Moral distress among senior nursing students: A mixed-methods study

Abstract

Background

Moral distress in nursing students has drawn attention due to its ethical and emotional impact during clinical training. Even without decision-making authority, students face ethically challenging situations that may cause psychological and professional strain.

Aim

This study aimed to explore the causes, effects, coping mechanisms, and predictors of moral distress among senior nursing students, integrating both quantitative and qualitative evidence.

Research design

A convergent parallel mixed methods design was used, combining a predictive correlational quantitative phase with a descriptive phenomenological qualitative phase. Both strands were analyzed separately and integrated through joint displays.

Participants and research context

The study was conducted with 200 senior nursing students from four public and two private universities in the capital city. Additionally, 25 students participated in in-depth interviews.

Results

Quantitative analysis revealed that higher moral distress was predicted by studying at public universities, taking only mandatory ethics courses, lower preparedness for caregiving and managerial roles, lack of self-confidence in resolving ethical issues, and limited legal knowledge. Qualitative findings identified causes such as ethical violations, team conflicts, institutional and systemic inadequacies, and challenges linked to student status. Effects included sadness, anger, guilt, and questioning professional commitment. Coping strategies involved seeking support, moral disengagement, or demonstrating moral courage. Students recommended improved applied ethics training, better managerial support, and systemic reforms.

Ethical considerations

Ethical approval was obtained from the relevant university ethics committee (GO 23/221). Informed consent was received electronically and verbally before data collection.

Conclusion

Senior nursing students experience moral distress at moderate-to-high levels, mainly due to systemic and educational inadequacies and limited authority in clinical practice. Strengthening ethics education, preparing students for professional roles, fostering legal literacy, and creating supportive environments are crucial to reducing moral distress and enhancing moral resilience.