Research in Nursing & Health, 2000, 23, 415±420

Focus on Research Methods

Mediator and Moderator
Variables in Nursing Research:
Conceptual and Statistical
Differences
Jill A. Bennett

School of Nursing, San Diego State University, 5500 Campanile Drive, San Diego, CA
Received 6 July 1999; accepted 17 April 2000

Abstract: Mediators and moderators are variables that affect the association
between an independent variable and an outcome variable. Mediators
provide additional information about how or why two variables are strongly
associated. In contrast, moderators explain the circumstances that cause a
weak or ambiguous association between two variables that were expected to
have a strong relationship. Mediators and moderators are often overlooked in
research designs, or the terms are used incorrectly. This article summarizes
the conceptual differences between mediators and moderators. The statistical
analysis of moderators and mediators in multiple regression is brie¯y
described and two examples are presented. ß 2000 John Wiley & Sons, Inc.
Res Nurs Health 23:415±420, 2000

Keywords: mediator; moderator; data analysis

Mediator and moderator variables provide useful
information about how, why, or when a phenom-
enon occurs. Unfortunately, many nurse research-
ers fail to test for mediators or moderators in their
data or use the terms incorrectly. For example,
``mediator'' is often used as if it meant ``pre-
dictor.'' A mediator or moderator is a third
variable that changes the association between an
independent variable and an outcome variable
(Baron & Kenny, 1986). Thus, consideration of a
mediator or moderator allows a more precise
description of the relationship between indepen-
dent and outcome variables. If a researcher fails
to consider the possibility of a mediator or mode-
rator effect in the data, a more exact explanation
for an outcome may be missed. The purpose of
this paper is to discuss the importance of media-
tors and moderators in nursing research and to
encourage more widespread analysis of these
effects in answering nursing questions. To achieve
*Assistant Professor.
that purpose, mediators and moderators are
de®ned and differentiated. In addition, statistical
methods for analysis of mediator and moderator
effects are described and examples presented.
In intervention studies, a mediator or mod-
erator can explain why a nursing intervention
works. For example, Kwekkeboom, Huseby-
Moore, and Ward (1998) hypothesized that a
moderator, imaging ability, could explain why
guided imagery (an intervention) had produced
mixed results in reducing cancer pain in earlier
studies. The researchers did an exploratory study
in which guided imagery was used to alleviate
anxiety and, in addition, they measured a
proposed moderator, individual ability to gener-
ate realistic images. The results showed that
participants who had high levels of imaging
ability (the moderator variable) had a reduction in
anxiety when the guided imagery intervention
was used, but those with low levels of imaging

ß 2000 John Wiley & Sons, Inc. 415

416 RESEARCH IN NURSING & HEALTH
ability did not reduce their anxiety. Thus, the
effect of the intervention on the outcome
depended on the level of the moderator. The
researchers hope to continue their research on this
moderator that may explain the previously
reported weak association between guided ima-
gery and cancer pain.
Likewise, the analysis of mediators and
moderators in descriptive studies can elicit
information about why or how a direct associa-
tion occurs between an independent variable and
an outcome variable. For example, Schumacher,
Dodd, and Paul (1993) studied caregivers of
persons receiving chemotherapy for cancer and
found that caregiver strain had a signi®cant single
order correlation with depression. However, the
researchers also investigated possible mediators
and moderators. They found that coping was a
mediator in the association and thus provided a
fuller picture of how caregiver strain can develop
(or not) into depression.
THE DEFINITIONS OF MEDIATOR
AND MODERATOR EFFECTS
Mediators are different from moderators and
many people are confused by the distinctions
between the two. It is important to understand
whether a mediator or moderator effect is
hypothesized, because they require different
statistical analyses.
A moderator is an independent variable that
affects the strength and/or direction of the
association between another independent variable
and an outcome variable. Figure 1 illustrates a
moderator effect. A moderator variable may
initially be analyzed in a multiple regression
model as one of the independent variables.
However, subsequent steps in the analysis may
uncover two distinct regression slopes in the data
that depend on the value of the moderator. The
moderator interacts with the independent variable
of interest so that the independent variable's
association with the outcome variable is stronger
or weaker at different levels of the moderator
variable. In other words, the association of the
FIGURE 1. Conceptual model of a moderator
effect.
FIGURE 2. Conceptual model of a mediator
effect.
independent variable with the outcome variable
``depends on'' the value (or level) of the
moderator variable (Cohen & Cohen, 1983).
On the other hand, a mediator is a variable that
speci®es how the association occurs between an
independent variable and an outcome variable. A
mediator effect is only tested when there is a
signi®cant direct effect between the independent
variable and the outcome variable, but there is a
possibility that a mediator variable conceptually
occurs ``between'' the two variables. A mediator
effect, shown in Figure 2, exists if the following
conditions are met: (a) variations in the indepen-
dent variable predict variations in the mediator
variable, (b) variations in the mediator variable
predict variations in the outcome variable, and (c)
When the associations in (a) and (b) are
controlled in the model, the direct relationship
between the independent variable and the out-
come variable becomes nonsigni®cant (Baron &
Kenny, 1986).
THE DIFFERENCES
BETWEEN MEDIATOR AND
MODERATOR EFFECTS
Sometimes it is dif®cult to distinguish mediators
and moderators when forming hypotheses about
variables. The de®nitional difference, that a
mediator is predicted by the independent variable
and a moderator is a separate independent
variable, is important but not always obvious. A
variable such as ``coping'' is an example. Some
researchers conceptualize ``coping'' as a media-
tor because it cannot occur unless a stressor has
occurred; an independent variable ``stressor''
predicts the mediator ``coping,'' and together they
predict an outcome. In contrast, some researchers
conceptualize ``coping'' as a moderator variable.
In this case, ``coping'' is an independent variable
that affects the stressor±outcome relationship;
when coping ability is high, the stressor±outcome
association is weak, whereas when coping ability
is low, the stressor±outcome association is strong
(Holmbeck, 1997). The decision about whether a
variable is a mediator or moderator should be
based on theory and the conceptual framework
that guides the research.
Baron and Kenny (1986) offer some guidelines
for determining whether a proposed variable
 MEDIATOR AND MODERATOR VARIABLES / BENNETT
represents a hypothesized mediator or moderator
effect. Mediator-oriented research is usually con-
cerned with the mechanism of the relationship
between the independent variable and the out-
come variable. In other words, the ``how'' and
``why'' is more interesting to the researcher than
the independent variable itself. In contrast, a
researcher who includes a moderator in the model
wants to know ``when'' the relationship occurs
between the independent and outcome variables.
Therefore, the researcher is usually more inter-
ested in the independent variable than the
moderator.
It follows then that mediators are usually
investigated when the relationship between the
independent variable and the outcome variable is
statistically signi®cant. If this relationship is
strong, the researcher is likely to be interested
in ®nding a mediator that explains how or why the
independent variable predicts the outcome. On
the other hand, if the association between the
independent variable and the outcome variable is
weak or inconsistent, the researcher may
hypothesize a moderator, the values of which
could explain the circumstances that strengthen
or weaken the association.
A mediator is likely to be an internal property
of the person or group being studied. If the
individual is the unit of analysis, the mediator
variable is often an ``in the head'' mechanism that
elaborates the meaning of the relationship
between the independent variable and the out-
come variable. For example, Song and Lee (1996)
found that depression mediated the relationship
between sensory de®cits in elders and their
functional capacity. However, mediators are not
always individual-level characteristics. If a group
is the unit of analysis, group-level characteristics,
such as cohesiveness or role con¯icts, could be
mediators.
In contrast, the investigation of a moderator
effect often includes experimental manipulation
of the moderator variable and, therefore, a mode-
rator may be a nursing intervention. However,
moderators may also be naturally occurring vari-
ables. For example, social resources were inves-
tigated by Hall, Sachs, and Rayens (1998) as a
moderator in the relationship between women's
childhood abuse and their potential for abuse of
their own children.
STATISTICAL TESTS FOR A
MODERATOR EFFECT
Though the approach to testing for statistical
signi®cance of a moderator effect varies if the
417
independent variables are categorical or contin-
uous, the general strategy is to test for an
interaction using hierarchical multiple regression
analysis. In the ®rst step (or steps) of the
regression, the independent variables (including
the moderator) are entered into the model as
predictors of the outcome variable. The indepen-
dent variables do not have to be signi®cant
predictors of the outcome variable in order to test
for an interaction in the next step. In a separate
step, an interaction term (the product of two
independent variables, which represents the
moderator effect) is entered. If the interaction
term explains a statistically signi®cant amount of
variance in the dependent variable, a moderator
effect is present. Figure 3 show a diagram of this
procedure.
The interaction term represents a joint relation-
ship between the two independent variables and
this relationship accounts for additional variance
in the outcome variable beyond that explained by
either single variable alone. In other words,
several different regression slopes represent the
association, rather than just one, and the associa-
tion of the independent variable with the outcome
variable depends on the value of the moderator
variable. It should be noted that this conditional
relationship is symmetrical; it can also be said
that the association of the moderator and the
outcome variable depends on the value of the
independent variable (Cohen & Cohen, 1983).
A hierarchical regression in which the interac-
tion term is entered in its own step allows the
researcher to see the main effects of the
independent variables (the independent variable
of interest and the moderator) in the earlier steps
separately from the effect of the moderator in the
®nal step. It is also possible to use a regression
model in which all the variables, including the
interaction term, are entered in a single step. In
this case, the signi®cance of the semi-partial
FIGURE 3. Statistical model of a moderator
effect.
418 RESEARCH IN NURSING & HEALTH
correlation of the interaction term will show if a
moderator effect is present. However, the main
effects of the independent variables cannot be
seen unless they are entered in a separate step,
because the presence of the interaction term in the
same step alters the variance explained by the
independent variables alone. Thus, the usual
procedure is to use a multi-step hierarchical
regression.
An interaction effect may be dif®cult to detect
statistically if the sample does not have a full
range of values for the independent variable and
the moderator variable. Thus, a homogeneous
sample may weaken detection of a moderator
effect. In addition, measurement error in either of
the variables is compounded in the interaction
variable. This error can be dif®cult to detect using
multiple regression analysis and may result in an
underestimation of the moderator effect (Holm-
beck, 1997).
STATISTICAL TESTS FOR A
MEDIATOR EFFECT
A mediator effect can also be tested with multiple
regression analysis. However, mediator effects
should only be tested if there is a signi®cant direct
association between an independent variable and
an outcome variable, otherwise there is no
relationship to mediate. An important assumption
of this method is that the outcome variable does
not predict the mediator variable.
The method, shown in Figure 4, uses three
regression equations to test for the statistical
signi®cance of a mediator effect. The ®rst
equation should show that the independent
variable is a signi®cant predictor of the mediator.
The second equation should show that the
independent variable is a signi®cant predictor of
the outcome variable. The third equation should
contain both the independent and mediator
variables entered simultaneously with the out-
come variable. Two conditions must be met in the
third equation if a mediator effect is present: (a)
the mediator is a signi®cant predictor of the
FIGURE 4. Statistical model of a mediator effect.
outcome variable and (b) the direct relationship
of the independent variable to the outcome
variable is less signi®cant than it was in the
second equation (Baron & Kenny, 1986).
AN EXAMPLE OF A
MEDIATOR EFFECT
Yarcheski, Scoloveno, and Mahon (1994)
reported their investigation of a mediator effect
in an article titled ``Social Support and Well-
Being In Adolescents: The Mediating Role of
Hopefulness.'' The authors provided a theoretical
basis for hopefulness as a mediating variable by
citing earlier research studies that provided
theoretical and empirical evidence for an associa-
tion between social support and well-being,
between social support and hope, and between
hope and well-being. They then hypothesized
that, in some instances, individuals may believe
that hopefulness is important to their well-being
because of their relationships with other people.
Thus, the purpose of the study was correctly and
clearly de®ned as testing the hypothesis that
hopefulness mediated, and therefore helped
explain, the relationship between perceived social
support and general well-being in adolescents.
Data from 99 participants between 15 and 17
years old were analyzed to test the hypothesis.
First, the single order relationships among the
variables were con®rmed by statistically signi®-
cant Pearson correlations in the expected direc-
tion. As predicted, perceived social support and
well-being were correlated (r ˆ .55), perceived
social support and hopefulness were correlated
(r ˆ .57), and hopefulness and well-being were
correlated (r ˆ .60).
Next, three regression analyses were per-
formed, following the method speci®ed by Baron
and Kenny (1986) and depicted in Figure 5. The
®rst equation regressed hopefulness on perceived
social support (F(1,97) ˆ 45.90, p < .001). Social
support explained 32% of the variance in hope-
fulness. The second equation regressed well-
being on social support (F(1,97) ˆ 41.84,
p < .001). Social support explained 30% of the
variance in well-being. The third equation
regressed well-being on both hopefulness and
perceived social support. This ®nal equation met
the two requirements for a mediator effect: (a)
The hypothesized mediator, hopefulness, was a
signi®cant predictor (t ˆ 4.69, p < .001) and
explained 19% of the variance in well-being,
and (b) the variance in well-being explained by
perceived social support was reduced from 30%
 MEDIATOR AND MODERATOR VARIABLES / BENNETT
FIGURE 5. Example of statistical analysis of a mediator effect (data
from Yarcheski, Scoloveno, and Mahon, 1990).
in the second equation to 9% in the third
equation. Thus, the reduced direct association
between perceived social support and well-being
when hopefulness was in the model supported the
hypothesis that hopefulness was at least one of
the mediators in the relationship between per-
ceived social support and general well-being.
AN EXAMPLE OF A
MODERATOR EFFECT
Spitzer, Bar-Tal, and Golander (1995) investi-
gated the hypothesized moderator effect of
demographic variables on the relationship
between stress and coping effectiveness. In their
paper, ``The Moderating Effect of Demographic
Variables on Coping Effectiveness,'' the research-
ers stated that the reason for conducting the
analysis was the lack of empirical evidence in the
literature for the theoretical proposition that
coping is a moderator in the relationship between
stress and adaptation. Therefore, they proposed
that personal and situational variables may
moderate the effectiveness of coping strategies
in a stressful situation. In other words, a particular
coping strategy would be more or less effective
depending on the level of a given demographic
variable. Data from 78 adults who were treated at
an outpatient clinic (mean age 54.2 years) were
analyzed with eight hierarchical regressions for
each of three different coping strategies.
For each coping strategy that might predict
coping effectiveness, the following hierarchical
steps were followed. Stress was entered alone in
the ®rst step. One demographic variable and
one coping strategy were entered as a block
in the second step. Three interaction terms
(stress  coping strategy, stress  demographic
characteristic, demographic characteristic 
coping strategy) were entered as a block in the
third step. A second level interaction term
(stress  coping strategy  demographic charac-
419
teristic) was entered as a block in the fourth step.
The dependent variable was coping effectiveness.
Thus, the analysis followed the correct procedure
for testing moderator effects by entering the
predictors, including the proposed moderator
variables, into the model before the interaction
terms were entered in a separate step.
The results showed that some interaction terms
were signi®cant for some coping strategy models,
indicating that particular demographic variables
moderated the effectiveness of the strategy. For
example, the strategy of active cognitive coping
was more effective for younger subjects than for
older (i.e., age was a moderator in the relationship
between coping strategy and coping effective-
ness).
INCORPORATING MEDIATORS
AND MODERATORS IN
NURSING RESEARCH
Analysis of mediator or moderator effects may
supply more in-depth information about a
research phenomenon than can be explained by
direct effects alone. Four elements that should be
included in reports of mediator or moderator
research are (a) correct de®nition and use of the
terms mediator or moderator, (b) a rationale for
the hypothesized mediator or moderator effect
and evidence for the hypothesis based on
literature and/or conceptual framework, (c)
statistical analysis that is matched to the
hypothesized mediator or moderator effect, and
(d) interpretation of the mediator or moderator
effect in the ®ndings. Nurse scientists who are
interested in exploring more than just the direct
effects of predictor variables on outcome vari-
ables may want to consider hypotheses about
mediators and moderators that could provide
additional information about why an observed
phenomenon occurs or under what circumstances
a nursing intervention has the greatest effect.
420 RESEARCH IN NURSING & HEALTH
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