The effect of moral distress on emergency nurses’ burnout: mediating role of moral resilience and moderating role of moral courage

Background The burnout rate among emergency nurses in China has reached 87.6%. This alarmingly high prevalence of burnout is driving a substantial number of experienced emergency nurses to leave their positions, thereby posing a serious threat to the sustainable and healthy development of the healthcare system. Moral distress represents a major modifiable risk factor for burnout. The present study aims to explore the correlation between moral distress and burnout, whether moral resilience could act as a mediator of the relationship, and whether moral courage moderates the mediating effect among emergency nurses. Methods This study employed a cross-sectional design and was carried out among emergency department nurses from seven tertiary Class A hospitals in the Ningxia Hui Autonomous Region, China, in August 2025. Survey instruments included a demographic questionnaire, the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), the Chinese version of the Rushton Moral Resilience Scale, the Moral Distress Scale-Revised (MDS-R), and the Nurses’ Moral Courage Scale (NMCS). Descriptive analysis and Pearson correlation analysis were performed using SPSS 27.0. The PROCESS macro was applied, with Model 4 for mediation analysis and Model 7 for moderated mediation analysis. Results The total scores were as follows: moral distress (45.63 ± 34.18), moral resilience (47.75 ± 6.51), moral courage (71.38 ± 15.24), and burnout (56.09 ± 17.06). Moral distress was positively correlated with burnout among emergency nurses. Moral resilience mediated the association between moral distress and burnout, accounting for 24.8% of the total effect. Moral courage moderated the path from moral distress to moral resilience. Conclusion This study found that among emergency nurses, moral distress was positively correlated with burnout; moral resilience mediated the relationship between moral distress and burnout; and moral courage moderated the relationship between moral distress and moral resilience.