Moral Distress, Psychological Resilience, and Burnout in Psychiatric Nurses: A Cross-Sectional Study with Social Support and Coping Strategies as Moderators
-
Ali Mlaghy Shakhat Al-Salhee
,
Ali Sabry Al-Yasari
,
Mohammed Kadhim Saadoon
,
Hussein Khlaif Ketab
,
Manar Majeed Hameed
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.
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2. Babamiri M, Bashirian S, Khazaei S, Sohrabi MS, Heidarimoghadam R, Mortezapoor A, et al. Burnout and Mental Health of COVID-19 Frontline Healthcare Workers: Results from an Online Survey. Iran J Psychiatry. 2022;17(2):136-43.
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4. Salehi R, Ardeshiri Z, Mohammadi MR. Psychiatrists Under Pressure: Exploring Occupational Risks and Protective Strategies. Iran J Psychiatry. 2026;21(2):164-78.
5. Rasouli A, Khaleghi A, Bashi SK, Zarafshan H. A Narrative Review of Challenges and Management Strategies for Pediatric Clients with Neurodevelopmental Disorders in Non-Psychiatric Settings. Iran J Psychiatry. 2026:1-8.
6. Kaya E, Molu NG. Relationship between moral distress, compassion fatigue, and burnout levels of psychiatric nurses. Journal of Psychiatric Nursing. 2023;14(2):103.
7. Lamoureux S, Mitchell AE, Forster EM. Moral distress among acute mental health nurses: A systematic review. Nurs Ethics. 2024;31(7):1178-95.
8. Mohammadi MR, Ahmadi N, Hooshyari Z, Khaleghi A, Rismanian Yazdi F, Mehrparvar AH. Prevalence, comorbidity, and predictors of obsessive-compulsive disorder in Iranian children and adolescents. J Psychiatr Res. 2021;141:192-8.
9. Lotfi-Bejestani S, Atashzadeh-Shoorideh F, Ghafouri R, Nasiri M, Ohnishi K, Ghadirian F. Is there any relationship between nurses' perceived organizational justice, moral sensitivity, moral courage, moral distress and burnout? BMC Nurs. 2023;22(1):368.
10. Orgambídez A, Borrego Y, Alcalde FJ, Durán A. Moral Distress and Emotional Exhaustion in Healthcare Professionals: A Systematic Review and Meta-Analysis. Healthcare (Basel). 2025;13(4).
11. Alonazi O, Alshowkan A, Shdaifat E. The relationship between psychological resilience and professional quality of life among mental health nurses: a cross-sectional study. BMC Nurs. 2023;22(1):184.
12. Troy AS, Willroth EC, Shallcross AJ, Giuliani NR, Gross JJ, Mauss IB. Psychological Resilience: An Affect-Regulation Framework. Annu Rev Psychol. 2023;74:547-76.
13. Castillo-González A, Velando-Soriano A, De La Fuente-Solana EI, Martos-Cabrera BM, Membrive-Jiménez MJ, Lucía RB, et al. Relation and effect of resilience on burnout in nurses: A literature review and meta-analysis. Int Nurs Rev. 2024;71(1):160-7.
14. Albaqawi HM, Alshammari MH. Resilience, compassion fatigue, moral distress and moral injury of nurses. Nurs Ethics. 2025;32(3):798-813.
15. Fattah A, Tabasi HRK, Al-Awabdeh E, Mottershead R, Forouzanfar H, Ahmadi Chenari H, et al. Investigating the Ethical Challenges and Quality of Care for Patients on Psychiatric Units With Aggressive Behaviors in Iraq. Nurs Sci Q. 2025:8943184251398988.
16. de Cordova PB, Reilly LL, Pogorzelska-Maziarz M, Gerolamo AM, Grafova I, Vasquez A, et al. A theoretical framework for Acute Care Nurse Stress Appraisal: Application of the transactional model of stress and coping. J Adv Nurs. 2024;80(9):3835-45.
17. Claponea RM, Iorga M. The Relationship between Burnout and Wellbeing Using Social Support, Organizational Justice, and Lifelong Learning in Healthcare Specialists from Romania. Medicina (Kaunas). 2023;59(7).
18. Smith MM, Saklofske DH, Keefer KV, Tremblay PF. Coping Strategies and Psychological Outcomes: The Moderating Effects of Personal Resiliency. J Psychol. 2016;150(3):318-32.
19. Jacobsen CF, Igra L, Lunn S, Karstoft KI, Nielsen J, Lauritzen L, et al. The association between therapist internal relational models, professional self-doubt, and coping strategies and the process and outcome of psychotherapy. Psychother Res. 2026;36(3):484-99.
20. Mai Y, Wu YJ, Huang Y. What Type of Social Support Is Important for Student Resilience During COVID-19? A Latent Profile Analysis. Front Psychol. 2021;12:646145.
21. Wong MCS, Huang J, Wang HHX, Yuan J, Xu W, Zheng ZJ, et al. Resilience level and its association with maladaptive coping behaviours in the COVID-19 pandemic: a global survey of the general populations. Global Health. 2023;19(1):1.
22. Kovanci MS, Atli Özbaş A. Moral resilience and intention to leave: Mediating effect of moral distress. Nurs Ethics. 2025;32(3):864-74.
23. Jobst LJ, Bader M, Moshagen M. A tutorial on assessing statistical power and determining sample size for structural equation models. Psychol Methods. 2023;28(1):207-21.
24. Hamric AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research. 2012;3(2):1-9.
25. Sharif Nia H, Shafipour V, Allen KA, Heidari MR, Yazdani-Charati J, Zareiyan A. A Second-Order Confirmatory Factor Analysis of the Moral Distress Scale-Revised for Nurses. Nurs Ethics. 2019;26(4):1199-210.
26. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76-82.
27. Wojujutari AK, Idemudia ES, Ugwu LE. Evaluation of reliability generalization of Conner-Davison Resilience Scale (CD-RISC-10 and CD-RISC-25): A Meta-analysis. PLoS One. 2024;19(11):e0297913.
28. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15(2):103-11.
29. Bassam S, Mohsen H, Barakat Z, Abou-Abbas L. Psychometric properties of the arabic version of the maslach burnout inventory-human services survey (MBI-HSS) among lebanese dentists. BMC Oral Health. 2023;23(1):451.
30. Fekih-Romdhane F, Fawaz M, Hallit R, Sawma T, Obeid S, Hallit S. Psychometric properties of an Arabic translation of the multidimensional social support scale (MSPSS) in a community sample of adults. BMC Psychiatry. 2023;23(1):432.
31. Mallhi TH, Ahmad N, Salman M, Tanveer N, Shah S, Butt MH, et al. Estimation of Psychological Impairment and Coping Strategies during COVID-19 Pandemic among University Students in Saudi Arabia: A Large Regional Analysis. Int J Environ Res Public Health. 2022;19(21).
32. Solberg MA, Gridley MK, Peters RM. The Factor Structure of the Brief Cope: A Systematic Review. West J Nurs Res. 2022;44(6):612-27.
33. Xue B, Wang S, Chen D, Hu Z, Feng Y, Luo H. Moral distress, psychological capital, and burnout in registered nurses. Nurs Ethics. 2024;31(2-3):388-400.
34. Ajoudani F, Baghaei R, Lotfi M. Moral distress and burnout in Iranian nurses: The mediating effect of workplace bullying. Nurs Ethics. 2019;26(6):1834-47.
35. Shaqiqi W, Abou El-Soud FA. The mediating role of social support on the relationship between secondary traumatic stress and burnout of nurses caring for COVID-19 patients: A cross-sectional study. Appl Nurs Res. 2024;79:151844.
36. Lamiani G, Montecalvo M, Luridiana Battistini C, Borghi L, Meyer EC, Vegni E. Coping with moral distress: a qualitative study exploring psychological strategies used by healthcare professionals. BMC Psychol. 2025;13(1):589.
37. Farchi MU, Peled-Avram M. The ART of resilience: a theoretical bridge across resilience perspectives. Front Psychol. 2025;16:1556047.
38. Hill Y, Dolezal ML, Nordbeck PC, Den Hartigh RJ, Pincus D, Kiefer AW, et al. Moving from traits to the dynamic process: The next steps in research on human resilience. Journal of Aggression, Maltreatment & Trauma. 2025;34(7):971-89.
39. Webb K, Penz K. Strategies to Reduce the Impact of Trauma in Psychiatric Nurses: An Integrative Review of the Literature. Issues Ment Health Nurs. 2024;45(2):173-85.
40. Moisoglou I, Katsiroumpa A, Malliarou M, Papathanasiou IV, Gallos P, Galanis P. Social Support and Resilience Are Protective Factors against COVID-19 Pandemic Burnout and Job Burnout among Nurses in the Post-COVID-19 Era. Healthcare (Basel). 2024;12(7).
41. Hamama L, Hamama-Raz Y, Stokar YN, Pat-Horenczyk R, Brom D, Bron-Harlev E. Burnout and perceived social support: The mediating role of secondary traumatization in nurses vs. physicians. J Adv Nurs. 2019;75(11):2742-52.
42. Chen YH, Chang YY, Wang IT, Chang SH. When Caring Hurts: The Buffering Role of Social Support in Emergency Department Nurses' Coping With Secondary Traumatic Stress. J Nurs Manag. 2026;2026(1):e8247254.
43. McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. Lancet. 2021;397(10288):1905-13.
44. Tavakol N, Molazem Z, Rakhshan M, Asemani O. Strategies of Iranian Psychiatric Nurses to Deal with Moral Distress. Indian J Occup Environ Med. 2023;27(1):67-72.
2. Babamiri M, Bashirian S, Khazaei S, Sohrabi MS, Heidarimoghadam R, Mortezapoor A, et al. Burnout and Mental Health of COVID-19 Frontline Healthcare Workers: Results from an Online Survey. Iran J Psychiatry. 2022;17(2):136-43.
3. Getie A, Ayenew T, Amlak BT, Gedfew M, Edmealem A, Kebede WM. Global prevalence and contributing factors of nurse burnout: an umbrella review of systematic review and meta-analysis. BMC Nurs. 2025;24(1):596.
4. Salehi R, Ardeshiri Z, Mohammadi MR. Psychiatrists Under Pressure: Exploring Occupational Risks and Protective Strategies. Iran J Psychiatry. 2026;21(2):164-78.
5. Rasouli A, Khaleghi A, Bashi SK, Zarafshan H. A Narrative Review of Challenges and Management Strategies for Pediatric Clients with Neurodevelopmental Disorders in Non-Psychiatric Settings. Iran J Psychiatry. 2026:1-8.
6. Kaya E, Molu NG. Relationship between moral distress, compassion fatigue, and burnout levels of psychiatric nurses. Journal of Psychiatric Nursing. 2023;14(2):103.
7. Lamoureux S, Mitchell AE, Forster EM. Moral distress among acute mental health nurses: A systematic review. Nurs Ethics. 2024;31(7):1178-95.
8. Mohammadi MR, Ahmadi N, Hooshyari Z, Khaleghi A, Rismanian Yazdi F, Mehrparvar AH. Prevalence, comorbidity, and predictors of obsessive-compulsive disorder in Iranian children and adolescents. J Psychiatr Res. 2021;141:192-8.
9. Lotfi-Bejestani S, Atashzadeh-Shoorideh F, Ghafouri R, Nasiri M, Ohnishi K, Ghadirian F. Is there any relationship between nurses' perceived organizational justice, moral sensitivity, moral courage, moral distress and burnout? BMC Nurs. 2023;22(1):368.
10. Orgambídez A, Borrego Y, Alcalde FJ, Durán A. Moral Distress and Emotional Exhaustion in Healthcare Professionals: A Systematic Review and Meta-Analysis. Healthcare (Basel). 2025;13(4).
11. Alonazi O, Alshowkan A, Shdaifat E. The relationship between psychological resilience and professional quality of life among mental health nurses: a cross-sectional study. BMC Nurs. 2023;22(1):184.
12. Troy AS, Willroth EC, Shallcross AJ, Giuliani NR, Gross JJ, Mauss IB. Psychological Resilience: An Affect-Regulation Framework. Annu Rev Psychol. 2023;74:547-76.
13. Castillo-González A, Velando-Soriano A, De La Fuente-Solana EI, Martos-Cabrera BM, Membrive-Jiménez MJ, Lucía RB, et al. Relation and effect of resilience on burnout in nurses: A literature review and meta-analysis. Int Nurs Rev. 2024;71(1):160-7.
14. Albaqawi HM, Alshammari MH. Resilience, compassion fatigue, moral distress and moral injury of nurses. Nurs Ethics. 2025;32(3):798-813.
15. Fattah A, Tabasi HRK, Al-Awabdeh E, Mottershead R, Forouzanfar H, Ahmadi Chenari H, et al. Investigating the Ethical Challenges and Quality of Care for Patients on Psychiatric Units With Aggressive Behaviors in Iraq. Nurs Sci Q. 2025:8943184251398988.
16. de Cordova PB, Reilly LL, Pogorzelska-Maziarz M, Gerolamo AM, Grafova I, Vasquez A, et al. A theoretical framework for Acute Care Nurse Stress Appraisal: Application of the transactional model of stress and coping. J Adv Nurs. 2024;80(9):3835-45.
17. Claponea RM, Iorga M. The Relationship between Burnout and Wellbeing Using Social Support, Organizational Justice, and Lifelong Learning in Healthcare Specialists from Romania. Medicina (Kaunas). 2023;59(7).
18. Smith MM, Saklofske DH, Keefer KV, Tremblay PF. Coping Strategies and Psychological Outcomes: The Moderating Effects of Personal Resiliency. J Psychol. 2016;150(3):318-32.
19. Jacobsen CF, Igra L, Lunn S, Karstoft KI, Nielsen J, Lauritzen L, et al. The association between therapist internal relational models, professional self-doubt, and coping strategies and the process and outcome of psychotherapy. Psychother Res. 2026;36(3):484-99.
20. Mai Y, Wu YJ, Huang Y. What Type of Social Support Is Important for Student Resilience During COVID-19? A Latent Profile Analysis. Front Psychol. 2021;12:646145.
21. Wong MCS, Huang J, Wang HHX, Yuan J, Xu W, Zheng ZJ, et al. Resilience level and its association with maladaptive coping behaviours in the COVID-19 pandemic: a global survey of the general populations. Global Health. 2023;19(1):1.
22. Kovanci MS, Atli Özbaş A. Moral resilience and intention to leave: Mediating effect of moral distress. Nurs Ethics. 2025;32(3):864-74.
23. Jobst LJ, Bader M, Moshagen M. A tutorial on assessing statistical power and determining sample size for structural equation models. Psychol Methods. 2023;28(1):207-21.
24. Hamric AB, Borchers CT, Epstein EG. Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research. 2012;3(2):1-9.
25. Sharif Nia H, Shafipour V, Allen KA, Heidari MR, Yazdani-Charati J, Zareiyan A. A Second-Order Confirmatory Factor Analysis of the Moral Distress Scale-Revised for Nurses. Nurs Ethics. 2019;26(4):1199-210.
26. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18(2):76-82.
27. Wojujutari AK, Idemudia ES, Ugwu LE. Evaluation of reliability generalization of Conner-Davison Resilience Scale (CD-RISC-10 and CD-RISC-25): A Meta-analysis. PLoS One. 2024;19(11):e0297913.
28. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15(2):103-11.
29. Bassam S, Mohsen H, Barakat Z, Abou-Abbas L. Psychometric properties of the arabic version of the maslach burnout inventory-human services survey (MBI-HSS) among lebanese dentists. BMC Oral Health. 2023;23(1):451.
30. Fekih-Romdhane F, Fawaz M, Hallit R, Sawma T, Obeid S, Hallit S. Psychometric properties of an Arabic translation of the multidimensional social support scale (MSPSS) in a community sample of adults. BMC Psychiatry. 2023;23(1):432.
31. Mallhi TH, Ahmad N, Salman M, Tanveer N, Shah S, Butt MH, et al. Estimation of Psychological Impairment and Coping Strategies during COVID-19 Pandemic among University Students in Saudi Arabia: A Large Regional Analysis. Int J Environ Res Public Health. 2022;19(21).
32. Solberg MA, Gridley MK, Peters RM. The Factor Structure of the Brief Cope: A Systematic Review. West J Nurs Res. 2022;44(6):612-27.
33. Xue B, Wang S, Chen D, Hu Z, Feng Y, Luo H. Moral distress, psychological capital, and burnout in registered nurses. Nurs Ethics. 2024;31(2-3):388-400.
34. Ajoudani F, Baghaei R, Lotfi M. Moral distress and burnout in Iranian nurses: The mediating effect of workplace bullying. Nurs Ethics. 2019;26(6):1834-47.
35. Shaqiqi W, Abou El-Soud FA. The mediating role of social support on the relationship between secondary traumatic stress and burnout of nurses caring for COVID-19 patients: A cross-sectional study. Appl Nurs Res. 2024;79:151844.
36. Lamiani G, Montecalvo M, Luridiana Battistini C, Borghi L, Meyer EC, Vegni E. Coping with moral distress: a qualitative study exploring psychological strategies used by healthcare professionals. BMC Psychol. 2025;13(1):589.
37. Farchi MU, Peled-Avram M. The ART of resilience: a theoretical bridge across resilience perspectives. Front Psychol. 2025;16:1556047.
38. Hill Y, Dolezal ML, Nordbeck PC, Den Hartigh RJ, Pincus D, Kiefer AW, et al. Moving from traits to the dynamic process: The next steps in research on human resilience. Journal of Aggression, Maltreatment & Trauma. 2025;34(7):971-89.
39. Webb K, Penz K. Strategies to Reduce the Impact of Trauma in Psychiatric Nurses: An Integrative Review of the Literature. Issues Ment Health Nurs. 2024;45(2):173-85.
40. Moisoglou I, Katsiroumpa A, Malliarou M, Papathanasiou IV, Gallos P, Galanis P. Social Support and Resilience Are Protective Factors against COVID-19 Pandemic Burnout and Job Burnout among Nurses in the Post-COVID-19 Era. Healthcare (Basel). 2024;12(7).
41. Hamama L, Hamama-Raz Y, Stokar YN, Pat-Horenczyk R, Brom D, Bron-Harlev E. Burnout and perceived social support: The mediating role of secondary traumatization in nurses vs. physicians. J Adv Nurs. 2019;75(11):2742-52.
42. Chen YH, Chang YY, Wang IT, Chang SH. When Caring Hurts: The Buffering Role of Social Support in Emergency Department Nurses' Coping With Secondary Traumatic Stress. J Nurs Manag. 2026;2026(1):e8247254.
43. McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. Lancet. 2021;397(10288):1905-13.
44. Tavakol N, Molazem Z, Rakhshan M, Asemani O. Strategies of Iranian Psychiatric Nurses to Deal with Moral Distress. Indian J Occup Environ Med. 2023;27(1):67-72.
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How to Cite
1.
Shakhat Al-Salhee AM, Al-Yasari AS, Kadhim Saadoon M, Khlaif Ketab H, Majeed Hameed M. Moral Distress, Psychological Resilience, and Burnout in Psychiatric Nurses: A Cross-Sectional Study with Social Support and Coping Strategies as Moderators. Iran J Psychiatry. 2026;:1-12.
