Moral distress poses a large threat to nearly all health care professionals and even goes beyond the health care realm (Jameton, 2017). Moral distress is a phenomenon that occurs when a person knows the correct action to take but is constrained from taking it (Jameton, 1984). Moral distress can be an experience prior to entering the profession in nursing school (Sasso et al., 2016). With the complexity of health care and continued growth of ethical dilemmas encountered in nursing practice, eliminating moral distress entirely is not practical (Rushton et al., 2017); instead, the focus continues to center on ways to mitigate the effects of moral distress.
To reduce the harmful effects of moral distress, a call to strengthen moral resilience has been established (American Nurses Association, 2017; Moss et al., 2016). Another documented concept known to reduce moral distress is moral courage (Bickhoff et al., 2017). Moral courage involves a person's capacity and readiness to speak up about a problem (Murray, 2010). In nursing students, one of the most frequent reasons for inaction occurs when students doubt their ability to speak up and instead remain silent (Bickhoff et al., 2017; Krautscheid et al., 2017).
Moral distress, moral courage, and moral resilience have been studied extensively in licensed nurses, particularly those in acute care settings. However, these three moral concepts are unstudied in the context of nursing students. This study investigated the relationships among moral distress, moral courage, and moral resilience in undergraduate nursing students.
Moral courage is necessary to improve patient outcomes and patient safety (Dinndorf-Hogenson, 2015; Hawkins & Morse, 2014). Furthermore, given that moral dilemmas causing moral distress are inherent in clinical and academic contexts, nurses and nursing students should be equipped with proper tools such as courage (Lindh et al., 2010). Although moral courage can be taught, nursing students are still in the process of learning their role as a nurse and the assertive behavior required to provide high-quality care (Aultman, 2008). In addition, recent literature supports the notion of practicing moral courage as a way to develop moral resilience (Lachman, 2016).
A shift is under way regarding the use of moral resilience; current thinking suggests replacing moral distress with moral resilience (Rushton et al., 2017). This shift aims to address health care problems not in terms of moral distress but in terms of moral resilience through “courage, cooperative speaking up, and persistent action” (Jameton, 2017, p. 620). Rushton (2016) highlights cultivating moral resilience through self-awareness, self-regulation capacities, and ethical competence, as well as speaking up with clarity and confidence.
During the past 5 years, the literature has noted an increase in moral distress among nursing students. Nursing students experience moral distress in their clinical experiences and professional education (Range & Rotherham, 2010; Renno et al., 2018; Sasso et al., 2016). Sasso et al. (2016) identified sources of moral distress in nursing students in mentor relationships, when taking care of patients with health disparities, and with interpersonal factors. According to Reader (2015), nursing students experience moral distress related to an overall feeling of disempowerment and lack of status or powerlessness (Savel & Munro, 2015). Students often find themselves in the middle of moral dilemmas and remain silent instead of questioning practice or patient safety due to their lack of ability to speak up and intervene (Bickhoff et al., 2016).
The theoretical framework guiding this study was derived from Corley's (2002) theory of moral distress that illustrates moral concepts linked between moral distress and moral courage. This was the first theory aimed specifically at moral distress from a nurse's point of view as well as that of an organization. This theory has been used to study the physiological (internal) and organizational (external) variables that surround moral distress and has been used in the large body of knowledge in moral distress in nurses.
The research questions for this study were:
Do nursing students with greater moral resilience and moral courage report significantly less moral distress?
Do students with higher moral resilience have less moral distress?
Do students with higher moral courage have less moral distress?
Does moral courage predict moral distress more than moral resiliency?
Study Design and Sample
This study used a descriptive correlational design to examine moral distress, moral courage, and moral resilience among undergraduate nursing students in addition to investigating their interrelationships. The study was conducted at a large university and two satellite campus settings in the Southwest. The study proposal was approved by the Institutional Review Board (IRB) at The University of Texas at Tyler, and approval also was obtained from Texas Tech University Health Sciences Center IRB.
Prelicensure baccalaureate nursing students comprised the convenience sample. Participants were recruited through their student email. Students who expressed interest in participating were screened for eligibility. A priori, a statistical power analysis was performed using G*Power Analysis 3.1 for sample size estimation (Faul et al., 2009). An accepted minimal power level of .80 was used to avoid a Type II error (Cohen, 1988). With minimal literature having previous effect sizes, this study intended to achieve a medium effect of f = .15. Therefore, using an alpha of .05, a total sample size of 68 students was suggested.
Demographic data were collected at baseline. Moral courage, moral resilience, and moral distress were assessed using the Moral Courage Scale for Physicians (MCSP) (Martinez et al., 2016), the Connor-Davidson Resilience Scale (CD-RISC) (Connor & Davidson, 2003), and the Moral Distress Thermometer (MDT) (Wocial & Weaver, 2013).
Descriptive statistics for demographic data, moral distress, moral courage, and moral resilience were analyzed using SPSS® version 24. In addition, Pearson r correlations and multiple regression analyses were performed to determine the relationship among the moral concepts. In testing the research questions, the assumptions were met. To rely on a confidence interval of 95% and produce more generalizability, a robust method known as bootstrapping was performed for correlation analyses (Field, 2013).
Seventy percent of the students (n = 88) responded to the initial survey through the email link. However, several of the respondents were ineligible for personal reasons or did not complete portions of the survey. The final data set (n = 45) resulted in a 36% response rate.
The majority of the respondents were women (91.1%) with a mean age of 22.15 years (SD, ±2.79) and a median age of 21 years. The majority of the respondents reported their ethnicity as White (77.8%), with the second largest percentage of respondents being Hispanic or Latino (13.3%). The majority of participants did not report prior health care experience (62.2%) and also had not considered quitting nursing school (82.2%).
A descriptive analysis of the main study variables of moral distress, moral courage, and moral resilience was conducted. Moral distress scores on the MDT ranged from 0 to 7; higher scores indicated a distressing and intense level. A majority of students reported moral distress ranging from mild to uncomfortable on the MDT (M = 2.73, SD = 1.9). A wide range of scores for moral courage (63 to 100) was elicited on the MCSP. Students' average scores on moral resilience (M = 78.44, SD = 11.6) were lower than their average scores on moral courage (M = 88.15, SD = 9.1). Moral resilience scores ranged from 46 to 99. The reliability for the instruments used in this study was analyzed, and both the CD-RISC and MCSP had a Cronbach's alpha of .80.
Research Question One
Research question one examined whether nursing students with greater moral resilience and moral courage reported significantly less moral distress. There was a small but nonsignificant negative correlation between moral distress and moral resilience, r(45) = −.21, p = .084, 95% CI [–0.47, 0.5]. There was no statistically significant correlation between moral distress and moral courage, r(45) = .02, p = .44, 95% CI [−0.30, 0.35]. Therefore, students who reported higher moral resilience and higher moral courage did not report less moral distress. However, there was a statistically significant relationship between moral courage and moral resilience, r(45) = .37, p = .006, 95% CI [0.07, 0.62].
Research Question Two
The second research question asked whether students with higher moral resilience had less moral distress. The simple correlation between the two variables was r(45) = −.21, p = .084. Pearson's partial correlation showed the strength of this linear relationship was greater after controlling for moral courage, rpartial (45) = −.24, p = .062, 95% CI [−0.47, 0.05].
Research Question Three
Research question number three asked whether students with higher moral courage had less moral distress The simple correlation between the two variables was r(45) = .024, p = .44. Pearson's partial correlation showed a weak, nonstatistically significant linear relationship between moral courage and moral distress, rpartial (45) = .112, p = .47, 95% CI [−0.22, 0.38].
Research Question Four
A multiple regression was conducted to determine whether moral courage and moral resilience predicted moral distress. Using the standard entry method, data indicated the overall model was not statistically significant, F(2,42) = 1.241, p = .30. The model only explained 2% (R = .056, adjusted R = .011) of the variance in the dependent variable moral distress. Therefore, moral courage did not predict moral distress more than moral resiliency.
Additional Analyses and Results
There was a strong correlation between the stand-alone questions and the original CD-RISC, r(45) = .589, p < .001, indicating moderate convergent validity of the two new questions. The stand-alone questions also had a statistically significant correlation with moral courage, r(45) = .445, p = .002. These findings warrant further analyses with the new stand-alone questions for measuring moral resilience.
The data showed a statistically significant relationship between moral resilience and age, r(45) = .314, p = .04, 95% CI [0.9, 0.54]. There was a significant difference in moral resilience for students who had a previous degree, χ2(1) = 28, p = .02, indicating that moral resilience was higher in those students who were seeking a second degree in nursing.
The purpose of this study was to address a scientific gap by explaining moral distress, moral courage, and moral resilience among undergraduate nursing students and their interrelationships. Results of this study parallel findings from studies that reported moral distress as being a phenomenon experienced by nursing students (Escolar-Chua, 2016; Krautscheid et al., 2017; Renno et al., 2018).
Curriculums providing education and training to future health care professionals should not underestimate the importance of keeping ethics and value-based training. However, one of the underlying issues is that many gaps still remain in ethics education in nursing curricula (Hoskins et al., 2018).
Furthermore, sociodemographic factors such as ethnicity and age have been associated with moral distress (Oh & Gastmans, 2015). This study found a statistically significant positive correlation between age and moral resilience, implying that the older a person gets, the higher moral resiliency he or she has. Similarly, there was a significant positive correlation between earning a second degree and moral resilience, asserting that moral resilience increased for students who indicated they were earning their second degree. Another interesting finding was that although students had mild moral distress, 82.2% had not considered quitting nursing school. Escolar-Chua (2016) reported this same finding in Filipino nursing students who rarely considered quitting the nursing profession despite frequent morally distressing situations. Thus, claiming moral stressors to be the cause of new graduates leaving the profession may not hold weight.
The findings of this study warrant further research. A multi-site study with a large sample size would help generalize findings for transferability (Polit & Beck, 2010). However, based on the results, future research in both quantitative and qualitative realms as an embedded design or using a longitudinal design might help pinpoint and highlight specific moral dilemmas nursing students experience along with their reactions both intraprofessionally and interprofessionally. Furthermore, researching the psychometric properties of a new or modified moral resilience scale would be beneficial in quantifying moral resilience as this concept is widely underdeveloped (Young & Rushton, 2017). As the conceptual definition of moral resilience is solidified, tools to measure moral resilience are necessary to determine where this concept occurs theoretically within ethical decision making, health care, nursing education, and other professional fields. In addition, the reliability and validity of the MDT should be investigated further in comparison with the Moral Distress Scale.
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