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Background <p>Oncology nurses frequently experience moral distress arising from ethical dilemmas inherent in cancer care. Although moral distress has been associated with professional attitudes and behaviors, its relationship with willingness to implement advance care planning (ACP) remains poorly understood. Perceived social support may serve as a psychosocial resource in this context, yet whether it modifies this relationship or shows an independent association with ACP implementation willingness remains unclear.</p> Objective <p>This study aimed to (1) assess the levels of moral distress, perceived social support, and ACP implementation willingness among oncology nurses; (2) estimate the correlations and independent associations among these three variables; and (3) investigate whether perceived social support moderates the association between moral distress and ACP implementation willingness.</p> Methods <p>A cross-sectional survey was conducted among 151 oncology nurses recruited from hospitals in Sichuan Province, China, from January to February 2026. Data were collected using the Moral Distress Scale-Revised (MDS-R), the Perceived Social Support Scale (PSSS), and a newly developed ACP Implementation Willingness Questionnaire with preliminary content-validity and internal-consistency evidence. Descriptive statistics, Pearson correlations, and hierarchical moderated regression analyses were performed. Sample-size planning targeted 159 participants for an incremental interaction effect of f² = 0.05; the achieved sample provided approximately 78% power for that effect and limited power for smaller interactions.</p> Results <p>The mean moral distress composite score was 133.32 ± 77.23, the mean PSSS total score was 67.51 ± 14.02, and the mean ACP implementation willingness score was 41.74 ± 7.85. Moral distress was positively correlated with ACP implementation willingness (<i>r</i> = 0.197, <i>p</i> = 0.015), and perceived social support was also positively correlated with ACP implementation willingness (<i>r</i> = 0.301, <i>p</i> &lt; 0.001). In the main-effects regression model, moral distress (B = 0.022, 95% CI 0.006 to 0.038, <i>p</i> = 0.006) and perceived social support (B = 0.174, 95% CI 0.089 to 0.259, <i>p</i> &lt; 0.001) were independently associated with ACP implementation willingness, and the model explained 13.5% of the variance. The interaction term was not statistically significant (B = − 0.001, 95% CI − 0.003 to 0.001, <i>p</i> = 0.262; ΔR² = 0.007), and the final model explained 14.3% of the variance.</p> Conclusion <p>In this cross-sectional sample, moral distress and perceived social support were independently associated with ACP implementation willingness among oncology nurses. The modest explanatory power of the model, limited power to detect small interaction effects, and preliminary validation status of the outcome questionnaire require cautious interpretation. The findings do not establish causal effects or the absence of a small moderation effect. Larger, multi-site longitudinal studies using independently validated outcome measures are needed to examine organizational, educational, and individual determinants of ACP implementation willingness.</p>

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Associations of moral distress and perceived social support with advance care planning implementation willingness among oncology nurses: a cross-sectional study

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  • 发表日期：

    2026年8月5日

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  • Longbao Zhao,
  • Rongchun Jiang,
  • Lijun Ran,
  • Limin Hu,
  • Yuqi Gou,
  • Juan Wu,
  • Mengjie Liu

摘要

Background

Oncology nurses frequently experience moral distress arising from ethical dilemmas inherent in cancer care. Although moral distress has been associated with professional attitudes and behaviors, its relationship with willingness to implement advance care planning (ACP) remains poorly understood. Perceived social support may serve as a psychosocial resource in this context, yet whether it modifies this relationship or shows an independent association with ACP implementation willingness remains unclear.

Objective

This study aimed to (1) assess the levels of moral distress, perceived social support, and ACP implementation willingness among oncology nurses; (2) estimate the correlations and independent associations among these three variables; and (3) investigate whether perceived social support moderates the association between moral distress and ACP implementation willingness.

Methods

A cross-sectional survey was conducted among 151 oncology nurses recruited from hospitals in Sichuan Province, China, from January to February 2026. Data were collected using the Moral Distress Scale-Revised (MDS-R), the Perceived Social Support Scale (PSSS), and a newly developed ACP Implementation Willingness Questionnaire with preliminary content-validity and internal-consistency evidence. Descriptive statistics, Pearson correlations, and hierarchical moderated regression analyses were performed. Sample-size planning targeted 159 participants for an incremental interaction effect of f² = 0.05; the achieved sample provided approximately 78% power for that effect and limited power for smaller interactions.

Results

The mean moral distress composite score was 133.32 ± 77.23, the mean PSSS total score was 67.51 ± 14.02, and the mean ACP implementation willingness score was 41.74 ± 7.85. Moral distress was positively correlated with ACP implementation willingness (r = 0.197, p = 0.015), and perceived social support was also positively correlated with ACP implementation willingness (r = 0.301, p < 0.001). In the main-effects regression model, moral distress (B = 0.022, 95% CI 0.006 to 0.038, p = 0.006) and perceived social support (B = 0.174, 95% CI 0.089 to 0.259, p < 0.001) were independently associated with ACP implementation willingness, and the model explained 13.5% of the variance. The interaction term was not statistically significant (B = − 0.001, 95% CI − 0.003 to 0.001, p = 0.262; ΔR² = 0.007), and the final model explained 14.3% of the variance.

Conclusion

In this cross-sectional sample, moral distress and perceived social support were independently associated with ACP implementation willingness among oncology nurses. The modest explanatory power of the model, limited power to detect small interaction effects, and preliminary validation status of the outcome questionnaire require cautious interpretation. The findings do not establish causal effects or the absence of a small moderation effect. Larger, multi-site longitudinal studies using independently validated outcome measures are needed to examine organizational, educational, and individual determinants of ACP implementation willingness.