THE MEDIATING EFFECT OF MORAL RESILIENCE AND PROFESSIONAL IDENTITY ON THE RELATIONSHIP BETWEEN MORAL DISTRESS AND COMPASSION FATIGUE AMONG NURSES IN SAUDI ARABIA
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Date
2025
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Journal ISSN
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Publisher
Saudi Digital Library
Abstract
Background:
Nurses frequently encounter ethically challenging situations that place them at risk
for moral distress and compassion fatigue, especially in high-stress healthcare
environments such as Saudi Arabia’s hospital system. These experiences can
undermine psychological well-being and professional performance. Moral
resilience and professional identity may serve as protective factors but are
underexplored as mediators in this context.
Aim:
To examine the mediating roles of moral resilience and professional identity in the
relationship between moral distress and compassion fatigue among Saudi nurses.
Methods:
A cross-sectional descriptive correlational design was employed with a sample of
370 nurses recruited from various Saudi governmental hospitals. Participants
completed four validated scales: the Moral Distress Scale-Revised (MDS-R),
Professional Quality of Life Scale (ProQOL-5), Rushton Moral Resilience Scale
(RMRS), and the Nurses' Professional Identity Scale. Descriptive statistics,
Pearson correlation, simple and multiple regression analyses were conducted to
explore associations and mediating effects.
Results:
Participants reported high moral distress (M = 85.90, SD = 13.90) and compassion
fatigue (M = 44.85, SD = 6.40), alongside moderate-to-high moral resilience (M =
56.20, SD = 5.85) and professional identity (M = 69.45, SD = 7.30). Moral distress
strongly predicted compassion fatigue (β = 0.667, p < .001, R² = 0.446). Moral
resilience (β = –0.354, p < .001) and professional identity (β = –0.201, p < .001)
significantly predicted compassion fatigue but mediated the relationship only
partially.
Conclusion:
Moral distress significantly drives compassion fatigue. While moral resilience and
professional identity offer partial protection, additional institutional and
psychological factors must be addressed to effectively mitigate nurse burnout.
Keywords:
Moral distress, Compassion fatigue, Moral resilience, Professional identity, Saudi
nurses
Description
The nursing profession is crucial to the healthcare system, serving as a
frontline resource for patient care. However, nurses frequently encounter
significant emotional and ethical challenges in their roles, resulting in inadequate
levels of moral resilience and professional identity, which can lead to catastrophic
consequences for both nurses and patients (Alharbi et al., 2020; Labrague & de Los
Santos, 2021; Li et al., 2024). Moral resilience is essential for effective nursing
practice (Li et al., 2024; Brewer et al., 2024). Unfortunately, many nurses report
insufficient moral resilience, with studies indicating that as few as 38% feel
adequately equipped to handle ethical dilemmas (Alharbi et al., 2020; Alreshidi &
Rayani, 2023). This inadequacy can lead to feelings of moral disengagement,
powerlessness, and ethical distress, ultimately compromising the quality of care
provided to patients (Labrague & de Los Santos, 2021). For instance, in a study by
Alharbi et al. (2020), nurses reported that inadequate support for moral resilience
directly affected their ability to make sound ethical decisions, resulting in adverse
patient outcomes.
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Simultaneously, a weak professional identity significantly exacerbates these issues.
Professional identity in nursing encompasses the values, beliefs, and roles
associated with the profession, shaping how nurses view themselves and their
responsibilities (van der Cingel & Brouwer, 2021; Hussien et al., 2021). A
fragmented professional identity can lead to low job satisfaction, emotional
exhaustion, and a high turnover rate among nurses, with studies suggesting that
turnover rates in nursing can exceed 20% in certain regions due to feelings of
inadequacy and lack of support (McGann et al., 2021; Alharbi et al., 2020; Xie et
al., 2021). In Saudi Arabia, cultural stigmas and systemic barriers further
undermine professional identity, leading to additional job dissatisfaction and
ethical conflict (Alharbi et al., 2020; Almadani et al., 2023). These factors not only
affect individual nurses but also have broader implications for patient care, leading
to reduced quality of service and increased medical errors (Alreshidi & Rayani,
2023).
Compounding these issues are the high levels of moral distress experienced by
nurses, which is frequently linked to ethical conflicts and systemic barriers
(Prompahakul et al., 2021). Studies indicates that approximately 60% of nurses
report significant moral distress, particularly in critical care settings where ethical
dilemmas are frequent (Alharbi et al., 2020; Salari et al., 2022). This distress can
lead to severe consequences, including burnout and compassion fatigue. For
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example, Saleh et al. (2019) found a significant positive correlation between moral
distress and compassion fatigue among neonatal intensive care unit nurses,
highlighting how moral distress can diminish nurses' capacity for empathy and care
(Xie et al., 2021; Alharbi et al., 2020).
The problematic relationship between moral distress, compassion fatigue, and the
mediating effects of moral resilience and professional identity further complicates
the nursing landscape (Alharbi et al., 2020; Xie et al., 2021). Higher levels of moral
distress are shown to exacerbate compassion fatigue, which, when coupled with
inadequate moral resilience and professional identity, leads to heightened
emotional exhaustion and disengagement from the nursing profession (Labrague &
de Los Santos, 2021; Berdida, 2023). Existing research demonstrates that nurses
with strong professional identities and higher levels of moral resilience can
mitigate the adverse effects of moral distress, resulting in lower levels of
compassion fatigue (Brewer et al., 2024; Li et al., 2024). Despite this knowledge,
significant gaps exist in the literature concerning the specific mediating effects of
moral resilience and professional identity on the relationship between moral
distress and compassion fatigue among nurses in Saudi Arabia.
This gap is particularly pronounced regarding the timeliness and quality of the
studies conducted. Most existing research has primarily focused on individual
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factors, such as moral distress or compassion fatigue, rather than exploring the
interplay between these factors and the mediating roles of moral resilience and
professional identity (Kaya & Molu, 2023; Xie et al., 2021). The majority of
studies on this topic are outdated, with many conducted before the COVID-19
pandemic, during which the healthcare environment and the challenges faced by
nurses have drastically changed (Morley et al., 2023; Alimoradi et al., 2023).
Furthermore, the quality of the existing studies often varies, with many lacking
rigorous methodological designs, appropriate sample sizes, or comprehensive
statistical analyses, leading to a limited understanding of these complex dynamics
(Getahun et al., 2024; Almadani et al., 2023).
In the Saudi Arabian context, unique cultural and systemic challenges further
complicate the experiences of nurses, necessitating research that specifically
addresses these factors (Alharbi et al., 2020; Alreshidi & Rayani, 2023).
Addressing these gaps not only has the potential to enhance the support provided to
nurses but also to positively impact the overall healthcare system in Saudi Arabia.
Consequently, this study aims to investigate the mediating effects of moral
resilience and professional identity on the relationship between moral distress and
compassion fatigue among nurses in Saudi Arabia, ultimately contributing to the
development of targeted interventions that improve nurse well-being and patient
care quality.
Keywords
Moral distress, Compassion fatigue, Moral resilience, Professional identity, Saudi nurses