Concept synthesis of ethical resilience in nurses.

COVID-19 has resulted in devastating economic, social, and psychological effects on a global scale due to its unstoppable and disastrous nature. There is a paucity of literature examining the interconnection between moral distress (MD) and resilience among nurses in the context of the pandemic. We have undertaken a narrative review of the available research on nurses' MD and resilience during the COVID-19 outbreak. A narrative review was performed through an extensive search in databases, such as PubMed, Web of Science, and Scopus, from December 1, 2020, to March 29, 2023. Keywords included "COVID-19", "2019-nCoV disease", "2019 novel coronavirus infection", "nurses", "moral distress", and "moral resilience". English-language published articles that matched the inclusion criteria were evaluated and included. Inclusion criteria included review and all descriptive studies evaluating MD and resilience in nurses during the COVID-19 pandemic. Gray literature and letters were excluded from the search results. The study results showed that nurses suffered from MD during the COVID-19 pandemic. Moral resilience is the opposite of MD, which can be reduced by using strategies such as developing the abilities of healthcare workers, strengthening honesty, and reducing their stress and anxiety. On the other hand, strengthening moral resilience by fostering self-regulation capacities, accountability and flexibility, recognizing the boundaries of honesty, and exercising conscientious objections can effectively promote their moral resilience. Considering the challenging conditions among healthcare professionals, especially nurses, in the era of COVID-19, this causes increased MD, which can cause mental and emotional risks for nurses. So, considering the relationship between MD and moral resilience (considered a protective factor) and the inverse relationship between them, it is suggested that by increasing moral resilience, we should reduce MD to survive the difficult period of COVID-19. Protect ourselves from moral and psychological problems and improve patient care quality by following the tips.

Moral distress among pediatric nurses negatively impacts their well-being and quality of care. Enhancing moral resilience may help mitigate this distress. To assess the effect of a code of ethics intervention on moral distress and moral resilience levels among pediatric nurses in Riyadh and Kanyakumari, a quasi-experimental study was conducted with 243 pediatric nurses (125 in Riyadh, 118 in Kanyakumari) using purposive sampling. Participants received a 15-minute daily ethics teaching intervention over 7 days during shift huddles. Moral distress and moral resilience were measured pre- and post-intervention using validated self-administered questionnaires. Post-intervention, moral distress frequency and intensity significantly decreased, while moral resilience significantly increased among nurses in Riyadh. In Kanyakumari, moral distress showed reduction, but changes in moral resilience were not significant. Significant associations were observed between moral distress, resilience, and demographic variables such as age, gender, and work department. The ethics intervention effectively reduced moral distress and enhanced moral resilience in pediatric nurses, highlighting the importance of ethics education in nursing practice to improve nurses' well-being and care quality.

BackgroundNurses often face complex moral distress in clinical practice, where maintaining emotional stability and making moral decisions under pressure is crucial for patient care and safety. Moral resilience helps nurses stay composed, think rationally, and navigate moral challenges effectively. Exploring the characteristics and influencing factors of different moral resilience subgroups can provide insights into nurses' resilience levels and inform targeted interventions to enhance their occupational well-being.AimTo identify the latent profile model of moral resilience in nurses and analyze the characteristic differences and influencing factors across different profiles.DesignA multicenter cross-sectional study.Participants and research contextThe study involved nurse practitioners from nine different hospitals. A total of 1098 nurses from different specialties participated in the study.Ethical considerationsThe study was approved by the ethical board of the 900 Hospital of the Joint Service Support Force.FindingsNurses' moral resilience was classified into three profiles: Vulnerable (46.45%), Discrepant (12.02%), and Robust (41.53%). Divorced or widowed nurses (p = .017, Z = 2.395) and those working in infectious disease departments (p < .001, Z = 3.796) were more likely to belong to the Robust profile. Higher moral distress increased the likelihood of being in the Vulnerable profile (p = .017/<.001, Z = -2.379/-7.001). A stronger ethical climate (p < .001, Z = 4.540) and greater workplace trust (p = .010, Z = 2.586) were more likely to belong to the Robust profile. Nurses with greater moral courage were more likely to have robust moral resilience and less likely to be in the Discrepant profile (p = .007/<.001, Z = 2.687/-5.225).ConclusionNurses' moral resilience is heterogeneous, highlighting the need for managers to consider profile characteristics and specialty-specific factors. Strengthening the hospital ethical climate can reduce moral distress, enhance workplace trust, and foster moral courage, ultimately improving moral resilience in nurses.

Q Maintaining my moral integrity is important to me, yet I have been faced with situations that challenge my ethical compass. How do I develop the internal strength to remain true to my values? How can my organization support efforts by my coworkers and me to speak up when we feel there are ethical concerns? What can I do as an individual and what can my organization do to enhance the environment to ensure ethical practice?A Karen Stutzer, rn, phd, and Mary Bylone, rn, msm, cnml, reply:It is well documented and acknowledged that the critical care environment contains daily challenges to individual nurses in regard to their moral integrity.1–3 Andrew Jameton4 initially described moral distress as when "one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action."4(p6) Identifying moral distress was the beginning of decades of work that has described and measured the impact of moral distress across multiple nursing specialties.1 The debilitating impact of moral distress on nurses is supported by research and includes burnout, disengagement from patients and families, stress-related illnesses, turnover, and leaving the profession.1A promising approach to addressing situations that challenge one's ethical compass and the resulting moral distress is to incorporate strategies that promote moral resilience into organizational and individual practices. Moral resilience has been described as "the capacity of an individual to sustain or restore integrity in response to moral complexity, confusion, distress or setbacks."5(pS13) Developing personal strategies to strengthen one's approach to ethically distressing situations and seeking organizational strategies to support ethical practice are 2 ways to build moral resilience capacity.At the National Teaching Institute held in May 2017, a panel led several hundred acute and critical care nurses in a discussion about moral distress. Participants were encouraged to "forge a new path"6 and consider strategies to shift the dialogue and experience to those that promote resilience. This column is a reflection of the thinking of these participant experts—acute and critical care nurses who navigate the health care system to advocate for patients and families daily (Tables 1 and 2).Care for the critically ill patients occurs within health care organizations, and the ethical climate of those environments directly affects the ability of the nurse and members of the interprofessional team to provide care ethically.8 Health care organizations can and should provide systemic support to ensure the environment is conducive to ethical practice. The American Nurses Association Code of Ethics requires nursing leaders, in collaboration with nursing care providers, to ensure the practice environment supports the moral integrity of nurses.9,10Policies that support ethical practice are key to creating organizational infrastructure that can mitigate morally distressing events. Nursing leadership and bedside care providers need to identify the policies that are most supportive of ethical practice and develop those policies collaboratively. Among the areas that might be covered are mechanisms for addressing ethical concerns, protection of moral integrity, and organizational priorities for ethical practice. More specific examples include informed consent, withholding and withdrawal of life-sustaining therapies, health care decision-making, and calling an ethics consultation.11Nursing leaders are positioned to influence ethical practice through their words and deeds. Through support of shared governance structures, nurses are able to ensure their voice is included in policy development. It is key that policies and practice reinforce the expectation that nurses will verbalize concerns.12Organizations must provide adequate financial and human resources to support an ethical culture. The presence of effective ethics committees and qualified ethics consultants provides organizational structure for ethical practice.8 There should also be support for nurses who provide care to patients to be part of these committees. Organizations should provide processes, structures, and well-prepared educators to ensure ongoing education to develop and sustain ethical competence. Inquiring daily about potential ethical concerns in concert with the presence of well-prepared ethics resources can provide opportunity for early intervention and perhaps diminish the degree of distress experienced by all members of the team.13The emergence of moral resilience as a strategy to manage and cope with moral distress is a relatively new discussion. As one thinks about personal actions, it is an important step to recognize one's intrinsic ability to care for oneself, advocate for patients, and work with organizational leadership to address ethically distressing situations. The professional Code of Ethics supports the requirement that nurses must promote personal health and well-being, and advocate for patients and ethical work environments.9Moral resilience comes from a place of intentional actions to build on personal strengths. Knowing one's personal values and being willing to take courageous action move the experience from one of distress to one of resilience.5 The ability to stay true to oneself, make decisions that are consistent with one's beliefs, and persevere in addressing concerns are attributes of moral resilience12 and behaviors one can develop and nurture. Additionally, nurses must be willing to support others in these situations, even when the issue is not a problem for themselves. Knowing your colleagues are supportive of what is important to you provides strength for speaking up, which, in turn, improves the dialogue.Maintaining balance and harmony in one's life needs to be a priority. A healthy diet, proper rest, and time for relaxation can foster the needed energy to cope with distressing situations. Mindfulness practices, exercise, yoga, or other activities that encourage respite from stress can also enhance resilience.Membership in professional organizations should be considered a strategy to promoting moral resilience. Nursing organizations provide a collective voice for nursing concerns and issues, and provide opportunities for networking and supportive dialogue with colleagues. The American Nurses Association has convened a professional issues panel that examines moral resilience with the intention of identifying strategies to strengthen the ethical voice of nurses and, thereby, promote moral resilience.14 In addition to the development and publication of the Healthy Work Environment Standards,7 the American Association of Critical-Care Nurses is an active participant in collaborating with a variety of nursing organizations to promote moral resilience.3 More work is needed to make these documents part of every workplace.Moral resilience moves the internal dialogue from one of disappointment and powerlessness to one of strength and empowerment. Consciously acting to develop moral resilience enhances one's self-confidence in managing ethically difficult situations.12 Through an ongoing commitment to developing self-awareness and insight when faced with ethical challenges, one can gain a deeper sense of understanding and sense of mastery when faced with ethically distressing situations.5

Nurses often face ethically challenging situations that can trigger moral distress and compromise their well-being. Understanding how ethical climate, moral courage, and moral resilience interact is essential for promoting ethical practice and supporting nurses’ psychological and professional integrity. This study examined the relationships among ethical climate, moral distress, moral courage, and moral resilience, and assessed the moderating role of moral resilience. A descriptive-correlational design was employed with a convenience sample of 350 nurses from a university-affiliated Egyptian hospital. Participants completed validated scales assessing ethical climate, moral distress, moral courage, and moral resilience. Data were analyzed using descriptive statistics, Pearson correlation, multiple regression, and moderation analysis. Nurses reported high levels of perceived ethical climate, moral courage, and moral resilience, alongside moderate moral distress. Ethical climate was negatively associated with moral distress (β = −.30, p &lt; .001) and positively associated with both moral courage (β = .36, p &lt; .001) and moral resilience (β = .39, p &lt; .001). Moral resilience moderated the relationships between ethical climate and moral distress (indirect effect = 0.16, p &lt; .001) and moral courage (indirect effect = 0.19, p &lt; .001), buffering distress and amplifying courage. A supportive ethical climate and enhanced moral resilience contribute significantly to reducing moral distress and fostering moral courage among nurses. These findings underscore the importance of resilience-building initiatives, ethical leadership, and targeted policy reforms in healthcare institutions. Nursing education should integrate moral resilience and ethical competence to strengthen professional practice.

AimsThis study aims to examine the mediating effect of moral distress on the relationship between moral resilience and the intention to leave.BackgroundMoral distress is a phenomenon that negatively impacts healthcare workers, healthcare institutions, and recipients. To eliminate or minimize the negative effects of moral distress, it is necessary to increase the moral resilience of nurses. Moral resilience is important in protecting against the negative effects of moral distress, such as burnout and turnover intention. In this direction, it is necessary to increase the moral resilience of nurses to reduce negative situations such as turnover intention in nurses.MethodsIt is a descriptive-predictive study. Sociodemographic Information Form, Measure of Moral Distress - Healthcare Professionals, and Rushton Moral Resilience Scale were used to collect data from the nurses. A total of 220 clinical nurses were recruited.Ethical considerationsApproval was obtained from the university's non-interventional ethics committee, and informed consent was obtained from the participants.ResultsThe study found a total moral distress score of 6.39 ± 0.3.12 and moral resilience score of 2.69 ± 0.48. A moderate and weak negative correlation was found between moral distress and moral resilience. Moral distress has a moderating effect on the intention to leave nursing (β = -0.158, p = .010) and the intention to leave the current position (β = -0.174, p = .000). Individual's moral resilience directly affects the intention to leave. The presence of moral distress eliminates the direct effect of moral resilience and affects the intention to leave together with moral resilience.ConclusionsMoral resilience leads to decreased intention to leave, and moral distress mediates this situation. An increase in moral distress decreases moral resilience and increases intention to leave. It can be assumed that if moral distress is not controlled, increasing moral resilience will not affect the intention to leave the job.

Nurses often face ethical issues in their daily work that can have an impact on their level of job embeddedness. And positive job embeddedness is essential to reduce burnout among nurses and improve professional retention in the medical industry. However, few studies have focused on the relationship between moral distress, moral resilience, and job embeddedness. To investigate the relationship between moral distress, moral resilience, and job embeddedness, and explore the mediating role of moral resilience between moral distress and job embeddedness among nurses. A quantitative, cross-sectional study. Nurses from a number of tertiary general hospitals in central China were surveyed and assessed using the Moral Distress Scale, the Nurse Moral Resilience Scale, and the nurse job embeddedness Scale from February to March 2023. The study was conducted in line with the 1964 Declaration of Helsinki. All study procedures were approved by the Ethics Committee of Hunan Normal University (No. 2023-313). Moral distress was positively correlated with moral resilience (β = 0.525, p < 0.01) and negatively correlated job embeddedness (β = -0.470, p < 0.01). Moral resilience partially mediated the relationship between moral distress with job embeddedness (β = -0.087, p < 0.01). The findings reveal a relationship between moral distress, job embeddedness, and moral resilience among nurses. Moral distress and moral resilience are important correlates of job embeddedness in nurses. Interventions to reduce moral distress and increase moral resilience may have potential benefits for improving nurses' job embeddedness. It is recommended that clinical nursing administrators create a favorable ethical atmosphere, educate nurses about ethics, and increase nurses' moral resilience.

The study aims to test the Turkish validity and reliability of the Rushton Moral Resilience Scale (RMRS) and examine the effect of moral resilience on moral distress. Moral distress is a phenomenon that negatively affects health workers, health institutions, and the person receiving care. In order to eliminate or minimize the negative effects of moral distress, it is necessary to increase the moral resilience of nurses. Moral resilience involves developing systems that support a culture of ethical practice in healthcare and aim to increase an individual's capacity to cope with moral challenges. A methodological and descriptive-predictive study design was adopted. Sociodemographic Information Form, Measure of Moral Distress - Healthcare Professionals (MMD-HP), and Rushton Moral Resilience Scale were used to collect data from the nurses. A total of 255 clinical nurses were recruited. Hacettepe University's non-interventional ethics committee approved the study's protocol and informed consent was obtained from the participants. The original four-factor structure of the scale was tested with confirmatory factor analysis, and the index values were evaluated and found at an acceptable level. The Cronbach Alpha coefficient of the scale was found to be 0.826. Moral resilience predicted moral distress total, intensity, and frequency levels. A moderate and weak relationship was found in the negative between all sub-dimensions of moral distress and moral resilience. The Rushton Moral Resilience Scale Turkish version showed good psychometric properties. Moral resilience has a reducing effect on moral distress. Young nurses who have less experience are at risk because they have lower moral resilience levels, while nurses working in intensive care units are at risk because of their high moral distress levels. A healthy workplace can be created by developing specific approaches to improve moral resilience in reducing the impact of moral distress in the healthcare environment.

The ethical behaviour of ICU nurses is closely related to their own psychological health, patient safety and quality of care. Current research shows that the practice of ethical behaviour of nurses faces serious challenges, the level of practice needs to be improved and few scholars pay attention to the special group of ICU nurses. Therefore, it is necessary to conduct an in-depth study on the ethical behaviour of ICU nurses. We aimed to understand the current status of ethical behaviour among ICU nurses and analyse its influencing factors. A multicentre cross-sectional study was conducted using the cluster sampling method. Between February and June 2025, ICU nurses from 10 tertiary Grade A hospitals in Guizhou Province, China, were selected. We used general information questionnaires, the Ethical Behaviour Scale for Nurses-Revise, the Moral Sensitivity Questionnaire-Revised Version into Chinese, the Rushton Moral Resilience Scale and the Ethical Leadership at Work Questionnaire for the investigation. Descriptive analysis, t-tests, ANOVA, correlation analysis and multiple linear regression analysis were used to analyse the results. A total of 405 ICU nurses were included, and the ethical behaviour score of ICU nurses was 62.32 ± 5.95 (range 15-90), with the highest score of 22.33 ± 2.32 for the risk prevention dimension and the lowest score of 19.05 ± 2.70 for the fair nursing dimension. The results of multiple linear regression analysis revealed that position (β = 2.266, p = 0.009), whether ethics-related training has been received (β = 1.540, p = 0.004), moral sensitivity (β = 0.326, p < 0.001), moral resilience (β = 0.109, p < 0.001), and ethical leadership (β = 0.196, p < 0.001) were the factors influencing the ethical behaviour of ICU nurses. The ethical behaviour of ICU nurses is at a moderate level and needs to be further improved, with position, whether ethics-related training has been received, moral sensitivity, moral resilience and ethical leadership confirmed as significant influences. We identified key intervenable factors to enhance the ethical behaviour of ICU nurses. In future practice, healthcare organisations and nursing administrators should focus on strengthening ethical leadership, ensuring full coverage of ethical training and enhancing the moral sensitivity and resilience of ICU nurses, so as to effectively promote the practice of ethical behaviour.

The mediating roles of moral courage and moral resilience between nurses’ moral distress and moral injury: An online cross-sectional study

BackgroundNursing interns often faced moral distress in clinical practice, similar to registered nurses, which can lead to compassion fatigue. The roles of moral resilience and professional identity in influencing the psychological well-being of nursing interns are recognized, but the interrelationships among moral distress, moral resilience, professional identity, and compassion fatigue in this group remain unclear.ObjectivesThis study aimed to investigate the impact of moral distress on compassion fatigue among nursing interns and to explore the mediating role of moral resilience and professional identity.MethodsA quantitative cross-sectional study was conducted with 467 nursing interns. Data were collected using Compassion Fatigue Short Scale, Moral Distress Scale-revised, Rushton Moral Resilience Scale, and Professional Identity Scale. Data analyses were performed using SPSS 22.0 and Amos 21.0, adhering to the STROBE statement.ResultsThe mean scores for compassion fatigue, moral distress, moral resilience, and professional identity were 35.876, 44.887, 2.578, and 37.610, respectively. Moral distress was positively correlated with compassion fatigue. Structural equation modeling showed that moral resilience and professional identity partially mediated the relationship between moral distress and compassion fatigue (β = 0.448, P < 0.001).ConclusionThe findings suggest that moral distress directly influences compassion fatigue among nursing interns and also exerts an indirect effect through moral resilience and professional identity. Interventions aimed at enhancing moral resilience and fostering a strong professional identity may help mitigate the adverse effects of moral distress on compassion fatigue among nursing interns.

BackgroundGlobal health crises, such as the COVID-19 pandemic, confront healthcare workers (HCW) with increased exposure to potentially morally distressing events. The pandemic has provided an opportunity to explore the links between moral distress, moral resilience, and emergence of mental health symptoms in HCWs.MethodsA total of 962 Canadian healthcare workers (88.4% female, 44.6 + 12.8 years old) completed an online survey during the first COVID-19 wave in Canada (between April 3rd and September 3rd, 2020). Respondents completed a series of validated scales assessing moral distress, perceived stress, anxiety, and depression symptoms, and moral resilience. Respondents were grouped based on exposure to patients who tested positive for COVID-19. In addition to descriptive statistics and analyses of covariance, multiple linear regression was used to evaluate if moral resilience moderates the association between exposure to morally distressing events and moral distress. Factors associated with moral resilience were also assessed.FindingsRespondents working with patients with COVID-19 showed significantly more severe moral distress, anxiety, and depression symptoms (F > 5.5, p < .020), and a higher proportion screened positive for mental disorders (Chi-squared > 9.1, p = .002), compared to healthcare workers who were not. Moral resilience moderated the relationship between exposure to potentially morally distressing events and moral distress (p < .001); compared to those with higher moral resilience, the subgroup with the lowest moral resilience had a steeper cross-sectional worsening in moral distress as the frequency of potentially morally distressing events increased. Moral resilience also correlated with lower stress, anxiety, and depression symptoms (r > .27, p < .001). Factors independently associated with stronger moral resilience included: being male, older age, no mental disorder diagnosis, sleeping more, and higher support from employers and colleagues (B [0.02, |-0.26|].InterpretationElevated moral distress and mental health symptoms in healthcare workers facing a global crisis such as the COVID-19 pandemic call for the development of interventions promoting moral resilience as a protective measure against moral adversities.

Background: Global health crises, such as the COVID-19 pandemic, confront healthcare workers (HCW) with increased exposure to potentially morally injurious events. The pandemic has provided an opportunity to explore the links between moral distress, moral resilience, and emergence of mental health symptoms in HCWs.Methods: A total of 962 Canadian healthcare workers (88·4% female, 44·6 + 12·8 years old) completed an online survey during the first COVID-19 wave in Canada (between April 3 rd and September 3 rd , 2020). Respondents completed a series of validated scales assessing moral distress, perceived stress, anxiety, and depression symptoms, and moral resilience. Respondents were grouped based on exposure to patients who tested positive for COVID-19. In addition to descriptive statistics and analyses of covariance, multiple linear regressions were used to evaluate association between moral resilience, demographic/professional factors and moral distress and to identify factors associated with moral resilience.Findings: Respondents working with patients with COVID-19 showed significantly more severe moral distress, anxiety and depression symptoms (F > 5·5, p 9·1, p = ·002), compared to healthcare workers who were not. Higher exposure to potentially morally injurious events (B=2·98, 95% CI [2·90, 3·05]) and lower moral resilience (B=3·12, 95% CI [0·04, 6·20]) were associated with worse moral distress. Moral resilience moderated the relationship between exposure to potentially morally injurious events and moral distress (p ·27, pInterpretation: Elevated moral distress and mental health symptoms in healthcare workers facing a global crisis such as the COVID-19 pandemic call for the development of interventions promoting moral resilience as a protective measure against moral adversities.Trial Registration: Data for this study was collected as part of a larger online survey (ClinicalTrials.gov: NCT04369690)Funding Statement: The Royal Ottawa Foundation for Mental Health allocated some funds to help support the wider project from which this study stems. The Royal Ottawa Foundation for Mental Health had no influence on the study design, data collection, analysis, interpretation, or decision to publish this manuscript. The authors have not been paid by any pharmaceutical company or other for profit organization to write this article.Declaration of Interests: CR receives royalties from Oxford University Press: Moral Resilience: Transforming Moral Suffering in Health Care. MG received honorariums for presentations on physician wellness by Amgen and Merck and is the CEO of PEAK MD Inc, through which she delivers keynote presentations, consultation to healthcare organizations, coach senior medical leaders and receive book royalties (unrelated to this research). None of the other authors have any conflict of interest to disclose.Ethics Approval Statement: This study was approved by the Clinical Trials Ontario-Qualified Research Ethics Board (Protocol #2131).

Aim: To translate the Rushton Moral Resilience Scale (RMRS) into Japanese and validate its applicability among Japanese healthcare professionals. Background: To overcome daily challenges in the field of healthcare, in which moral difficulties are routinely encountered, the development of intervention methods to address moral suffering and moral distress is crucial. Methods: We conducted a cross-sectional survey using a web-based questionnaire. The RMRS-16 was translated into Japanese and confirmed through back-translation. Reliability analyses (Cronbach's alpha and intraclass correlation coefficient [ICC]), confirmatory factor analyses (CFAs), correlation analyses, t-tests, and analysis of variance (ANOVA) were used to assess the validity of the scale. Results: Participants comprised 1295 healthcare professionals, including 498 nurses. All subscales and the total scale had acceptable reliability values (α ≥ 0.70). CFA supported the original four-factor structure (response to moral adversity, personal integrity, relational integrity, and moral efficacy), with acceptable fit indices. The ANOVA results suggested that, among Japanese healthcare professionals, nurses and individuals from other professions showed lower average moral resilience scores compared to physicians, consistent with previous research on mental health and moral distress. In addition, women scored lower for moral resilience than men. However, the ICC values for the subscales of the RMRS were below acceptable levels, and the results of the standardized residual covariances also suggested a model misfit. Conclusion and Implications: The reliability, validity, and utility of the Japanese version of the RMRS were generally supported. However, there were areas at the item level that required structural examination. The current findings suggest that there are cultural differences in the concept of moral resilience. Therefore, for future cultural comparisons, the original four-factor structure was maintained in the Japanese version without modifications. Further conceptual development of moral resilience is needed in Japanese healthcare.

Intensive care nurses experience moral distress due to moral conflicts, which negatively impact their attitudes and behaviours towards end-of-life care. Moral resilience is considered a potential factor in mitigating these negative effects. This study aims to examine the mediating role of moral resilience in the relationship between moral distress and intensive care nurses' attitudes and behaviours towards end-of-life care. A descriptive and cross-sectional study was conducted in accordance with the guidelines for observational studies (STROBE). The study was conducted with 228 intensive care nurses between December 2024 and February 2025. Data were collected using the 'Personal Information Form', 'Moral Distress Scale', 'Moral Resilience Scale' and 'Scale of Attitudes and Behaviours of Intensive Care Nurses Towards End-of-Life Care'. Statistical analyses were performed using SPSS 26.0 and AMOS V 24.0. The moral distress levels of female nurses were higher and significantly higher than male nurses (OR 0.245; 95% CI 0.074-0.598; p = 0.011). Nurses with 11 years or more of work experience had a higher and significant level of moral distress compared to other nurses (OR 0.053; 95% CI 0.080-0.115; p = 0.012). The moral resilience level of nurses with 3-6 years of work experience was higher and significantly higher than other nurses (OR 0.067; 95% CI 0.048-0.107; p = 0.023). Moral distress negatively affects nurses' attitudes and behaviours towards end-of-life care. Moral resilience has a significant and positive effect on attitudes and behaviours. Moreover, moral resilience mediated the relationship between moral distress and attitudes and behaviours towards end-of-life care (β;-0.266, CI 95% -0.301-0.197). Moral distress negatively influences intensive care nurses' attitudes and behaviours in end-of-life care. Enhancing moral resilience can help mitigate these effects. The findings highlight the need for nursing education programmes and workplace interventions to strengthen nurses' moral resilience and improve their ability to manage moral distress. While moral distress damages intensive care nurses' attitudes towards end-of-life care, moral resilience may help to reduce its negative effects. Supporting nurses is thought to improve the quality of adverse end-of-life care.