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.
