PREVALENCE AND FACTORS ASSOCIATED WITH MORAL DISTRESS AMONG UNDERGRADUATE NURSING STUDENTS IN KHYBER PAKHTUNKHWA (KPK), PAKISTAN

Abstract

Moral distress represents an acute psychological and ethical challenge in nursing education, occurring when students recognize the ethically appropriate action but are constrained by institutional hierarchies, systemic resource shortages, or clinical evaluative pressure. In developing healthcare environments, this disconnects between theoretical education and clinical reality becomes particularly severe. This analytical cross-sectional study evaluated the point prevalence and factors associated with moral distress among undergraduate nursing students during clinical rotations in Khyber Pakhtunkhwa (KPK), Pakistan. Conducted across nursing colleges with N = 294 regular undergraduate BS Nursing students (3rd to 8th semesters), data were gathered via a structured online survey (Google Forms) containing demographic details, the single-item 11-point Moral Distress Thermometer (MDT, scale 0–10; Cronbach’s α = 0.732), and a 22-item checklist assessing reasons for withholding ethical action. Data analysis was performed using IBM SPSS Version 26.0 through descriptive metrics and inferential Chi-square tests of independence (p < 0.05). Findings revealed that 82.0% (n = 241) of students experienced active moral distress (MDT score 4 or above), with an overall mean score of 5.51±2.06. Categorically, 48.0% suffered from moderate distress, 34.0% experienced severe distress, 17.7% reported mild distress, and only 0.3% indicated zero distress. Severe moral distress was significantly associated with male gender (χ² = 11.382, p = 0.010; 38.5% male vs. 21.1% female) and clinical rotation areas (χ² = 50.687, p < 0.001), with surgical units (42.4%) and specialized departments (51.0%) having the highest rates. Academic semester was not significantly associated with distress levels (χ² = 10.598, p = 0.102). Among the 22 withholding factors, 8 cognitive and psychological barriers significantly predicted moral distress severity (p < 0.05): general fear (p = 0.001), lack of knowledge (p = 0.003), nervousness and fear of being wrong (p = 0.007), lack of self-confidence (p = 0.022), concern over grades (p = 0.026), confusion over clinical matters (p = 0.036), reluctance due to previous failed attempts (p = 0.037), and fear of assigned preceptors (p = 0.044). The study highlights the urgent need for supportive preceptorship, simulation-based ethical dilemma training, and institutional psychological safety to protect student well-being and clinical retention.