Abstract
BACKGROUND: Intensive care unit (ICU) nurses frequently encounter ethical dilemmas, patient death and emotional distress, which can shape attitudes towards end-of-life care. Spiritual coping and psychological flexibility may support nurses' well-being and caregiving behaviour, but the mechanisms by which these factors affect ICU nurses' attitudes towards end-of-life care remain underexplored, particularly in Eastern cultural contexts. AIMS: To examine associations between spiritual coping, psychological flexibility and attitudes towards end-of-life care among ICU nurses, and to test whether psychological flexibility mediates the spiritual coping-attitude relationship. STUDY DESIGN: A cross-sectional study was conducted between November and December 2024 in a large teaching hospital in China. Participants were selected using convenience sampling, and data were collected using the Chinese versions of the Spiritual Coping Questionnaire, Comprehensive Assessment of Acceptance and Commitment Therapy Processes (CompACT) and the End-of-Life Care Attitude Scale for Medical Workers. Descriptive statistics, group comparisons, Pearson correlations, multiple linear regression and PROCESS (Model 4) bootstrap mediation were used. RESULTS: A total of 244 ICU nurses were included. Psychological flexibility and spiritual coping were positively correlated with attitudes towards end-of-life care (r = 0.635 and r = 0.282, both p < 0.001). In regression, psychological flexibility (p < 0.001), spiritual coping (p = 0.015), death education (p < 0.001), end-of-life care practice (p < 0.001) and educational level (p = 0.036) were significant predictors; the model explained 67.9% of the variance (R(2) = 0.679). Bootstrap mediation showed a significant indirect effect of spiritual coping on attitudes via psychological flexibility (indirect effect = 0.118, 95% CI 0.064-0.193), accounting for 48.96% of the total effect. CONCLUSIONS: ICU nurses with greater spiritual coping report more positive end-of-life care attitudes, partly through higher psychological flexibility. Interventions integrating Acceptance and Commitment Therapy-informed flexibility training with culturally sensitive spiritual support and structured death education may strengthen nurses' preparedness for end-of-life care. RELEVANCE TO CLINICAL PRACTICE: Incorporating psychological flexibility and spiritual coping into continuing education could enhance ICU nurses' resilience and improve end-of-life care quality.