Multinational intensive care unit nurses' moral courage, resilience, neutralisation, injury, and distress: A...

There is a wealth of studies about nurses' moral courage (MC), resilience, injury, and distress. However, the mediating roles of various moral constructs among their relationships remain understudied, specifically in intensive care unit (ICU) nurses.

The aim of this study was to examine the mediating roles of MC, resilience, neutralisation, and injury among their associations.

A cross-sectional and correlational study was conducted. Participant ICU nurses were consecutively recruited from five hospitals with adult ICUs in Saudi Arabia. Five standardised self-report scales were employed to collect data. The covariance-based structural equation modelling analysis was used to determine significant paths among the study variables.

Mediation analyses showed that MC had statistically significant indirect association with moral neutralisation (MN) (β = -0.05, p = 0.003) and moral distress (MD) (β = -0.11, p = 0.001) via the mediation of moral resilience (MR). MR had indirect association with moral injury (MI) (β = 0.04, p = 0.005) and MD (β = -0.04, p = 0.014) through the mediating effects of MN and MI, respectively. MI was a mediator between the indirect association of MN and MD (β = -0.03, p = 0.035). MC measured 5.59% of the variance of MR. The 18.34% total variance of MN was contributed by MC and resilience. MC, resilience, and neutralisation measured 7.22% of the variance of MI. Finally, 8.96% of the variance of MD was measured by MR, injury, and neutralisation.

MR buffers nurses' MD and supports MC, while MI undermines these effects. MN offers short-term relief but risks long-term disengagement, revealing a complex dynamic of protective and harmful moral factors. Healthcare institutions that employ ICU nurses may need to prioritise resilience training, structured moral support, and culturally sensitive interventions to sustain nurses' ethical integrity and reduce harm from MD and neutralisation.