Students' experiences in associate degree nursing programs: A qualitative study looking at moral distress

Student nurses experiences of moral distress: A concept analysis

AIM

To understand how pre-registration student nurses experience moral distress and refine the concept in this population.

BACKGROUND

The experience of moral distress has positive and negative effects for health professionals and negatively impacts on patient care. Moral distress is a fluid concept which permits the experience to be varied among different populations. Despite empirical research, a concept analysis has not been performed in the student nurse population.

DATA SOURCES

Electronic databases were searched via Ebsco Host Complete and included Cinahl, Medline, APA Psych in March 2024. Search terms included 'Moral Distress' AND 'Student', 'Moral Distress' and 'Baccalaureate.' Search limits included articles between 2014 and 2024, English Language. Twenty-five papers were included in the review and consisted of eight quantitative studies, 11 qualitative studies, three mixed methods studies and three literature/systematic reviews.

METHODS

An integrated mixed research synthesis (Sandelowski, Voils, Barroso 2006) was conducted and organized into Walker, Avant's (2005) framework of antecedents, attributes and consequences. Braun and Clarkes (2006) thematic analysis was then used to generate themes from the literature.

RESULTS

Antecedents emerged as students having moral sensitivity, they recognize unethical circumstances. Attributes identified roots of moral distress. These roots include poor patient care, harm to the patient and unsafe care. Students experience of morally reprehensible events is exacerbated by the disempowerment they experience as being 'just a student'. Student nurses who do not exhibit moral courage and do not oppose immoral practices do so due to internal constraints which transpire as fear of conflict, withdrawal of learning opportunities, and fear of disruption to learning. This is influenced by their registered nurse supervisor relationship. Consequences of moral distress identify negative feelings, coping mechanisms and positive effects.

CONCLUSION

The attributes of moral distress in the student nurse population have distinctive features which should be considered by nurse educators and in empirical research.

PATIENT OR PUBLIC CONTRIBUTION

None, as this is a concept analysis that contributes to theory development and is not empirical research.

Nursing students' experience of moral distress in clinical settings: A phenomenological study

AIM

To explore nursing students' moral distress (MD) experiences in clinical settings.

DESIGN

An interpretative phenomenological analysis (IPA) design was employed.

METHODS

Purposive sampling was used. In-depth semi-structured face-to-face interviews were conducted from December 2020 to June 2021 with nursing students who were taking the internship course in clinical settings. Data analysis was conducted following Dickman et al.'s (1989) method.

RESULTS

Ten nursing students participated in this study. Three main themes were identified, including (1) negative learning environments, (2) internal disgust and (3) threats to professional identity.

CONCLUSION

Findings showed that value conflict, lack of knowledge of ethical standards and its application, and unprofessional approaches result in negative environmental learning perceptions from the nursing students. Therefore, due to being unable to change the situation, they start to feel guilt and shame and, as a result, decide to escape the problem instead of managing it. These feelings lead to internal disgust. This issue indicates the importance of improving the knowledge and perception of these situations. Thus, nursing students must be prepared for the real world, where their ideals are constantly challenged. MDs were experienced as threats to dignity, inequality, distrust, and change of mentality towards nursing, characterised as threats to professional identity. It is suggested to inquire about the process of nursing students' resiliency in morally disturbing situations to deduce the suitable approach for clinical education.

Experiences of moral distress in nursing students - A qualitative systematic review

OBJECTIVES

The review aims to synthesize and consolidate the factors and situations in which student nurses experience moral distress during their clinical practice and its potential implications for patient care and outcomes.

DESIGN

A qualitative systematic review.

DATA SOURCES

The articles were sourced from PubMed, Embase, CINAHL, Scopus, PsycInfo, Web of Science, ERIC (ProQuest), and ProQuest Dissertations and Theses Global Database between their inception dates to December 2022. Reference lists of included studies were also screened for additional studies.

REVIEW METHODS

Published and unpublished primary studies of any qualitative research methods focused on student nurses' experiences of moral distress regardless of their education level were included in this review. Two reviewers independently screened titles and abstracts, assessed full-text articles for eligibility, extracted data, and appraised the quality of included studies. Sandelowski and Barroso's (2007) two-step meta-synthesis approach and Braun and Clarke's (2006) thematic analysis framework were used to analyze and interpret findings from included studies.

RESULTS

Seven studies met the inclusion criteria and were included in the review. The meta-synthesis revealed an overarching theme, "Moral Distress and its Intertwined Roots". This was supported by the four main themes: 1) Inadequacy and lack of autonomy, 2) Unprofessionalism of healthcare professionals, 3) Differing cultural views and values of patients and their relatives, and 4) Healthcare needs versus resource constraints.

CONCLUSION

This review highlights the experiences of student nurses in situations of moral distress, including feelings of inadequacy and powerlessness when faced with ethical challenges, and the negative impact of resource constraints, unprofessional behavior, and cultural differences. Collaborative efforts between healthcare professionals and student nurses are needed to promote shared decision-making, prioritize ethical training, and provide culturally sensitive care to address these challenges and ultimately improve patient care.

Registered Nurses' and nursing students' perspectives on moral distress and its effects: A mixed-methods systematic review and thematic synthesis

AIM

To examine Registered Nurses (RNs') and nursing students' perspectives on factors contributing to moral distress and the effects on their health, well-being and professional and career intentions.

DESIGN

Joanna Briggs Institute mixed-methods systematic review and thematic synthesis. Registered in Prospero (Redacted).

METHODS

Five databases were searched on 5 May 2021 for studies published in English since January 2010. Methodological quality assessment was conducted in parallel with data extraction.

RESULTS

Searches yielded 2343 hits. Seventy-seven articles were included. Most were correlational design and used convenience sampling. Studies were mainly from North America and Asia and situated in intensive and critical care settings. There were common, consistent sources of moral distress across continents, specialities and settings. Factors related to perceived inability or failure to enact moral agency and responsibility in moral events at individual, team and structural levels generated distress. Moral distress had a negative effect on RNs health and psychological well-being.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Student courage: An essential for today's health education

AIM

The aim of this concept analysis is to propose the new concept of student courage as it operates within the context of healthcare professionals' education.

BACKGROUND

Nurses have a moral obligation that often requires courage. However, nursing students do not have the capacity to act with moral courage until they are close to licensure. Student courage is propositioned as a precursor to moral courage.

DESIGN

The Walker and Avant approach is used to examine the attributes, antecedents, consequences, and empiric referents of student courage. Cases are provided to represent how student courage can be operationalized and to distinguish student courage from moral courage.

RESULTS

The analysis demonstrates that the concept of student courage has four critical attributes: (a) persistence, (b) bravery, (c) overcoming fear, and (d) self-advocacy. Positive and negative consequences are associated with student courage and include: (a) moral distress, (b) criticism, (c) empowerment, and (d) self-knowledge.

CONCLUSIONS

This concept analysis helps fill the gap for nursing students transitioning into a professional role as well as clarifying a nursing student's role in patient care.