Effectiveness of a moral resilience-based supportive-educational intervention on moral distress among emergency nurses: a quasi- experimental study

Moral distress is a substantial challenge for emergency nurses and has implications for staff wellbeing. Moral resilience has been proposed as a protective capacity, but theory-based intervention evidence remains limited, particularly in Iranian emergency settings. Two-site quasi-experimental study with a pretest–posttest–follow-up design and an active control group, conducted in the emergency departments of two teaching hospitals in Borujerd, Iran (March–September 2024). All eligible emergency nurses were invited (census sampling). Inclusion criteria were a bachelor’s degree in nursing and at least six months of emergency nursing experience. The intervention group ( n = 34) received a six-session moral resilience programme based on Rushton’s framework (personal integrity, relational integrity, buoyancy, self-regulation, self-stewardship, and moral efficacy). The active control group ( n = 34) received communication-skills training of equivalent duration, delivered by the same facilitator. Hospitals, not individual nurses, were allocated by a single coin toss after an equivalence check; no within-hospital randomisation was used. The primary outcome was moral distress (Persian Corley Moral Distress Scale) at baseline, two weeks after the programme, and three-month follow-up. Analyses used mixed 2 × 3 repeated-measures ANOVA. Sixty-eight emergency nurses were enrolled and groups were comparable at baseline. Mean moral distress declined by 43.58 points in the intervention group and 5.45 points in the control group from baseline to post-intervention. The between-group difference at post-intervention was large (Cohen’s d = 0.95, p < 0.001) and remained large at three months (d = 0.83). The observed within-group change in the intervention arm exceeded the 20-point minimal clinically important difference used in this study. Because each condition was delivered in only one hospital, these contrasts cannot isolate the programme from unmeasured hospital-level factors. A Rushton-based moral resilience programme was associated with a larger and sustained reduction in self-reported moral distress than attention-matched communication training. Findings are promising but preliminary. Multi-site cluster-randomised trials that measure moral resilience directly and separate programme effects from organisational context are needed before routine implementation.