Moral Distress, Moral Resilience, and Organizational Factors in Predicting Consideration of Leaving Among Nurses Working in Infectious Isolation Wards: A Logistic and Machine‐Learning Analysis
Shiyi Li, Mianli Li, Ting Du, Lefei Wang, Jiajun Zhou, Qimin Xie, Bixia Huang, Zhihui ZhengAim
To identify internally stable ethics‐related predictors for consideration of leaving among nurses working in infectious isolation wards and to characterize internal model performance and uncertainty.
Method
In this exploratory cross‐sectional prediction study, 268 nurses working in infectious isolation wards at a specialized infectious disease hospital and several general hospitals in China completed structured questionnaires between July and December 2023. The outcome was a study‐specific item on moral distress–related consideration of leaving, with responses of never considered leaving, considered leaving but did not leave, or considered leaving and subsequently left; the latter two categories were combined for the primary analysis. Twenty dimension‐level ethics‐related predictors were evaluated using elastic‐net penalized logistic regression, classification and regression tree (CART), and random forest models under repeated nested cross‐validation.
Results
Of 268 nurses, 104 (38.8%) had considered leaving because of moral distress, including 2 who subsequently left. Predictor collinearity was substantial (maximum variance inflation factor = 11.75). Moral adversity coping and moral distress related to harm to patients’ interests were retained in 100% of elastic‐net fits, with negative and positive standardized coefficients, respectively; the same two variables accounted for all CART root splits and had the largest model‐specific random forest permutation importance. Internally validated AUCs were 0.747 (95% CI 0.688–0.805) for penalized logistic regression, 0.740 (0.679–0.799) for CART, and 0.761 (0.702–0.818) for random forest, with no statistically significant pairwise differences (all p ≥ 0.158). The leading signals remained stable after excluding the 2 participants who had subsequently left and after adding demographic and work‐related characteristics to an extended penalized model.
Conclusion
Consideration of leaving was most consistently associated with moral distress related to harm to patients’ interests and lower moral adversity coping. These internally stable associations highlight ethical experiences and coping demands that warrant further study in nursing management and retention research. Model discrimination was moderate, with some overestimation at higher predicted probabilities; prospective external validation is warranted.
Implications for Nursing Management
Nursing managers should pay attention to ethical concerns involving patients’ interests and nurses’ ability to cope with moral adversity. These findings may help guide the development and evaluation of ethics support initiatives.