{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T08:01:40Z","timestamp":1780905700764,"version":"3.54.1"},"reference-count":64,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T00:00:00Z","timestamp":1780617600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Investigating the predictors of moral distress is particularly important for protecting nurses\u2019 mental health and professional satisfaction, thereby preventing burnout and attrition from the profession. The primary aim of this study was to evaluate the predictors of moral distress among nurses. A cross-sectional study design was used. The sample consisted of 412 nurses from 11 hospitals across Slovakia. The mean age of the respondents was 40.48 years (SD = 10.92). Moral distress was assessed using the Modified Moral Distress Scale. Linear regression analysis was used to evaluate predictors of moral distress. Personal accomplishment, the maladaptive coping strategy of self-distraction, continuous shift operation, and emotional burnout emerged as significant predictors of the frequency of moral distress among nurses (AdjR2 = 15.5%; R2 = 0.155). Regarding the intensity of moral distress, significant predictors included personal accomplishment, the maladaptive strategy of self-distraction and the adaptive strategy of religiosity and spirituality (AdjR2 = 14.0%; R2 = 0.140), which appear to function as adaptive coping mechanisms for dealing with the intensity of moral distress. Systematic investigation of predictors of moral distress among nurses may contribute to the development of interventions and programs that support nurses, thereby improving not only their job satisfaction but also the quality of patient care.<\/jats:p>","DOI":"10.3390\/ijerph23060761","type":"journal-article","created":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T07:43:02Z","timestamp":1780904582000},"page":"761","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Predictors of Moral Distress Among Nurses: A Cross-Sectional Study"],"prefix":"10.3390","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-7318-828X","authenticated-orcid":false,"given":"Vladim\u00edr","family":"Siska","sequence":"first","affiliation":[{"name":"Department of Nursing, Faculty of Nursing and Health Professional Studies, Slovak Medical University in Bratislava, 833 03 Bratislava, Slovakia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6174-4797","authenticated-orcid":false,"given":"Andrea","family":"Soll\u00e1rov\u00e1","sequence":"additional","affiliation":[{"name":"Department of Nursing, Faculty of Social Sciences and Health Care, Constantine the Philosopher University in Nitra, 949 01 Nitra, Slovakia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7171-7189","authenticated-orcid":false,"given":"Zuzana","family":"Slez\u00e1kov\u00e1","sequence":"additional","affiliation":[{"name":"Department of Nursing, Faculty of Nursing and Health Professional Studies, Slovak Medical University in Bratislava, 833 03 Bratislava, Slovakia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7164-8515","authenticated-orcid":false,"given":"Luk\u00e1\u0161","family":"Kober","sequence":"additional","affiliation":[{"name":"Department of Nursing, Faculty of Health Sciences, Catholic University in Ru\u017eomberok, 034 01 Ruzomberok, Slovakia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2387-0485","authenticated-orcid":false,"given":"Peter","family":"Min\u00e1rik","sequence":"additional","affiliation":[{"name":"Department of Nursing, Faculty of Social Sciences and Health Care, Constantine the Philosopher University in Nitra, 949 01 Nitra, Slovakia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom\u00e1\u0161","family":"Forgon","sequence":"additional","affiliation":[{"name":"Department of Nursing, Faculty of Social Sciences and Health Care, Constantine the Philosopher University in Nitra, 949 01 Nitra, Slovakia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,5]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1002\/nop2.91","article-title":"Advancement of the German version of the moral distress scale for acute care nurses\u2014A mixed methods study","volume":"4","author":"Spichiger","year":"2017","journal-title":"Nurs. Open"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1007\/s10730-012-9179-8","article-title":"Moral Distress and the Contemporary Plight of Health Professionals","volume":"24","author":"Austin","year":"2012","journal-title":"HEC Forum"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1017\/orp.2013.1","article-title":"Recommendation for Expanding the Definition of Moral Distress Experienced in the Workplace","volume":"6","author":"Crane","year":"2013","journal-title":"Australas. J. Organ. Psychol."},{"key":"ref_4","unstructured":"Jameton, A. (1984). Nursing Practice, Prentice-Hall."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"636","DOI":"10.1191\/0969733002ne557oa","article-title":"Nurse moral distress: A proposed theory and research agenda","volume":"9","author":"Corley","year":"2002","journal-title":"Nurs. Ethics"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1075","DOI":"10.1016\/S0277-9536(03)00279-X","article-title":"Living with conflicts-ethical dilemmas and moral distress in the health care system","volume":"58","author":"Hansson","year":"2004","journal-title":"Soc. Sci. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1177\/0969733012462049","article-title":"Moral distress in nursing: Contributing factors, outcomes and interventions","volume":"20","author":"Burston","year":"2013","journal-title":"Nurs. Ethics"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1086\/JCE200920406","article-title":"Moral distress, moral residue, and the crescendo effect","volume":"20","author":"Epstein","year":"2009","journal-title":"J. Clin. Ethics"},{"key":"ref_9","first-page":"240","article-title":"Modified Moral Distress Scale (MDS-11): Validation Study Among Italian Nurses","volume":"70","author":"Badolamenti","year":"2017","journal-title":"Prof. Inferm."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1016\/j.ijnurstu.2012.08.017","article-title":"Determinants of moral distress in daily nursing practice: A cross sectional correlational questionnaire survey","volume":"50","author":"Francke","year":"2013","journal-title":"Int. J. Nurs. Stud."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"196","DOI":"10.1177\/1751143718787753","article-title":"A survey of moral distress in staff working in intensive care in the UK","volume":"20","author":"Colville","year":"2019","journal-title":"J. Intensive Care Soc."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1981","DOI":"10.1177\/09697330251350384","article-title":"Nurses\u2019 moral distress and ethical climate: A systematic review and meta-analysis","volume":"32","author":"Xue","year":"2025","journal-title":"Nurs. Ethics"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1177\/0969733013502803","article-title":"Moral distress experienced by nurses: A quantitative literature review","volume":"22","author":"Oh","year":"2015","journal-title":"Nurs. Ethics"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1567","DOI":"10.2147\/PRBM.S329036","article-title":"Personality Profiles and Personal Factors Associated with Psychological Distress in Chinese Nurses","volume":"14","author":"Huang","year":"2021","journal-title":"Psychol. Res. Behav. Manag."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1586","DOI":"10.1177\/09697330241246089","article-title":"Coping strategies of intensive care unit nurses reducing moral distress: A content analysis study","volume":"31","author":"Esmaeili","year":"2024","journal-title":"Nurs. Ethics"},{"key":"ref_16","first-page":"e3747","article-title":"Association between Moral Distress and Burnout Syndrome in university-hospital nurses","volume":"31","author":"Villagran","year":"2023","journal-title":"Rev. Lat. Am. Enferm."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Orgamb\u00eddez, A., Borrego, Y., Alcalde, F.J., and Dur\u00e1n, A. (2025). Moral Distress and Emotional Exhaustion in Healthcare Professionals: A Systematic Review and Meta-Analysis. Healthcare, 13.","DOI":"10.3390\/healthcare13040393"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Hosseinpour, A., and Keshmiri, F. (2024). Inductive process of moral distress development in viewpoints from surgical nurses: A mixed-method study. BMC Nurs., 23.","DOI":"10.1186\/s12912-024-01786-3"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"319","DOI":"10.4103\/ijnmr.IJNMR_158_19","article-title":"Moral Distress and its Influential Factors in the Nurses of the Nursing Homes in Khorasan Provinces in 2019: A Descriptive-Correlational Study","volume":"25","author":"Sedaghati","year":"2020","journal-title":"Iran. J. Nurs. Midwifery Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1016\/j.iccn.2016.04.003","article-title":"Moral distress and intention to leave: A comparison of adult and paediatric nurses by hospital setting","volume":"36","author":"Dyo","year":"2016","journal-title":"Intensive Crit. Care Nurs."},{"key":"ref_21","first-page":"2326","article-title":"Moral distress","volume":"Volume 7","author":"Piazza","year":"2018","journal-title":"The SAGE Encyclopedia of Business Ethics and Society"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"327","DOI":"10.2478\/FON-2019-0037","article-title":"Analytical study of care quality and moral distress in clinical situations and patient care","volume":"6","author":"Hasanlo","year":"2019","journal-title":"Front. Nurs."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1016\/j.medin.2021.06.004","article-title":"Moral distress among healthcare professionals working in intensive care units in Spain","volume":"46","author":"Veiras","year":"2022","journal-title":"Med. Intensiv. (Engl. Ed.)"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1007\/s10730-018-9349-4","article-title":"The Standard Account of Moral Distress and Why We Should Keep It","volume":"30","author":"Mccarthy","year":"2018","journal-title":"HEC Forum"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/j.jcrc.2016.04.033","article-title":"Causes of moral distress in the intensive care unit: A qualitative study","volume":"35","author":"Henrich","year":"2016","journal-title":"J. Crit. Care"},{"key":"ref_26","first-page":"1","article-title":"Instruments for Detecting Moral Distress in Clinical Nurses: A Systematic Review","volume":"58","author":"Tian","year":"2021","journal-title":"INQUIRY J. Health Care Organ. Provis. Financ."},{"key":"ref_27","first-page":"43","article-title":"A grounded theory of moral reckoning in nursing","volume":"4","author":"Nathaniel","year":"2004","journal-title":"Grounded Theory Rev."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1007\/s44155-024-00072-6","article-title":"Moral distress and associated factors among nurses working in central Ethiopia: A cross-sectional study","volume":"4","author":"Getahun","year":"2024","journal-title":"Discov. Soc. Sci. Health"},{"key":"ref_29","unstructured":"Lerkiatbundit, S., and Borry, P. (2009). Moral Distress Part I: Critical Literature Review on Definition, Magnitude, Antecedents and Consequences. Thai J. Pharm. Pract., 1\u201311. Available online: https:\/\/www.researchgate.net\/profile\/Pascal-Borry\/publication\/267406522_Moral_Distress_Part_I_Critical_Literature_Review_on_Definition_Magnitude_Antecedents_and_Consequences\/links\/546483da0cf2cb7e9da9fdc6\/Moral-Distress-Part-I-Critical-Literature-Review-on-Definition-Magnitude-Antecedents-and-Consequences.pdf."},{"key":"ref_30","first-page":"16","article-title":"Moral distress in health care professional","volume":"69","author":"Hamric","year":"2006","journal-title":"Pharos"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1177\/1477750920927174","article-title":"Factors affecting moral distress in nurses working in intensive care units: A systematic review","volume":"16","author":"Chashmi","year":"2021","journal-title":"Clin. Ethics"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"202","DOI":"10.4037\/ajcc2004.13.3.202","article-title":"Critical care nurses\u2019 perceptions of futile care and its effect on burnout","volume":"13","author":"Meltzer","year":"2004","journal-title":"Am. J. Crit. Care"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"192","DOI":"10.1037\/1040-3590.18.2.192","article-title":"The Mini-IPIP Scales: Tiny-yet-effective measures of the Big Five Factors of Personality","volume":"18","author":"Donnellan","year":"2006","journal-title":"Psychol. Assess."},{"key":"ref_34","unstructured":"Hullov\u00e1, D., and Duri\u0161, R. (2026, February 10). Slovensk\u00e1 Verzia Dotazn\u00edku Mini IPIP. Available online: http:\/\/ipip.ori.org\/newItemTranslations.htm."},{"key":"ref_35","first-page":"8","article-title":"Prediktory zvl\u00e1dania z\u00e1\u0165a\u017ee u pacientov po prekonan\u00ed infarktu myokardu","volume":"9","year":"2019","journal-title":"O\u0161etrovate\u013estvo Te\u00f3ria V\u00fdskum\u2014Vzdel."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Maslach, C., and Jackson, S.E. (1981). Maslach Burnout Inventory\u2014ES Form (MBI), APA PsychTests.","DOI":"10.1037\/t05190-000"},{"key":"ref_37","first-page":"272","article-title":"Konfirma\u010dn\u00e1 faktorov\u00e1 anal\u00fdza slovenskej verzie dotazn\u00edka MBI-HSS pre pom\u00e1haj\u00face profesie","volume":"64","year":"2020","journal-title":"Ceskoslov. Psychol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1207\/s15327558ijbm0401_6","article-title":"You want to measure coping but your protocol\u2019s too long: Consider the brief COPE","volume":"4","author":"Carver","year":"1997","journal-title":"Int. J. Behav. Med."},{"key":"ref_39","unstructured":"V\u00fdrost, J., and Slam\u011bn\u00edk, I. (2001). Zvl\u00e1danie stresu\u2014Coping. Aplikovan\u00e1 Soci\u00e1ln\u00ed Psychologie II, Grada."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Chai, F., Hu, W., Xu, D., Ji, Y., Wang, Y., Xu, C., and Li, X. (2026). The relationship between moral distress and occupational burnout among ICU nurses: Social support and psychological resilience as mediating variables. Front. Public Health, 13.","DOI":"10.3389\/fpubh.2025.1743774"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Wu, S., Sun, Y., Zhong, Z., Li, H., Ding, B., and Deng, Q. (2025). The effect of moral distress on emergency nurses\u2019 job burnout: The mediating roles of hospital ethical climate and moral resilience. Front. Public Health, 13.","DOI":"10.3389\/fpubh.2025.1562209"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Best, N.C., Thomas, C.S., Pierre-Louis, B., Wu, A., Chang, A., Bevens, W., and Powell, S.B. (2026). Burnout and moral distress among school nurses during the COVID-19 pandemic: A brief report. Front. Public Health, 13.","DOI":"10.3389\/fpubh.2025.1750354"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Maunder, R.G., Heeney, N.D., Greenberg, R.A., Jeffs, L.P., Wiesenfeld, L.A., Johnstone, J., and Hunter, J.J. (2023). The relationship between moral distress, burnout, and considering leaving a hospital job during the COVID-19 pandemic: A longitudinal survey. BMC Nurs., 22.","DOI":"10.1186\/s12912-023-01407-5"},{"key":"ref_44","unstructured":"Russell, S.R. (2025). The Role of Moral Distress on Burnout and Spiritual Well-Being Among Clinical Healthcare Professionals. [Ph.D. Thesis, Liberty University]. Available online: https:\/\/digitalcommons.liberty.edu\/doctoral\/6983\/."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1095","DOI":"10.1177\/09697330231153915","article-title":"Psychiatric nurses\u2019 experience of moral distress: Its relationship with empowerment and coping","volume":"30","author":"Tomura","year":"2023","journal-title":"Nurs. Ethics"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1177\/09697330221122905","article-title":"Moral distress and spiritual\/religious orientation: Moral agency, norms and resilience","volume":"30","author":"Koonce","year":"2023","journal-title":"Nurs. Ethics"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"737","DOI":"10.4103\/ijnmr.ijnmr_157_23","article-title":"The Relationship between Spiritual Intelligence and Fatigue and Moral Distress in Emergency Nurses: A Cross-Sectional Study","volume":"29","author":"Shahcheragh","year":"2024","journal-title":"Iran. J. Nurs. Midwifery Res."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Tavakol, N., Tavakol, M., and Daman, S. (2025). Moral distress effects on spirituality determinants in nurses. BMC Nurs., 24.","DOI":"10.1186\/s12912-025-03003-1"},{"key":"ref_49","unstructured":"Abebaw, H., Belay, A., and Tesema, M. (2026, April 05). Predictors of Moral Distress Among Nurses Working in Jimma University Medical Center, Jimma Zone, Jimma Town, South West, Ethiiopia. Available online: https:\/\/repository.ju.edu.et\/\/handle\/123456789\/4115."},{"key":"ref_50","first-page":"45","article-title":"Predictors of Moral Distress among Jordanian Critical Care Nurses","volume":"3","author":"Allari","year":"2013","journal-title":"Int. J. Nurs. Sci."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"30596","DOI":"10.1038\/s41598-025-14792-5","article-title":"A predictive study of factors associated with burnout, compassion fatigue, and moral distress among emergency nurses","volume":"15","author":"Alshammari","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"59","DOI":"10.4037\/ajcc2018968","article-title":"Predictors of Moral Distress in a US Sample of Critical Care Nurses","volume":"27","author":"Hiler","year":"2018","journal-title":"Am. J. Crit. Care"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"e187443462203030","DOI":"10.2174\/18744346-v16-e2203030","article-title":"Determinants of Moral Distress Among Mental Health Professionals","volume":"16","author":"Shehadeh","year":"2022","journal-title":"Open Nurs. J."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Beadle, E.S., Walecka, A., Sangam, A.V., Moorhouse, J., Winter, M., Munro Wild, H., Trivedi, D., and Casarin, A. (2024). Triggers and factors associated with moral distress and moral injury in health and social care workers: A systematic review of qualitative studies. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0303013"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"e13284","DOI":"10.1111\/nicc.13284","article-title":"Missed nursing care and its causes and effects on moral distress in neonatal intensive care nurses","volume":"30","author":"Teki","year":"2025","journal-title":"Nurs. Crit. Care"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"34837","DOI":"10.1038\/s41598-025-19770-5","article-title":"Family satisfaction and healthcare providers\u2019 moral distress in intensive care units: A cross-sectional study","volume":"15","author":"Shojaie","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"147","DOI":"10.4103\/JNMS.JNMS_1_18","article-title":"Assessing nurses\u2019 moral distress and patients\u2019 satisfaction with the observance of the patients\u2019 rights charter","volume":"4","author":"Rokhafrooz","year":"2017","journal-title":"J. Nurs. Midwifery Sci."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1590\/S0104-07072012000100023","article-title":"Implica\u00e7\u00f5es do sofrimento moral para os(as) enfermeiros(as) e aproxima\u00e7\u00f5es com o Burnout","volume":"21","author":"Dalmolin","year":"2012","journal-title":"Texto Contexto-Enferm."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1097\/NCQ.0000000000000596","article-title":"Nursing Moral Distress and Intent to Leave Employment During the COVID-19 Pandemic","volume":"37","author":"Sheppard","year":"2022","journal-title":"J. Nurs. Care Qual."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"2315635","DOI":"10.1080\/17482631.2024.2315635","article-title":"Strategies to mitigate moral distress as reported by eldercare professionals","volume":"19","author":"Koivisto","year":"2024","journal-title":"Int. J. Qual. Stud. Health Well-Being"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"2227","DOI":"10.1002\/nop2.1248","article-title":"Moral distress among nurses during COVID-19 pandemic: Challenges and coping strategies","volume":"9","author":"Ghazanfari","year":"2022","journal-title":"Nurs. Open"},{"key":"ref_62","unstructured":"European Commission (2026, April 07). Legal and Policy Framework. Available online: https:\/\/employment-social-affairs.ec.europa.eu\/policies-and-activities\/skills-and-qualifications\/recognition-professional-qualifications\/legal-and-policy-framework_en?utm_source=chatgpt.com."},{"key":"ref_63","unstructured":"National Health Information Centre (2026, April 07). Available online: https:\/\/www.nczisk.sk."},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Maghsoud, F., Rezaei, M., Asgarian, F.S., and Rassouli, M. (2022). Workload and quality of nursing care: The mediating role of implicit rationing of nursing care, job satisfaction and emotional exhaustion by using structural equations modeling approach. BMC Nurs., 21.","DOI":"10.1186\/s12912-022-01055-1"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/6\/761\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T07:47:33Z","timestamp":1780904853000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/6\/761"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,5]]},"references-count":64,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["ijerph23060761"],"URL":"https:\/\/doi.org\/10.3390\/ijerph23060761","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,5]]}}}