Most nursing students feel moral pressure in clinical practice, Slovenian survey finds

Nursing students in Slovenia often report being pushed to act against their moral principles during clinical placements, yet this pressure appears to be unrelated to how strongly they endorse Kant-informed ethical principles or whether they can recognise a basic description of Kantian duty ethics. Those are the central findings of a cross-sectional survey of 205 undergraduate and postgraduate nursing students, published as an open access article in BMC Medical Ethics on 19 October 2026 by Sabina Ličen, Sandra Martinuč and Mirko Prosen.

The study set out to examine whether three things line up: students’ self-reported Kant-informed ethical orientation, their ability to identify a duty-based description of Kantian ethics, and their perceived pressure to act against their moral principles during clinical practice. The researchers also wanted to identify educational and demographic factors associated with ethical orientation. Ethical orientation was measured with a newly developed instrument, the Kantian Ethical Orientation Scale for Nursing Students (KEOS-NS), while recognition of Kantian ethics and perceived moral pressure were each captured with single items.

The results reveal a striking gap between theoretical recognition and lived experience. Only 75 students, or 36.6 percent, correctly identified Kantian ethics as duty-based, meaning nearly two-thirds could not match the theory to its core idea despite the survey’s focus on Kant-informed orientation. At the same time, 126 students, or 61.5 percent, reported having felt pressure during clinical practice to act contrary to their moral principles. Neither of these two factors was associated with KEOS-NS scores, suggesting that recognising a philosophical framework, endorsing its principles, and experiencing moral strain in practice are distinct dimensions of ethical learning rather than a single competency.

Employment status did matter for moral pressure. Students who were employed in nursing were more likely to report perceived moral pressure than those who were not, at 72.7 percent versus 56.1 percent, with an odds ratio of 2.09 (95 percent confidence interval 1.10 to 3.94). This association, tested with a chi-square test, hints that greater exposure to real clinical work environments may come with more frequent conflicts between what students believe is right and what they feel pushed to do.

Level of study showed the opposite pattern for ethical orientation. Second-cycle students had lower KEOS-NS scores than first-cycle students, and level of study remained the only significant individual predictor in the multivariable linear regression model, with a coefficient of −5.57 (95 percent CI −9.94 to −1.19; p = .013). The authors are careful to flag the limits of this result: the overall regression model was not statistically significant (p = .265), and the bootstrap confidence interval included zero. The lower scores among second-cycle students therefore require further investigation rather than firm interpretation.

Methodologically, the study is a cross-sectional survey, so it captures a snapshot at one point in time and cannot establish causal relationships. Associations were examined using non-parametric tests and multiple linear regression, appropriate for the data structure, but single-item measures of Kantian ethics recognition and perceived moral pressure are necessarily coarse. The sample was limited to nursing students in Slovenia, which constrains how far the findings generalise to other countries or healthcare professions.

The authors conclude that recognition of a basic duty-based description of Kantian ethics and endorsement of Kant-informed ethical principles appear to represent distinct aspects of ethical learning. Perceived moral pressure was common but was not associated with ethical orientation, indicating that students can endorse ethical principles while still feeling pressure to act contrary to them in practice. On that basis, they argue that ethics education should connect theoretical frameworks with critical reflection on ethically challenging clinical experiences, so that classroom learning and ward realities are addressed together rather than in isolation.

Subject of Research: The relationship between Kant-informed ethical orientation, recognition of Kantian duty ethics, and perceived moral pressure among nursing students in Slovenia

Article Title: Kant-informed ethical orientation, recognition of Kantian duty ethics, and perceived moral pressure among nursing students: a cross-sectional study

Article References: Ličen, S., Martinuč, S., & Prosen, M. (2026). Kant-informed ethical orientation, recognition of Kantian duty ethics, and perceived moral pressure among nursing students: a cross-sectional study. BMC Medical Ethics. https://doi.org/10.1186/s12910-026-01650-w

Image Credits: AI Generated

DOI: 10.1186/s12910-026-01650-w

Keywords: nursing students, Kantian ethics, moral pressure, clinical practice, cross-sectional study, ethical orientation, ethics education, Slovenia, KEOS-NS, duty ethics, Kant-informed, ethical