道德困扰对几乎所有医护人员都构成了巨大威胁，甚至超出了医护领域（Jameton，2017 年）。道德困扰是指一个人知道应该采取正确的行动，但却受到限制而无法采取的一种现象（Jameton，1984 年）。道德困扰可能是在进入护理学校学习护理专业之前的一种经历（Sasso 等人，2016 年）。随着医疗保健的复杂性和护理实践中遇到的道德困境的不断增加，完全消除道德困扰是不现实的（Rushton et al.

2017）；相反，焦点仍然集中在如何减轻道德困扰的影响上。

为了减少道德困扰的有害影响，人们呼吁加强道德韧性（美国护士协会，2017 年；Moss 等人，2016 年）。另一个已知可减少道德困扰的文献概念是道德勇气（Bickhoff 等人，2017 年）。道德勇气涉及一个人直言问题的能力和意愿（Murray，2010）。在护理专业学生中，最常见的不作为原因之一是学生怀疑自己是否有能力直言不讳，而是保持沉默（Bickhoff 等人，2017 年；Krautscheid 等人，2017 年）。

对持证护士，尤其是急症护理环境中的护士的道德困扰、道德勇气和道德韧性进行了广泛的研究。然而，这三个道德概念在护理专业学生中还没有得到研究。本研究调查了护理专业本科生的道德困扰、道德勇气和道德韧性之间的关系。

文献综述

道德勇气

Moral courage is necessary to improve patient outcomes and patient safety (Dinndorf-Hogenson, 2015; Hawkins & Morse, 2014). Furthermore, given that moral dilemmas causing moral distress are inherent in clinical and academic contexts, nurses and nursing students should be equipped with proper tools such as courage (Lindh et al., 2010). Although moral courage can be taught, nursing students are still in the process of learning their role as a nurse and the assertive behavior required to provide high-quality care (Aultman, 2008). In addition, recent literature supports the notion of practicing moral courage as a way to develop moral resilience (Lachman, 2016). 

Moral Resilience 

A shift is under way regarding the use of moral resilience; current thinking suggests replacing moral distress with moral resilience (Rushton et al., 2017). This shift aims to address health care problems not in terms of moral distress but in terms of moral resilience through “courage, cooperative speaking up, and persistent action” (Jameton, 2017, p. 620). Rushton (2016) highlights cultivating moral resilience through self-awareness, self-regulation capacities, and ethical competence, as well as speaking up with clarity and confidence. 

Exploring the Relationships Among Moral Distress, Moral Courage, and Moral Resilience in Undergraduate Nursing Students 

Erin Gibson, PhD, RN, CCRN-K; Gloria Duke, PhD, RN; and Danita Alfred, PhD, RN 

ABSTRACT 

Background: Nurses and students face a demanding and fluid health care system that can present overwhelming challenges. Moral distress is a challenge encountered by students who experience complex situations. Certain virtues such as moral courage and moral resilience are necessary to navigate around this phenomenon. Method: Using a descriptive correlational study design, a convenience sample of nursing students distributed among three sites were surveyed using three tools: The Moral Distress Thermometer (MDT), the Connor-Davidson Moral Resilience Scale (CD-RISC), and the Moral Courage Scale for Physicians (MCSP). Results: Students reported mild levels of moral distress (M = 2.73, SD = 1.9). Moral resilience was significantly correlated with moral courage, age, and students having a previous degree. Conclusion: Interventions to cultivate moral resilience in nursing curricula are necessary. Valid instruments to measure moral resilience and moral distress in nursing students should be investigated further. [J Nurs Educ. 2020;59(7):392-395.] 

Dr. Gibson is Assistant Professor, Texas Tech Health Sciences Center School of Nursing, Lubbock, and Dr. Duke is Professor and Dr. Alfred is Professor, College of Nursing & Health Sciences, The University of Texas at Tyler, Tyler, Texas. 

The authors have disclosed no potential conflicts of interest, financial or otherwise. 

Address correspondence to Erin Gibson, PhD, RN, CCRN-K, Assistant Professor, Texas Tech Health Sciences Center School of Nursing, 3601 4 Street MS 6264, Lubbock, TX 79430; email: Erin.gibson@ttuhsc.edu. 

Received: September 19, 2019; Accepted: January 28, 2020 doi:10.3928/01484834-20200617-07 

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Moral Distress 

During the past 5 years, the literature has noted an increase in moral distress among nursing students. Nursing students experience moral distress in their clinical experiences and professional education (Range & Rotherham, 2010; Renno et al., 2018; Sasso et al., 2016). Sasso et al. (2016) identified sources of moral distress in nursing students in mentor relationships, when taking care of patients with health disparities, and with interpersonal factors. According to Reader (2015), nursing students experience moral distress related to an overall feeling of disempowerment and lack of status or powerlessness (Savel & Munro, 2015). Students often find themselves in the middle of moral dilemmas and remain silent instead of questioning practice or patient safety due to their lack of ability to speak up and intervene (Bickhoff et al., 2016). 

Theoretical Framework 

The theoretical framework guiding this study was derived from Corley’s (2002) theory of moral distress that illustrates moral concepts linked between moral distress and moral courage. This was the first theory aimed specifically at moral distress from a nurse’s point of view as well as that of an organization. This theory has been used to study the physiological (internal) and organizational (external) variables that surround moral distress and has been used in the large body of knowledge in moral distress in nurses. 

The research questions for this study were: 

Do nursing students with greater moral resilience and moral courage report significantly less moral distress? 

Do students with higher moral resilience have less moral distress? 

Do students with higher moral courage have less moral distress? 

Does moral courage predict moral distress more than moral resiliency? 

Method Study Design and Sample 

This study used a descriptive correlational design to examine moral distress, moral courage, and moral resilience among undergraduate nursing students in addition to investigating their interrelationships. The study was conducted at a large university and two satellite campus settings in the Southwest. The study proposal was approved by the Institutional Review Board (IRB) at The University of Texas at Tyler, and approval also was obtained from Texas Tech University Health Sciences Center IRB. 

Prelicensure baccalaureate nursing students comprised the convenience sample. Participants were recruited through their student email. Students who expressed interest in participating were screened for eligibility. A priori, a statistical power analysis was performed using G*Power Analysis 3.1 for sample size estimation (Faul et al., 2009). An accepted minimal power level of .80 was used to avoid a Type II error (Cohen, 1988). With minimal literature having previous effect sizes, this study intended to achieve a medium effect of f = .15. Therefore, using an alpha of .05, a total sample size of 68 students was suggested. 

Instruments 

Demographic data were collected at baseline. Moral courage, moral resilience, and moral distress were assessed using the Moral Courage Scale for Physicians (MCSP) (Martinez et al., 2016), the Connor-Davidson Resilience Scale (CD-RISC) (Connor & Davidson, 2003), and the Moral Distress Thermometer (MDT) (Wocial & Weaver, 2013). 

Data Analysis 

Results 

Seventy percent of the students (n = 88) responded to the initial survey through the email link. However, several of the respondents were ineligible for personal reasons or did not complete portions of the survey. The final data set (n = 45) resulted in a 36% response rate. 

The majority of the respondents were women (91.1%) with a mean age of 22.15 years (SD, ±2.79) and a median age of 21 years. The majority of the respondents reported their ethnicity as White (77.8%), with the second largest percentage of respondents being Hispanic or Latino (13.3%). The majority of participants did not report prior health care experience (62.2%) and also had not considered quitting nursing school (82.2%). 

A descriptive analysis of the main study variables of moral distress, moral courage, and moral resilience was conducted. Moral distress scores on the MDT ranged from 0 to 7; higher scores indicated a distressing and intense level. A majority of students reported moral distress ranging from mild to uncomfortable on the MDT (M = 2.73, SD = 1.9). A wide range of scores for moral courage (63 to 100) was elicited on the MCSP. Students’ average scores on moral resilience (M = 78.44, SD = 11.6) were lower than their average scores on moral courage (M = 88.15, SD = 9.1). Moral resilience scores ranged from 46 to 99. The reliability for the instruments used in this study was analyzed, and both the CD-RISC and MCSP had a Cronbach’s alpha of .80. 

Research Question One 

Research question one examined whether nursing students with greater moral resilience and moral courage reported significantly less moral distress. There was a small but nonsignificant negative correlation between moral distress and moral resilience, r(45) = −.21, p = .084, 95% CI [–0.47, 0.5]. There was no statistically significant correlation between moral distress and moral courage, r(45) = .02, p = .44, 95% CI [−0.30, 0.35]. Therefore, students who reported higher moral resilience and higher moral courage did not report less moral distress. However, there was a statistically significant relationship between moral courage and moral resilience, r(45) = .37, p = .006, 95% CI [0.07, 0.62]. 

Journal of Nursing Education • Vol. 59, No. 7, 2020 

Research Question Two 

The second research question asked whether students with higher moral resilience had less moral distress. The simple correlation between the two variables was r(45) = −.21, p = .084. Pearson’s partial correlation showed the strength of this linear relationship was greater after controlling for moral courage, rpartial (45) = −.24, p = .062, 95% CI [−0.47, 0.05]. 

Research Question Three 

Research question number three asked whether students with higher moral courage had less moral distress The simple correlation between the two variables was r(45) = .024, p = .44. Pearson’s partial correlation showed a weak, nonstatistically significant linear relationship between moral courage and moral distress, rpartial (45) = .112, p = .47, 95% CI [−0.22, 0.38]. 

Research Question Four 

A multiple regression was conducted to determine whether moral courage and moral resilience predicted moral distress. Using the standard entry method, data indicated the overall model was not statistically significant, F(2,42) = 1.241, p = .30. The model only explained 2% (R = .056, adjusted R = .011) of the variance in the dependent variable moral distress. Therefore, moral courage did not predict moral distress more than moral resiliency. 

Additional Analyses and Results 

There was a strong correlation between the stand-alone questions and the original CD-RISC, r(45) = .589, p < .001, indicating moderate convergent validity of the two new questions. The stand-alone questions also had a statistically significant correlation with moral courage, r(45) = .445, p = .002. These findings warrant further analyses with the new stand-alone questions for measuring moral resilience. 

The data showed a statistically significant relationship between moral resilience and age, r(45) = .314, p = .04, 95% CI [0.9, 0.54]. There was a significant difference in moral resilience for students who had a previous degree, x(1) = 28, p = .02, indicating that moral resilience was higher in those students who were seeking a second degree in nursing. 

Discussion 

The purpose of this study was to address a scientific gap by explaining moral distress, moral courage, and moral resilience among undergraduate nursing students and their interrelationships. Results of this study parallel findings from studies that reported moral distress as being a phenomenon experienced by nursing students (Escolar-Chua, 2016; Krautscheid et al., 2017; Renno et al., 2018). 

Curriculums providing education and training to future health care professionals should not underestimate the importance of keeping ethics and value-based training. However, one of the underlying issues is that many gaps still remain in ethics education in nursing curricula (Hoskins et al., 2018). 

Furthermore, sociodemographic factors such as ethnicity and age have been associated with moral distress (Oh & Gastmans, 2015) 

This study found a statistically significant positive correlation between age and moral resilience, implying that the older a person gets, the higher moral resiliency he or she has. Similarly, there was a significant positive correlation between earning a second degree and moral resilience, asserting that moral resilience increased for students who indicated they were earning their second degree. Another interesting finding was that although students had mild moral distress, 82.2% had not considered quitting nursing school. Escolar-Chua (2016) reported this same finding in Filipino nursing students who rarely considered quitting the nursing profession despite frequent morally distressing situations. Thus, claiming moral stressors to be the cause of new graduates leaving the profession may not hold weight. 

Conclusion 

The findings of this study warrant further research. A multisite study with a large sample size would help generalize findings for transferability (Polit & Beck, 2010). However, based on the results, future research in both quantitative and qualitative realms as an embedded design or using a longitudinal design might help pinpoint and highlight specific moral dilemmas nursing students experience along with their reactions both intraprofessionally and interprofessionally. Furthermore, researching the psychometric properties of a new or modified moral resilience scale would be beneficial in quantifying moral resilience as this concept is widely underdeveloped (Young & Rushton, 2017). As the conceptual definition of moral resilience is solidified, tools to measure moral resilience are necessary to determine where this concept occurs theoretically within ethical decision making, health care, nursing education, and other professional fields. In addition, the reliability and validity of the MDT should be investigated further in comparison with the Moral Distress Scale. 

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