DIFFERENCES IN MORAL

JUDGMENT BETWEEN NURSING

STUDENTS AND QUALIFIED NURSES
Yong-Soon Kim, Jin-Hee Park and Sung-Suk Han
Key words: moral judgment; nursing student; qualified nurse

This longitudinal study examined how nursing students moral judgment changes after
they become qualified nurses working in a hospital environment. The sample used was a
group of 80 nursing students attending a university in Suwon, Korea, between 2001 and
2003. By using a Korean version of the Judgment About Nursing Decisions questionnaire,
an instrument used in nursing care research, moral judgment scores based on Ketefians
six nursing dilemmas were determined. The results were as follows: (1) the qualified
nurses had significantly higher idealistic moral judgment scores than the nursing students;
(2) the qualified nurses showed significantly higher realistic moral judgment scores than
the nursing students; and (3) when comparing idealistic and realistic moral judgment
scores, both the qualified nurses and the nursing students had higher scores for idealistic
moral judgment. Further study is recommended to examine changes in moral judgment.

Background
Advances in science and industrial development have conversely created adverse
effects on levels of ethical sensitivity and moral justice owing to the dehumanization
of patients.1 Advancements in medical technology have reached the level of clone
creation. As moral issues in health care become increasingly familiar, health
care professionals who are subject to high levels of moral decision making2 must be
aware of human dignity and values.
For professional nurses in particular, the need for ethical values is increasingly
emphasized. Nursing is recognized as a professional field and the responsibilities of
nurses must also meet professional standards. The codes of ethics of both the
International Council of Nurses and the Korean Nurses Association state that the true
character of the nurse is to respect the dignity of human nature and the rights of
people. Accordingly, as advocates for patients, nurses are expected to achieve the best
possible outcomes for patients rather than to make decisions solely based on a medical
perspectives.3

Address for correspondence: Professor Sung-Suk Han, The Catholic University, College of
Nursing, 505 Banpo-dong Socho-gu, Seoul 137-701, Korea. Tel: /82 02 590 1287; Fax: /82 02 590
1297; E-mail: hanss@catholic.ac.kr

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310 Y-S Kim et al.

Health care professionals, including nurses, therefore need to understand the

situations nurses encounter in practice and in diverse decision-making circumstances.
Although some Korean nursing and medical schools provide courses in bioethics to
aid future professionals in making informed decisions, education in ethics, justice and
accountability is not compulsory. Issues of euthanasia, nursing personnel shortage and
incompetent practice are found in only a few nursing programs, despite the fact that
these pose the most frequent ethical problems for nurses.4 Thus, systematic educa-
tional programs in ethics need to be developed so that students can have a better
foundation for the decision-making skills that are integral to the practice of nursing.3
6
Kohlberg7 proposed that certain conditions may stimulate or account for the level of
a persons moral development, and the change demonstrated displays the process of
active response to social issues and moral situations. Decisions made about social
values provide a conceptual basis for morality, and, with a considerable number of
stages, the development of morality is achieved through experiences in personal
settlement of social moral issues. In clinical practice, nurses face such moral dilemmas
when they encounter, for example, abortion, euthanasia or conflict among profes-
sionals.5.8 In such situations, professional nurses often encounter ethical dilemmas,
and most are not prepared to make moral judgments.9
11 Although nursing students
learn idealistic nursing ethics, they become stressed when dealing with real ethical
dilemmas, which may not necessarily reflect what they have learned in theory.12
14
This study was conducted to analyze how students moral judgments changed with
their transition to qualified nursing practice; to make suggestions for helping nursing
students and professional nurses to form good values; to shape ethics education
policies by identifying the factors affecting moral judgments; and to provide helpful
guidance to nursing practice and research.

Aims of this research

The aims of this study were:
1. To determine the differences in idealistic and realistic moral development scores
between nursing students and qualified nurses (hospital settings);
2. To analyze the difference between idealistic and realistic moral decision scores;
and
3. To identify the factors affecting the idealistic and realistic decision-making
abilities of qualified nurses.

Method
Design and sample
In this longitudinal study the Judgment About Nursing Decisions (JAND) ques-
tionnaire was administered to nursing students in their senior years and later when
they were working in hospitals as qualified nurses. The first research participants were
100 students in their senior years between 2001 and 2003 at a nursing school in Suwon,
Korea. Prior to the survey, the students were informed about the purpose and content

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 Moral judgment 311

of the study; they were told that their participation was voluntary and their verbal
consent was obtained. The questionnaire was distributed only to those students who
agreed to participate. The second data collection took place from October to December
in 2004, when the questionnaire was mailed to each participant who had filled in the
first questionnaire and were working in hospitals as qualified nurses. Only 80 nurses
agreed to participate in the second data collection and returned the questionnaire.

Instrument
The JAND tool for scoring moral judgment was first introduced by Ketefian;15 the
Korean version used for this study was developed by Kim16 to customize it for the
Korean population. JAND is a popular instrument used in nursing care research and
consists of two rows (row A and row B) and six case examples of different nursing
dilemmas on which the responses are based. Row A relates to idealistic moral
judgments, showing ideal behaviors when there are no restrictions from within
the organization. It demonstrates professionally ideal choices that a nurse could
follow if no constraining factors are present. Examples of restricting or constraining
factors include organizational norms, autonomy, feedback from supervisors and co-
workers.15 Row B displays the realistic behaviors nurses would have or are expected to
have according to the given rules or restrictions operating in their organization.
The responses to these questions are in terms of a choice being a realistic choice
that a nurse is most likely to follow when considering the possible constraints that
may be present.
Case 1 contains a dilemma where a nurse reports to the organization about his or her
colleagues misbehavior in order to protect a given patient. The second case involves
interpersonal relations: a nurse faces the dilemma of whether to report the insincerity
of a physician to the organization. Case 3 is based on a clinical trial and asks whether a
health care professional should press for autopsies to be carried out in the interest of
medical advancement. The fourth case is also about a clinical trial and focuses on
whether to offer a medicine that is in an experimental stage. In case 5, the sharing of
resources and ethics are emphasized to illustrate a dilemma between a shortage of
nursing staff and the quality of practice. The final case, on ethics related to death,
presents the dilemma of whether or not to withhold treatment for end-stage cancer
patients.
These six cases have a total of 39 associated questions (there are six or seven
questions for each case) concerning idealistic and realistic judgments: a proper moral
judgment earns 1 point; an improper judgment scores 0. The criteria for determining a
judgments appropriateness are based on the codes of ethics of the International
Council of Nurses and the American Nurses Association. The correct answers in row A
are used to score idealistic moral judgments (if the nurse should or should not do
something), and those in row B are for realistic moral judgments (whether the nurse is
realistically likely to do or not do something).
The internal consistency of the study by Ketefian15 was shown by a Cronbachs
alpha value of 0.70. In the study by Kim and Park,17 Cronbachs alpha for idealistic
moral judgments was 0.63 and for realistic moral judgments it was 0.56. Cronbachs
alpha values for the present study were 0.64 and 0.58 for idealistic and realistic moral
judgments, respectively.

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312 Y-S Kim et al.

Data analysis
The general characteristics of the participants were calculated as percentages, and a
paired t-test was used to analyze differences between the idealistic and realistic
judgment scores. The factors affecting moral judgment were determined by an
independent t-test and analysis of variance.

Limitations of the study

This study examined moral judgment, which is a cognitive process; the data should
thus have been adjusted for differences in the cognitive characteristics of each
participant. However, we did not control for their critical thinking, intellectual abi-
lities or job experience. Moreover, the total number of participants was very small.
Although JAND is a popular tool used in nursing ethics research, the Cronbachs
alpha scores were low. It is thus not possible to make broad generalizations from
the results.

Results
Sociodemographic factors
The general characteristics of the participants are summarized in Table 1. The
percentages for clinical experience were: 5/12 months, 31.3%; 13
/24 months, 38.7%;
and 25
/36 months, 30.0%. Many of the participants, 41.3%, worked in intensive care
units (ICUs). Most, 82.5%, answered that their father had graduated from college or
higher, while for 17.5% this was from high school. On the question of their mothers

Table 1 Sociodemographic factors (n /80).

Variable Category No. (%)

Clinical experience (months) 5/12 25 (31.3)

13
/24 31 (38.7)
25
/36 24 (30.0)
Department General ward 28 (35.0)
ICU 33 (41.3)
Other 19 (23.7)
Fathers education High school 14 (17.5)
College or higher 66 (82.5)
Mothers education High school 22 (27.5)
College or higher 58 (72.5)
Religion Religious 58 (72.5)
Non-religious 22 (27.5)
Place in family Eldest 39 (48.7)
Middle 27 (33.8)
Youngest 14 (17.5)
Monthly income (US$) 5/2000 27 (33.7)
2000
/3000 27 (33.7)
/3000 26 (32.6)

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 Moral judgment 313

education, 72.5% replied college or higher. The percentage of the participants who
practiced a religion was 72.5%. For their place in their family, eldest accounted for
48.7%; middle for 33.8%; and youngest for 17.5%. Monthly income was 5/US$2000
in 33.7%; US$2000
/3000 in 33.7%; and /US$3000 in 32.6%.

Moral judgment scores

Idealistic moral judgment scores
The differences in idealistic moral judgment scores between when the participants
were students and when they were qualified nurses are shown in Table 2. In
general, these scores were significantly higher when they were qualified than when
they were students (t/ /4.982, p B/0.001). We found significant score differences
for case 1 (t/ /10.737, pB/0.001), case 2 (t/ /8.345, pB/0.001) and case 3 (t/
5.560, p B/0.001). In both cases 1 and 2, the idealistic moral judgment scores when
qualified were higher than those obtained when nursing students. On the contrary,
for case 3, the idealistic moral judgment scores were lower when they were
qualified nurses.
Although the idealistic moral judgment scores increased slightly after the students
became qualified nurses, no significant difference was found in case 4 (t/ /0.253,
p B/0.801), case 5 (t/ /0.616, P/0.539) or case 6 (t / /1.917, P/0.059).

Realistic moral judgment scores (Table 3)

Overall, the realistic moral judgment scores were significantly higher after qualifica-
tion than when studying (t/ /2.692, P/0.009). In case 1, the participants scored
higher for realistic moral judgment after qualification (t/ /10.377, P B/0.001).
However, the participants realistic moral judgment scores when qualified nurses

Table 2 Differences in idealistic moral judgment scores when participants were

nursing students and when professional nurses (n /80).

Variable Nursing students Professional nurses Paired t-test P value

Mean9/SD Mean9/SD
a
Case 1 0.8109/0.091 0.9469/0.083 /10.737 B/0.001
Case 2b 0.6009/0.154 0.8099/0.151 /8.345 B/0.001
Case 3c 0.8189/0.132 0.7119/0.127 5.560 B/0.001
Case 4d 0.8429/0.135 0.8489/0.160 /0.253 0.801
Case 5e 0.9529/0.089 0.9639/0.109 /0.616 0.539
Case 6f 0.9139/0.132 0.9419/0.11 /1.917 0.059
Total 0.8209/0.062 0.8699/0.065 /4.982 B/0.001
a
Medication errors by nurses.
b
Insincere practices by physicians.
c
Recommending autopsy for medical research.
d
Testing of new medicines for medical research.
e
Staff shortage.
f
Suspending treatment for terminally ill patients.
SD, standard deviation.

Nursing Ethics 2007 14 (3)

314 Y-S Kim et al.

Table 3 Differences in realistic moral judgment scores when participants were

nursing students and when professional nurses (n /80).

Variable Nursing Professional Paired t-test P value

students nurses

Mean9/SD Mean9/SD

Case 1 0.5759/0.150 0.8069/0.179 /10.377 B/0.001

Case 2 0.4919/0.185 0.5099/0.204 /0.571 0.570
Case 3 0.7309/0.136 0.6849/0.134 2.325 0.023
Case 4 0.7219/0.179 0.6219/0.186 3.802 B/0.001
Case 5 0.9009/0.165 0.9339/0.105 /1.633 0.106
Case 6 0.8779/0.147 0.8919/0.123 /0.775 0.441
Total 0.7149/0.077 0.7469/0.080 /2.692 0.009

For subjects of cases 1
/6, refer to Table 2.

were significantly lower than those when they were students for case 3 (t/2.325,
P /0.023) and case 4 (t/3.802, P B/0.001). Although when qualified the nurses
showed slightly higher realistic moral judgment scores, there were no significant
differences for case 2 (t / /0.571, P /0.570), case 5 (t/ /1.633, P/0.106) and case
6 (t/ /0.755, P /0.441).

Differences between idealistic and realistic judgments

The differences between participants idealistic and realistic moral judgment scores
are presented in Table 4. For both when students (t /11.319, P B/0.001) and when
qualified nurses (t/11.861, P B/0.001), the idealistic moral judgment scores were
remarkably higher than the realistic moral judgment scores for all the cases.
When the participants were nursing students, both the idealistic and realistic
judgment scores were highest for case 5 but lowest for case 2. When they were
qualified nurses, both the idealistic and realistic judgment scores were also highest for
case 5; the idealistic and realistic moral judgment scores were lowest for cases 3 and 2,
respectively.

Moral judgments according to sociodemographic factors

The sociodemographic factors affecting moral judgment are given in Table 5. We
analyzed the factors that are widely known to affect moral judgment: career
experience, department, educational level of parents, religion and monthly income.
We found that monthly income had a significant effect on the idealistic moral
judgment scores (F /3.580, P /0.033) but other factors had no significant effect on
moral judgments.
Although there was no significant difference for career experience, the idealistic
and realistic moral judgment scores were highest at 0.885 and 0.764, respectively, in the
5/12 months group. In terms of work department, the nurses working in a general
ward showed higher idealistic moral judgment scores but lower realistic moral
judgment scores than those at an ICU unit.

Nursing Ethics 2007 14 (3)

 Table 4 Differences between idealistic judgment and realistic judgment (n/80).

Variable Nursing students Professional nurses

Idealistic Realistic t (P value) Idealistic Realistic t (P value)

Mean9/SD Mean9/SD Mean9/SD Mean9/SD

Case 1 0.8109/0.091 0.5759/0.150 13.887 (B/0.001) 0.9469/0.083 0.8069/0.179 7.062 (B/0.001)

Case 2 0.6009/0.154 0.4919/0.185 4.474 (B/0.001) 0.8099/0.151 0.5099/0.204 11.382 (B/0.001)
Case 3 0.8189/0.132 0.7309/0.136 4.191 (B/0.001) 0.7119/0.127 0.6849/0.134 2.147 (0.035)
Case 4 0.8429/0.135 0.7219/0.179 5.056 (B/0.001) 0.8489/0.160 0.6219/0.186 9.482 (B/0.001)
Case 5 0.9529/0.088 0.9009/0.165 2.692 (0.009) 0.9639/0.109 0.9339/0.105 2.402 (0.019)
Case 6 0.9139/0.132 0.8779/0.147 2.545 (0.013) 0.9419/0.111 0.8919/0.123 4.094 (B/0.001)
Total 0.8209/0.062 0.7149/0.077 11.319 (B/0.001) 0.8709/0.065 0.7469/0.080 11.861 (B/0.001)

For subjects of cases 1
/6, refer to Table 2.

Moral judgment 315

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 316

Table 5 Moral judgment according to sociodemographic factors (n/80).

Variable Category No. (%) Idealistic moral judgment Realistic moral judgment

Mean9/SD F (P value) t (P value) Mean9/SD F (P value) t (P value)

Career experience 51/ 2 25 (31.3) 0.8859/0.062 0.7649/0.081

Y-S Kim et al.

(months)

Nursing Ethics 2007 14 (3)

13
/24 31 (38.7) 0.8709/0.058 0.7289/0.080
25
/36 24 (30.0) 0.8529/0.074 0.7529/0.078
1.639 (0.201) 1.499 (0.230)
Department General 28 (35.0) 0.8859/0.054 0.7299/0.099
ward
ICU 33 (41.3) 0.8549/0.078 0.7559/0.075
Other 19 (23.7) 0.8719/0.048 0.7579/0.055
1.781 (0.175) 1.044 (0.357)
Fathers education High school 14 (17.5) 0.8559/0.075 0.7629/0.061
College or 66 (82.5) 0.8749/0.061 0.7419/0.086
higher
/1.187 (0.239) 1.018 (0.312)
Mothers education High school 22 (27.5) 0.8619/0.072 0.7479/0.082
College or 58 (72.5) 0.8749/0.061 0.7469/0.080
higher
/0.852 (0.397) 0.023 (0.981)
Religion Religious 58 (72.5) 0.8719/0.061 0.7449/0.082
Non-reli- 22 (27.5) 0.8669/0.075 0.7539/0.078
gious
0.311 (0.757) /0.468 (0.641)
Place in family Eldest 39 (48.7) 0.8829/0.064 0.7439/0.089
Second 27 (33.8) 0.8599/0.053 0.7569/0.065
Youngest 14 (17.5) 0.8539/0.084 0.7389/0.085
1.630 (0.203) 0.285 (0.753)
Monthly income (US$) 5/2000 27 (33.7) 0.8879/0.045 0.7409/0.075
2000
/3000 27 (33.7) 0.8779/0.066 0.7369/0.089
/3000 26 (32.6) 0.8439/0.065 0.7639/0.075
3.580 (0.033) 0.876 (0.421)
 Moral judgment 317

Discussion
Nursing ethics is a required curriculum subject for nursing students in most Korean
universities. However, in the majority of colleges ethics is not taught as a separate
subject and is included only in an introductory module or in the nursing management
module of the curriculum.4 Nursing students usually experience ethical dilemmas
when they go on their first clinical placement and develop a new ability to make moral
decisions.6,13 In this study, it was found that the idealistic moral scores were higher
than the realistic moral scores both before and after qualification, which is consistent
with the findings of other studies using the JAND instrument.17,18
Comparisons between the idealistic and realistic moral judgment scores showed
that, in all cases, the realistic scores were relatively lower in both phases of the study.
In particular, nurses in practice need to make proper decisions using realistic moral
views based on idealistic moral judgments. The study showed that when the
participants were engaged in nursing practice they had difficulty in applying idealistic
moral judgments to realistic decision-making situations. This implies that, when
individuals are faced with moral dilemmas they tend to apply actions that are based
on specific rights and duties rather than considering an abstract concept for any given
situation.19
When comparing the participants as students and as nurses in practice, except for
cases 3 and 4, it was clear that the idealistic and realistic moral judgment scores after
qualification were relatively higher than those when they were students, indicating
that practical nursing experience enhanced their moral judgment scores after the
students became qualified nurses.
In cases 3 and 4, which were based on moral judgments of medical research, the
qualified nurses however displayed lower scores than when they were students. In
particular, both the idealistic and realistic moral judgment scores were much lower for
case 3. This result may be exceptional because the data were gathered in Korean
hospital settings, where autopsies are rarely carried out, and may also be due to the
interests of individual researchers being in conflict with those of their organization and
research participants.
Nevertheless, patients rights are exceedingly important when the target of research
is human nature.20 Informed consent (when study participants are given a full
explanation and researchers ensure that the participants fully understand the
implications before they give their consent to involvement), is especially important
from an ethical point of view.21 Any such clinical study could enhance patients health
status or it may cause unexpected harm; therefore it is essential that patients
voluntary informed consent has an ethical basis. This study showed that, when
qualified, the nurses achieved lower moral judgment scores in the cases concerning
medical research. This means it is necessary to offer more ethics-centered education to
provide sufficient information about medical research and to ensure that researchers
follow the rules of informed consent.22
Among the sociodemographic factors affecting moral judgment, the various levels of
monthly income generated a significant difference in the idealistic moral judgment
scores. None of the other factors were statistically significant. These findings are
significantly different from the results previously obtained by Kim et al.,18 which
showed idealistic moral judgments to be affected by age, fathers educational level,

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318 Y-S Kim et al.

department and career experience, while the realistic moral judgments were
influenced by department alone.
Although the difference was not significant, the nurses with less career experience
had higher idealistic moral judgment scores. This is consistent with the finding that
there was a significant difference in idealistic moral judgment scores according to
monthly income because the monthly income of nurses in Korea depends on their
years of service. In terms of department, the nurses working in a general ward showed
higher idealistic moral judgment scores but lower realistic moral judgment scores than
those working in an ICU, implying that, after qualification, the nurses had higher
idealistic and realistic moral judgment scores in their early career than when they were
students, but their moral judgment scores gradually decreased. Since examples of the
cases used in the JAND more often take place in general wards than in ICUs, the
nurses working in a general ward had higher scores in idealistic moral judgments but
lower scores in realistic moral judgments than those working in an ICU. This is
indicative of a need to offer ethics-centered education programs, particularly to nurses
in general wards. In addition, factors such as department and career experience must
be considered in order to create suitable ethics programs. In this study, however, the
sample size was too small to obtain consistent results. Further studies should be
conducted to develop efficient tools for ethical thinking in Korean culture.

Conclusion and recommendations

This longitudinal study examined how Korean nurses shifted ethically after becoming
qualified nurses in practice. We analyzed the outcomes of the research and factors
affecting the development of moral judgment. Fundamental suggestions for ethics-
centered education were proposed and guidance for practice and further research has
been introduced.
In summary, the findings suggest that idealistic moral judgment scores of nurses in
practice are relatively high compared with when they were nursing students.
However, in the cases of recommending autopsy for medical research and testing
of new medicines for medical research, when qualified, the participants scored lower
on making moral decisions compared with the student scores. In comparing idealistic
and realistic moral judgment scores, higher scores were obtained for idealistic moral
judgment in both qualified and unqualified phases of the study.
This study revealed that moral judgment scores in the case of medical research were
lower when the participants were qualified nurses than when they were students. No
matter how much interventions or medical research seem helpful to patients, nurses
should be sensitive to their patients right to refuse both such care and participation in
research when patients are unable to give consent. Schopp et al.23 emphasize the role of
ethics education in achieving this and that the principles of informed consent should
be taught in a basic nursing ethics education course. According to Kohlberg,24 an
environment that provides opportunity for group participation, shared decision
making, and assumption of responsibility for the consequences of actions, tends to
stimulate moral judgment development.
Based on these results, future studies should aim to examine the development of
moral judgment in nurses and to identify the influencing factors for moral judgment
development. We also suggest that attention should be paid to patients decisions and

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 Moral judgment 319

to health care providers responsibility for nursing practices in current health policies.
Ethics-centered education should be provided to enable nurses to become expert in
practicing their profession within the law.

Yong-Soon Kim and Jin-Hee Park, Ajou University, Suwon, Korea.

Sung-Suk Han, The Catholic University, Seoul, Korea.

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