{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,21]],"date-time":"2026-09-21T03:43:44Z","timestamp":1789962224905,"version":"4.0.1"},"reference-count":48,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2026,2,1]],"date-time":"2026-02-01T00:00:00Z","timestamp":1769904000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2026,2,1]],"date-time":"2026-02-01T00:00:00Z","timestamp":1769904000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Nursing in Critical Care"],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Intensive care unit (ICU) nurses frequently encounter ethical dilemmas, patient death and emotional distress, which can shape attitudes towards end\u2010of\u2010life care. Spiritual coping and psychological flexibility may support nurses' well\u2010being and caregiving behaviour, but the mechanisms by which these factors affect ICU nurses' attitudes towards end\u2010of\u2010life care remain underexplored, particularly in Eastern cultural contexts.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>To examine associations between spiritual coping, psychological flexibility and attitudes towards end\u2010of\u2010life care among ICU nurses, and to test whether psychological flexibility mediates the spiritual coping\u2013attitude relationship.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Design<\/jats:title>\n                    <jats:p>A cross\u2010sectional 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\u2010of\u2010Life Care Attitude Scale for Medical Workers. Descriptive statistics, group comparisons, Pearson correlations, multiple linear regression and PROCESS (Model 4) bootstrap mediation were used.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 244 ICU nurses were included. Psychological flexibility and spiritual coping were positively correlated with attitudes towards end\u2010of\u2010life care (\n                      <jats:italic>r<\/jats:italic>\n                      \u2009=\u20090.635 and\n                      <jats:italic>r<\/jats:italic>\n                      \u2009=\u20090.282, both\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). In regression, psychological flexibility (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), spiritual coping (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.015), death education (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), end\u2010of\u2010life care practice (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) and educational level (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.036) were significant predictors; the model explained 67.9% of the variance (R\n                      <jats:sup>2<\/jats:sup>\n                      \u2009=\u20090.679). Bootstrap mediation showed a significant indirect effect of spiritual coping on attitudes via psychological flexibility (indirect effect\u2009=\u20090.118, 95% CI 0.064\u20130.193), accounting for 48.96% of the total effect.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>ICU nurses with greater spiritual coping report more positive end\u2010of\u2010life care attitudes, partly through higher psychological flexibility. Interventions integrating Acceptance and Commitment Therapy\u2013informed flexibility training with culturally sensitive spiritual support and structured death education may strengthen nurses' preparedness for end\u2010of\u2010life care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Relevance to Clinical Practice<\/jats:title>\n                    <jats:p>Incorporating psychological flexibility and spiritual coping into continuing education could enhance ICU nurses' resilience and improve end\u2010of\u2010life care quality.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/nicc.70376","type":"journal-article","created":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T04:35:24Z","timestamp":1770006924000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Psychological Flexibility as a Mediator Between Spiritual Coping and End\u2010of\u2010Life Care Attitudes in ICU Nurses: A Cross\u2010Sectional Study"],"prefix":"10.1111","volume":"31","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-1881-4227","authenticated-orcid":false,"given":"Ruijuan","family":"Wu","sequence":"first","affiliation":[{"name":"Nursing Department Sir Run Run Shaw Hospital, Zhejiang University School of Medicine  Hangzhou Zhejiang China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xin","family":"Chen","sequence":"additional","affiliation":[{"name":"Journal of Nursing and Rehabilitation  Hangzhou Zhejiang China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shan","family":"Li","sequence":"additional","affiliation":[{"name":"Nursing Department Sir Run Run Shaw Hospital, Zhejiang University School of Medicine  Hangzhou Zhejiang China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hong","family":"Zhu","sequence":"additional","affiliation":[{"name":"Nursing Department Sir Run Run Shaw Hospital, Zhejiang University School of Medicine  Hangzhou Zhejiang China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Li","family":"Wang","sequence":"additional","affiliation":[{"name":"Nursing Department Sir Run Run Shaw Hospital, Zhejiang University School of Medicine  Hangzhou Zhejiang China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hui","family":"Zhang","sequence":"additional","affiliation":[{"name":"Nursing Department Sir Run Run Shaw Hospital, Zhejiang University School of Medicine  Hangzhou Zhejiang China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaoyan","family":"Gong","sequence":"additional","affiliation":[{"name":"Nursing Department Sir Run Run Shaw Hospital, Zhejiang University School of Medicine  Hangzhou Zhejiang 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