Mapping the conceptualisation, contributing factors and interventions of moral distress among healthcare providers in Africa: a scoping review.

INTRODUCTION: Moral distress is the psychological discomfort experienced by healthcare providers when prevented from acting on their ethical values. Although extensively studied in high-income settings, it remains relatively unexplored in Africa, where chronic resource limitations and systemic constraints shape clinical practice. This scoping review mapped African literature examining how moral distress is conceptualised and discussed, its drivers and interventions implemented to address it with a particular focus on the balance between individual and organisational perspectives.

METHODS: A systematic search of databases identified papers on moral distress and related concepts among healthcare providers in Africa. Data extracted included: publication year, geographical focus, study design, participants, healthcare setting, conceptual framing, definitions, factors contributing to moral distress and descriptions of interventions and their evaluations. The results were analysed thematically considering individual and organisational perspectives.

RESULTS: 30 papers published between 1999 and 2025 across 11 African countries were included. Of these, 14 were qualitative, 10 quantitative, 2 mixed methods, 1 review, 2 commentaries and 1 book chapter. Moral distress was commonly framed as an individual psychological burden, yet its primary drivers were identified as organisational including staff shortages, excessive workloads, inadequate resources and limited institutional support. Quantitative papers explicitly referred to 'moral distress', while qualitative papers generally described ethical and moral challenges more widely. Reported interventions were mainly proposed: counselling, debriefing, ethics committees and better staffing were recommended but rarely implemented or evaluated. In practice, healthcare workers relied on informal coping strategies such as peer support, prayer and improvisation.

CONCLUSION: Moral distress is increasingly explored in the literature on African health systems but remains inconsistently defined and inadequately addressed at the organisational level. Despite widespread acknowledgement of its organisational and systemic origins, responsibility for managing its effects falls largely on individuals. This review supports a systems-level understanding of moral distress and highlights the need for organisational and policy change processes. Future research should move beyond description to identifying and evaluating team-based and organisational strategies that effectively reduce or manage moral distress.