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References

Escolar Chua, R. L., & Magpantay, J. C. J. (2019). Moral distress of undergraduate nursing students in community health nursing. Nursing Ethics, 26(7/8), 2340–2350. https://doi-org.resu.idm.oclc.org/10.1177/0969733018819130

Original Manuscript

Moral distress
of undergraduate nursing
students in community
health nursing

Rowena L Escolar Chua and Jaclyn Charmaine J Magpantay
University of Santo Tomas, Philippines

Abstract
Background: Nurses exposed to community health nursing commonly encounter situations that can be
morally distressing. However, most research on moral distress has focused on acute care settings and very
little research has explored moral distress in a community health nursing setting especially among nursing
students.
Aim: To explore the moral distress experiences encountered by undergraduate baccalaureate nursing
students in community health nursing.
Research design: A descriptive qualitative design was employed to explore the community health nursing
experiences of the nursing students that led them to have moral distress.
Participants and research context: The study included 14 senior nursing students who had their
course in Community Health Nursing in their sophomore year and stayed in the partner communities in
their junior year for 6 and 3 weeks during their senior year.
Ethical considerations: Institutional review board approval was sought prior to the conduct of the study.
Self-determination was assured and anonymity and confidentiality were guaranteed to all participants.
Findings: Nursing students are vulnerable and likely to experience moral distress when faced with ethical
dilemmas. They encounter numerous situations which make them question their own values and ideals and
those of that around them. Findings of the study surfaced three central themes which included moral
distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of
powerlessness, and the differing values and mindsets of the people they serve in the community.
Conclusion: This study provides educators a glimpse of the morally distressing situations that often occurs
in the community setting. It suggests the importance of raising awareness and understanding of these
situations to assist nursing students to prepare themselves to the “real world,” where the ideals they
have will be constantly challenged and tested.

Keywords
Community health nursing, ethical dilemmas, moral distress, nursing ethics, nursing students

Corresponding author: Rowena L Escolar Chua, College of Nursing, University of Santo Tomas, Room 307, San Martin de Porres

Building, España, 1015 Metro Manila, Philippines.

Email: rlescolar-chua@ust.edu.ph

Nursing Ethics
1–11

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Introduction

Changes in healthcare delivery systems globally have placed an increasing emphasis on health promotion and

wellness.
1

From the traditional perspective of being disease-oriented, modern healthcare is now more focused

on health promotion strategies, health risk reduction, and health education. Moreover, due to changing

demographics and increasing healthcare costs, patients are now being discharged early from acute care

facilities to their homes or long-term care facilities.
2,3

These changes have contributed to the expanding role

of community health nurses. Community health nurses play a vital role in health promotion and disease

prevention such as initiating health promotion and health screening programs and other wellness activities. To

enable them to do this, nurses working in various community-based settings need to be culturally competent,

resourceful, proficient in nursing skills, and morally sensitive to the needs of the patients and their families.

However, similar to clinical practice, nurses exposed in community health nursing are also confronted

with various ethical challenges. Community health nurses commonly encounter situations that can be

morally distressing for them. Corley
4

noted that nurses suffer from moral distress when “there is incon-

gruence between the care they are to provide and that which the nurse perceives ought to be provided.”

Some situations that give rise to moral distress in community health settings include providing care without

optimal supports, services and safeguards for patients,
5

inter-professional and intra-professional conflicts

such as differences in opinion among members of the healthcare team,
6–8

lack of resources to provide the

care thought to be appropriate, lack of time to implement the desired care,
8

and challenging clinical

situations such as dealing with non-compliant patients and families. Furthermore, these ethical issues are

often more acute and common in rural and isolated healthcare settings due to limited human and material

healthcare resources available.
5

Moral distress has been found to contribute to nurses’ dissatisfaction with their jobs, professional

burnout, emotional exhaustion, and physical and mental stress.
9

The effects of moral distress can be very

alarming as it can impact nurses’ job performance, damage the moral integrity of nurses, and affect the

quality of care provided to patients and families. Thus, addressing the issue of moral distress among

community health nurses could lead to better job satisfaction and improved work performance, preserve

the moral integrity of nurses, and ultimately enhance the quality of patient care.

Most research on moral distress in nursing has focused on acute care settings. However, a thorough search

of literature has yielded very little research on ethical issues, particularly on moral distress in community

health nursing.
5,8,10

More importantly, these issues have not been explored among undergraduate baccalaure-

ate nursing students. As noted by Escolar Chua,
11

nursing students do encounter moral distress in their clinical

practice but may be hesitant to voice out their concerns due to their being inexperienced and to avoid conflict

and confrontation. Teaching undergraduate students the knowledge and technical skills of nursing do not

prepare them for the realities of ethical dilemmas that they might encounter in the community setting.

Exploration of moral distress in various cultural contexts and population is still needed to enhance our

understanding of this important concern in nursing. Thus, the overall intent of this article is to explore the

moral distress and ethical concerns encountered by undergraduate baccalaureate nursing students in commu-

nity health nursing. Results of this article will assist nursing educators in enhancing the ethical competencies

of nursing students, which they can use in their everyday practice in the community setting.

Methods

Design, study site, and sample

To address the central question of this inquiry, a descriptive qualitative design was employed. The study

was conducted in a comprehensive university in Manila, Philippines, offering a Bachelor’s degree in

2 Nursing Ethics XX(X)

Nursing. Purposive sampling was used to recruit the nursing students and the study included 14 senior

nursing students, aged 18 years and above, with five male and nine female participants. All the participants

had their course in Community Health Nursing in their sophomore year and stayed in the partner commu-

nities in their junior year for 6 and 3 weeks during their senior year. The partner communities are located in

the nearby provinces and the residents living in these communities belong to the low- to middle-income

groups.

Ethical considerations

Institutional review board approval was sought prior to the conduct of the study. After seeking approval

from the Dean of the College of Nursing, the qualified respondents were given information about the aim of

the study. An appointment was made with the nursing students who agreed to participate in the study at a

time and place that was agreeable to both parties. Anonymity and confidentiality were guaranteed. All the

respondents signed a consent form prior to the start of the interviews. All responses from the respondents

were kept anonymous and non-traceable to individual student nurses. Since the interview might have caused

some of the participants to recall some situations where they might feel uncomfortable, the participants had

the option to terminate their participation at any given time. Furthermore, an optional debriefing session

with a licensed psychologist was offered to all participants.

Data collection

The study involved in-depth interviews that were conducted individually from June 2017 to February 2018.

The participants were informed of the nature, relevance, and purpose of the study, and their consent was

obtained. They were asked to complete a demographic questionnaire as part of the study. Prior to the

interviews, participants were asked to think of ethical concerns that might have caused them to experience

moral distress during their exposure to the community. They were asked an open-ended question, which was

“What ethical concerns did you have that caused you to experience moral distress while working in the

community as a student nurse?” The interviews were unstructured and were conducted over a period of 30

min to 1 h until no new information was extracted from the participant. All interviews were tape recorded

with permission from the participants and transcribed for analysis.

Data analysis

A qualitative thematic analysis was used to explore the moral distress and ethical concerns that under-

graduate nursing students experienced in their exposure in community health nursing. The voice-recorded

interviews were transferred verbatim into field texts
12

where phenomenal referents and anchors were

extracted. The transcribed field texts were then scrutinized for repetitions, similarities, and differences.

After which, to facilitate the extraction of themes from the texts, the researcher opted to use a dendrogram.
13

Finally, the cluster of themes was categorized and subjected to validation with the participants and repeated

member checking procedures with the researchers and an external community health nursing expert con-

sultant was done for data trustworthiness.

Findings

Sharing the insights of the nursing students led to a clearer understanding of the moral dilemmas they

encountered during their community exposure. Despite the different communities that they were exposed

to, the experiences they shared overlapped with each other. From the detailed interpretation of the students’

Chua and Magpantay 3

experiences and narratives, three central themes emerged from the personal experiences of the nursing

students in this study.

Discordant modeling: conflicting ideals of healthcare professionals

Healthcare professionals, especially doctors and nurses who are at the forefront of care, are not only

expected to be professional and critical thinkers but more so, to be ethical in their dealings with patients.

However, the nursing students described their experiences with several healthcare professionals in negative

terms such as unethical, rude, and unprofessional. For example, some student nurses articulated,

P1: There are some health care professionals acting like, as if they are gods. Even if you don’t want the patients to

feel inferior because they are the patients, some of the healthcare professionals make them feel inferior. Maybe

the patients don’t know much. But for me, I think they deserve better than that.

P7: One concern I had was the unprofessional behavior of the health care providers. It bothers me to see how rude

they treat patients who really need help.

P13: We had a chance to observe and interact with the patients in the health center. The way the doctor on duty

and nurse who were there behaved, it was very unprofessional Like what we studied in Bioethics are all violated.

It’s just sad. For me, it’s so wrong. They treat patients so badly, it was sick.

In addition to the generally negative behaviors of the healthcare professionals described above, violation

of some basic ethical principles such as confidentiality and justice were also observed. Several student

nurses stated,

P1: Breach of confidentiality, like when we were in the health center, there was information that you know you

can’t say and yet it’s like a norm to them, they divulge the information. People can hear what they say. They don’t

have any regard for confidentiality.

P3: Not everyone is treated equally in terms of their financial standing . . . I was questioning a lot of things to my

instructor because it̀ s not how we were taught. That’s not what I think we were taught.

From the perspective of the nursing students, these kind of behaviors are unacceptable and can yield

negative effects to the healthcare profession. One of the concerns raised by the nursing students was the fact

that some patients might experience psychological trauma due to these kinds of unethical and unprofes-

sional behaviors exhibited by some healthcare professionals. This can lead to a fear of going back to the

healthcare institutions especially during times that they need to seek help for more severe health conditions.

As verbalized by one participant,

P2: They were doing their job but they were very insensitive. It’s like they are not medical professionals. It is both

demoralizing and dehumanizing. The patients might not come back anymore because they are treated that way

before. What if they get a severe illness, but they are already scared to go back because of their bad experience?

Moreover, several nursing students noted that negative behaviors like these can place healthcare pro-

fessionals in a bad light. Doctors and nurses are looked up to by their peers in the healthcare field especially

those who are still undergoing their formal training as student nurses and interns. When situations like these

arise, behaviors like these are generalized to all healthcare professionals, even if its exhibited only by some.

One nursing student stated,

P9: It’s like they are traumatized because of how these people treated them. Not all healthcare workers are like

that but people tend to generalize it to all. One act like that extends to all. They are bad examples to all health

4 Nursing Ethics XX(X)

professionals especially student nurses and interns. We know very well that not all are like that. It’s frustrating. It

really bothers me because we are not all like that.

Disabled sense of self: feeling helpless amidst encountered distressing situations

This theme focuses on the nursing students’ feelings of losing control while in the community, whether it is

because of the environment they are around in or the people around them. Many of the participants struggled

with feelings of frustration due to the lack of resources in the community especially those that relate to their

health as well as how some healthcare professionals treat their patients. In school, student nurses have

always been taught how to be patient advocates. Seeing the realities of community life opened the eyes of

the nursing students to ethical, social, and health issues of underserved communities.

Some of the feelings of frustration and disappointment emanated from the powerlessness felt by the

students when they find themselves facing unethical behaviors of other healthcare professionals. As pre-

viously mentioned, there were situations wherein the student nurses witnessed that the healthcare workers

were acting unethically and they were not able to say or do anything about it. Some of the participants

underscored their frustration through the following statements:

P5: Even if I wanted 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.

P3: Unfortunately, nothing. I wasn’t able to say anything. My group mates as well, we didn’t say anything. I felt

like a coward. It’s like I lost my voice.

P14: What can we do? It’s like you know what is right and yet you can’t stop people from doing it.

The nursing students further elucidated that their hesitance to voice out their concerns despite their role

of being patient advocates were due to their lack of confidence and competence to question the unethical

behavior of others as well as avoiding conflict within the team. A number of the participants even reported

questioning their capabilities and even their sense of self. The following verbalizations support these

observations:

P7: Who are we? We are still studying. They might tell us to shut up because we don’t know anything because we

are just student nurses.

P4: Who are you? You are just a student nurse. So I keep quiet but my heart was heavy. I remember the saying,

Don’t rock the boat. You are just a passenger on the boat. Someone else is steering the boat so just keep quiet.

P8: I was so disappointed also in myself, that I was not able to do anything to correct them because I immediately

thought that I was inferior to them. I had no power.

P12: It’s hard! It’s different when you are a student. Like if I observe . . . a doctor, a nurse, a teacher, someone

older than you . . . it’s disrespectful to say, “hey you are doing something wrong.” They might tell me, what do I

know. I am only a student nurse. So at my stage, I might not have the position to say, “hey stop it.”

Moreover, while it might seem that there are government support and services available to the commu-

nities, there remain unaddressed crucial issues such as the poor living conditions, lack of access to health-

care services, and lack of basic social necessities like safe and clean drinking water. This is illustrated in the

excerpts of several participants:

P6: It really bothers me that they have to walk for kilometers just to have a supply of water. I witnessed and

experienced it myself since we went to the brook where they get their water supply.

Chua and Magpantay 5

P10: They have a health center but it’s at the bottom of the mountain. They still have to walk a long way and go all

the way down.

Encountering disheartening situations like these caused a number of nursing students to have feelings of

sadness and disappointment. As verbalized by several participants,

P14: You feel heavy, you feel there are so many things you can’t do to change the way things are.

P12: It’s a person’s right to have access to basic healthcare services. And yet, they don’t have it because they are

poor. Their situation is so sad. I felt sad because I can’t do anything.

Divergent health ideals: community versus nursing students’ views on health issues

Nursing students have always been taught how to be a patient advocate, mediating on behalf of the patient.

Moreover, student nurses are taught how to provide patient-centered care, focusing on what the patients

need and respecting their decision making. A therapeutic nurse–patient relationship is the foundation for

providing nursing services that can contribute to the patient’s health and well-being. However, there were

instances wherein the student participants felt that it was difficult and challenging to take care of the people

in the community because their ideals and expectations clashed with those in the community. The feeling of

distress felt by some of the nursing students emanated from conflicting views on health issues. Some of the

student nurses

noted,

P5: Another concern I encountered would be the participation of the patients and the knowledge they have when

it comes to their health. The elderly people would at times not come into the health center until they feel

something really bad, because they don’t want to be a burden. It is difficult to change the mindset of “traditions”

or beliefs, especially if the whole family feels the same way.

P11: It was quite distressing to see some preschool children playing by the canal. Even as we told them the canal

is dirty and to play elsewhere, they did not stop. We thought that they lacked parental guidance or wasn’t

educated enough to know the consequences of playing by the canal could bring.

P12: Parents would work day and night just to provide for the family and they would at times disregard their own

health. More health problems can lead to more financial needs, but without work, there would be no finances. It

can be very distressing since I want to understand their situation but I know they also need to take care of

themselves too.

Moreover, there were some people in the community whose lifestyle, beliefs, and values are viewed as

different or unacceptable by the student nurses. The student nurses understand that everyone is entitled to

their own values, attitudes, and beliefs, and that they need to respect that; however, they feel uncomfortable

accepting their behaviors at times:

P6: I have noticed that the youth in ages 14 to 20 are already carrying babies. When presented about the dangers

of early pregnancy, she brushes it off and acts like it’s not a real danger because her friends who also got

pregnant at this early age was able to give birth without a problem. I guess . . . it’s distressing to know

sometimes that they believe that raising kids is easy. For me it’s not, I believe raising kids is a lifetime

responsibility.

P11: There were a lot of instances when we visited the families during our immersion. Parents are separated

because the mother or the father left their families for someone else. No one takes care of the children and they are

neglected. It’s the children who suffer the most.

6 Nursing Ethics XX(X)

Discussion

The in-depth information provided by the respondents contributes to filling the gap in moral distress

literature regarding the experiences of student nurses in community health nursing. While most previous

studies have focused on the moral distress of nurses in clinical settings,
4,14–18

this study explored the

immersion experiences of student nurses in a community health setting. This resulted to surfacing the three

central themes of the study which included moral distress emanating from the unprofessional behavior of

some healthcare workers, the resulting sense of powerlessness among the student nurses, as well as their

differing values and mindsets from the people they serve in the community. The findings of this article run

parallel to that of various authors
11,19–21

which identified that during their undergraduate nursing education,

nursing students are also vulnerable and likely to experience a period of moral distress when faced with

ethical dilemmas and decision-making in clinical practice. Nursing students encounter numerous situations

which make them question their own values and ideals and those of that around them. This also affirms the

findings of Baldwin
22

wherein she noted that there is a disconnect between nursing education and nursing

practice. She noted that student nurses are taught the ideal in school while they encounter morally distres-

sing situations in the real world, where most of the time they compromise what they believe in. Moreover, as

asserted by Zuzelo,
23

current nursing educational programs do not sufficiently teach students how to

identify their feelings of moral distress, much so, how to handle them.

This study also revealed that nursing students encounter moral distress related to the perceived unethical

and unprofessional behaviors of some practicing nurses and physicians which is congruent to the study of

Erdil and Korkmaz.
21

The healthcare profession is focused on providing safe, competent, and quality patient

care, and each member of the healthcare team is expected to behave professionally and ethically. Unfor-

tunately, unprofessional and unethical behaviors of healthcare workers are well documented in the literature

but not limited to disrespecting patients, inappropriate anger, publicly degrading and intimidating patients

and staff
24,25

which negatively impacts patient safety and outcomes. Additionally, violation of patients’

rights such as the right to confidentiality, justice, and privacy are common findings in the community health

setting as observed by the nursing students. Healthcare professionals are obligated to observe the various

ethical principles such as respect for the person, autonomy, beneficence, non-maleficence, and confidenti-

ality, among others. Findings of this study concur with that of the study of Aroca et al.
26

wherein they

reported that breaches to confidentiality and privacy in clinical practice are common due to carelessness and

indiscretion of some healthcare workers. Furthermore, according to Ulrich et al.,
27

common unethical

practices of healthcare professionals were breaches of patient confidentiality, right to privacy, autonomy

issues, and end-of-life decision-making. Notably, this affirms the findings of Butters
28

and Nordam et al.
29

that failure to provide just and ethical care to clients potentiates the moral distress of nurses.

It is also crucial to note that nursing students believe that unethical and unprofessional behaviors of some

healthcare workers can have a significant negative impact not only on patient care but also on other

healthcare professionals. These findings affirm the study done by Fayez et al.,
30

where they noted that

students who observed unethical incidents and behaviors from physicians can lead them to have “traumatic

de-idealization” where students become cynical, experience moral distress, and lose their moral sensitiv-

ities. Moreover, moral distress can lead to anger, hopelessness, depression, shamefulness, and disappoint-

ment.
31

Accordingly, novice healthcare workers may become dissatisfied
32

and choose to leave their chosen

profession because of the negative environment and experiences that they encounter.

Another disconcerting finding in the study is the fact that the moral distress emanating from the

perceived rampant unethical behaviors of healthcare practitioners can be a deterrent among the people in

the community in seeking care and treatment for illnesses. When moral distress is not resolved, long-term

consequences emerge and moral residue occurs. This can include tolerance and compromise on the health-

care worker’s part and dissatisfaction on the part of the patient receiving the care.
31

More than that, it also

Chua and Magpantay 7

breeds distrust in the entire healthcare profession which can impact their health seeking behavior. This is in

line with the studies of Lavado et al.,
33

Hechanova et al.,
34

Quimbo et al.,
35

and Fitzpatrick et al.
36

wherein

they noted that negative perceptions on care delivery, trust issues, and lack of responsiveness among

healthcare providers were more significant deterrents than concrete barriers (e.g. geographical barriers).

The manner of care and service by healthcare practitioners play an important role, not only in the health-

seeking behavior of those in the community but also in their healthcare utilization.

Findings of the study also revealed that nursing students experience moral distress when they confront

situations in the community setting where there is inadequate basic care, lack of healthcare facilities, limited

financial resources and lack of trained healthcare workers. As part of the community themselves, the

nursing students expected that fair and equitable access to healthcare is available for all, that every single

person should be respected and receive compassionate care and that resources are provided for disease

prevention and health promotion. It is undeniable, however, that this may not be true at all times. As noted

by Brazil,
5

ethical issues are more common in rural health settings due to the limited resources available.

Moreover, conflict or crisis occurs when a person’s expectations are not met which could be the result of

having unreasonable expectations or it could be that the government or the healthcare system did not

provide what one should reasonably expect. This finding is congruent with that of Taylor and Hill
37

where

they noted that consumers in the community expect their governments, health service providers, and health

practitioners to assist them in managing their health when possible and to provide appropriate and equitable

access to healthcare. Realizing the realities of the deep inequities in public health and how it affects the

people in the community, the nursing students felt morally distressed and challenged; however, they feel

powerless because they feel they do not have the capacity to change anything at this time. This runs parallel

to Hartrick Doane and Varcoe’s
38

study where they noted that nurses are constantly challenged to provide

quality nursing care but due to the limitation in resources, they are not able to fulfill their obligations and

their role as patient advocates. The findings of this article also resonate the results of Burston and Tuckett,
39

Almonte,
40

Laabs,
41

and Kälvemark et al.
42

wherein they noted that being unable to provide proper care due

to unavailability of resources can lead to intense feelings of inadequacy and reinforce moral distress.

It is also troubling to note that the nursing students feel they are not able to voice out their concerns

regarding the unethical situations they observed. They were reluctant to speak up despite the fact that they

knew that some of the situations they witnessed were erroneous or unethical. This is consistent with

previous studies by Bradbury-Jones et al.,
43

Bradbury-Jones et al.,
44

and Levett-Jones and Lathlean,
45

where they noted that student nurses are hesitant to voice out their opinions because they do not want to

“rock the boat.” Similarly, student nurses also feel that they do not have the authority to verbalize their

concerns due to their feelings of incompetence and inexperience.
11

Being novice healthcare practitioners,

they “conform and comply”
45

to maintain group consensus, prevent conflict, and avoid shame.
11

This

finding echoed as well the study of Stacey et al.,
46

where student nurses appeared to justify their acceptance

by regarding their powerlessness as an inevitable consequence of their position within the system. The

feelings of powerlessness felt by these nursing students can lead to moral distress, frustration, exasperation,

dissatisfaction with the healthcare system, cynicism, and disengagement.
47

These negative emotions and

outcomes can have serious consequences, both personal and organizational,
48–52

that can affect the nurses

themselves as well as the people they care for.

Finally, the nursing students also verbalized that another source of moral distress during their community

immersion is the differing cultures, beliefs, and ideals of the people in the community that at times goes

against their personal beliefs and convictions. Nurses are expected to develop trust and effective relationships

with their patients for them to provide the best quality patient care; however, nurses often experience conflict

and moral distress when the values they hold is not in accord with that of their patients.
53

Nurses are constantly

challenged in their clinical exposure when dealing with non-compliant patients and families
8

but an important

part in establishing trust between patients and nurses is to acknowledge and respect individual cultural and

8 Nursing Ethics XX(X)

value differences. If moral distress continues and conflicts are unresolved, this can hinder the nurse’s ability to

provide quality patient care. As Narayanasamy,
54

Leininger and McFarland,
55

and Campinha-Bacote
56

noted,

healthcare workers’ attitudes and personal biases can serve as barriers to culturally competent care.

Conclusion

Moral distress among nursing students is increasingly becoming a key issue in nursing. There is a need to

explore the sources of moral distress among nursing students because it can affect their decision, not only to

stay and survive in the nursing profession but to thrive in it as well. This study aimed to describe the morally

distressing experiences of a select group of nursing students as they went through their community health

nursing exposure. From their individual and collective experiences, three central themes were derived

which described their moral distress arising from ethical concerns such as the unprofessional and unethical

behavior of healthcare professionals, feeling of powerlessness to change the community’s situation, as well

as from the conflicting values and ideals of the nurse and the people they serve. This study has important

implications for nursing literature as it provides educators a glimpse of the morally distressing situations

that often occurs in the community setting. It suggests the importance of raising awareness and understand-

ing of these situations so as to assist nursing students to prepare themselves to the “real world,” where the

ideals they have will be constantly challenged and tested. Despite the fact that ethics education is present in

nursing education, nursing students still struggle with it in real life situations. Support strategies should be in

place such as debriefing students after each exposure, discussing and questioning them about values and

principles they have learned, and assisting them to be morally sensitive and morally courageous so that they

are able to cope with the various ethical conflicts they encounter.

While this study provided an interesting description of the moral distress of nursing students in the

community setting, it is important to note that Strauss and Corbin
57

are keen in their stand that general-

izability is not the primary goal of a qualitative research. Hence, it is recommended that the applications of

this study be implemented on a wider scale, which can include a larger sample size, different cultural

backgrounds, and more diverse gender mix in order to explore more of these experiences. It is also

suggested that future longitudinal studies be conducted to assess how nursing students were able to cope

with morally distressing situations and how it affects their decision to stay in the profession.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or

publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Rowena L Escolar Chua https://orcid.org/0000-0002-0517-6174

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Chua and Magpantay 11

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http://www.eaber.org/sites/default/files/documents/PIDS_Lavado_2010

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