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.