ArticleFrontiers in public health2026
The effect of moral distress on emergency nurses' burnout: mediating role of moral resilience and moderating role of moral courage.
Article in Frontiers in public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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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.
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