DOI: https://doi.org/10.21203/rs.3.rs-2768355/v1
Background: During clinical placement, nursing students may experience unease and moral distress, negatively impacting their professional values and vocational choices.This study explored factors affecting nursing students’ vocational choices.
Methods: This cross-sectional study recruited the participants from three universities in South Korea Between September and October 2021. This study was adopted with a convenience sample of 270 Korean fourth-year nursing students who completed their clinical practice at tertiary general hospitals in three provinces in the North, Middle, and South areas of South Korea. Data were collected through a self-administered structured questionnaire.
Results: The factors affecting higher vocational choice were higher professional values, intention not to choose nursing as a future career, having no vision for choosing nursing, democratic family climate, and having at least one parent who was a medical professional.
Conclusion: Fostering students’ nursing professionalism and professional values through university education curricula may help maintain nursing students’ professional identity.
The nursing curriculum must be aligned with the clinical setting to ensure that graduates are prepared to face the challenges of a complex and dynamic healthcare delivery system [1]. Thus, clinical education forms the foundation for bridging the theory–practice gap [2].
Choosing the nursing profession comes from the desire to help individuals, families, and the community improve their quality of life by finding solutions to health problems [3, 4]. Nursing students, as future nursing professionals, should possess professional values guiding professional behaviors that enable them to provide a qualified service that respects human life, honor, individuality, integrity, and others’ values and preferences [5]. Nursing students should shape their professional values throughout their clinical nursing practice.
Moral distress is defined as the psychological and physiological suffering that may be experienced when we act in ways that are inconsistent with deeply held ethical values, principles, or moral commitments [6]. A key element in moral distress is an individual’s sense of powerlessness and inability to act following ethical appropriateness [7]. Several studies have reported that moral distress is a common problem among healthcare professionals [6, 8]. In particular, nurses face moral distress when they know what is best for the patient, but that course of action conflicts with what is best for the organization, other providers, patients, family, or society [9]. This study specifically focused on moral distress among undergraduate nursing students. Nursing students can be exposed to moral distress, because they are placed in a borderline position where they have not the authority to make clinical decisions and cannot act according to the theories learned in school. Nursing students’ inexperience, lack of skills, high client contact time, frequent ward changes, and the challenge of encountering a new environment and patients with whom they must develop a relationship make them potentially vulnerable to patient-to-nurse violence [10, 11, 12]. Additionally, nursing students experience frustration by witnessing the unkind behaviors of medical staff, causing them psychological distress [13]. Thus, during clinical placement, nursing students may experience moral distress, which may negatively affect their professional values and vocational choices. Nursing students who experience moral distress may lose the professional values of nursing and become skeptical of their career choice [14, 15]. Although moral distress is an important issue for nursing students, an appropriate measurement has not yet been developed to explore its contributing factors.
This study aimed to investigate whether the professional values cultivated during the four-year nursing program affect senior nursing students’ choice of the nursing profession and whether moral distress formed during clinical practice affect the choice of the nursing profession when senior nursing students experience both the perception of professional values and moral distress. Exploring the relationship between moral distress, professional values, and vocational choices among undergraduate senior nursing students is also necessary. We also aimed to evaluate the construct validity of the moral distress scale in senior nursing students using the Consensus-Based Standards for the Selection of Health Status Measurement Instrument (COSMIN) checklist [16].
The present study addresses the following main research questions:
(1) How can we examine the constructs of moral distress in senior nursing students?
(2) How are personal details, moral distress, and professional values associated with nursing students’ vocational choices?
We adopted a descriptive cross-sectional design with a convenience sample of nursing students in their fourth year from three large universities located in Seoul and Gyeonggido (north), Daejeon and Chung-nam (middle), and Daegu and Kyungpook (south), South Korea. We used a structured self-administered questionnaire.
The participants in this online survey were nursing students in their fourth year (aged ≥ 19 years) who attended four-year nursing colleges across three provinces of South Korea. Self-reported questionnaires were administered using Google Forms between September and October 2021. The professors at the nursing colleges introduced this study to nursing students in their fourth year. Interested students participated in the anonymous online survey through a questionnaire URL shared with them. The survey lasted for approximately 15 minutes. After completing the survey, the participants received mobile gift cards as an acknowledgment.
A total of 270 students were invited to participate in this study. The required sample size was obtained using the G*Power 3.1.9.7 program [17]. Sample size calculations with an index of power of 0.80, α < 0.05, effect size f2 = 0.10, number of predictors = 28, and multiple linear regression predicted a minimum necessary sample of 261 participants. The questionnaire was administered to 270 students.
The participants’ personal details included sociodemographic data and clinical placement characteristics, including age, sex, household income, whether one of the parents was a medical professional, religion, parents’ education level, family climate, intent to opt for or reject a nursing job, the reason for choosing a nursing degree, and clinical experience in which department.
Moral distress experienced by Korean nursing students in a clinical environment is unique, and there are currently no tools to measure their moral distress levels. We developed constructs to measure moral distress among senior nursing students in a Korean clinical setting. The subscales of the Moral Distress Scale (MDS) were developed through multistep methods following COSMIN recommendations [16]: elaboration of the questionnaire and measurement properties of the questionnaire.
Step 1: Elaboration of the questionnaire. We conducted a literature review to identify studies on moral distress during nursing students’ clinical practicums. Based on a review of the research findings for nursing students in hospital settings, qualified nursing professors identified items about how distressed they felt when nursing students could not provide a morally correct response [10, 13, 18]. Using a triangulation approach [19], we interviewed three senior nursing students in South Korea. The verbatim data were analyzed using an itinerary method [20] to conceptualize and understand the phenomenon of nursing students’ moral distress. A multidisciplinary work group, including researchers, clinical nurses, and nursing students, drafted a preliminary questionnaire based on qualitative analysis. A total of 45 items for the MDS were identified in this analysis. Each item was evaluated on a 7-point scale ranging from 1 (little/almost none) to 7 (great).
Step 2: Measurement properties of the questionnaire. The measurement properties of the questionnaire were assessed in three steps as follows.
We reduced the number of items by eliminating redundant items, which were determined by an inter-item correlation—evaluated by the Spearman correlation coefficient—greater than 0.8 [21]. We designed the questionnaire to be useful in all contexts of nursing students’ moral distress, as these items can differ significantly. The five items that were excluded had a high inter-item correlation, and 40 items for the MDS remained.
To allocate each MDS item to a subscale, principal component analysis (PCA) applying the oblique rotation (Promax) method of exploratory factor analysis (EFA) was performed. The suitability of the EFA was assessed based on a Kaiser–Meyer–Olkin (KMO) value greater than 0.8 for all items [22]. A scree plot and Kaiser eigen value criteria were adopted to extract the optimal number of components [23]. Items presenting a factor loading (eigenvalue) less than 0.6 or communalities less than 0.2 were excluded from the questionnaire [24]. Thus, 22 items met the criteria of factor loadings greater than 0.6 and communalities greater than 0.2 [24].
Factorial validity was assessed using higher-order factor confirmatory analysis. The subscale repartition was assessed using the following criteria: comparative fit index (CFI) greater than 0.9, Tucker-Lewis index (TLI) greater than 0.9, and root mean square error of approximation (RMSEA) less than 0.8. The final 22 items were affirmatively determined based on the theoretical foundation and assumptions of the MDS.
Assessment of reliability. Students were asked whether the final 22 items were related to their distress in situations of conflict or dilemma involving ethical and moral values and the impossibility of action during academic training. Test-retest reliability was verified using a convenience sample of 35 nursing students. Identical forms were administered in person, three weeks apart. The test-retest reliability coefficient was 0.84 (p < 0.01). In this study, Cronbach’s alpha coefficient for the 22-item MDS was 0.98. We use the 22 items to measure MDS of Korean nursing students.
The Nurses Professional Values Scale-Revised (NPVS-R) [25] was derived from the American Nurses Association (ANA) Code of Ethics for Nurses, which was designed to measure nurses’ professional values. The NPVS-R is a 26-item instrument with a 5-point Likertscale ranging from 1 (not important) to 5 (most important). The possible scores ranged from 26 to 130. Higher scores indicated stronger professional value orientation. The total scores were obtained by summing the numeric responses for each item. Reliability and validity studies of the original version were conducted, and Cronbach’s alpha coefficient was 0.92 [25]. In this study, Cronbach’s alpha coefficient was 0.95.
Vocational choices were measured using the Entering Nursing Scale (ENS) [26], a self-report questionnaire assessing participants’ motivations and reasons for choosing nursing as a vocation. The students were asked to report their motivation to choose the nursing profession. The ENS is a 20-item instrument with a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). This scale comprises two subgroups: “vocational congruence” and “survival motivation.” Items included statements such as “I always wanted to be a nurse” and “I always wanted to help people.” The total scale points were obtained by summing the points in the scale items. The possible scores ranged from 20 to 100. Higher scores indicated stronger motivation and reason for choosing nursing as a vocation. The ENS was originally developed and used for American and Turkish nursing students in a previous study [5]. However, the ENS consists of items suitable for application to students in their fourth year preparing to become nurses. In a previous study, Cronbach’s alpha coefficients for congruency and survival were 0.86 and 0.78, respectively [25]. Cronbach’s alpha for all items was 0.79.
As there was no Korean version of the NPVS-R and ENS, these tools were translated and reverse-translated, and the translation was validated based on linguistic validation guidelines [27].
Psychometric properties in terms of the subscales’ univariate statistics (mean, standard deviation, and range), factor loadings, communalities, eigen values, Kaiser’s measure of sampling adequacy (MSA), and internal consistency (standardized) measured by Cronbach’s alpha were examined. Kaiser’s MSA summarizes how much smaller the partial correlations are for each variable and all the variables together. Values of 0.8 or 0.9 are considered good.
Descriptive statistics for the main variables were presented as means, standard deviations, ranges, frequencies, and percentages. The associations between sociodemographic characteristics and moral distress, professional values, and vocational choices were evaluated using independent t-tests to identify the confounding variables. Pearson’s correlation coefficient was used to determine correlations between the main variables. Factors affecting vocational choices were evaluated using multiple regression analysis adjusted for the confounding variables (family climate, intent to leave a nursing job, intent to get a nursing job, and dummy variables of the reason for choosing nursing as a major and the department of clinical experience). All statistical analyses were two-sided, with p-values < 0.05 considered statistically significant. All statistical analyses were performed using SAS (version 9.4; SAS Institute, Cary, NC, USA).
Ethical approval
for the research was granted by the IRB of the University. In the introduction, survey respondents were informed that their participation implied voluntary consent and that a data privacy statement should be followed.
Table 1 shows the results for the mean and standard deviation of each item before performing EFA. Among all the items, “Nurses struggled due to overwork” had the highest mean scores, and “I witnessed unaccompanied patients dying without receiving any care” had the lowest mean scores.
| Items | Mean (SD) | Range | Factor loading | |||
|---|---|---|---|---|---|---|
| Factor 1: moral distress by low quality of care | Factor 2: moral distress by a heavy workload and an insufficient workforce in a clinical work environment | Factor 3: conflict between workers and devalued nurses’ competence | Communality | |||
| 1. I witnessed unaccompanied patients dying without receiving any care | 2.1 (1.9) | 1–7 | 0.834 | 0.681 | ||
| 2. I was harmed by an unfaithful practitioner | 2.2 (1.8) | 1–7 | 0.867 | 0.743 | ||
| 3. Medical staff dismissed medical accidents as trivial matters | 2.2 (1.9) | 1–7 | 0.872 | 0.770 | ||
| 4. I witnessed medical staff neglecting human life | 2.4 (2.0) | 1–7 | 0.873 | 0.781 | ||
| 5. I witnessed medical staff (including doctors) neglecting patients | 2.5 (2.0) | 1–7 | 0.793 | 0.703 | ||
| 6. I witnessed insincere attitudes of medical staff towards patients | 3.1 (2.0) | 1–7 | 0.703 | 0.701 | ||
| 7. I witnessed patients’ dignity being damaged | 2.9 (1.9) | 1–7 | 0.753 | 0.711 | ||
| 8. I witnessed nurses struggling due to overwork | 4.9 (1.8) | 1–7 | 0.769 | 0.593 | ||
| 9. I witnessed nurses’ unprofessional behaviors | 3.7 (1.9) | 1–7 | 0.806 | 0.593 | ||
| 10. I witnessed nurses bullying new nurses | 3.9 (2.0) | 1–7 | 0.790 | 0.682 | ||
| 11. I witnessed a coercive ward atmosphere | 3.5 (1.9) | 1–7 | 0.812 | 0.683 | ||
| 12. The amount of practice and work was too much to me | 4.1 (2.1) | 1–7 | 0.665 | 0.520 | ||
| 13. The hospital environment was vulnerable to infection | 3.1 (2.1) | 1–7 | 0.644 | 0.614 | ||
| 14. The clinical practice environment did not protect nursing students | 3.7 (2.1) | 1–7 | 0.741 | 0.657 | ||
| 15. I was ignored by the patient or caregiver | 3.5 (2.1) | 1–7 | 0.673 | 0.508 | ||
| 16. I witnessed nurses being ignored by the patient or relatives | 3.3 (2.2) | 1–7 | 0.609 | 0.614 | ||
| 17. I was suspected unilaterally | 2.4 (1.9) | 1–7 | 0.723 | 0.690 | ||
| 18. I witnessed nursing leaders behaving unfairly | 2.6 (1.8) | 1–7 | 0.707 | 0.655 | ||
| 19. The nurse used verbal and physical violence | 3.0 (1.8) | 1–7 | 0.818 | 0.679 | ||
| 20. I was ignored by the nurses | 3.6 (1.9) | 1–7 | 0.793 | 0.651 | ||
| 21. I witnessed nurses being treated unfairly | 3.5 (1.9) | 1–7 | 0.792 | 0.654 | ||
| 22. There is a critical atmosphere among medical professionals. | 3.6 (1.9) | 1–7 | 0.658 | 0.589 | ||
| Total Communality | 15.20 | |||||
| Cronbach’s alpha | 0.94 | 0.92 | 0.91 | |||
| Eigenvalue | 12.315 | 1.509 | 0.650 | |||
| % of explanatory variance (rotated value) | 45.3% (2.84) | 34.8% (2.18) | 20.0% (1.25) | Total 6.27 | ||
| Kaiser’s MSA | 0.95 | |||||
| Note. SD, standard deviation. | ||||||
The 22 remaining items provided the most meaningful factor pattern and were labeled as moral distress in low quality of care, moral distress in heavy workload and insufficient workforce in the clinical work environment, and conflict between workers and devalued nurses’ competence. Factor 1 on moral distress in low quality of care comprised Q 1–7 and accounted for 45.3% of the explanatory variance. Cronbach’s α for internal consistency of low quality of care was 0.94. Factor 2 on moral distress in heavy workload and insufficient workforce in the clinical work environment comprised Q 8–15 and accounted for 34.8% of the explanatory variance. Cronbach’s α for internal consistency was 0.92. Factor 3 on conflict between workers and devalued nurses’ competence comprised Q 16–22 and accounted for 20.0% of the explanatory variance. Cronbach’s α for internal consistency was 0.91. These three patterns explained 45.3%, 34.8%, and 20.0% of the variation in the MDS, respectively.
Table 2 shows the differences in moral distress according to the participants’ general characteristics. Analysis of the differences in the participants’ moral distress showed significant differences in their home environment and identified the reason for choosing nursing as a major (talented and applied based on test scores) and the department of clinical experience (medical ward, intensive care unit, emergency department, nursing administration department, and urology ward). Analysis of the differences in the participants’ professional values showed significant differences in the intention to leave the nursing job, reason for choosing nursing as a major (vision and fit the aptitude), and department of clinical experience (emergency and nursing administration departments). Moreover, analysis of the differences in the participants’ vocational choices showed significant differences in the intention to get a nursing job and reasons for choosing nursing as a major (vision, fit the aptitude, or grade).
| N = 270 | Moral distress | Professional value | Vocational choice | ||||
|---|---|---|---|---|---|---|---|
| n (%) | Mean (SD) | P | Mean (SD) | P | Mean (SD) | P | |
| Age, years | |||||||
| 21–23 | 224 (83.0) | 70.0 (32.2) | 114.2 (13.6) | 69.8 (10.1) | |||
| 24–30 | 46 (17.0) | 69.3 (35.7) | 0.893 | 111.1 (22.7) | 0.379 | 66.7 (15.8) | 0.082 |
| Sex | |||||||
| Male | 30 (11.1) | 69.3 (34.8) | 112.1 (13.7) | 68.3 (11.6) | |||
| Female | 240 (88.9) | 70.0 (32.6) | 0.916 | 113.9 (15.7) | 0.546 | 69.4 (11.3) | 0.597 |
| Household income, US $ | |||||||
| < 3000 | 112 (41.5) | 70.1 (32.6) | 113.0 (16.0) | 68.6 (11.5) | |||
| ≥ 3000 | 158 (58.5) | 69.76 (32.9) | 0.935 | 114.2 (15.2) | 0.554 | 69.8 (11.2) | 0.362 |
| Having parents as medical professionals | |||||||
| No | 198 (73.3) | 70.6 (30.2) | 114.1 (14.2) | 68.5 (10.7) | |||
| Yes | 72 (26.7) | 67.9 (39.2) | 0.556 | 111.9 (21.6) | 0.337 | 71.0 (14.9) | 0.190 |
| Practice a religion | |||||||
| No | 170 (63.0) | 67.3 (32.2) | 114.5 (14.5) | 69.2 (10.6) | |||
| Yes | 100 (37.0) | 74.3 (33.3) | 0.089 | 111.8 (19.4) | 0.185 | 69.1 (14.1) | 0.940 |
| Mother’s education level | |||||||
| High school | 116 (43.0) | 69.9 (30.1) | 113.3 (13.3) | 68.0 (11.5) | |||
| ≥College | 154 (57.0) | 69.9 (34.7) | 0.985 | 113.7 (18.6) | 0.823 | 70.1 (12.3) | 0.149 |
| Father’s education level | |||||||
| High school | 92 (34.1) | 67.1 (31.9) | 114.7 (12.9) | 70.2 (11.3) | |||
| ≥College | 178 (65.9) | 71.3 (33.2) | 0.321 | 112.9 (18.1) | 0.400 | 68.6 (12.3) | 0.296 |
| Home environment | |||||||
| Authoritative, protective, others | 52 (19.3) | 80.4 (33.2) | 116.6 (13.8) | 70.9 (12.3) | |||
| Democratic | 218 (80.7) | 67.4 (32.2) | 0.010 | 112.8 (17.0) | 0.132 | 68.8 (11.9) | 0.254 |
| Intent to get a nursing job | |||||||
| Yes | 244 (90.4) | 75.3 (32.7) | 108.9 (14.1) | 59.2 (8.4) | |||
| No | 26 (9.6) | 69.3 (32.8) | 0.380 | 114.0 (16.7) | 0.136 | 70.2 (11.8) | < .0001 |
| Reason for choosing nursing as a major | |||||||
| Good prospect | |||||||
| No | 192 (71.1) | 72.1 (33.1) | 112.1 (17.1) | 67.7 (12.7) | |||
| Yes | 78 (28.9) | 64.5 (31.5) | 0.083 | 117.1 (14.5) | 0.024 | 72.8 (8.9) | 0.002 |
| Talented | |||||||
| No | 154 (57.0) | 76.2 (31.5) | 109.8 (18.8) | 66.8 (12.6) | |||
| Yes | 116 (43.0) | 61.6 (32.6) | < 0.001 | 118.4 (11.1) | < .0001 | 72.4 (10.2) | < .0001 |
| Recommendation from others | |||||||
| No | 186 (68.9) | 69.6 (31.8) | 112.9 (18.0) | 69.1 (11.7) | |||
| Yes | 84 (31.1) | 70.5 (34.9) | 0.845 | 115.0 (12.4) | 0.265 | 69.4 (12.6) | 0.869 |
| Getting a good job | |||||||
| No | 92 (34.1) | 74.8 (36.8) | 112.0 (21.6) | 68.6 (15.4) | |||
| Yes | 178 (65.9) | 67.3 (30.2) | 0.075 | 114.3 (13.1) | 0.343 | 69.5 (9.8) | 0.576 |
| Applied based on test scores | |||||||
| No | 196 (72.6) | 66.7 (33.2) | 113.8 (18.0) | 70.3 (12.8) | |||
| Yes | 74 (27.4) | 78.4 (30.2) | 0.009 | 112.7 (11.6) | 0.548 | 66.3 (8.8) | 0.005 |
| Department of clinical experience | |||||||
| Medical clinics (respiratory, gastrointestinal, endocrine) | |||||||
| No | 54 (20.0) | 55.0 (28.8) | 111.9 (25.3) | 68.5 (16.9) | |||
| Yes | 216 (80.0) | 73.6 (32.7) | < 0.001 | 113.9 (13.5) | 0.429 | 69.4 (10.4) | 0.634 |
| Surgical ward | |||||||
| No | 44 (16.3) | 78.2 (31.9) | 112.2 (11.5) | 69.0 (11.7) | |||
| Yes | 226 (83.7) | 68.3 (32.7) | 0.066 | 113.8 (17.3) | 0.558 | 69.2 (12.0) | 0.936 |
| Operation room | |||||||
| No | 138 (51.1) | 70.4 (33.9) | 115.2 (13.1) | 70.0 (10.9) | |||
| Yes | 132 (48.9) | 69.3 (31.5) | 0.789 | 111.8 (19.3) | 0.089 | 68.3 (13.0) | 0.233 |
| Intensive care unit | |||||||
| No | 168 (62.2) | 66.4 (32.5) | 114.2 (13.4) | 70.0 (11.3) | |||
| Yes | 102 (37.8) | 75.6 (32.6) | 0.026 | 112.3 (20.6) | 0.359 | 67.9 (12.9) | 0.160 |
| Emergency department | |||||||
| No | 232 (85.9) | 68.1 (32.7) | 114.9 (13.1) | 69.1 (10.1) | |||
| Yes | 38 (14.1) | 80.6 (31.2) | 0.029 | 105.0 (28.6) | 0.042 | 69.9 (20.1) | 0.670 |
| Nursing management department | |||||||
| No | 212 (78.5) | 65.1 (30.6) | 114.6 (17.3) | 69.2 (12.5) | |||
| Yes | 58 (21.5) | 87.3 (34.5) | < .0001 | 109.6 (12.6) | 0.016 | 68.9 (10.0) | 0.860 |
| Hemato-oncology ward | |||||||
| No | 176 (65.2) | 67.1 (32.3) | 112.3 (17.8) | 69.1 (13.4) | |||
| Yes | 94 (34.8) | 75.1 (33.1) | 0.057 | 115.8 (13.4) | 0.073 | 69.3 (8.8) | 0.938 |
| Urology ward | |||||||
| No | 224 (83.0) | 66.4 (31.6) | 113.4 (17.1) | 68.9 (12.1) | |||
| Yes | 46 (17.0) | 86.9 (33.1) | < .0001 | 114.2 (13.1) | 0.709 | 70.1 (11.2) | 0.555 |
| Ear-nose-and-throat department | |||||||
| No | 248 (91.9) | 69.2 (32.8) | 113.4 (16.9) | 69.3 (12.2) | |||
| Yes | 22 (8.1) | 77.4 (31.9) | 0.262 | 115.1 (10.9) | 0.511 | 68.4 (8.6) | 0.740 |
| Dermatology and plastic surgery department | |||||||
| No | 256 (94.8) | 69.4 (32.9) | 113.4 (16.7) | 69.1 (11.9) | |||
| Yes | 14 (5.2) | 78.9 (29.5) | 0.294 | 115.7 (11.7) | 0.610 | 71.1 (12.9) | 0.529 |
| Residence | |||||||
| Metropolitan | 194 (71.9) | 70.0 (33.8) | 113.3 (17.6) | 69.8 (12.6) | |||
| City | 60 (22.2) | 68.6 (30.9) | 113.9 (13.8) | 69.0 (9.4) | |||
| Rural | 16 (5.9) | 73.3 (26.6) | 0.876 | 114.4 (11.8) | 0.947 | 62.6 (12.1) | 0.072 |
| Note. SD, standard deviation. | |||||||
The participants’ average scores for moral distress, professional values, and vocational choices are presented in Table 3. Professional values among the participants were high, with a mean score of 113.5 (SD = 16.5). The participants’ mean score for vocational choices in ENS was 69.2 (SD = 11.9), and that for moral distress was 69.9 (SD = 32.7). The participants’ moral distress showed a significant negative correlation with professional values (r = -0.33, p < 0.0001) and vocational choices (r = -0.20, p = 0.001). The participants’ professional and vocational values were positively and significantly correlated (r = 0.48, p < 0.0001).
| Mean (SD) | Range | Moral distress r (P) | Professional value r (P) | Vocational choice r (P) | |
|---|---|---|---|---|---|
| Moral distress | 69.9 (32.7) | 22.0 ~ 154.0 | 1 | ||
| Professional value | 113.5 (16.5) | 26.0 ~ 130.0 | -0.33 (< .0001) | 1 | |
| Vocational choice | 69.2 (11.9) | 20.0 ~ 100.0 | -0.20 (0.001) | 0.48 (< .0001) | 1 |
| Note. SD, standard deviation. | |||||
Multicollinearity was tested before performing the multiple regression analysis. Variance inflation factors ranged from 1.09 to 2.04 (criteria < 10), tolerance ranged from 0.48 to 0.91 (criteria > 0.1), and the condition index ranged from 1 to 13.9 (criteria < 15); thus, the sociodemographic variables had no multicollinearity. The Durbin–Watson statistic was 1.98 (criteria: close to 2), which indicated no autocorrelation between the sociodemographic variables.
The factors Influencing participants’ vocational choices are listed in Table 4. We imputed the independent variables such as family climate, intention to leave the nursing job, intention to get a nursing job, reason for choosing nursing, fit the aptitude according to the grade, and the department of clinical experience, which significantly varied according to the general characteristics of the participants. The nominal variables (reason for choosing nursing as a major and department of clinical experience) were dummy-coded. The factor that most significantly affected lower choice of nursing as a vocation was the intention to not choose nursing as a future career (β=−9.10, p < 0.001). The factors that most significantly affected higher choice of nursing as a vocation were the reason for choosing nursing as a major (e.g., vision) (β = 3.79, p = 0.005), a democratic family climate (β = 3.43, p = 0.011), having at least one of the parents as a medical professional (β = 3.36, p = 0.015), and higher professional values (β = 0.33, p < 0.001).
| β coefficient (se) | Partial R2 | F value | P | |
|---|---|---|---|---|
| No intent to get a nursing job | -9.10 (2.05) | 0.05 | 19.87 | < .0001 |
| Reason for choosing nursing as a major, good prospect | 3.79 (1.35) | 0.02 | 6.11 | 0.005 |
| Democratic home environment | 3.43 (1.33) | 0.02 | 6.61 | 0.011 |
| At least one of the parents is a medical professional, yes (vs. no) | 3.36 (1.37) | 0.02 | 6.15 | 0.015 |
| Higher professional value | 0.33 (0.04) | 0.23 | 79.31 | < .0001 |
| Model | Adjusted R2: 0.33 | 26.07 | < .0001 | |
| Note. Multiple regression analysis adjusted for confounding variables (home environment, intent to get a nursing job, and dummy variables for the reason for choosing nursing as a major and the department of clinical experience). | ||||
This cross-sectional study on senior undergraduate nursing students indicated that the factor that most significantly influenced higher vocational choices was higher professional values. Experiencing moral distress in undergraduate nursing students might not affect their intention to choose the nursing profession. Other factors affecting higher vocational choice were the intention to choose nursing as a future career, the motive for choosing nursing was a prospect, a democratic home environment, and having at least one parent as a medical professional.
We found that the factor that most significantly affected vocational choices was higher professional value, not moral distress. Our findings support the results of a previous study, which indicated that higher vocational choices increased professional values among nursing students [5]. Previous studies showed that when nursing students hold high professional values, their satisfaction with their major is high [28]. Additionally, high satisfaction with one’s major is positively correlated with career identity, which is linked to higher professional value [29, 30]. Nursing is a professional discipline with a scientific rationale; its professional value should be taught via a well-organized academic discipline [31]. As professional identity development starts with acceptance in the nursing program and ends substantially with the end of the program, professional values can be formed concretely through education, which may affect nurses’ career choices. Students often perceive nursing as a career choice based on personality, beliefs, identity, perception of nursing, and sociocultural values and accordingly make a career decision [32] Therefore, our findings suggest that nursing students’ professional values are significantly more critical for choosing nursing as a career. More focus should be placed on professional value training during undergraduate education to prepare nurses to work in the current complex healthcare setting [33, 34].
This study showed that moral distress among undergraduate nursing students might not affect their vocational choices. Nursing students’ practice period lasted at most for one to two weeks in one ward. Thus, even if they had such an experience, they felt that it was not their own experience, but rather an experience in which they were onlookers or one shared with other friends and colleagues who participated in the practice. Despite being morally distressed, as reported in a previous study, nurses have high intent to stay in the profession [35]. However, nursing students do not take responsibility for practicing nursing skills in a clinical setting. Although our findings showed a medium level of moral distress, it did not affect the choice of nursing as a career.
Moreover, employment stability, satisfactory wages, and professional and social status of nurses affect nursing students’ career choices [36]. In other words, nursing students have multiple reasons for their career choice. Although investigation of the different factors affecting vocational choices in this study did not show this, some reasons based on previous studies were related to choosing the nursing profession. Therefore, moral distress was not deemed a significant indicator of nursing students’ vocational choices.
Senior nursing students’ vocational choices may be influenced by their intention to choose nursing as a future career and vision as the motive for choosing nursing majors. Previous studies indicated that students who voluntarily chose the nursing profession did not want to quit their nursing major and wished to work as nurses after graduation [5]. Although nursing students have multiple reasons for choosing a nursing career, their vision for future career development is to facilitate them through professional nursing services. Nursing students who continue their education out of compulsion to pursue a higher education program or have a job in the future experience problems such as being restless at the workplace, being non-productive, and making mistakes because they do not like or adopt their profession [5]. These problems negatively affect students’ perceptions of continuing with the nursing profession. Therefore, nursing educators at universities should provide a path for the vision of this discipline’s future development and related professions.
Senior nursing students’ vocational choices may be influenced by a democratic family climate and whether one of the parents is a medical professional. This result is supported by previous results showing that parents considerably impact their children’s nursing career choices. Our findings are related to previous results on the factors impacting students’ career choice, which showed that the majority had a relative who was a nurse [37], and their decision was strongly related to that factor [38]. Some nursing students choose their profession based on family requests [39, 40]. Moreover, having a positive opinion and attitude toward nursing is a requisite for choosing it as a profession, leading to competency in the profession and a productive work life [41]. This study indicated that professional values and attitudes toward the nursing job were formed before entering school and that students had positive feelings toward nursing due to the family climate.
In this study, the scores for professional value among senior nursing students were higher (M = 113.5, SD = 16.5) than the mean score of their counterparts in the United States (M = 106.16, SD = 12.93) and Taiwan (M = 104.27, SD = 16.81) [42]. Moreover, the average score for professional values in this study was higher than that reported in previous studies [43] conducted on sophomore and junior nursing students in China. Our participants were senior nursing students prepared to become future nurses to enhance the clinically competent nursing workforce during the learning process. Senior nursing students acquire more professional knowledge and accumulated professional values from their clinical experience than lower-grade nursing students. These findings indicated that nursing education resulted in a difference in the total scores for professional values among sophomore, junior, and senior students. Consistent with previous studies, nursing students’ participation in continuous nursing education positively increased the total scores for professional values from the first year to graduation [44, 45].
Moreover, differences in professional values among nursing students from various countries suggest the influence of cultural experiences, backgrounds, ethical codes, and professional identities [46, 47, 48]. A previous study showed that professional values depend on an individual’s background, including the country’s culture, which is one of the most significant factors affecting the development of professional values among nursing students [49]. Nursing students accidentally learn through clinical experience and acquire the necessary knowledge and skills through the educational curriculum. Therefore, nursing educators are essential role models for nursing professionalism [33, 34]. To develop professional values, nurse educators should focus on forming the beliefs, values, and ethics of nursing professionalism and preparing nursing students to determine the essential aspects of professional behavior and vocational choice.
Senior nursing students experienced three constructs of moral distress: low quality of care, heavy workload and insufficient workforce, and conflict between workers and devalued nurses’ competence.
The first construct might be caused by the low quality of care provided to patients. This result is supported by a previous study that reported that ethical conflict among nurses was “distress resulting from not taking the required nursing action despite knowing about a problem [50].” Moral distress among nurses was mainly caused by futile or inadequate care or treatment contrary to patient wishes [51, 52] and by patient negligence [53]. These previous studies supported the idea that the moral distress experienced by senior nursing students due to low quality of care.
The second construct was attributed to a heavy workload and an insufficient workforce. Nurses may experience moral distress in nursing practice when faced with situations such as high workload, insufficient workforce, and lack of proper collaboration between doctors and nurses [54, 55, 56, 57], all of which can lead to insufficient quality and quantity of care [58]. These previous studies also supported the idea that heavy workload and insufficient workforce experienced by senior nursing students may be similar to those experienced by clinical nurses.
The third construct was caused by conflict between workers and devalued nurses’ competence in a clinical setting. Existing studies on moral distress among clinical nurses do not specify this attribute, suggesting that it might be unique to nursing students. Nursing students attain professional nursing values and feel empowered when they learn about nursing theories. Students’ perception of the importance of professional values was significantly higher than that of nurses [33, 34]. Thus, they may perceive a significant gap between theory and practice during clinical training, which could lead to moral distress. This is particularly true when students witness conflict between nurses and physicians and devalued nurses’ competence in clinical practice.
This is the first study that identifies senior nursing students’ moral distress in an uncertain position in clinical practice who cannot make voluntary decisions. In addition, although it is well known that nursing students choose a clear career path, few studies have been conducted on the factors affecting their vocational choices. Nursing students may experience moral distress, a negative emotion experienced in clinical practice; however, moral distress is not an influencing factor in their career choice. It was found that professional values formed or acquired through nursing education are an important factor in choosing the nursing profession.
This study has several limitations. It is difficult to identify causal relationships and the study results cannot be generalized owing to the convenience sampling of cross-sectional studies. A future experimental study is needed to determine whether interventions that improve professional values lead to vocational choices in the nursing profession. To compensate for the shortcomings of convenience sampling, nursing students from three regional hub universities with regional distances were selected for sampling.
Professional values may affect nursing students’ choice of the nursing profession formed while pursuing their studies. Therefore, fostering students’ nursing professionalism and professional values through university education will help maintain their professional identity. This study showed that moral distress among undergraduate nursing students might not affect their vocational choices. As nurses are immersed in clinical work, they feel more burdened with moral distress sustained chronically. As this experience of moral distress can affect vocational choices differently among nurses and nursing students, a comparative study between nursing students and nurses is needed.
Undergraduate nursing students’ choice of the nursing profession is influenced by professional values and motivation shaped when choosing nursing as a major. Therefore, fostering students’ nursing professionalism and professional values through educational curricula may help maintain nursing students’ professional identity.
American Nurses Association
Comparative Fit Index
Consensus-Based Standards for the Selection of Health Status Measurement Instrument
Moral Distress Scale
Principal Component Analysis
Exploratory Factor Analysis
Entering Nursing Scale
Kaiser–Meyer–Olkin
Measure of Sampling Adequacy
Nurses Professional Values Scale–-Revised
Root Mean Square Error of Approximation
Tucker-Lewis Index
Ethics approval and Consent to participate: This study was conducted in accordance with the principles of the Declaration of Helsinki and the study plan and process were approved by the Clinical Ethics Committee of Kyungpook University. The participants were assured that their information would be kept strictly confidential and used only for research purposes. The ability to exit the study at any time has been ensured. Informed consent obtained from all the participants included in the study. All methods were carried out in accordance with relevant guidelines and regulations.
Consent for publication: Not applicable
Availability of data and materials: The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request
Competing interests: The authors declare that they have no competing interests.
Funding: This research was funded by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (Grant number 2020R1F1A1057423) and (Grant number 2022R1H1A2093192).
Authors' contributions:
Conceptualization: Myung Kyung Lee, Jihyun Oh; Data curation; Myung Kyung Lee, Jihyun Oh; Formal analysis; Myung Kyung Lee, Jihyun Oh; Funding acquisition and investigation: Myung Kyung Lee; Methodology: Myung Kyung Lee, Jihyun Oh; Project administration and supervision: Myung Kyung Lee; Validation: Myung Kyung Lee, Jihyun Oh; Writing - original draft, review & editing: Myung Kyung Lee, Jihyun Oh
Acknowledgements: We thank all those who have helped in carrying out the research and anonymous reviewers.