Oweidat, IslamAlruwashid,Faleh2025-07-162025https://hdl.handle.net/20.500.14154/75842The 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. 23 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 24 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 25 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.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 nurses154en-USMoral distressCompassion fatigueMoral resilienceProfessional identitySaudi nursesThesis