Modeling How Moral Distress & Ethical Confidence Impact Nurses' Emotional & Physical Health and Safety Culture

护士在提供适当护理方面每天都会遇到道德挑战--这种情况可能会 未解决或解决得不令人满意--可能会导致精神上的痛苦(即无法执行 由于内部或外部的限制，被认为是道德上适当的行动)。因此，许多人 经历焦虑、抑郁、自杀风险和其他与健康相关的问题。很少有系统的研究 重点关注减少或加剧精神痛苦的因素--尤其是护士的精神痛苦如何影响 护士、病人和组织结果。此应用程序建立在我们成功的科学计划的基础上 经验性生命伦理学研究，并使用混合方法设计来解决三个互补的目标，通过 调查了四个地理位置不同的州(加利福尼亚州、 宾夕法尼亚州、马里兰州和马萨诸塞州)，并创新性地将这些调查数据链接到公开可用的 患者结局数据来源。因此，我们的第一个目标是收集护士对他们的观点的详细数据 通过确定和评估(通过定量和定性方法)个人、工作场所的挑战 造成道德痛苦和道德自信(即自信)的环境和道德因素 关于在临床实践中做出与伦理相关的决定)。我们的第二个目标是(通过聚类分析)开发一个 实习护士的类型学，详细说明个人、工作场所和职业道德方面的异同 对道德痛苦、道德自信、健康和幸福影响最大的问题；从这种类型来看， 推荐减少精神痛苦的策略，并(通过知觉映射)创建三维 感知模型显示每种类型的护士如何概念化这些因素之间的关系和 使用这些地图来评估不同类型护士所经历的安全文化，这将使甚至 关于减轻道德压力的更具体的建议。我们的第三个目标是研究 目标1中确定的关系与住院患者的结果相关，包括患者 对护理的看法、住院死亡率、医院获得性条件和30天内急性护理的超时天数 出院天数以及护士的幸福感、病人的安全等级和离职意向。这个 调查结果将对导致护士精神困扰和道德规范的因素提供更清晰的图景 信心，并提供关于精神痛苦和道德信心如何影响患者安全和质量的证据 结果。医疗保健越来越多地在复杂的组织中提供，在这些组织中，解决不明确的道德问题 这些问题可能会耗尽最好的临床医生。我们的发现将为行为干预的发展提供信息， 结构/运营工作场所的变化，以及减少现有和 未来的护士队伍，并改善他们工作的安全文化。

Nurses' daily encounters with ethical challenges in providing appropriate care—situations that may go unresolved or are resolved unsatisfactorily—may lead to moral distress (i.e., the inability to carry out what is believed to be an ethically appropriate action because of internal or external constraints). As a result, many experience anxiety, depression, suicide risk, and other health-related problems. Little systematic research has focused on factors that reduce or exacerbate moral distress—and, critically, how nurses' moral distress affects nurse, patient, and organizational outcomes. This application builds upon our successful scientific program of empirical bioethics research and uses a mixed-methods design to address three complementary objectives, by surveying 20,652 practicing registered nurses (RNs) across four geographically diverse states (California, Pennsylvania, Maryland, and Massachusetts) and innovatively linking these survey data to publicly available patient outcome data sources. Thus, our first aim is to gather detailed data on nurses' perspectives on their workplace challenges by identifying and assessing (via quantitative and qualitative methods) individual, work environment, and ethical factors that contribute to moral distress and ethical confidence (i.e., self-confidence about making ethics-related decisions in clinical practice). Our second aim is to develop (via cluster analysis) a typology of practicing nurses, detailing similarities/differences across the personal, workplace, and ethics issues that most impact moral distress, ethical confidence, health, and wellbeing; and from this typology, recommend strategies for reducing moral distress , and create (via perceptual mapping) 3-dimensional perceptual models showing how each type of nurse conceptualizes the relationships among these factors and use these maps to assess safety culture as experienced by the different types of nurses, which will permit even more specific recommendations about moral stress reduction. Our third aim is to examine how the relationships identified in aim 1 are associated with outcomes of hospitalized patients, including patient perceptions of care, inpatient mortality, hospital-acquired conditions, and excess days in acute care within 30 days of hospital discharge as well as nurses' well-being, patient safety grade and intention to leave. The findings will provide a clearer picture of factors contributing to nurses' moral distress and to their ethical confidence and provide evidence on how moral distress and ethical confidence affect patient safety and quality outcomes. Healthcare is increasingly provided in complex organizations where resolving ambiguous ethical issues may deplete the best of clinicians. Our findings will inform development of behavioral interventions, structural/operational workplace changes, and message campaigns that reduce moral distress in existing and future cohorts of nurses and improve the safety culture in which they work.