Introduction
Emergency departments (EDs) are one of the important wards of hospitals due to facing high mortality rates, staff shortages, and conflicts and tensions between specialists and nurses. Consequently, nurses in these departments face numerous challenges, including heavy workloads, intense patient needs, technological advancements, and interactions with the medical team, which may lead to ethical conflicts and uncertainties. One of the ethical challenges that ED nurses may face is the occurrence of moral distress. Moral distress (MD) was first introduced to nursing by Jameton. He stated that MD arises when an individual knows the right thing, but organizational constraints make it nearly impossible to pursue that right course.
 Jameton believes that MD is one of the most significant occupational issues among nurses, leading to tension and negatively impacting health and healthcare delivery. A proper nursing care requires unique coping strategies and personality traits. One of the personality traits that seems to be effective in dealing with ethical challenges in nursing is resilience. Resilience acts as a buffer against stressful events and work-related problems. It means having control over stressors before they cause harm to the individual. Resilience is the ability to adapt to challenges and threats and to overcome them. Considering the importance of MD in nurses' performance and its impact on the quality of nursing care, as well as the role of resilience in nursing performance, this study aimed to investigate the relationship between resilience and MD among nurses working in the EDs of hospitals in Urmia, Iran.

Methods
This is a descriptive-analytical study with a cross-sectional study conducted on 120 male and female nurses working in the EDs of hospitals affiliated with Urmia University of Medical Sciences. The data collection tools included a sociodemographic form, the Connor-Davidson resilience scale (CD-RISC), and Nash's moral injury events scale (MIES) with nine items. The data were analyzed in SPSS software, version 23 using the independent t-test, Pearson’s correlation test, and chi-square test. The predictive ability of the variables was tested using regression analysis. The normality of data distribution was assessed using the Kolmogorov-Smirnov test, with a significance level set at 0.05. 

Results
Out of 120 questionnaires distributed among nurses, 7 questionnaires were discarded due to incompleteness, and ultimately, 113 questionnaires were included in the statistical analysis. The mean age of the participants was 32.57±5.45 years. They included 57.5% females, and 94.2% had a bachelor's degree. The mean CD-RISC score was 78.33±0.54, indicating an acceptable level of resilience (>50). Additionally, there was a significant difference in the resilience score based on the hospital where the nurses worked (P= 0.000), where the nurses working at Motahari Hospital had greater resilience compared to those working in other hospitals (Kosar, Imam Khomeini, Taleghani). A significant difference was also found in the resilience score based on the economic status (P=0.00), where the nurses with higher incomes reported greater resilience.
The mean MIES score was 30.19±8.44, which is considered high. There was a significant difference in the MIES score based on the employment status of nurses, where nurses with temporary employment reported higher levels of MD. Based on the findings of this study, there was a significant and negative relationship between resilience and MD (r=-0.45, P=0.001). As resilience increased, the MD level of ED nurses decreased.

Conclusion
There is a significant negative relationship between resilience and MD in ED nurses. By increasing the resilience of nurses, their MD level can be decreased. Fostering resilience-related capacities may help develop nurses' personal resources to mitigate the impact of ethical challenges they encounter in the EDs.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Urmia University of Medical Sciences (Code: IR.UMSU.REC.1403.366). After explaining the study objectives to all participants, their written informed consent was obtained. They were assured that their information would remain confidential.

Funding
This is part of a research project funded by the Vice-Chancellor for Research of Urmia University of Medical Sciences.

Authors' contributions
Conceptualization, supervision, funding acquisition, resources, data collection, data analysis, and writing: Reza Abdollahi; Methodology: Reza Abdollahi and Yousef Mohammadpour; Review and editing: All authors. 

Conflict of interest
The authors declare no conflicts of interest.

Acknowledgments
The authors would like to thank all the nurses who participated in this study for their cooperation.


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