Moral distress in nursing students: Cultural adaptation and validation study

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.

Moral distress and compassion fatigue among nursing interns: a cross-sectional study on the mediating roles of moral resilience and professional identity

BACKGROUND

Nursing interns often faced moral distress in clinical practice, similar to registered nurses, which can lead to compassion fatigue. The roles of moral resilience and professional identity in influencing the psychological well-being of nursing interns are recognized, but the interrelationships among moral distress, moral resilience, professional identity, and compassion fatigue in this group remain unclear.

OBJECTIVES

This study aimed to investigate the impact of moral distress on compassion fatigue among nursing interns and to explore the mediating role of moral resilience and professional identity.

METHODS

A quantitative cross-sectional study was conducted with 467 nursing interns. Data were collected using Compassion Fatigue Short Scale, Moral Distress Scale-revised, Rushton Moral Resilience Scale, and Professional Identity Scale. Data analyses were performed using SPSS 22.0 and Amos 21.0, adhering to the STROBE statement.

RESULTS

The mean scores for compassion fatigue, moral distress, moral resilience, and professional identity were 35.876, 44.887, 2.578, and 37.610, respectively. Moral distress was positively correlated with compassion fatigue. Structural equation modeling showed that moral resilience and professional identity partially mediated the relationship between moral distress and compassion fatigue (β = 0.448, P < 0.001).

CONCLUSION

The findings suggest that moral distress directly influences compassion fatigue among nursing interns and also exerts an indirect effect through moral resilience and professional identity. Interventions aimed at enhancing moral resilience and fostering a strong professional identity may help mitigate the adverse effects of moral distress on compassion fatigue among nursing interns.

Moral Distress and Its Determinants among Nursing Students in an Italian University: A Cross-Sectional Study

BACKGROUND

Moral Distress (MD) is a unique form of distress that occurs when people believe they know the ethically correct action to take but are constrained from doing so. Limited clinical experience and insufficient ethical knowledge contribute to nursing students' MD, which can potentially cause negative outcomes. The aims of this study are: (1) to describe the MD intensity of nursing students, and (2) to analyze differences and associations between MD intensity and socio-demographic and academic variables.

METHODS

A cross-sectional study design with a convenience sample of the second, third, and delayed graduation students was included; only students willing to participate and who had attended their scheduled internships in the last six months were eligible for inclusion. To measure the level of MD, we used the It-ESMEE. We collected socio-demographic and academic variables. The data collection occurred from January 2024 to March 2024.

RESULTS

The students who adhered to the collection were N = 344. The findings reveal that the students perceived a high level of MD in situations related to clinical internship and class. They perceived higher levels of MD when nursing was not their first career choice, were separated or divorced, did not have children, and were not an employed student. The overall MD score is statistically significantly lower among students who had nursing as their first career choice (β = -0.267, p < 0.05), have children (β = -0.470, p < 0.01), and are employed (β = -0.417, p < 0.01). In contrast, being separated or divorced (β = 0.274, p < 0.01) was associated with a higher MD score.

CONCLUSIONS

This study has some limitations: data reflect a local context, and the findings may not be generalizable to other regions or educational environments. Additionally, students' recollections of their experiences could be influenced by the passage of time, and there may be a selection bias since only students willing to participate were included. The findings suggest that nursing education programs should incorporate more robust training in ethical decision-making and stress management to better prepare students for the moral challenges in their professional practice.

Gendered and racial experiences of moral distress: A scoping review

AIM

To inform efforts to integrate gender and race into moral distress research, the review investigates if and how gender and racial analyses have been incorporated in such research.

DESIGN

Scoping review.

METHODS

The PRISMA (Preferred Reporting Items for Systematic and Meta-Analysis) Extension for Scoping Reviews was adopted.

DATA SOURCES

Systematic literature search was conducted through PubMed, CINAHL and Web of Science databases. Boolean operators were used to identify moral distress literature which included gender and/or race data and published between 2012 and 2022.

RESULTS

After screening and full-text review, 73 articles reporting on original moral distress research were included. Analysis was conducted on how gender and race were incorporated in research and interpretation of moral distress experiences among healthcare professionals.

IMPACT

This study found that while there is an upward trend in including gender and race-disaggregated data in moral distress research, over half of such research did not conduct in-depth analysis of such data. Others only highlighted differential experiences such as moral distress levels of women vis-à-vis men. Only about 20% of publications interrogated how experiences of moral distress differed and/or explored factors behind their findings.

CONCLUSION

There is a need to not only collect disaggregated data in moral distress research but also engage this data through gender and race-based analysis. Particularly, we highlight the need for intersectional analysis, which can elucidate how social identities and categories (such as gender and race) and structural inequalities (such as those sustained by sexism and racism) interact to influence moral experiences.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Moral distress as experienced by healthcare professionals is increasingly recognized as an important area of research with significant policy implications in the healthcare sector. This study offers insights for nuanced and targeted policy approaches.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

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.

Moral Distress among Frontline Physicians and Nurses in the Early Phase of COVID-19 Pandemic in Italy

During the COVID-19 health emergency, healthcare professionals faced several ethical demanding job stressors, becoming at particular risk of moral distress. To date, only a few scales have been developed to evaluate moral distress among frontline professionals working in contact with COVID-19 patients. Moreover, although many healthcare professionals from various disciplines were converted to COVID-19 patient care, no study has yet analyzed whether the resulting change in duties might represent a risk factor for moral distress. Thus, this study aimed to investigate how and when the change in duties during the emergency would be related to healthcare professionals' psycho-physical malaise. To this aim, a first Italian adaptation of the Stress of Conscience Questionnaire (SCQ) was provided. In total, 272 Italian healthcare professionals participated in this cross-sectional study. Healthcare professionals who had to perform tasks outside their usual clinical duties were more likely to experience moral distress and then psycho-physical malaise. This was particularly likely for those who were extremely concerned about becoming infected with the virus. The results also indicated that the Italian adaptation of the SCQ had a one-factor solution composed of six items. This study provides the first Italian adaptation of SCQ and practical suggestions on how supporting professionals' well-being during emergencies.