The mediating effect of moral distress on the relationship between work environment and depression among critical care nurses.

backgroundCritical care nurses (CCNs) frequently encounter ethical dilemmas and institutional constraints that contribute to moral distress, a phenomenon linked to adverse psychological outcomes, such as depression and increased turnover intentions. Despite growing evidence of these relationships, comprehensive studies examining the interplay between the work environment, moral distress, and depression among CCNs in Saudi Arabia remain scarce.

objectivesThis study aimed to assess the mediating role of moral distress on the relationship between the work environment and depression among CCNs.

methodsA cross-sectional design was employed, recruiting 230 critical care nurses from four tertiary hospitals in Hail, Saudi Arabia. Validated instruments—the Practice Environment Scale of the Nursing Work Index (PES-NWI), Measure of Moral Distress for Healthcare Professionals (MMD-HP), and Patient Health Questionnaire (PHQ-9)—were used to measure the work environment, moral distress, and depression, respectively. Data were analyzed using descriptive statistics, Pearson’s correlation, and mediation analysis using Hayes’ PROCESS macro.

resultsThe means of the work environment, moral distress, and depression were 2.67 ± 0.46, 104.24 ± 76.12, and 11.57 ± 5.72, respectively. A significant weak negative correlation was found between the work environment and moral distress (r = − .323, p < .001) and between the work environment and depression (r = − .243, p < .001). Moral distress positively correlated with depression (r = .285, p < .001). Mediation analysis revealed that moral distress (β=-0.075, p = .003) serves as a partial negative mediator between work environment and depression. Nurses with lower educational attainment (diploma/associate degree) or three or more children reported higher levels of depression (p < .05).

conclusionsThis study underscores the detrimental impact of a poor work environment on moral distress and depression among CCNs. Moral distress serves as a key mediator amplifying psychological harm. Interventions targeting ethical climate improvement, mental health support, and educational advancement are urgently required to mitigate these effects. These findings advocate for systemic changes to enhance nurses’ well-being and retention, particularly in high-intensity settings, such as critical care units. Future research should employ a longitudinal design to establish causality and evaluate intervention efficacy. CLINICAL TRIAL NUMBER: Not applicable.