Moral Distress, Psychological Resilience, and Burnout in Psychiatric Nurses: A Cross-Sectional Study with Social Support and Coping Strategies as Moderators

Abstract

Objective: We investigated the potential mediating effect of psychological resilience on the relationship between moral distress and burnout in psychiatric nurses, and examined how coping mechanisms and social support moderate this relationship.

Method: A cross-sectional study was performed with 385 psychiatric nursing staff from four psychiatric hospitals in Iraq. Participants completed the Moral Distress Scale-Revised (MDS-R), Connor-Davidson Resilience Scale-10 (CD-RISC-10), Maslach Burnout Inventory-Human Services Survey (MBI-HSS), Multidimensional Scale of Perceived Social Support (MSPSS), and Brief Coping Orientation to Problems Experienced (Brief COPE) inventory. Structural equation modeling with bootstrapping (5,000 resamples) was utilized for testing mediation, and PROCESS-based moderated mediation analysis (Model 7) was utilized to explore the moderating roles of social support and adaptive coping.

Results: Moral distress showed a significant total effect on burnout (β = 0.52, P < 0.01), and psychological resilience was negatively linked to burnout (β = -0.36, P = 0.01). Resilience showed a significant indirect effect, consistent with its mediating role in the relationship between moral distress and burnout (indirect effect = 0.15, 95% CI [0.08, 0.23]), accounting for 28.8% of the total effect. The direct effect of moral distress on burnout remained significant after accounting for resilience (β = 0.37, 95% CI [0.23, 0.51], P = 0.009), indicating partial mediation. Social support and adaptive coping strategies significantly moderated the indirect pathway, with the mediation effect being stronger among nurses reporting higher social support (index of moderated mediation = 0.07, 95% CI [0.03, 0.12]) and greater use of adaptive coping strategies (index = 0.09, 95% CI [0.04, 0.14]).

Conclusion: Psychological resilience partially mediates the connection between moral distress and burnout in psychiatric nurses. The findings imply that resilience, social support, and coping skills may be promising targets for intervention development. However, experimental studies are needed to determine whether interventions addressing these factors are effective in reducing burnout in this population.