The Mediating Role of Moral Resilience in the Relationship Between Moral Distress and End-Of Care Attitudes and Behaviours Among Intensive Care Nurses

Abstract

Background: Intensive care nurses experience moral distress due to moral conflicts, which negatively impact their attitudes and behaviours towards end-of-life care. Moral resilience is considered a potential factor in mitigating these negative effects. Aim: This study aims to examine the mediating role of moral resilience in the relationship between moral distress and intensive care nurses' attitudes and behaviours towards end-of-life care. Study Design: A descriptive and cross-sectional study was conducted in accordance with the guidelines for observational studies (STROBE). The study was conducted with 228 intensive care nurses between December 2024 and February 2025. Data were collected using the ‘Personal Information Form’, ‘Moral Distress Scale’, ‘Moral Resilience Scale’ and ‘Scale of Attitudes and Behaviours of Intensive Care Nurses Towards End-of-Life Care’. Statistical analyses were performed using SPSS 26.0 and AMOS V 24.0. Results: The moral distress levels of female nurses were higher and significantly higher than male nurses (OR 0.245; 95% CI 0.074–0.598; p = 0.011). Nurses with 11 years or more of work experience had a higher and significant level of moral distress compared to other nurses (OR 0.053; 95% CI 0.080–0.115; p = 0.012). The moral resilience level of nurses with 3–6 years of work experience was higher and significantly higher than other nurses (OR 0.067; 95% CI 0.048–0.107; p = 0.023). Moral distress negatively affects nurses' attitudes and behaviours towards end-of-life care. Moral resilience has a significant and positive effect on attitudes and behaviours. Moreover, moral resilience mediated the relationship between moral distress and attitudes and behaviours towards end-of-life care (β;-0.266, CI 95% −0.301–0.197). Conclusions: Moral distress negatively influences intensive care nurses' attitudes and behaviours in end-of-life care. Enhancing moral resilience can help mitigate these effects. The findings highlight the need for nursing education programmes and workplace interventions to strengthen nurses' moral resilience and improve their ability to manage moral distress. Relevance to Clinical Practice: While moral distress damages intensive care nurses' attitudes towards end-of-life care, moral resilience may help to reduce its negative effects. Supporting nurses is thought to improve the quality of adverse end-of-life care. © 2025 Elsevier B.V., All rights reserved.