Qualitative article

Nurse Education Today 129 (2023) 105912

Available online 17 July 2023 0260-6917/© 2023 Elsevier Ltd. All rights reserved.

Review

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

Tonya Jing Ting Heng, Shefaly Shorey *

Alice Lee Center for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

A R T I C L E I N F O

Keywords: Moral distress Nursing students Experiences Qualitative research Systematic reviews

A B S T R A C T

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 Review methods: Published and unpublished primary studies of any qualitative research methods focused on student nurses’ experiences of moral distress regardless of their education level were included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.

1. Introduction

In today’s highly interconnected society, marked by diverse cultural and value systems, moral distress poses a big challenge in healthcare environments, especially where ethical and moral complexities arise (Hoskins et al., 2018). It is common and inevitable for nurses to expe- rience moral distress in clinical practice, as they frequently face situa- tions that require ethical and moral decision-making (Ulrich et al., 2010). The concept of ‘moral distress’ was first introduced by Andrew Jameton (1984), defined as the feeling of recognizing the proper course of action, yet being in a situation that prevents its execution. In 1993,

Jameton refined this definition to better reflect the nursing context, describing moral distress as the experience of a nurse who faces a moral judgment, but institutional or coworker constraints make it difficult to act upon that decision. Building on this definition, the Canadian Nurses Association (2008) emphasized that values, commitments, and moral identity may be compromised when moral distress arises.

Numerous studies have highlighted the harmful effects of moral distress on both nurses and student nurses in clinical settings. Repeated episodes of moral distress may result in ‘moral residue’, causing nurses to become desensitized to morally complex situations and avoid ethical challenges. This can negatively impact patient care, increase burnout

* Corresponding author at: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, 117597, Singapore.

E-mail address: [email protected] (S. Shorey).

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https://doi.org/10.1016/j.nedt.2023.105912 Received 12 April 2023; Received in revised form 29 June 2023; Accepted 14 July 2023

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rates, and prompt nurses to leave their institution or even the nursing profession completely (Cavaliere et al., 2010; Hamric and Blackhall, 2007; Laabs, 2005; Corley, 1995; Wilkinson, 1987). ‘Moral residue’ occurs when moral distress goes unacknowledged and the accompa- nying emotions are not adequately addressed, leading to a build-up of frustration and further distress (Epstein and Hamric, 2009). Webster and Bayliss (2000) further elaborated on this concept of moral residue, describing it as the lingering feeling that an individual bears the burden of situations in which they have substantially compromised their prin- ciples or allowed themselves to be compromised. Given the significance of this issue, there is a need for more research to explore and address the issue of moral distress in nursing. This will enable a better under- standing and management of moral distress and help prevent the development of moral residue.

Over the years, there have been extensive debates surrounding the similarities and differences between ‘moral distress’ and ‘ethical dilemma’. An ‘ethical dilemma’ is defined as a situation in which two or more ethically justifiable actions are available, but no clear solution can be identified (Mooney, 2021). According to Craven and Hırnle (1996), a nurse encounters an ethical dilemma when faced with multiple choices and cannot determine which option would resolve the problem, or when no available options can adequately address the issue. Despite both concepts being associated with feelings of unease or negative emotions, they were distinct from one another. In moral distress, a clear and ethically correct option exists, but external or internal constraints make it difficult or impossible to pursue. Conversely, in an ethical dilemma, no straightforward justification exists for choosing any of the available options, as each has its ethical complexities.

In recent years, several systematic reviews addressing moral distress in the nursing profession have been published (Huffman and Ritten- meyer, 2012; Lamiani et al., 2016; Salari et al., 2022; Sasso et al., 2016). For instance, a review by Salari et al. (2022) revealed that moral distress contributes to higher burnout and reduced job satisfaction, which in turn, leads many nurses to leave the profession. The review highlighted the importance of support from colleagues, policymakers, and hospital management, as well as the establishment of dedicated ethics commit- tees that nurses can consult during times of doubt or distress, as these measures can help improve the situation. Similarly, another systematic review by Lamiani et al. (2016) highlighted that enhanced structural empowerment could lead to better outcomes in morally distressing situations.

Student nurses may experience feelings similar to those described in the aforementioned systematic reviews, but their reactions to such sit- uations may differ. Compared to registered nurses, student nurses possess less experience, skill, and confidence when confronted with morally challenging situations, particularly in clinical settings (Bickhoff et al., 2017). Although student nurses are taught ethical theories and principles, as well as how to respond to dilemmas, they may find it daunting to apply this knowledge due to interprofessional and hierar- chical struggles, fear of repercussions (Bickhoff et al., 2017), and a lack of guidance in clinical settings (Dimitriadou et al., 2014). Furthermore, in the traditional nursing education model, students are often repri- manded and disciplined for making mistakes, which fosters a highly anxious environment and makes it difficult for them to speak up in morally ambiguous situations (Dolansky et al., 2013). Consequently, it is crucial to examine the experiences of moral distress in student nurses, as these situations may lead to psychological distress and burnout, ulti- mately affecting their learning and development within the nursing profession (Albert et al., 2020).

A notable review on this topic was conducted by Sasso et al. in 2016. The mixed-study review aimed to synthesize research on moral distress among undergraduate students. The review identified several factors contributing to moral distress, including (i) ethical dilemmas, and (ii) environmental, relational, and organizational factors. Students often felt helpless due to the lack of confidence and fear of incompetence, believing they were in no position to voice their opinions because of

their limited clinical experience. Additionally, the review discussed the physical effects of moral distress, such as sleep disorders, headaches, gastrointestinal issues, and psychological symptoms. However, as only four studies were identified and included in the review, the authors recommended further research to better understand moral distress, how to identify it, and its impact on student nurses.

Since the review by Sasso et al. (2016), several new primary studies discussing the moral distress experienced by student nurses have been published. However, no systematic reviews have been conducted to consolidate the findings of these primary studies. Therefore, this review aims to address the gaps identified in the previous review by synthe- sizing and consolidating findings on the issues and situations in which student nurses experience moral distress with the ultimate aim of informing nursing educators and clinical instructors about the struggles that student nurses face in morally distressing situations and how they react to them.

2. Methods

2.1. Study design

This qualitative systematic review abided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which allows for standardized reporting, enhancement of methodolog- ical rigor and transparency, and facilitation of meaningful comparisons and synthesis of findings (Page et al., 2021) (see Supplementary Table 1). Analysis of the experiences of moral distress in student nurses was guided by Sandelowski and Barroso’s (2007) two-step approach, and Braun and Clarke’s (2006) thematic analysis framework.

2.2. Search strategy

Eight databases (PubMed, Excerpta Medica database (Embase), Cu- mulative Index to Nursing and Allied Health Literature (CINAHL), Sco- pus, PsycInfo, Web of Science, ERIC (ProQuest), and ProQuest Dissertations and Theses Global Database) were searched from their inception dates to December 2022 using keywords, Boolean, index terms, and truncation symbols. A medical librarian was consulted to refine and optimize the search strategy. The preliminary search was conducted on PubMed to search for relevant studies and identify key- words and index terms. A more thorough search was then conducted throughout the remaining seven databases. The main concepts included in the search strategy were (“Moral distress” OR “Ethical dilemma” OR “Ethical challenges” OR “Ethical issues” OR “Ethical conflicts” OR “Ethical distress”) AND (“Nursing students” OR “Student” OR “Pupil” OR “Undergraduate” OR “Post-graduate” OR “Diploma”). Thereafter, a backward citation tracking method was done through the hand- searching reference lists of selected studies to identify other eligible studies that may have been missed during the comprehensive search. Any discrepancies that surfaced were resolved through discussion be- tween reviewers and the content experts (co-authors with extensive research experience). The detailed search strategy for each database is presented in Supplementary Table 2.

2.3. Eligibility criteria

The inclusion criteria for this review were English-language pub- lished and unpublished qualitative studies of any research designs (e.g., grounded, descriptive, and phenomenology) or mixed-methods studies (where qualitative data can be exclusively extracted) exploring the contextual factors of moral distress for student nurses regardless of ed- ucation level (diploma, undergraduates, etc.) in clinical or community settings. Studies that discussed the experiences of moral distress of student nurses from a third-person perspective (e.g., from a healthcare professional, nursing faculty staff, or clinical instructor) or in the educational institute (e.g., University or College) were excluded.

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Quantitative studies, correlation studies, exploratory studies, confer- ence proceedings, opinion reports, and reviews, were also excluded. The retrieved studies were imported into EndNote Version 20 (The EndNote Team, 2013) to organize the search results and remove duplicate articles.

2.4. Quality appraisal

Two reviewers independently appraised the quality of the included studies using the Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist (CASP, 2018). The studies’ design, methods, and reporting were assessed for their relevance, reliability, and validity using the CASP checklist (Nadelson and Nadelson, 2014). To enhance the rigor of the review, all studies were included regardless of their appraisal scores (Walsh and Downe, 2006). Discrepancies between the reviewers were resolved through discussion or by consulting the third reviewer. The CASP appraisal for each included study is presented in Supplementary Table 3.

2.5. Data extraction

The extracted data by two reviewers was guided by an extraction form adapted from a review by Munro et al. (2007). The data extracted included: author(s), publication year, study title, country, aims, ethics, recruitment context, sampling, sample (participants) characteristics, data collection, data analysis, results, discussion, and recommendation (s). The data extraction form was pilot tested on five studies, after which no changes were made to the form. Primary constructs (verbatim from participants) and secondary constructs (the authors’ interpretations) of the experiences of student nurses in situations of moral distress.

2.6. Data synthesis

Data synthesis was guided by Sandelowski and Barroso’s (2007) two- step approach. By extracting, separating, grouping, and abstracting text findings and constructs, the findings of included studies were eventually meta-summarized into statements. Thereafter, Braun and Clarke’s (2006) thematic analysis approach was used to analyze and synthesize the data extracted to generate the themes of this review. Two

Fig. 1. PRISMA flow chart.

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independent reviewers engaged in a thorough process of reviewing the text findings, which involved repeated readings and coding of key concepts, followed by categorization of similar concepts and inductive generation of the main themes of the review. Team meetings were held among the research team members and an independent expert reviewer was consulted to finalize the identified themes.

3. Results

The initial search yielded 3222 studies. After the exclusion of 1589 duplicates, 1633 titles, and abstracts were screened, and 1570 were excluded due to irrelevancy. The remaining 63 full texts were further assessed for eligibility, and six qualitative studies and one mixed- method study were selected and included in the final synthesis. The screening process is displayed in Fig. 1.

3.1. Characteristics of the included studies

The seven included studies were peer-reviewed and published be- tween 2013 and 2022. The study designs of the included qualitative studies were descriptive qualitative design (n = 5) and phenomenolog- ical (n = 1) and mixed-methods (n = 1). They were conducted in Brazil (n = 1), Canada (n = 2), the Philippines (n = 1), Turkey (n = 1), and the United States (n = 2). Of the seven studies, five focused on the experi- ences of moral distress in student nurses in a general clinical setting, one was in a mental health setting, and the last was in a community setting. A total of 523 student nurses’ responses were analyzed. The character- istics of each included study are summarized in Table 1.

The meta-synthesis identified an overarching theme, “Moral Distress and Its Intertwined Roots”, which encapsulated the complex in- terconnections between the various situations that contribute to moral distress among student nurses as illuminated by the included studies. This was supported by the four main themes: 1) Inadequacy and lack of autonomy, 2) Unprofessionalism of healthcare professionals, 3) Differing cultures and values of patients and their relatives, and 4) Healthcare needs versus resource constraints. The organization of the overarching theme and main themes are presented in Fig. 2 and the studies contributing to the main themes are presented in Supplementary Table 4.

3.2. Inadequacy, lack of autonomy

This theme highlighted the feeling of inadequacy and lack of au- tonomy experienced by student nurses in clinical practice. Despite the clinical practice being perceived as a safe and controlled environment for student nurses to put their skills into practice under the guidance of registered nurses and clinical instructors, students felt “belittled” and “disregarded” (Reader, 2015). This left them feeling powerless and helpless, and unable to voice their opinions due to their subordinate positions when faced with morally challenging situations (Chua and Magpantay, 2018; Mæland et al., 2021; Krautscheid et al., 2017; Yilmaz and Keskin Kiziltepe, 2022). Students reported feeling “uncomfortable to speak with [registered nurses]” about non-compliance with hand- washing protocols “since they are superiors” (Krautscheid et al., 2017). Another student stated that: “Even if I want to do something, at least tell the doctor and the nurse that they are violating that person’s dignity, I wasn’t able to do so. I didn’t have the guts to say anything. I don’t have the guts to tell them directly.” (Chua and Magpantay, 2018). Moreover, studies reported that in some instances, clinical instructors managing students were also hesitant to speak up for fear of angering the senior staff, resulting in students suppressing their concerns and experiencing pent-up guilt and frustration of having no avenue to vent (Reader, 2015; Wojtowicz et al., 2013; Yilmaz and Keskin Kiziltepe, 2022).

The lack of support from nursing faculties and clinical instructors in distressing situations contributed to the student’s sense of inadequacy and lack of autonomy. In several instances, students feared being

marked down or punished by nursing faculties. A student verbalized that: “I did not engage in dialogue unless it was necessary, but I think that I was noticed enough to get my score lowered due to a ‘contro- versial’ conversation I had.” (Yilmaz and Keskin Kiziltepe, 2022).

3.3. Unprofessionalism of healthcare professionals

Students from the included studies reported experiencing moral distress when they witnessed unprofessional behaviors and practices of healthcare professionals. Despite being taught evidence-based practice in nursing school, student nurses faced healthcare professionals who did not follow these practices be in due to personal or external reasons. These compromised patient care practices such as substandard infection control practices, careless attitudes when administering medications or doing a procedure, and taking shortcuts when documenting informa- tion, caused moral distress in student nurses (Rennó et al., 2016; Krautscheid et al., 2017; Yilmaz and Keskin Kiziltepe, 2022). One stu- dent recounted an experience, stating, “treatment with [blood pressure lowering medicine] was started for a patient with high blood pressure. Blood pressure measurements had to be taken every 15 minutes and recorded in the file. The patient’s blood pressure was not written in the file at the time and one of the nurses wrote the patient’s blood pressure values from her head, saying ‘There’s no problem with their blood pressure.’” (Yilmaz and Keskin Kiziltepe, 2022).

Furthermore, students were taught to be the “patient’s advocate”, providing comprehensive information about medication and treatment plans, which may affect the patient’s decision. Witnessing healthcare professionals withholding medical information from patients to steer their decision toward what they thought was best or for their conve- nience caused moral distress in student nurses, as it contradicted what they had learned in school and resulted in misinformed decisions by patients regarding treatment plans (Wojtowicz et al., 2013; Yilmaz and Keskin Kiziltepe, 2022).

In addition to compromised patient care practices and withholding medical information, disrespectful attitudes and behaviors of healthcare professionals toward patients or nursing colleagues also caused moral distress in student nurses. These attitudes violated ethical principles such as privacy, confidentiality, and justice, especially in cases where healthcare professionals “poked fun” at their patients (Chua and Mag- pantay, 2018; Krautscheid et al., 2017; Yilmaz and Keskin Kiziltepe, 2022). Moreover, the studies revealed that doctors often undermined the professional judgment of nurses, neglecting or overlooking their assessments when discussing the patient’s treatment plans. Student nurses who witnessed such attitudes and behaviors felt indignant toward their nursing seniors and questioned the value of their nursing educa- tion. For example, a student stated, “I know the doctor really, really wanted to give her ECT, even though the nurses didn’t want to, … but then the discussions were that doctor wouldn’t order any test for any- thing, leading everyone to just follow orders” (Wojtowicz et al., 2013). Such situations led student nurses to feel like doctors are “always right” and are “unchallengeable” (Wojtowicz et al., 2013; Rennó et al., 2016; Mæland et al., 2021).

3.4. Differing cultures and values of patients and their relatives

This theme sheds light on how differences in culture and beliefs of patients sparked negative emotions such as frustration and eventually lead to moral distress among student nurses. The student nurses were taught the importance of patient-centered care and being patient advocate, which involved understanding the needs of patients and respecting their values, beliefs, lifestyle, and decisions (Chua and Mag- pantay, 2018; Krautscheid et al., 2017). However, in actual clinical practice, students reported that they found some patients’ lifestyles, beliefs, and values “unacceptable” and felt “uncomfortable” and “conflicted” accepting them (Krautscheid et al., 2017; Chua and Mag- pantay, 2018; Yilmaz and Keskin Kiziltepe, 2022). For example, one

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Table 1 Summary of study characteristics.

Author/s (year)/ Country

Title Aim(s) of study Study design Level of study Data collection method/analysis used

Themes

Yilmaz and Keskin Kiziltepe (2022)/ Turkey

Moral Distress in Nursing Undergraduates: A Qualitative Study

This study aimed to explore the moral distress experiences encountered by undergraduate student nurses

Phenomenological Design

Final-year undergraduates

Data collection form with descriptive characteristics of students and open- ended structure questions/Thematic Analysis

1. Situations that cause moral distress in student nurses -Situations related to Healthcare Professionals -Situations related to patients and their relatives -Situations related to the role of the student nurse 2. Student Feelings and Emotions 3. Student Attitudes and Behaviors toward moral Distress

Chua and Magpantay (2018)/ Philippines

Moral distress of undergraduate student nurses in Community Health Nursing

To explore the moral distress experiences encountered by undergraduate baccalaureate student nurses in community health nursing.

Descriptive Qualitative Design

Senior student nurses Individual in-depth interviews (demographic and open-ended questions)/ Qualitative thematic analysis

1. Discordant modeling: conflicting ideals of healthcare professionals 2. Disabled sense of self: feeling helpless amidst encountered distressing situations 3. Divergent health ideals: community versus student nurses’ views on health issues

Reader (2015)/ United States of America

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

Describe experiences of moral distress among students enrolled in associate degree nursing programs and provides a different perspective to expand understanding of moral distress

Descriptive Qualitative Design

Senior-year student nurses

Face-to-face interviews/thematic and narrative analysis

1. Dealing with the inherent stress of nursing school while also dealing with situations of moral distress 2. Learning and working in an unjust culture 3. Disempowerment and status 4. Moral residue and regret

Wojtowicz et al. (2013)/ Canda

No place to turn: Student nurses’ experiences of moral distress in mental health settings.

Explore student nurses’ experiences of moral distress during clinical rotations on an inpatient psychiatric unit.

Descriptive Qualitative Design

Student nurses who had completed their 13-week clinical practicum on acute inpatient psychiatric units

Individual semi- structured interview/ inductive thematic analysis

1. What the hell do you do here? 2. The doc’s word is law 3. Tricking the patient 4. No place to turn

Mæland et al. (2021)/ Norway

Nursing education: Students’ narratives of moral distress in clinical practices

To provide knowledge of the experiences that can appear as examples of moral distress, based upon students’ written reflections about challenging experiences

Descriptive Qualitative Design

3rd-year undergraduates students specializing in oncology and gerontology

Anonymous written online form/ hermeneutic reading inspired by the narrative method

1. Undermining of professional judgment 2. Disagreement concerning treatment and care 3. Undignified care by superiors 4. Colliding values and priorities of care

Rennó et al. (2016)/ Brazil

Moral distress of nursing undergraduates: Myth or reality?

Identify the existence of moral distress in undergraduates facing experiences of ethical conflicts and dilemmas during their nursing education, not only in order to uncover a little-studied phenomenon but also to highlight the need for problematizations, in nursing education, for the cases and consequences of moral distress for professional socialization

Descriptive Qualitative Design

Nursing Undergraduates

Focus group discussion/thematic content analysis

1. Health Service as a locus of moral distress 2. The teacher as a source of anxiety and moral distress 3. Moral distress as a positive experience- “suffering and learning”

Krautscheid et al. (2017)/

Moral distress and associated factors among baccalaureate

3 aims: Assess moral distress among BSN via a moral distress

Mixed-method Study

Senior level student nurses

Anonymous paper survey/Narrative content analysis

1. Compromised best practices 2. Disrespect for

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student shared feeling “uncomfortable” talking to clients who had multiple partners and were diagnosed with sexually transmitted diseases (STDs), when talking to a gay sex addict who advocated for gay rights (Krautscheid et al., 2017). These experiences caused student nurses to fear that they are unable to provide the best care for their patients in events of cultural and ideal conflict.

Furthermore, student nurses experienced moral distress when faced with the unreceptiveness of patients and their relatives when receiving healthcare advice. In some cases, patients or their relatives made de- cisions based on preconceived ideas which may not be the best for the patient, and when corrected, they were defensive and “exhibited accu- satory behavior” toward healthcare professionals (Yilmaz and Keskin Kiziltepe, 2022).

3.5. Healthcare needs versus resource constraints

This theme explored how resource constraints negatively impacted the care provided to patients by healthcare professionals, causing moral distress in student nurses. Despite the emphasis placed on prioritizing the patient’s needs and wishes throughout nursing education, this was seen as not being possible in practice due to external constraints. The main constraint faced by hospitals and communities was the lack of resources, including human and financial resources, necessities, and materials (Chua and Magpantay, 2018; Krautscheid et al., 2017; Mæland et al., 2021; Rennó et al., 2016).

These constraints led to suboptimal care plans for patients and had serious consequences. As one student nurse shared, “Many morally

distressing things occur here due to lack of resources. People unable to get mental health counseling when needed leading to suicide is a main problem” (Krautscheid et al., 2017). To address these challenges, nursing managers and healthcare professionals must properly assess and balance the organization’s vision, resource allocation, and the interests of patients. When faced with these situations, student nurses experi- enced a “reality shock” as the decisions made went against their ideals and contradicted what they had learned in school (Mæland et al., 2021). Experiencing the gulf between their nursing education and the daily challenges of the healthcare professionals left students feeling stressed and bothered by what they had witnessed, as many felt unjust for the patients and “[wished] they could do more” for patients (Chua and Magpantay, 2018; Krautscheid et al., 2017; Mæland et al., 2021).

4. Discussion

This qualitative systematic review consolidated and synthesized the results of six qualitative studies and one mixed-methods study that explored the experiences of moral distress faced by student nurses in clinical and community practice outside the school environment. Cur- rent findings revealed various circumstances and reasons that resulted in student nurses experiencing moral distress. Notably, most of the included studies were conducted on student nurses in Western countries in general clinical settings, with one each in mental health and com- munity settings. This highlights the need for more research to be con- ducted in geographically and clinically diverse settings.

This review identified two categories of moral distress: external

Table 1 (continued )

Author/s (year)/ Country

Title Aim(s) of study Study design Level of study Data collection method/analysis used

Themes

United States of America

student nurses: A multisite descriptive study.

thermometer Describe clinical situations contributing to moral distress as experienced by students in clinical practice Describe predominant reasons why student nurses do not take action during distressing situations

Inherent Human Dignity 3. Perceived constraints 4. Navigating personal values and patient- centered care

Fig. 2. Summary of the overarching theme and main themes.

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constraints (e.g., powerlessness and lack of support) and internal con- straints (e.g., conflicting values and beliefs). This aligns with existing research on moral distress in healthcare professionals (Fourie, 2015). Moral distress from external constraints could be explained by Structural Empowerment Theory (SET) (Kanter, 1993), which posits that organi- zational structures, resources, and support influence employee empowerment and autonomy. In the context of student nurses, limited access to resources such as equipment or staffing could affect the student nurses’ abilities to deliver adequate care due to resource constraints. Moreover, a hierarchical or unsupportive organizational culture may discourage student nurses from voicing their ethical concerns or advo- cating for patient-centered care. This disempowerment could lead to moral distress when student nurses are unable to act according to their ethical beliefs. On the other hand, Rest’s (1992) Four-Component Model of Morality could help explain moral distress from internal constraints. It provides a framework composed of four components involved in moral decision-making (i.e., moral sensitivity – recognizing that a situation has moral implications and being aware of the potential consequences of one’s actions; moral judgment – the cognitive process of determining the most ethically appropriate course of action; moral motivation – priori- tizing moral values over other competing values, such as personal or professional interests; moral character – the ability to act on one’s moral judgment despite potential challenges). Moral distress arises when there is conflict or misalignment between these components, which could be applicable in the current context. This review found that student nurses often experienced moral distress in situations where they felt inadequate and lacked autonomy when faced with morally distressing situations. While existing research focused on experienced nurses, it is crucial to consider the potential link between their experiences and those of stu- dent nurses. For instance, previous research by Atabay et al. (2015) suggested that nurses’ subordinate positions in the medical hierarchy can make them more vulnerable to moral distress. It is plausible that this vulnerability extends to student nurses, who may also find themselves in similarly subordinate positions within the clinical environment. Arends et al. (2022) further supported this potential link, noting that moral distress is more likely to occur when nurses are excluded from the decision-making process. Given that student nurses are still developing their clinical skills and knowledge, they may be even more likely to be excluded from decision-making, potentially exacerbating feelings of moral distress. This is especially troubling as both experienced and student nurses often have frequent and close contact with patients and can provide valuable information about their wishes and preferences (Arends et al., 2022). The experiences of moral distress in experienced nurses may serve as a reflection of the potential challenges faced by student nurses. As these students navigate their clinical practice, they may also feel that their opinions and values are not taken into consid- eration, leading to feelings of being unheard and undervalued (Arends et al., 2022). This situation suggests that understanding the moral distress encountered by experienced nurses can shed light on the po- tential experiences of student nurses, as they too may distress, guilt, and frustration when they are unable to advocate for their patients and ex- press their concerns. Future research is needed to triangulate the find- ings by examining the experiences of both student nurses and registered nurses so that moral distress can be understood holistically. Moreover, the finding suggested the need to promote shared decision-making processes and collaborative approaches to encourage professionals, especially nurses to collaborate with student nurses and other healthcare professionals in the decision-making process so that the vicious cycle of submissiveness and lack of opportunities to equally contribute to patient care and moral distress does not continue (Truglio-Londrigan and Slyer, 2018). Such organizational infrastructure and role modeling would allow nurses and student nurses to participate in discussions and express their opinions and values openly, thereby providing them with a sense of autonomy and ownership over patient care decisions. Moreover, it would ensure that the patient’s wishes and preferences are prioritized, thereby reducing the risk of unsafe patient care and undue moral

distress. If needed, anonymous whistleblowing platforms can be intro- duced so that relevant personnel especially student nurses can express their concerns without any fear of repercussions to their studies or clinical attachments.

Consistent with the results of previous studies (Bordignon et al., 2019; Huffman and Rittenmeyer, 2012), our review highlighted that resource constraints were one of the contributing factors to moral distress experienced by student nurses. These constraints include the lack of necessary human and financial resources, such as medical sup- plies, equipment, and an appropriate nurse-to-patient ratio (Bordignon et al., 2019; Huffman and Rittenmeyer, 2012). A previous study by Chen et al. (2018) similarly emphasized this issue, as nurses expressed concern over the need to complete excessive general administrative tasks and written assignments, resulting in higher workloads and over- time hours due to low staffing. This pressure on nurses to provide care quickly and effectively ended up compromising their ability to deliver comprehensive and sometimes unsafe patient care, leading to moral distress (Harrowing and Mill, 2010; LeBaron et al., 2014; Maluwa et al., 2012). Previous studies have also reported that the lack of equipment and supplies, such as medications, food, and linen, have contributed to moral distress as they prevent nurses from achieving the standard of care (Harrowing and Mill, 2010; LeBaron et al., 2014; Maluwa et al., 2012). In some cases, this lack of supplies has not only prompted nurses to resort to purchasing food and medications for patients using their own money (Harrowing and Mill, 2010), but it also led to the undertreatment of pain (LeBaron et al., 2014). Such discrepancies led to moral distress among student nurses and nurses who believed in the moral and ethical principles of the profession but were unable to carry them out due to resource constraints. These findings highlighted that many of the morally distressing situations are co-experienced by both the student nurses and the nurses themselves. These findings can be further explained by the fact, with limited resources, healthcare professionals must weigh various external factors with the patient’s needs, which can deviate from ideals and theories taught in nursing schools or be required to maintain safety and quality care where the patient’s interests and wishes are prioritized when making decisions. These findings suggest the urgent need to address resource constraints to reduce moral distress and improve patient outcomes (DeBoer et al., 2021). To achieve this, stakeholders such as hospital administrators can work with nurses to develop strategies that help alleviate excessive administrative tasks and workloads such as delegating tasks to non-clinical ancillary staff, increasing staffing levels by introducing overlapping shifts or providing additional training to staff or guiding junior nurses especially student nurses so that they feel welcomed and contribute effectively as a collaborative team to ultimately achieve safe and quality patient care. Nursing schools can also integrate resource management into their curriculum, which could help student nurses develop a better under- standing of the resource constraints that they may encounter on the ground and develop strategies to manage resources and their emotions effectively. Most importantly, nursing schools can work with clinical stakeholders to establish comprehensive guidance and supervision for students as they transition into clinical practice. This joint effort ensures that students are well-supported and have access to appropriate re- sources when confronted with moral distress during their clinical experiences.

In addition, our review revealed that student nurses experienced moral distress when they observed healthcare professionals violating ethical codes and compromising patient care practices. Previous research by Cho et al. (2022) supports these findings, attributing this distress to the power dynamics between the doctors, nurses, and student nurses, along with the fear of defying the higher status of the doctor and impacting their professional journey and grades. Healthcare pro- fessionals are expected to serve as role models for each other, especially the students, witnessing unprofessional behavior and attitudes can cause moral dilemmas, leading to feelings of being torn between their ideals and the norms of the healthcare profession (Cho et al., 2022). This can

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lead to a desensitization process, where students become more accepting of the unethical medical culture, which can result in a sense of help- lessness and internal conflict, ultimately leading to moral distress Cho et al., 2022; Leggett et al., 2013). Therefore, healthcare institutions should prioritize ethical training and establish a culture of ethical conduct in their facilities. This can be achieved through the imple- mentation of regular ethics workshops and training programs for both student nurses and healthcare professionals (Poorchangizi et al., 2019). These programs should aim to enhance awareness of ethical issues, provide a platform for discussion of moral dilemmas, and facilitate the development of decision-making skills that are aligned with ethical principles. Moreover, healthcare institutions could establish a system for reporting ethical violations and addressing them promptly to foster an environment of ethical responsibility and accountability. This would ensure that healthcare professionals are held to a high ethical standard and that patients receive the care they deserve without compromise. Ultimately, the provision of ethical training and the establishment of an ethical culture would not only prevent moral distress among student nurses or other professionals but also contribute to the delivery of high- quality and safe patient care. Lastly, student nurses in our review experienced moral distress when confronted with cultural differences between themselves and the patients. This distress was primarily caused by the disapproval of the patient’s beliefs, values, and lifestyle choices. The unreceptiveness of patients and their relatives to healthcare advice was also found to contribute to moral distress among student nurses. These findings are in line with previous research by Nasrabadi et al. (2021), which alluded to this moral distress to differences in ethical and religious understandings across different societal and cultural back- grounds. Religion and spirituality can significantly impact a patient’s decision-making process regarding healthcare, as they turn to their faith to cope with medical challenges and reduce anxieties (Swihart et al., 2022). Consequently, religion and culture can influence their prefer- ences for diet, medicines based on animal products, and the preferred gender of their health providers (Swihart et al., 2022). Thus, student nurses may find themselves in situations where they are expected to provide care that conflicts with their personal beliefs or values, this can be especially challenging if the patient’s cultural or religious beliefs differ significantly from their own. This could lead to a sense of conflict between the student nurse’s duty to provide appropriate care and their respect for the patient’s autonomy and beliefs. Moreover, the unrec- eptiveness of patients and their relatives to healthcare advice can also contribute to this moral distress in student nurses. These students may feel that their efforts to provide care are being undermined or dismissed, or that they are being judged for not understanding or respecting their cultural values and beliefs, which could result in a sense of guilt and distress. Therefore, to provide culturally sensitive and appropriate care to patients, nursing schools need to introduce cultural diversity, recep- tiveness, and equity-related topics in the curriculum so that students can comprehend and be more receptive to the influence of cultural and religious differences on healthcare delivery. Offering patients, the op- portunity to share their religious and spiritual beliefs upfront and modifying treatment plans accordingly to meet their specific needs are valuable (Polzer and Engebretson, 2012). Such an approach would allow for the provision of culturally sensitive care and promote patient- centered care. Additionally, nursing schools and healthcare organiza- tions can introduce cultural competence training to better understand and navigate cultural and religious differences in healthcare delivery. Such training would equip professionals and students with the knowl- edge and skills necessary to provide effective and culturally sensitive care, thereby mitigating the risk of moral distress among students and other healthcare professionals.

4.1. Limitations

There are a few limitations to this review. Due to the limited scope of the database search, imprecise titles or abstracts, or the inclusion of only

English language studies may have resulted in the exclusion of relevant studies. Moreover, as most of the included studies were conducted in Western countries (Asian [n = 1], transcontinental [n = 1], western [n = 5]), this could limit the transferability of the findings to other regions and cultures. There is a need to conduct future research in non-Western countries to explore the experiences of student nurses in diverse con- texts, which would allow for a more comprehensive understanding of the experiences and factors that contribute to moral distress among student nurses. Despite these limitations, to the best of our knowledge, this is the first qualitative systematic review that has shed light on the experiences and factors causing moral distress among student nurses in clinical and community settings.

4.2. Implications to future research and practice

This review revealed the various circumstances and reasons which contributed to student nurses’ experience of moral distress in clinical and community practice and highlighted several areas for future research and practice. First, there is a need for more studies to explore student nurses’ experiences of moral distress in geographically and clinically diverse settings. This would provide a more comprehensive understanding of the factors that contribute to moral distress among student nurses from different cultural and clinical backgrounds. As the transition from student to newly qualified nurse is a critical period, future research should examine the experiences of newly qualified nurses; triangulation of the findings from both student nurses and registered nurses may provide further insights into the similarities and differences of the factors causing moral distress and could provide a holistic view of this phenomenon. Evaluation of the strategies shared in this review to reduce moral distress needs to be explored in future research. Moreover, future research should also consider conducting comparative qualitative studies on the experiences of moral distress experienced by other healthcare students, such as those in medicine and allied health. This would provide a more holistic view of moral distress and inform the development of supportive interventions in the smooth transition of their learning from educational institutes to clinical environments.

In terms of practice, healthcare organizations and nursing schools should collaborate to create a supportive environment for student nurses transitioning into clinical settings. This includes promoting shared decision-making processes and collaboration among healthcare pro- fessionals and student nurses can provide a sense of autonomy and ownership over patient care decisions, reduce the risk of moral distress, and prioritize patient preferences. Addressing resource constraints through strategies such as delegating tasks to non-clinical ancillary staff, increasing staffing levels by introducing overlapping shifts, and providing additional training on delegation, decision-making, ethical training, and cultural competency to staff can improve patient outcomes and reduce moral distress. Introducing anonymous platforms for reporting ethical violations and establishing regular workshops and discussion platforms to address moral distress can foster an open and supportive culture within the organization. Nursing schools should also focus on integrating cultural and ethical education into their curricula, emphasizing the importance of understanding and navigating cultural, religious, or other differences in healthcare settings. This would better equip student nurses with the necessary skills and knowledge to provide culturally sensitive care and mitigate the risk of moral distress. Furthermore, healthcare organizations should prioritize ethical training and establish a culture of ethical conduct to ensure that healthcare professionals, including student nurses, are held to high ethical stan- dards and that patients receive safe, high-quality care without compromise.

5. Conclusion

This review consolidated the experiences of student nurses

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experiencing moral distress in clinical and community settings. The findings indicated that nursing students felt inadequate and powerless when faced with moral challenges, and lack of support to share their experiences openly and resource constraints exacerbated this issue. Additionally, witnessing unprofessional behavior and encountering cultural differences with patients also led to moral distress. To address these concerns which have the potential of effective quality and safe care to the patients, healthcare institutes and nursing schools should collaborate to develop curriculums and on-job training programs that promote shared decision-making, address resource constraints, priori- tize ethical training, and provide culturally sensitive care. By intro- ducing such an open and caring learning environment, healthcare settings can support student nurses, other healthcare students, and healthcare professionals, and ultimately improve patient care and so- cietal outcomes.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

No conflict of interest has been declared by the author(s).

Acknowledgments

The authors would like to thank the Medical Librarian from the National University of Singapore for her assistance with developing the search strategy. The authors would like to extend their appreciation to Ms. Nur Anasthasha Bte Sudar Sono for her invaluable assistance as a second reviewer in the search, extraction, and quality approval of the relevant articles.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.nedt.2023.105912.

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