Moral Distress and Its Determinants among Nursing Students in an Italian University: A Cross-Sectional Study
Abstract
:1. Introduction
1.1. Background and Rationale
1.2. Study Objectives
- To describe the MD intensity of nursing students;
- To analyze the differences in MD in socio-demographic and academic variables;
- To identify the most significant domains within MD occurrence.
2. Materials and Methods
2.1. Study Design
2.2. Setting
2.3. Participants
- (a)
- were enrolled in the studied program from the 2021–2022 academic year (or previous academic years, but were still attending still attending their bachelor’s course);
- (b)
- had attended at least one internship (worth at least 10 European Credit Transfer System—ECTS) in the six months before data collection;
- (c)
- were willing to participate in the study.
2.4. Measurement
2.5. Data Collection Procedures and Ethical Issues
2.6. Statistical Analysis
3. Results
3.1. Participants Characteristics
3.2. Moral Distress Intensity
3.3. Determinants of Moral Distress Intensity by Socio-Demographic and Academic Variables
4. Discussion
4.1. Key Results
4.2. Strengths and Limitations
4.3. Nursing Clinical Implications
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Public Involvement Statement
Guidelines and Standards Statement
Use of Artificial Intelligence
Conflicts of Interest
References
- Jameton, A. Dilemmas of moral distress: Moral responsibility and nursing practice. AWHONNs Clin. Issues Perinat. Womens Health Nurs. 1993, 4, 542–551. [Google Scholar]
- Jameton, A. Nursing Practice: The Ethical Issues; Prentice-Hall: Englewood Cliffs, NJ, USA, 1984. [Google Scholar]
- Topal, S.; Çaka, S.Y.; Öztürkler, S.; Gürbüz, Y. Burnout inpediatric nurses: Examining the relationship between moral distress and missed nursing care. J. Pediatr. Nurs. 2024, in press. [Google Scholar] [CrossRef] [PubMed]
- Delgado-Ron, J.A.; Tiwana, M.H.; Murage, A.; Morgan, R.; Purewal, S.; Smith, J. Moral distress, coping mechanisms, and turnover intent among healthcare providers in British Columbia: A race and gender-based analysis. BMC Health Serv. Res. 2024, 24, 925. [Google Scholar] [CrossRef] [PubMed]
- Kovanci, M.S.; Atli Özbaş, A. Moral resilience and intention to leave: Mediating effect of moral distress. Nurs. Ethics 2024, 09697330241272882. [Google Scholar] [CrossRef] [PubMed]
- Hoskins, K.; Grady, C.; Ulrich, C. Ethics Education in Nursing: Instruction for Future Generations of Nurses. Online J. Issues Nurs. 2018, 23, 3. [Google Scholar] [CrossRef]
- Ulrich, C.M.; Taylor, C.; Soeken, K.; O’Donnell, P.; Farrar, A.; Danis, M.; Grady, C. Everyday ethics: Ethical issues and stress in nursing practice. J. Adv. Nurs. 2010, 66, 2510–2519. [Google Scholar] [CrossRef]
- Wojtowicz, B.; Hagen, B.; Van Daalen-Smith, C. No place to turn: Nursing students’ experiences of moral distress in mental health settings. Int. J. Ment. Health Nurs. 2014, 23, 257–264. [Google Scholar] [CrossRef]
- McCarthy, J.; Gastmans, C. Moral distress: A review of the argument-based nursing ethics literature. Nurs. Ethics 2015, 22, 131–152. [Google Scholar] [CrossRef]
- Jameton, A. What Moral Distress in Nursing History Could Suggest about the Future of Health Care. AMA J. Ethics 2017, 19, 617–628. [Google Scholar] [CrossRef]
- Rennó, H.M.S.; Ramos, F.R.S.; Brito, M.J.M. Moral distress of nursing undergraduates: Myth or reality? Nurs. Ethics 2018, 25, 304–312. [Google Scholar] [CrossRef]
- Escolar-Chua, R.L. Moral sensitivity, moral distress, and moral courage among baccalaureate Filipino nursing students. Nurs. Ethics 2018, 25, 458–469. [Google Scholar] [CrossRef]
- Bickhoff, L.; Sinclair, P.M.; Levett-Jones, T. Moral courage in undergraduate nursing students: A literature review. Collegian 2017, 24, 71–83. [Google Scholar] [CrossRef] [PubMed]
- Dimitriadou, M.; Papastavrou, E.; Efstathiou, G.; Theodorou, M. Baccalaureate nursing students’ perceptions of learning and supervision in the clinical environment. Nurs. Health Sci. 2015, 17, 236–242. [Google Scholar] [CrossRef] [PubMed]
- Comrie, R.W. An analysis of undergraduate and graduate student nurses’ moral sensitivity. Nurs. Ethics 2012, 19, 116–127. [Google Scholar] [CrossRef] [PubMed]
- Klocko, M.N. Academic Dishonesty in Schools of Nursing: A Literature Review. J. Nurs. Educ. 2014, 53, 121–125. [Google Scholar] [CrossRef] [PubMed]
- Krautscheid, L.; DeMeester, D.A.; Orton, V.; Smith, A.; Livingston, C.; McLennon, S.M. Moral Distress and Associated Factors Among Baccalaureate Nursing Students: A Multisite Descriptive Study. Nurs. Educ. Perspect. 2017, 38, 313–319. [Google Scholar] [CrossRef]
- Gonella, S.; Viottini, E.; Gastmans, C.; Tambone, S.; Conti, A.; Campagna, S.; Dimonte, V. Lived experience of ethical challenges among undergraduate nursing students during their clinical learning. Nurs. Ethics 2024, 09697330241262311. [Google Scholar] [CrossRef]
- Heng, T.J.T.; Shorey, S. Experiences of moral distress in nursing students—A qualitative systematic review. Nurse Educ. Today. 2023, 129, 105912. [Google Scholar] [CrossRef]
- Von Elm, E.; Altman, D.G.; Egger, M.; Pocock, S.J.; Gøtzsche, P.C.; Vandenbroucke, J.P. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. J. Clin. Epidemiol. 2008, 61, 344–349. [Google Scholar] [CrossRef] [PubMed]
- Mazzotta, R.; De Maria, M.; Bove, D.; Badolamenti, S.; Saraiva Bordignon, S.; Silveira, L.C.J.; Vellone, E.; Alvaro, R.; Bulfone, G. Moral distress in nursing students: Cultural adaptation and validation study. Nurs. Ethics 2022, 29, 384–401. [Google Scholar] [CrossRef]
- Bordignon, S.S.; Lunardi, V.L.; Barlem, E.L.D.; Dalmolin, G.D.L.; Da Silveira, R.S.; Ramos, F.R.S.; Barlem, J.G.T. Moral distress in undergraduate nursing students. Nurs. Ethics 2019, 26, 2325–2339. [Google Scholar] [CrossRef] [PubMed]
- Lix, L.M.; Keselman, J.C.; Keselman, H.J. Consequences of Assumption Violations Revisited: A Quantitative Review of Alternatives to the One-Way Analysis of Variance “F” Test. Rev. Educ. Res. 1996, 66, 579. [Google Scholar] [CrossRef]
- Vinci, A.; Furia, G.; Cammalleri, V.; Colamesta, V.; Chierchini, P.; Corrado, O.; Mammarella, A.; Ingravalle, F.; Bardhi, D.; Malerba, R.M.; et al. Burden of delayed discharge on acute hospital medical wards: A retrospective ecological study in Rome, Italy. PLoS ONE 2024, 19, e0294785. [Google Scholar] [CrossRef]
- Furia, G.; Vinci, A.; Colamesta, V.; Papini, P.; Grossi, A.; Cammalleri, V.; Chierchini, P.; Maurici, M.; Damiani, G.; De Vito, C. Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy. Front. Public Health 2023, 11, 1150511. [Google Scholar] [CrossRef] [PubMed]
- Misure Urgenti per la Riduzione dei Tempi Delle Liste di Attesa Delle Prestazioni Sanitarie. Decreto-Legge, GU n.132 7 June 2024. Available online: https://www.normattiva.it/uri-res/N2Ls?urn:nir:stato:decreto-legge:2024-06-07;73!vig= (accessed on 22 August 2024).
- Factor, E.M.R.; De Guzman, A.B. Explicating Filipino student nurses’ preferences of clinical instructors’ attributes: A conjoint analysis. Nurse Educ. Today 2017, 55, 122–127. [Google Scholar] [CrossRef]
- Labrague, L.J.; McEnroe-Petitte, D.M.; D’Souza, M.S.; Hammad, K.S.; Hayudini, J.N.A. Nursing faculty teaching characteristics as perceived by nursing students: An integrative review. Scand. J. Caring Sci. 2020, 34, 23–33. [Google Scholar] [CrossRef]
- Al-Rjoub, S.F.; Diener, E.; AL-Fayyadh, S. Nurse administrators as the cause of moral distress among nurse educators: A qualitative research study. J. Prof. Nurs. 2022, 43, 117–123. [Google Scholar] [CrossRef]
- Sasso, L.; Bagnasco, A.; Bianchi, M.; Bressan, V.; Carnevale, F. Moral distress in undergraduate nursing students: A systematic review. Nurs. Ethics 2016, 23, 523–534. [Google Scholar] [CrossRef]
- Nohr, E.A.; Liew, Z. How to investigate and adjust for selection bias in cohort studies. Acta Obs. Gynecol. Scand. 2018, 97, 407–416. [Google Scholar] [CrossRef]
- Tahmasbi, S.; Alavi, A. Ethical Sensitivity and Moral Self-concept of Nursing Students During Internship: Factors and Assessment. Health Spirit. Med. Ethics 2023, 10, 55–62. [Google Scholar]
- Rebecca, T. Student nurses experiences of moral distress: A concept analysis. J. Adv. Nurs. 2024, 1–19. [Google Scholar] [CrossRef]
- Usset, T.; Fantus, S. Moral Distress Is a Systemic Problem Requiring Organizational Solutions. Am. J. Bioeth. 2023, 23, 84–86. [Google Scholar] [CrossRef] [PubMed]
- Carlson, J. Organizational Virtue Ethics and Moral Distress among Healthcare Workers. J. Clin. Ethics 2024, 35, 169–179. [Google Scholar] [CrossRef]
Variable | N (%) or Mean ± SD (Min–Max) | |
---|---|---|
Program year | 2nd year | 259 (75.29%) |
3rd year | 64 (18.6%) | |
Delayed Graduation | 21 (6.1%) | |
Age | 23.12 ± 5.3 (18–53) | |
Gender | Male | 92 (26.74%) |
Female | 252 (73.26%) | |
Marital status | Single | 299 (86.92%) |
Married/with partner | 3 (0.87%) | |
Separated/divorced | 42 (12.21%) | |
Parental status | No children | 330 (95.93%) |
1 child | 6 (1.74%) | |
2 children or more | 7 (2.03%) | |
3 | 1 (0.29%) | |
Employment status during program | Employed | 274 (79.65%) |
Not employed | 70 (20.35%) | |
Nursing as first career choice | Yes | 221 (64.24%) |
No | 123 (35.76%) | |
Previous University program | Attended | 79 (22.97%) |
Not attended | 265 (77.03%) | |
Passed all exams of previous year | Yes | 223 (64.83%) |
No | 121 (35.17%) | |
GPA | 25.43 ± 1.49 (21–29.33) | |
ECTS | 70.27 ± 24.58 (4–153) |
Variables | Dimension 1 | p-Value | Dimension 2 | p-Value | Dimension 3 | p-Value | Dimension 4 | p-Value | Dimension 5 | p-Value | Overall Moral Distress | p-Value | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Immatricolation Year | 2nd year | 2.48 ± 1.22 | 0.116 | 2.52 ± 1.33 | 0.353 | 2.75 ± 1.31 | 0.452 | 3.06 ± 1.37 | 0.312 | 2.39 ± 1.15 | 0.179 | 2.54 ± 1.07 | 0.285 |
3rd year | 2.37 ± 1.13 | 2.28 ± 1.17 | 2.77 ± 1.31 | 2.96 ± 1.38 | 2.2 ± 1.04 | 2.4 ± 1.04 | |||||||
Delayed in graduation | 1.93 ± 0.87 | 2.29 ± 1.06 | 2.39 ± 0.94 | 2.61 ± 1.1 | 2.13 ± 1.02 | 2.21 ± 0.9 | |||||||
Gender | Male | 2.46 ± 1.2 | 0.341 | 2.42 ± 1.27 | 0.446 | 2.73 ± 1.25 | 0.964 | 3.05 ± 1.34 | 0.401 | 2.31 ± 1.07 | 0.405 | 2.48 ± 1.03 | 0.68 |
Female | 2.32 ± 1.16 | 2.55 ± 1.33 | 2.74 ± 1.4 | 2.91 ± 1.4 | 2.43 ± 1.27 | 2.53 ± 1.15 | |||||||
Marital status | Single | 2.41 ± 1.16 | 0.46 | 2.47 ± 1.3 | 0.216 | 2.72 ± 1.28 | 0.142 | 3 ± 1.34 | 0.049 | 2.31 ± 1.11 | 0.072 | 2.48 ± 1.04 | 0.084 |
Married/with partner | 1.5 ± 0.71 | 1.17 ± 0.29 | 1.39 ± 0.35 | 1.25 ± 0.25 | 1.45 ± 0.11 | 1.4 ± 0.16 | |||||||
Separated/divorced | 2.53 ± 1.38 | 2.44 ± 1.23 | 2.89 ± 1.36 | 3.22 ± 1.41 | 2.65 ± 1.22 | 2.7 ± 1.14 | |||||||
Parental status | No child | 2.45 ± 1.19 | 0.157 | 2.48 ± 1.29 | 0.157 | 2.76 ± 1.29 | 0.144 | 3.05 ± 1.35 | 0.057 | 2.36 ± 1.13 | 0.196 | 2.52 ± 1.06 | 0.74 |
1 child | 1.7 ± 0.45 | 1.06 ± 0.13 | 1.57 ± 0.37 | 1.56 ± 0.43 | 1.21 ± 0.2 | 1.46 ± 0.36 | |||||||
2 children or more | 1.57 ± 1.22 | 2.13 ± 1.39 | 2.29 ± 1.51 | 2.32 ± 1.32 | 2.06 ± 0.83 | 1.99 ± 0.7 | |||||||
Employment Condition | Yes | 2.01 ± 1.09 | 0.003 | 2 ± 1.19 | 0.001 | 2.36 ± 1.22 | 0.008 | 2.58 ± 1.21 | 0.004 | 2 ± 0.91 | 0.005 | 2.14 ± 0.88 | 0.002 |
No | 2.52 ± 1.19 | 2.57 ± 1.29 | 2.82 ± 1.29 | 3.11 ± 1.37 | 2.43 ± 1.16 | 2.58 ± 1.08 | |||||||
Nursing as first career choice | Yes | 2.33 ± 1.18 | 0.06 | 2.3 ± 1.23 | 0.005 | 2.62 ± 1.28 | 0.026 | 2.92 ± 1.38 | 0.92 | 2.26 ± 1.11 | 0.079 | 2.4 ± 1.05 | 0.031 |
No | 2.59 ± 1.2 | 2.73 ± 1.34 | 2.94 ± 1.29 | 3.18 ± 1.3 | 2.48 ± 1.14 | 2.66 ± 1.07 | |||||||
Previous University program | Yes | 2.41 ± 1.18 | 0.795 | 2.49 ± 1.28 | 0.43 | 2.78 ± 1.3 | 0.266 | 3.05 ± 1.35 | 0.408 | 2.37 ± 1.11 | 0.457 | 2.51 ± 1.04 | 0.512 |
No | 2.45 ± 1.24 | 2.35 ± 1.31 | 2.59 ± 1.26 | 2.9 ± 1.37 | 2.26 ± 1.19 | 2.43 ± 1.12 | |||||||
Passed all exams of previous year | Yes | 2.29 ± 1.02 | 0.129 | 2.37 ± 1.21 | 0.351 | 2.7 ± 1.3 | 0.699 | 2.86 ± 1.32 | 0.139 | 2.21 ± 1.03 | 0.122 | 2.38 ± 0.96 | 0.155 |
No | 2.5 ± 1.27 | 2.51 ± 1.33 | 2.75 ± 1.29 | 3.09 ± 1.37 | 2.41 ± 1.17 | 2.55 ± 1.11 |
Variables | Dimension 1 | Dimension 2 | Dimension 3 | Dimension 4 | Dimension 5 | Moral Distress (Overall) | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Univariate | Multivariate | Univariate | Multivariate | Univariate | Multivariate | Univariate | Multivariate | Univariate | Multivariate | Univariate | Multivariate | |||||||||||||
β | p-Value | β | p-Value | β | p-Value | β | p-Value | β | p-Value | β | p-Value | β | p-Value | β | p-Value | β | p-Value | β | p-Value | β | p-Value | β | p-Value | |
Age (years) | 0.007 | 0.58 | 0.006 | 0.49 | 0.004 | 0.77 | 0.001 | 0.98 | 0.014 | 0.28 | 0.013 | 0.31 | 0.004 | 0.78 | 0.003 | 0.81 | 0.015 | 0.19 | 0.013 | 0.27 | 0.01 | 0.37 | 0.007 | 0.5 |
Gender | −0.145 | 0.34 | −0.127 | 0.41 | 0.126 | 0.45 | 0.172 | 0.3 | 0.007 | 0.96 | 0.032 | 0.85 | −0.142 | 0.4 | −0.106 | 0.54 | 0.116 | 0.4 | 0.153 | 0.28 | 0.054 | 0.68 | 0.097 | 0.46 |
First career choice | −0.258 | 0.06 | −0.275 | <0.05 | −0.422 | <0.01 | −0.437 | <0.01 | −0.032 | <0.05 | −0.343 | <0.05 | −0.259 | 0.09 | −0.268 | 0.08 | −0.224 | 0.08 | −0.222 | 0.08 | −0.258 | <0.05 | −0.267 | <0.05 |
Marital status | 0.047 | 0.64 | 0.23 | <0.05 | −0.036 | 0.74 | 0.102 | 0.38 | 0.063 | 0.55 | 0.228 | 0.06 | 0.078 | 0.49 | 0.264 | <0.05 | 0.155 | 0.1 | 0.311 | <0.01 | 0.096 | 0.27 | 0.274 | <0.01 |
Parental status | −0.453 | <0.01 | −0.597 | <0.01 | −0.263 | 0.22 | −0.215 | 0.35 | −0.352 | 0.08 | −0.453 | <0.05 | −0.485 | <0.05 | −0.638 | <0.01 | −240 | 0.18 | −0.376 | 0.05 | −0.345 | <0.05 | −0.47 | <0.01 |
Previous University program | 0.041 | 0.79 | 0.093 | 0.56 | −0.135 | 0.43 | −0.02 | 0.91 | −0.185 | 0.27 | −0.147 | 0.39 | −0.145 | 0.41 | −0.114 | 0.52 | −0.108 | 0.46 | −0.02 | 0.89 | −0.089 | 0.51 | −0.024 | 0.86 |
Employment condition | −0.507 | <0.01 | −0.473 | <0.01 | −0.569 | <0.001 | −0.561 | <0.01 | −0.467 | <0.01 | −0.387 | <0.05 | −0.53 | <0.01 | −0.423 | <0.05 | −0.43 | <0.01 | −0.431 | <0.01 | −0.441 | <0.01 | −0.417 | <0.01 |
Passed all exams of previous year | 0.21 | 0.13 | 0.178 | 0.2 | 0.14 | 0.35 | 0.114 | 0.44 | 0.057 | 0.7 | 0.028 | 0.85 | 0.229 | 0.14 | 0.195 | 0.21 | 0.198 | 0.12 | 0.164 | 0.19 | 0.17 | 0.15 | 0.137 | 0.24 |
GPA | −0.022 | 0.63 | −0.008 | 0.86 | −0.044 | 0.38 | −0.009 | 0.86 | −0.011 | 0.82 | 0.014 | 0.77 | −0.009 | 0.85 | 0.015 | 0.77 | −0.08 | 0.06 | −0.06 | 0.15 | −0.044 | 0.26 | −0.023 | 0.56 |
ECTS | 0.001 | 0.99 | −0.002 | 0.52 | −0.003 | 0.29 | −0.004 | 0.12 | 0.001 | 0.62 | −0.001 | 0.98 | 0.002 | 0.5 | 0.001 | 0.94 | 0.001 | 0.85 | −0.002 | 0.39 | 0.001 | 0.92 | −0.02 | 0.43 |
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Bulfone, G.; Bressan, V.; Zerilli, I.; Vinci, A.; Mazzotta, R.; Ingravalle, F.; Maurici, M. Moral Distress and Its Determinants among Nursing Students in an Italian University: A Cross-Sectional Study. Nurs. Rep. 2024, 14, 2140-2152. https://doi.org/10.3390/nursrep14030160
Bulfone G, Bressan V, Zerilli I, Vinci A, Mazzotta R, Ingravalle F, Maurici M. Moral Distress and Its Determinants among Nursing Students in an Italian University: A Cross-Sectional Study. Nursing Reports. 2024; 14(3):2140-2152. https://doi.org/10.3390/nursrep14030160
Chicago/Turabian StyleBulfone, Giampiera, Valentina Bressan, Irene Zerilli, Antonio Vinci, Rocco Mazzotta, Fabio Ingravalle, and Massimo Maurici. 2024. "Moral Distress and Its Determinants among Nursing Students in an Italian University: A Cross-Sectional Study" Nursing Reports 14, no. 3: 2140-2152. https://doi.org/10.3390/nursrep14030160