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

护士在提供适当护理时每天遇到的伦理挑战-可能会发生的情况 未解决的或未解决的-可能导致道德上的痛苦（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为）。结果很多 经历焦虑、抑郁、自杀风险和其他健康相关问题。很少有系统的研究 关注减少或加剧道德困扰的因素，以及关键的是，护士的道德困扰如何影响 护士、病人和组织的结果。这项应用建立在我们成功的科学计划， 实验性生物伦理学研究，并采用混合方法设计，以解决三个互补的目标， 调查了四个地理位置不同的州（加州， 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。 工作场所的挑战，通过确定和评估（通过定量和定性方法）个人，工作 环境，以及导致道德困境和道德信心的道德因素（即，自信 关于在临床实践中做出伦理相关的决定）。我们的第二个目标是开发（通过聚类分析） 执业护士的类型学，详细说明个人，工作场所和道德的相似性/差异 最影响道德困扰，道德信心，健康和福祉的问题;从这个类型学， 建议减少道德痛苦的策略，并创建（通过感知映射）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， 使用这些地图来评估不同类型的护士所经历的安全文化，这将允许甚至 关于减少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局相关，包括患者 对护理的看法，住院死亡率，医院获得性疾病，以及30年内急性护理的超额天数 出院天数以及护士的幸福感、患者安全等级和离职意愿。的 研究结果将提供一个更清晰的画面的因素，有助于护士的道德困扰和他们的道德 信心，并提供有关道德困扰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， 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/业务工作场所的变化，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.