The Mediating Role of Self-compassion in the Relationship Between Moral Distress and Mental Health Symptoms (Stress, Anxiety, and Depression) Among Intensive Care Unit Nurses: A Structural Equation Modeling Study

Abstract

Background: Given the nature of critical care settings, nurses working in intensive care units (ICUs) experience high levels of stress, anxiety, depression, and moral distress. Objectives: This study investigated the mediating role of self-compassion in the relationship between moral distress and mental health symptoms among ICU nurses. Methods: In this cross-sectional descriptive-analytical study using structural equation modeling (SEM), 220 ICU nurses from hospitals affiliated with Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran, were selected through stratified random sampling with proportional allocation and were studied between April and September 2025. Data were collected during on-site visits using a demographic form and validated self-report questionnaires: the Short Form of the Self-Compassion Scale (SCS-SF), the Moral Distress Scale-Revised (MDS-R), and the 21-item Depression, Anxiety, and Stress Scale (DASS-21). Data were analyzed using SPSS version 24 and LISREL version 8.8. Results: Among ICU nurses, scores for depression (7.60 ± 7.84), anxiety (8.11 ± 6.66), and stress (13.42 ± 7.03) were within the normal-to-mild range. Moral distress was substantial (90.14 ± 61.32), whereas self-compassion was moderate (37.26 ± 7.46). Mental health symptoms were positively correlated with moral distress and negatively correlated with self-compassion (r = -0.456 to 0.604; all P < 0.001). Self-compassion significantly mediated the association between moral distress and anxiety (standardized indirect effect = 0.18; 95% CI, 0.12 to 0.24); however, its mediating role was not statistically significant for depression (95% CI, -0.05 to 0.10) or stress (95% CI, -0.04 to 0.13). Conclusions: Moral distress is positively associated with mental health symptoms among ICU nurses. Self-compassion significantly mediates the association between moral distress and anxiety, but not the associations between moral distress and depression or stress. These findings support targeted self-compassion interventions for anxiety, along with organizational strategies. Longitudinal studies are needed to confirm directionality.