrich et al. 2020 ; Weigel 2019 ).
Identify Model Case The model case is an example from real‐life, literature or construction by the researcher (Walker and Avant 2019 ). It demonstrates all the defining attributesterm·mth and characteristics of the concept of moral distressterm·dom among family caregiversterm·dom and works as a model. The author constructed the following model case.
Model Case Ali is a 52‐year‐old male taking care of his wife, Laila, who experienced a stroke 1 year ago. Despite months of rehabilitation, her condition has not improved. Recently, Laila was admitted to the hospital because of recurrent infections, bedsores and difficulty breathing. Ali faced a difficult medical decision of whether to go with aggressive medical treatment and intervention, such as mechanical ventilation, or to go to palliative care since her condition did not improve. The doctor explained to Ali that his wife's condition is difficult and that the intensive treatment and intervention may prolong her life but not improve her quality of life and may increase her suffering. Ali feels a deep internal conflictterm·dom between his ethical obligations, values and beliefs that his wife deserves every possible chance to live versus the reality that continued medical treatment may only add to her suffering and increase harm more than good. He experiences intense negative feelings, including frustration, sadness, anger, self‐doubt, shame, anxiety, helplessnessterm·dom and powerlessness as he struggles to choose what is best for his wife. His exhaustion and inability to balance caregiving responsibilities, family obligations, and his job make the decision even harder. With time, he decided to go with palliative care. However, after he made this decision, he struggled with prolonged negative feelings of guilt, regret and deep sadness. He constantly thinks that he made the wrong decision, blames himself for her death, and feels like he failed to be a good husband.
Contrary Caseterm·mth The cases that do not reflect the defining attributesterm·mth are called contrary casesterm·mth (Walker and Avant 2019 ). The author constructed the following contrary caseterm·mth. Maria is a 55‐year‐old woman taking care of her husband, Jad, who was diagnosed with terminal cancer. Jad expresses his clear desire to spend the last days of his life with his family at home without hospitalisation or chemotherapy. Maria discussed the condition of her husband with the physicians, and they told her that the cancer had already spread extensively. The physician told Maria that chemotherapy was an option, but it would not guarantee an improvement in his health. Maria discussed the situation and Jad's desire with her family members, and they all made the decision to respect their father's wishes. Maria feels at peace with this decision because she knows that this is the desire of her husband and that all family members are in agreement with this decision. She experiences normal feelings of sadness and anxiety regarding her husband's condition with no feelings of regret or guilt about her decision. She provides emotional and physical support for her husband in his final days. This case lacks the key defining attributesterm·mth of moral distressterm·dom. Instead, she has full support from her family and medical team, allowing her to provide care without distress or regret.
Borderline Caseterm·mth The cases that contain most of the defining attributesterm·mth but not all of them are called borderline casesterm·mth (Walker and Avant 2019 ). Tom is a 33‐year‐old man taking care of his mother, who has been diagnosed with Alzheimer's disease. She is completely dependent on him for daily care, and in recent months, her condition has worsened. She became more agitated, aggressive, and confused, and refused to eat. As a result, she lost weight, and Tom took her to the doctor, who diagnosed her with malnutrition and dehydration. The doctor suggested putting in a feeding tube because they had already tried all the other available options, but she still refused to eat. However, Tom's mother repeatedly expresses her wish not to receive medical interventions, saying, ‘I just want to die in peace’. Tom became conflicted between respecting his mother's wishes and his fear that her health would deteriorate further without this intervention. He felt stressed, sad, and doubtful, struggling with whether to go with her wishes or proceed with the feeding tube. After he had discussed the situation with her doctor, he decided to proceed with the feeding tube. While he experienced feelings of guilt, he reassured himself that he had made the right decision for her health. When his mother woke up and realised she had a feeding tube, she began crying and screaming, which sometimes made him feel guilty and regretful. However, after a short time, he felt hopeful that he had made the right decision as her condition stabilised.
The Final Definition Based on the findings of this analysis, a conceptual definition of moral distressterm·dom in the context of family caregiving is described as follows: The emotional and psychological turmoil that arises when family caregiversterm·dom experience ethically challenging and complex decision‐making situations that prevent them from acting according to their moral values and beliefs is characterised by self‐directed negative feelings and emotions, internal conflictsterm·dom, and feelings of powerlessness and helplessnessterm·dom. It can lead to long‐term consequencesterm·mth such as long‐term health effects (physical and psychological), social isolation, burnoutterm·dom and moral residueterm·dom.
Discussion The findings from this concept analysisterm·key contribute to an understanding of moral distressterm·dom among family caregiversterm·dom. Although several concept analyses have explored moral distressterm·dom, none have specifically examined this concept within the context of family caregiving. Some concept analysisterm·key papers connect the concept of moral distressterm·dom to healthcare providers, such as critical care nurses (Cooke et al. 2022 ), nursing students (Rebecca 2025 ), midwifery (Foster et al. 2022 ) and moral distressterm·dom in pain management (Byma 2025 ). The primary purpose of this analysis was to examine and define the concept of moral distressterm·dom in the context of family caregiving.
This concept analysisterm·key identified both similarities and differences in how family caregiversterm·dom experience moral distressterm·dom compared to other populations in terms of defining attributesterm·mth, antecedentsterm·mth and consequencesterm·mth. After reviewing the included articles, the defining attributesterm·mth and characteristics used in the literature to identify moral distressterm·dom among family caregiversterm·dom are self‐directed negative emotionsterm·dom, internal conflictterm·dom and feelings of powerlessness and helplessnessterm·dom. These attributes align with those reported by Cooke et al. ( 2022 ) and Foster et al. ( 2022 ), who found that nurses and midwives experiencing moral distressterm·dom exhibited negative feelings and emotions, as well as a lack of power. However, a distinctive attribute identified by Byma's ( 2025 ) work on moral distressterm·dom in pain management was the feeling of ownership over the patient's pain. Nurses in this context knew they had a clear intervention (e.g., analgesia) to manage patients' pain but were constrained from administering it, leading to moral distressterm·dom. In contrast, family caregiversterm·dom often lack a clear or accessible solution to alleviate their loved one's suffering, which distinguishes their experience of moral distressterm·dom from that of nurses in pain management contexts.
Six antecedentsterm·mth were identified in this analysis as sources of moral distressterm·dom among family caregiversterm·dom: caregiving burdenterm·key, role conflictterm·dom, ethical dilemmaterm·dom, complex decision‐making process, internal constraints and external constraints. One of these antecedentsterm·mth that is similar across all contexts is the external constraints, including a lack of resources and institutional barriers (Byma 2025 ; Cooke et al. 2022 ; Foster et al. 2022 ). While some antecedentsterm·mth are shared, others differ. For example, unlike family caregiversterm·dom, a key antecedentterm·mth for moral distressterm·dom among critical care nurses is perceptions of futile care (Cooke et al. 2022 ). In contrast, family caregiversterm·dom often struggle with the complex decision‐making process (Hosseini et al. 2024 ; Kristanti and Effendy 2021 ).
This analysis also highlighted the negative outcomes and consequencesterm·mth that family caregiversterm·dom experience as a result of experiencing moral distressterm·dom, including social isolation, burnoutterm·dom, long‐term health effects (physical and psychological), as well as moral residueterm·dom. While burnoutterm·dom and long‐term health effects (physical and psychological) are common to both healthcare providers and family caregiversterm·dom (Byma 2025 ; Cooke et al. 2022 ; Foster et al. 2022 ). Social isolation is a distinct consequenceterm·mth that is primarily associated with family caregiversterm·dom. One possible reason for this distinct consequenceterm·mth is that family caregiving is like a full‐time job (AARP and National Alliance for Caregiving 2020 ). Unlike nurses, who typically work defined shifts, family caregiversterm·dom often face continuous demands, which increases their risk of social withdrawal and isolation.
Limitations This concept analysisterm·key has limitations regarding the included studies and regarding the analysis process itself. First, nine of the included articles were qualitative studies, and the remaining three were theoretical and perspective papers, which limit the generalizability of the results. Perhaps the reason for the exclusive focus on qualitative papers is that no instrument is available to measure moral distressterm·dom among family caregiversterm·dom quantitatively. Second, only five articles explicitly discussed moral distressterm·dom among family caregiversterm·dom. The other seven articles primarily discussed ethical decision‐making challenges and ethical dilemmasterm·key. While these concepts overlap with moral distressterm·dom, they may not fully capture its defining attributesterm·mth and characteristics. Third, the articles that explicitly discuss moral distressterm·dom involve family caregiversterm·dom of individuals with cancer, dementia and Alzheimer's. Notably, none of these articles refer to family caregiversterm·dom of stroke survivors who face significant caregiving burdensterm·key.
Implications for Research and Practice The findings of this concept analysisterm·key highlight some very important implications for future research and practice. Future research should investigate moral distressterm·dom among family caregiversterm·dom in greater detail. Most specifically, there is a gap in studying ethical challenges and moral distressterm·dom among caregivers of stroke survivors. In addition, instruments specifically designed to measure moral distressterm·dom in family caregiversterm·dom need to be developed and validated. Once these instruments are developed, quantitative research is recommended to assess the prevalence and severity of moral distressterm·dom among family caregiversterm·dom.
In practice, healthcare providers, including physicians and nurses, should be aware of the ethical dilemmasterm·key that family caregiversterm·dom experience, as well as their effects on the caregivers' lives and health. Support systems such as training and educational programmes should be designed to help family caregiversterm·dom build the skills and knowledge needed to manage ethically challenging situations. Healthcare providers also play an important role in linking caregivers to helpful resources, including counselling, peer support groups and community‐based services. Such initiatives will not only improve the well‐being of caregivers but also enhance the quality of patient care and promote more ethical, collaborative healthcare environments.
Conclusion Moral distressterm·dom among family caregiversterm·dom is a significant and underrecognized issue. It affects their well‐being and the quality of care they provide. This paper offered a structured examination and a clear conceptual definition of moral distressterm·dom within the context of family caregiving. The conceptual definition will help operationalise moral distressterm·dom in the context of family caregiversterm·dom by developing relevant instruments. Researchers can use these instruments to measure, study and develop interventions that support family caregiversterm·dom.
Funding The authors have nothing to report.
Ethics Statement The authors have nothing to report.
Consent The authors have nothing to report.
Conflicts of Interest The authors declare no conflicts of interest.
Data Availability Statement No new data were generated or analysed in support of this research. Data sharing is not applicable to this article.
References Associated Data Data Availability Statement No new data were generated or analysed in support of this research. Data sharing is not applicable to this article.