Abstract
Background
The burnout rate among emergency nurses in China has reached 87.6%. This alarmingly high prevalence of burnout is driving a substantial number of experienced emergency nurses to leave their positions, thereby posing a serious threat to the sustainable and healthy development of the healthcare system. Moral distress represents a major modifiable risk factor for burnout. The present study aims to explore the correlation between moral distress and burnout, whether moral resilience could act as a mediator of the relationship, and whether moral courage moderates the mediating effect among emergency nurses.
Methods
This study employed a cross-sectional design and was carried out among emergency department nurses from seven tertiary Class A hospitals in the Ningxia Hui Autonomous Region, China, in August 2025. Survey instruments included a demographic questionnaire, the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), the Chinese version of the Rushton Moral Resilience Scale, the Moral Distress Scale-Revised (MDS-R), and the Nurses’ Moral Courage Scale (NMCS). Descriptive analysis and Pearson correlation analysis were performed using SPSS 27.0. The PROCESS macro was applied, with Model 4 for mediation analysis and Model 7 for moderated mediation analysis.
Results
The total scores were as follows: moral distress (45.63 ± 34.18), moral resilience (47.75 ± 6.51), moral courage (71.38 ± 15.24), and burnout (56.09 ± 17.06). Moral distress was positively correlated with burnout among emergency nurses. Moral resilience mediated the association between moral distress and burnout, accounting for 24.8% of the total effect. Moral courage moderated the path from moral distress to moral resilience.
Conclusion
This study found that among emergency nurses, moral distress was positively correlated with burnout; moral resilience mediated the relationship between moral distress and burnout; and moral courage moderated the relationship between moral distress and moral resilience.
Keywords: emergency, job burnout, moral distress, moral resilience, nurse
1. Introduction
Nurses represent a high-risk group for burnout, with an incidence rate as high as 64.5% (1). Emergency nurses care for critically ill patients daily and are required to provide precise and rapid management of their conditions. Factors such as frequent night shifts, heavy workloads, and occupational exposure increase nurses’ susceptibility to burnout (2, 3). Research has indicated (4) that the incidence of burnout among emergency nurses in China reaches 87.6%.
Burnout leads to reduced work efficiency, poor nursing quality, and increased adverse event rates among nursing staff, negatively impacting their physical and mental health (5, 6). Previous research findings indicate that moral distress experienced by nurses is a significant factor influencing burnout among emergency nurses (7). Moral distress refers to the negative psychological experience where an individual is aware of the corresponding behavioral norms but, for various reasons, is unable to act in accordance with them (8). Nurses choose to proactively avoid situations to prevent direct conflicts arising from moral distress. When nurses reach the point where the psychological distress caused by moral distress becomes overwhelming, they are more likely to develop burnout (9).
Nursing moral resilience is defined as the ability of nurses to maintain or restore their own moral integrity when confronted with complex moral situations, moral distress, or stressors (10). Li et al. (11) found that nurses’ moral resilience is negatively correlated with burnout, and moral resilience is crucial for mitigating burnout. Meanwhile, research by Asadi et al. (12) confirmed that moral distress is negatively correlated with moral resilience. Currently, there is limited research on the relationship among moral distress, moral resilience, and burnout. Accordingly, Hypothesis 1 is proposed: Moral resilience mediates the relationship between moral distress and burnout among emergency nurses. Moreover, moral courage and moral resilience jointly serve to uphold professional integrity in the face of moral distress (13), and nurses with higher moral courage are more likely to possess robust moral resilience (5, 6), thereby alleviating burnout. Based on these findings, Hypothesis 2 is proposed: Moral courage moderates the relationship between moral distress and moral resilience among emergency nurses.
According to the Comer and Sekerka (14) model of enduring moral courage, moral courage is the authentic expression of authenticity in the face of discomfort arising from dissent, opposition, or exclusion. Through psychological and behavioral factors, moral courage can be transformed into enduring moral courage—a specific form of moral resilience—thereby helping individuals alleviate burnout. An intermediary mediation model was proposed to examine the relationship between moral distress and burnout among emergency nurses, as shown in Figure 1. Exploring the relationship between moral distress and burnout among emergency nurses serves two purposes: it enriches and advances the theoretical understanding of the relationship between moral distress and burnout, while also providing valuable insights for nursing administrators seeking to alleviate burnout levels among emergency nurses.
Figure 1.
The hypothesized moderated mediation model.
2. Method
2.1. Aims
The purpose of this study is to examine the relationship between moral distress and burnout among emergency nurses, as well as the mediating role of moral resilience between moral distress and burnout, and the moderating role of moral courage between moral distress and moral resilience.
2.2. Design
This study employed a cross-sectional, online questionnaire survey design. The results were reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (15).
2.3. Participants
From August to September 2025, nurses from the emergency departments of seven tertiary Class A hospitals in Ningxia Hui Autonomous Region, China, were selected as study subjects using convenience sampling. Inclusion criteria: ① Years of experience in the emergency department ≥ 1 year; ② Currently employed and not in the process of resigning; ③ Voluntarily agreed to participate in the study and signed the informed consent form.
The exclusion criteria were: (1) Nurses who withdrew from the study due to reasons such as further education, maternity leave, or personal leave.
2.4. Samples
This study was designed as a cross-sectional investigation. The sample size was calculated using the cross-sectional formula n = ( σ/δ)2 With α = 0.05, = 1.96, and σ = 8.76 based on previous studies, and setting δ = 1, we obtained n = (1.96 × 8.76/1)2 ≈ 295. Accounting for a 10% non-response rate, the study required a minimum sample size of 325 cases. Ultimately, 333 cases were enrolled, meeting the sample size requirement.
2.5. Measures
2.5.1. Demographic questionnaire
The questionnaire was designed by the researcher based on a systematic review of relevant literature and the results of group discussions within the research team. It encompasses 14 variables covering the research subjects’ gender, age, working years, marital status, educational level, professional title, labor and personnel relations, average number of night shifts, participation in hospital ethics training, average monthly income, only child status, fertility status, department, and health status.
2.5.2. MBI-human service survey, (MBI-HSS)
The Maslach Burnout Inventory, developed jointly by Maslach and Jackson and validated by Feng et al. (16) among Chinese nurses, demonstrates excellent reliability and validity. This scale comprises three dimensions and 22 items: Emotional Exhaustion (9 items), Depersonalization (5 items), and Personal Achievement (8 items). The Personal Achievement dimension (items 4, 7, 9, 12, 17, 18, 19, 21) is reverse-scored. After reverse-scoring the personal achievement dimension, a 7-point Likert scale is applied, ranging from “never” to “every day,” with scores ranging from 0 to 6 points, respectively. Higher scores indicate more severe burnout. The total score range is 0–132 points, with a Cronbach’s α coefficient of 0.905.
2.5.3. Moral distress scale (MDS-R)
The scale was developed by Corley et al. (17), and later revised by Hamric and Blackhall (18), and its Chinese version was validated by Sun (19). The scale comprises four dimensions: Individual Responsibility (8 items), Not in the Patient’s Best Interest (5 items), Value Conflicts (6 items), and Harming in the Patient’s Interest (3 items), totaling 22 items. Each item is evaluated based on two dimensions: frequency of occurrence and level of distress, using a 5-point scoring system. Frequency is rated from “never” to “very frequently,” scoring 0 to 4 points, respectively. Distress is rated from “none” to “severe,” scoring 0 to 4 points, respectively. The final score for each item is the product of its frequency and distress score. The total scale score ranges from 0 to 352, with higher scores indicating greater levels of moral distress among survey participants. In this study, the Cronbach’s α coefficient for the scale was 0.879.
2.5.4. Rushton moral resilience scale Chinese version
The scale was developed by Heinze et al. (20), and translated and revised by Tian et al. (21). This scale comprises three dimensions: the Ability to Cope with Moral Adversity Flexibly (5 items), Relational Moral Soundness (6 items), and Moral Efficacy (6 items), totaling 17 items. Each item uses a 4-point Likert scale from 1 to 4, ranging from “strongly disagree” to “strongly agree.” The total score ranges from 17 to 68, with higher scores indicating stronger moral resilience. Items 2, 4, 5, 6, 8, 10, 11, 13, 14, 15, and 16 are reverse-scored. In this study, the Cronbach’s α coefficient for this scale was 0.811.
2.5.5. Nurses moral courage scale (NMCS)
The scale was developed by Numminen et al. (22), and translated by Wang et al. (23). It encompasses four dimensions: Moral Integrity (7 items), Commitment to Good Care for Patients (5 items), Compassion and True Presence with Patients (5 items), and Moral Responsibility (4 items), totaling 21 items. Each item is scored on a 5-point scale, ranging from 1 to 5 (1 = “does not describe me at all”, 5 = “describes me excellently”). The total scale score ranges from 21 to 105, with higher scores indicating greater moral courage among nurses. In this study, the Cronbach’s α coefficient for the scale was 0.905.
2.6. Data collection
The researchers developed an online survey on the WenjuanXing platform. Prior to the survey, they explained the purpose and significance of the study to the head nurses of the emergency departments at each hospital and obtained their consent. The head nurses then shared the survey in their department’s work group, emphasizing the principles of voluntary participation, anonymity, and informed consent. Participants could access the questionnaire via the link or QR code. They had to read and agree to the informed consent form before proceeding to the next step. They could withdraw from the survey at any time. If they had any questions while completing the questionnaire, they could contact the researchers by phone or WeChat. To ensure the quality of collected data, each IP address was allowed to complete the survey only once. Prior to the formal study, 20 emergency nurses who met the inclusion criteria were invited to participate in a pilot study; the survey data from these participants were not included in the final study. Preliminary research indicated that all items could be understood correctly and required no revision. A total of 373 questionnaires were collected for this study, with an average completion time of 10 to 15 min. Invalid questionnaires were identified according to two criteria: (1) excessively fast completion (i.e., <10 min); and (2) illogical response patterns, defined as mechanically repetitive answers (i.e., uniform ratings across all Likert scale items). After excluding 40 invalid questionnaires meeting the above criteria, 333 valid questionnaires were ultimately retained, resulting in a valid response rate of 89.27%.
2.7. Ethical considerations
This study was approved by the Ethics Committee of Ningxia Medical University General Hospital (Ethics Approval Number: KYLL-2026-0341). All participants provided informed consent and participated voluntarily. All data were used only for this study and kept strictly confidential.
2.8. Data analysis
2.9. Statistical analysis
Descriptive analysis of the data was performed using SPSS 27.0. The Harman single-factor test was employed to examine common method bias. Moral distress, moral resilience, moral courage, and burnout were analyzed using Pearson correlation. PROCESS macro Version 4.1 was used to test mediation and moderation effects: Model 4 examined the mediating effect of moral resilience between moral distress and burnout; Model 7 examined the moderating effect of moral courage on the relationship between moral distress and moral resilience. The bootstrap method with 5,000 resamples was used to estimate 95% confidence intervals (CIs) for indirect effects; an indirect effect was considered significant if the CI did not include zero.
3. Result
3.1. Common method Bias
The Harman single-factor test was employed to examine the presence of common method bias. Results indicated that 17 factors had eigenvalues greater than 1, with the largest factor explaining 16.8% of the variance (<40%). Therefore, no significant common method bias was identified in this study.
3.2. Descriptive statistics of demographic data
A total of 373 questionnaires were collected for this survey. After excluding 40 questionnaires that were completed in less than 10 min or contained mechanical responses, 333 valid questionnaires were retained, resulting in a valid response rate of 89.27%.
Among the 333 emergency nurses, 264 (79.3%) were female; 220 (66.0%) were aged 31–40 years; 113 (33.9%) had 11–15 years of emergency nursing experience; 274 (82.2%) were married; 318 (95.4%) held bachelor’s degrees; 176 (52.8%) held the title of supervisor nurse; 300 (90.1%) were contract or personnel agency staff; 222 (66.6%) worked 5–10 night shifts monthly; 262 (78.6%) had participated in hospital ethics courses; 262 (78.6%) had an average monthly income of 5,001–10,000 RMB; 290 (87.1%) were non-only children; 138 (41.4%) had two children; 160 (48.0%) worked in the resuscitation zone; and 168 (50.5%) reported good health. Data are presented in Table 1.
Table 1.
Sociodemographic information of the participants (n = 333).
| Variable | n (%) |
|---|---|
| Gender | |
| Male | 69 (20.7%) |
| Female | 264 (79.3%) |
| Age [years] | |
| 21–30 | 67 (20.1%) |
| 31–40 | 220 (66.0%) |
| 41–50 | 39 (11.7%) |
| 51–60 | 7 (2.2%) |
| Years of working | |
| 1–5 | 66 (19.8%) |
| 6–10 | 98 (29.4%) |
| 11–15 | 113 (33.9%) |
| 16–20 | 35 (10.5%) |
| 21–25 | 12 (3.6%) |
| >25 | 9 (2.8%) |
| Marital status | |
| Unmarried | 51 (15.3%) |
| Married | 274 (82.2%) |
| Divorced/widowed | 8 (2.5%) |
| Educational level | |
| Below bachelor’s degree | 13 (3.9%) |
| Bachelor’s degree | 318 (95.4%) |
| Above bachelor’s degree | 2 (0.7%) |
| Professional title | |
| Nurse | 28 (8.4%) |
| Senior nurse | 118 (35.4%) |
| Supervisor nurse | 176 (52.8%) |
| Deputy/director nurse | 11 (3.4%) |
| Labor and personnel relations | |
| Formally in the compilation | 33 (9.9%) |
| Contract system/personnel agency | 300 (90.1%) |
| Average number of night shifts (pieces) | |
| <5 | 89 (26.7%) |
| 5–10 | 222 (66.6%) |
| >10 | 22 (6.7%) |
| Participation in hospital ethics course | |
| Yes | 262 (78.6%) |
| No | 71 (21.4%) |
| Average monthly income (RMB) | |
| <5,000 | 32 (9.6%) |
| 5,001–10,000 | 262 (78.6%) |
| 10,001–20,000 | 39 (11.8%) |
| Single child | |
| Yes | 43 (12.9%) |
| No | 290 (87.1%) |
| Fertility status | |
| Be childless | 44 (13.2%) |
| 1 child | 115 (34.5%) |
| 2 children | 138 (41.4%) |
| >2 children | 36 (10.9%) |
| Department | |
| Resuscitation zone | 160 (48.0%) |
| Observation zone | 28 (8.4%) |
| Emergency ward | 53 (15.9%) |
| EICU | 65 (19.5%) |
| General outpatient area | 27 (8.2%) |
| State of health | |
| Generally | 165 (49.5%) |
| Good | 168 (50.5%) |
3.3. Descriptive statistics and correlation analysis of variables
The mean, standard deviation, and correlation coefficient results for the variables in this study are presented in Table 2. Emergency nurses scored 45.63 ± 34.18 on the moral distress scale, 47.75 ± 6.51 on the moral resilience scale, 71.38 ± 15.24 on the moral courage scale, and 56.09 ± 17.06 on the burnout scale. Pearson correlation analysis revealed that moral distress was negatively correlated with moral resilience (r = −0.238, p < 0.01) and moral courage (r = −0.207, p < 0.01), while was positively correlated with burnout (r = 0.201, p < 0.001). Moral resilience was positively correlated with moral courage (r = 0.256, p < 0.01) and was negatively correlated with burnout (r = −0.248, p < 0.01). Furthermore, moral courage was negatively correlated with burnout (r = −0.411, p < 0.01), as shown in Table 2.
Table 2.
Descriptive statistics and correlation analysis of each variable.
| Variables | M ± SD | 1 | 2 | 3 | 4 |
|---|---|---|---|---|---|
| 1. Moral distress | 45.63 ± 34.18 | 1 | – | – | – |
| 2. Moral resilience | 47.75 ± 6.51 | −0.238** | 1 | – | – |
| 3. Moral courage | 71.38 ± 15.24 | −0.207** | 0.256** | 1 | – |
| 4. Burnout | 56.09 ± 17.06 | 0.201*** | −0.248** | −0.411** | 1 |
**p < 0.01, ***p < 0.001.
3.4. Mediating effect analysis
To assess the mediating effect of moral resilience between moral distress and burnout among emergency nurses, Model 4 from PROCESS was employed. After controlling for factors such as age and gender, the results revealed a significant positive correlation between moral distress and burnout (β = 0.101, t = 3.746, p < 0.01). Moral distress was negatively correlated with moral resilience (β = −0.456, t = −4.456, p < 0.001). Moral resilience was negatively correlated with burnout (β = −5.513, t = −3.862, p < 0.001). Furthermore, after including the mediating variable, the direct effect of moral distress on burnout remained significant (β = 0.076, t = 2.792, p < 0.01). As shown in Table 3. Moreover, the upper and lower bounds of the bootstrap 95% CI for both the direct effect of moral distress on burnout and the mediating effect of moral resilience did not include zero, indicating that the mediating effect was significant. The mediating effect accounted for 24.8% of the total effect. As shown in Table 4. Therefore, Hypothesis 1 was supported.
Table 3.
The mediating effect of moral resilience on the relationship between moral distress and burnout.
| Variables | Moral resilience | Burnout | Burnout | ||||||
|---|---|---|---|---|---|---|---|---|---|
| β | t | p | β | t | p | β | t | p | |
| Moral distress | −0.456 | −4.456 | <0.001 | 0.101 | 3.746 | <0.01 | 0.076 | 2.792 | <0.01 |
| Moral resilience | −5.513 | −3.862 | <0.001 | ||||||
| R 2 | 0.058 | 0.044 | 0.085 | ||||||
| F | 5.104 | 3.793 | 6.147 | ||||||
Table 4.
Direct and indirect effects of moral distress on burnout.
| Variables | β | SE | LICI | ULCI | Ratio of effect value |
|---|---|---|---|---|---|
| Total effect | 0.101 | 0.270 | 0.048 | 0.154 | 100 |
| Direct effect | 0.076 | 0.272 | 0.022 | 0.129 | 75.2 |
| Indirect effect | 0.025 | 0.087 | 0.010 | 0.044 | 24.8 |
3.5. Moderated mediation effect analysis
PROCESS macro Model 7 was used to test the moderating effect of moral courage. Moral courage was introduced as a moderator into the moderation model, while controlling for factors such as age and gender. Results indicated that moral distress was negatively correlated with moral resilience (β = −0.184, t = −4.378, p < 0.01), while moral courage was positively correlated with moral resilience (β = 0.041, t = 5.821, p < 0.01). Moreover, in the moderated mediation model, the interaction term moral distress × moral courage was significant (β = 0.001, t = 3.343, p < 0.001), indicating that moral courage moderated the relationship between moral distress and moral resilience, as shown in Table 5 and Figure 2. Thus, Hypothesis 2 was supported. To analyze the differential effects of moral courage, this study conducted a simple slope test categorizing moral courage into high levels (one standard deviation above the mean) and low levels (one standard deviation below the mean). When moral courage levels were low, moral distress was significantly negatively correlated with moral resilience (β = −0.773, t = −5.873, p < 0.001). When moral courage levels were high, the negative correlation of moral distress with moral resilience was not significant (β = −0.189, t = −1.469, p > 0.05). Simple slope analysis confirmed that moral courage buffers the link between moral distress and moral resilience: the relationship was significant at low levels of moral courage but not at high levels, as shown in Figure 3.
Table 5.
Results of the moderated mediation model.
| Variables | moral resilience | burnout | ||||
|---|---|---|---|---|---|---|
| β | SE | t | β | SE | t | |
| Constant | 46.954 | 2.24 | 20.958 | – | – | – |
| Moral distress | −0.184 | 0.042 | −4.378** | 0.075 | 0.027 | 2.771** |
| Moral courage | 0.041 | 0.030 | 5.821** | – | – | – |
| Moral resilience | – | – | – | −0.556 | 0.142 | −3.916** |
| Moral distress × moral courage | 0.001 | 0.006 | 3.343*** | – | – | – |
| R 2 | 0.156 | 0.083 | ||||
| F | 20.302*** | 14.939*** | ||||
**p < 0.01, ***p < 0.001.
Figure 2.
The final moderated mediation model (***p < 0.001).
Figure 3.
The moderating role of moral courage in mediating model.
4. Discussion
This study explored the relationship between moral distress and burnout among emergency nurses in China, building upon existing theoretical frameworks and previous research. It emphasizes the mediating role of moral resilience and the moderating role of moral courage. The findings revealed a significant positive correlation between moral distress and burnout. Furthermore, moral resilience was identified as a partial mediator in this relationship, while moral courage moderated the link between moral distress and moral resilience. These results contribute to a deeper understanding of the relationship between moral distress and burnout among emergency nurses, providing empirical evidence to support strategies aimed at enhancing psychological well-being, work engagement, and the quality of care in emergency nursing settings.
4.1. Relationship between moral distress and burnout
Our study revealed a positive correlation between moral distress and burnout, consistent with previous findings (24). The emergency department is characterized by a fast-paced environment and high levels of uncertainty, with nurses constantly exposed to traumatic and distressing events such as severe injuries, death, and suicide (25). Emergency nurses often face verbal and physical aggression from patients and their families (26). As a result, nurses in the emergency department are more likely to experience burnout than nurses in other departments (27). Emergency nurses often face uneven distribution of resources and a lack of understanding from patients and their families regarding treatment decisions. Most emergency nurses have experienced physical or non-physical violence, and the convergence of these multiple factors leaves them facing greater moral distress (2, 3). A recent cross-sectional study has confirmed that moral distress was significantly associated with burnout and turnover intention among nurses (7). Therefore, deeply understanding and effectively addressing moral distress have become crucial to identifying factors linked to burnout and sustaining the quality of care.
4.2. The mediating role of moral resilience
This study demonstrated that moral resilience partially mediated the relationship between nurses’ moral distress and burnout, supporting Hypothesis 1 and consistent with prior research (7). It is particularly noteworthy that this study found the mediating effect of moral resilience accounted for as much as 24.8% of the total effect. In the first stage of the mediation pathway, moral distress was significantly negatively associated with moral resilience (r = −0.238, p < 0.01), indicating that higher moral distress is associated with lower moral resilience. This is consistent with previous research (28). In the second stage, moral resilience was also negatively associated with burnout (r = −0.248, p < 0.01), further supporting the notion that fostering moral resilience is essential for effectively mitigating burnout, a finding consistent with previous studies (11). Specifically, greater exposure to moral distress is associated with lower moral resilience, which, in turn, is related to higher burnout.
Previous studies (7) applied a similar framework but used instruments validated for general healthcare workers, limiting reliability in certain dimensions. By contrast, this study employed a tool specifically designed for registered nurses, ensuring a targeted sample and items aligned with nursing practice, as supported by a recent Chinese review (10). These findings provide robust evidence that moral resilience mediates the relationship of moral distress on burnout among emergency nurses.
4.3. The moderating role of moral courage
This study examined the moderating role of moral courage in the relationship between moral distress and moral resilience among emergency nurses, supporting Hypothesis 2. We found that moral courage plays a moderating role in the first half of the mediation process, suggesting that moral courage moderated the relationship between moral distress and moral resilience. Moral courage was identified as a protective factor for moral resilience, consistent with previous research (5). According to the theory of moral resilience, moral resilience, defined as the ability to maintain or restore moral integrity in the face of ethical challenges, is fundamentally supported by moral courage (29). Nurses with higher moral courage are more adept at identifying core conflicts in moral distress, enabling them to mobilize resources and sustain moral resilience (30). Given these findings, nursing administrators and educators should consider interventions to enhance moral courage among emergency nurses, thereby supporting moral resilience and promoting psychological well-being.
While previous studies have explored moral resilience and moral courage as serial mediators, this study contributes by examining moral courage as a moderator in the relationship between moral distress and moral resilience.
4.4. Research strengths
This study has several notable strengths. First, the Moral Courage Scale and the Rushton Moral Resilience Scale assess different ethical-related capacities, supporting their appropriateness for concurrent application in this model. Second, we adopted the Chinese version of the Rushton Moral Resilience Scale for its favorable psychometric properties and better clinical comprehensibility among participants. Third, moderated mediation analysis was used as it is well-suited for testing the proposed hypothetical pathways. Fourth, by incorporating moral courage as a moderator, this study extends previous findings and enhances the novelty of the research model.
5. Limitations
This present study has several limitations. First, the cross-sectional design precludes causal conclusions, as the findings reflect associations rather than causal effects. Longitudinal or experimental studies are needed to establish temporal relationships and rule out alternative explanations. Thus, the observed mediation effect should be viewed as an indirect relationship rather than a causal mechanism. Second, the sample consisted of emergency nurses from the Ningxia Hui Autonomous Region, which limits the generalizability of the findings. Multicenter studies are necessary to confirm these results across diverse populations. Finally, the study was conducted in a single cultural context (China), and the generalizability of the findings to other healthcare systems and cultures requires further investigation.
6. Conclusion
In summary, our study examined the association between moral distress and burnout among emergency nurses, testing the mediating role of moral resilience and the moderating role of moral courage. Findings indicated a positive association between moral distress and burnout, with moral resilience partially mediating this link and moral courage moderating the path from moral distress to moral resilience.
Funding Statement
The author(s) declared that financial support was received for this work and/or its publication. This research was funded by the Natural Science Foundation of Ningxia Province (2024AAC03634).
Footnotes
Edited by: Ulrich Wesemann, Military Hospital Berlin, Germany
Reviewed by: Hirokazu Tachikawa, University of Tsukuba, Japan
Nayoon Lee, Dong-A University, Republic of Korea
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
Ethics statement
The studies involving humans were approved by Ethics Committee of Ningxia Medical University General Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
Author contributions
QD: Formal analysis, Investigation, Methodology, Software, Writing – original draft, Writing – review & editing. JB: Funding acquisition, Writing – original draft, Writing – review & editing. YY: Methodology, Writing – original draft, Writing – review & editing. SM: Data curation, Methodology, Writing – original draft, Writing – review & editing. FH: Writing – original draft, Writing – review & editing.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that Generative AI was not used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
- 1.Luo G, Xiao N, Chen XL. A meta-analysis of detection rate of Chinese nurses' job burnout. Occup Health. (2022) 38:1854–9. doi: 10.13329/j.cnki.zyyjk.2022.0367 [DOI] [Google Scholar]
- 2.Zhang JL, Lu AH, Li GJ, Huang XH, Guan XY, Sun FM. Study on mediating role of emotion regulation between self-denial tendency and occupational burnout in emergency department nurses. Occup Health. (2025) 41:1330–4. doi: 10.13329/j.cnki.zyyjk.20250427.001 [DOI] [Google Scholar]
- 3.Zhang Y, Liu J, Dai F, Fan T. Moral distress in emergency nurses: a qualitative systematic review and meta-synthesis protocol. BMJ Open. (2025) 15:e107371. doi: 10.1136/bmjopen-2025-107371, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Qu G, Lei ZH, Feng J, Shen X, Li XY, Gan Y. Study on current situation and spatial distribution of job burnout of nurses in emergency department in China. Chin J Health Policy. (2022) 15:71–6. doi: 10.3969/j.issn.1674-2982.2022.10.010 [DOI] [Google Scholar]
- 5.Zheng D, Chen Y, Cao J, Li H, Chu W, Yan C. Sleep disorders mediate the relationship between work family conflict and burnout in shift nurses. Sci Rep. (2025) 15:41708. doi: 10.1038/s41598-025-25658-1, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Zheng Z, Li S, Wang J, Li M, Du T, Shen Z, et al. Latent profile analysis of nurses' moral resilience and its influencing factors. Nurs Ethics. (2025) 33:205. doi: 10.1177/09697330251366609, [DOI] [PubMed] [Google Scholar]
- 7.Wu S, Sun Y, Zhong Z, Li H, Ding B, Deng Q. The effect of moral distress on emergency nurses' job burnout: the mediating roles of hospital ethical climate and moral resilience. Front Public Health. (2025) 13:1562209. doi: 10.3389/fpubh.2025.1562209, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Austin W. Moral distress and the contemporary plight of health professionals. HEC Forum. (2012) 24:27–38. doi: 10.1007/s10730-012-9179-8, [DOI] [PubMed] [Google Scholar]
- 9.Yu CS, Ni TT, Liu XY, Yu HL, Gu ZE. Nurses’ experience of moral distress in emergency setting: a qualitative study. Mil Nurs. (2025) 42:1–4. doi: 10.3969/j.issn.2097-1826.2025.05.001 [DOI] [Google Scholar]
- 10.Xie XH, Zhang C, Zhou XL, Tang JJ, Xu JT, Dong JH, et al. Conceptual analysis of moral resilience in nurses. J Nurs Train. (2025) 40:1355–60. doi: 10.16821/j.cnki.hsjx.2025.13.003 [DOI] [Google Scholar]
- 11.Li Y, Chen Z, JimIénez-herrera MF, Gan X, Ren Y, Tian X. The impact of moral resilience on nurse turnover intentions: the mediating role of job burnout in a cross-sectional study. BMC Nurs. (2024) 23:687. doi: 10.1186/s12912-024-02357-2, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Asadi Z, Jackson AC, Jahangirimehr A, Bahramnezhad F. The relationship between moral resilience, moral distress, and second victim syndrome among Iranian ICU nurses: a cross-sectional correlational study. J Med Ethics Hist Med. (2025) 18:3. doi: 10.18502/jmehm.v18i3.18879, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Stutzer K, Rodriguez AM. Moral Resilience for Critical Care Nurses. Crit Care Nurs Clin North Am. (2020) 32:383–93. doi: 10.1016/j.cnc.2020.05.002 [DOI] [PubMed] [Google Scholar]
- 14.Comer DR, Sekerka LE. Keep calm and carry on (ethically): durable moral courage in the workplace. Hum Resour Manag Rev. (2018) 28:116–30. doi: 10.1016/j.hrmr.2017.05.011 [DOI] [Google Scholar]
- 15.Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. (2007) 370:1453–7. doi: 10.1016/s0140-6736(07)61602-x [DOI] [PubMed] [Google Scholar]
- 16.Feng Y, Luo H, Ye ZH. Job burnout of nurses. Chin Ment Health J. (2004) 07:477–9. doi: 10.3321/j.issn:1000-6729.2004.07.009 [DOI] [Google Scholar]
- 17.Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. J Adv Nurs. (2001) 33:250–6. doi: 10.1046/j.1365-2648.2001.01658.x, [DOI] [PubMed] [Google Scholar]
- 18.Hamric AB, Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med. (2007) 35:422–9. doi: 10.1097/01.Ccm.0000254722.50608.2D, [DOI] [PubMed] [Google Scholar]
- 19.Sun X. Revising and Application of the Chinese Version of the Moral Distress Scale-Revised for Nurses [Master's thesis]. Shandong: Shandong University; (2011). [Google Scholar]
- 20.Heinze KE, Hanson G, Holtz H, Swoboda SM, Rushton CH. Measuring health care Interprofessionals' moral resilience: validation of the Rushton moral resilience scale. J Palliat Med. (2021) 24:865–72. doi: 10.1089/jpm.2020.0328, [DOI] [PubMed] [Google Scholar]
- 21.Tian X, He Q, Liu X, Gan X, Jiménez Herrera MF. Moral resilience in registered nurses: cultural adaption and validation study. Nurs Ethics. (2024) 31:355–70. doi: 10.1177/09697330231196229, [DOI] [PubMed] [Google Scholar]
- 22.Numminen O, Katajisto J, Leino-kilpi H. Development and validation of nurses' moral courage scale. Nurs Ethics. (2019) 26:2438–55. doi: 10.1177/0969733018791325, [DOI] [PubMed] [Google Scholar]
- 23.Wang SY, Wei LL, Zhang Y, Liu T, Jiang WB, Yang HP, et al. The reliability and validity of the Chinese version nurses' moral courage scale. J Nurs Sci. (2019) 34:92–95. doi: 10.3870/j.issn.1001-4152.2019.21.092 [DOI] [Google Scholar]
- 24.Chai F, Hu W, Xu D, Ji Y, Wang Y, Xu C, et al. The relationship between moral distress and occupational burnout among ICU nurses: social support and psychological resilience as mediating variables. Front Public Health. (2025) 13:1743774. doi: 10.3389/fpubh.2025.1743774 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Li KF, Jia HY, Fang ZJ. The mediating effect of authentic leadership between organizational climate and job embeddedness among emergency nurses. Mod Nurse. (2025) 32:116–21. doi: 10.19793/j.cnki.1006-6411.2025.30.024 [DOI] [Google Scholar]
- 26.Yuan Y, Wang ZH, Shao YX, Xia X, Lu F, Xie F, et al. Dispositional mindfulness and post-traumatic stress symptoms in emergency nurses: multiple mediating roles of coping styles and emotional exhaustion. Front Psychol. (2022) 13:787100. doi: 10.3389/fpsyg.2022.787100 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Fernandes JB, Antunes R, Ivabel M, Lucas M, Oliveira R, Bico W, et al. Assessing the magnitude of burnout among emergency nurses in Portugal. Front Public Health. (2025) 13:1699355. doi: 10.3389/fpubh.2025.1699355 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Kovanci MS, Özbas AA. Moral resilience and intention to leave: mediating effect of moral distress. Nurs Ethics. (2025) 32:864–74. doi: 10.1177/09697330241272882, [DOI] [PubMed] [Google Scholar]
- 29.Rushton CH. Moral resilience: a capacity for navigating moral distress in critical care. AACN Adv Crit Care. (2016) 27:111–9. doi: 10.4037/aacnacc2016275, [DOI] [PubMed] [Google Scholar]
- 30.Hthelee LHH, Sadooghiasl A, Kermanshahi SM. Moral distress and moral courage among Iraqi nurses during the COVID-19 pandemic: a cross-sectional study. J Med Ethics Hist Med. (2023) 16:19. doi: 10.18502/jmehm.v16i19.14618, [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.