Building moral resilience to neutralize moral distress

Moral distress occurs when one recognizes one’s moral responsibility in a situation; evaluates the various courses of action; and identifies, in accordance with one’s beliefs, the morally correct decision—but is then prevented from following through.
The literature is replete with the mounting evidence of the incidence and sources of moral distress.It’s a growing problem that not only contributes to burnout, fractured inter-professional relationships, and shortages of healthcare workers, but also undermines the safety and quality of care. Despite the widespread scholarship and dialogue about moral distress, few interventions have been effective in mitigating its negative impact. What has been missing is a way forward that acknowledges the reality of moral distress and points to effective ways to build moral resilience.

Moral resilience

As nurses, our primary focus is on the people we serve. When ethical challenges arise in clinical care, we need to be morally resilient to respond in ways that minimize our distress and preserve our integrity. Moral resilience is the capacity of a person to sustain, restore or deepen their integrity in response to moral complexity, confusion, distress, or setbacks. It’s founded on our self-knowledge of and commitment to our values and intentions.

Moral resilience requires us to conscientiously examine our views. Fundamentally, moral resilience arises from a self-regulated, balanced mind and heart, an open, curious, nonreactive mindset, clear values, and principled action. If we are morally resilient, we are resolute in our moral actions despite fear and realistic about our own limitations; we seek meaning in situations that threaten our moral sensitivity and reasoning. Likewise, we are able to discern the appropriate levels of moral responsibility in morally complex, ambiguous, or conflict-laden situations.

Strategies to Cultivate Moral Resilience

As nurses, we can adopt strategies that help us cultivate our individual moral resilience, and advocate for systems strategies that create a culture of ethical practice. We can take steps to address moral distress in ethically difficult situations. Based on previous work, here are some ideas that can enrich and leverage heart, mind, and spirit. These individual strategies, in tandem with systems-focused interventions to foster a culture of ethical practice, are essential to preserve or restore nurse’s integrity.

Foster self-awareness

Explore your thoughts and feelings that accompany moral distress, and be willing to acknowledge that they may be biased, incorrect, or congruent with your values. Become curious about the conscious or unconscious assumptions (positive and negative) that may be guiding your actions. Repeatedly inquire to determine if they are true or relevant in the current situation or if they may involve projections from prior experiences. By being self-honest and transparent, we can expand our ability to respond to morally distressing situations with clarity, confidence, and diminished personal cost.

Develop self-regulation capacities

Cultivate your ability to make and uphold your moral commitments despite fear or uncertainty. Self-regulation includes the capacity to mindfully notice and respond to signals from the body, emotions, and thought patterns to restore balance when upsets or ethical challenges occur. When our nervous system becomes imbalanced or reactive, we can become judgmental, narrow-minded, or experience self-doubt. When fear arises, courage is needed to name, notice, and potentially release the source of our fears. Building a self-regulation “muscle” is a foundation for principled choice and ethically grounded action. When we focus on our core values, we can practice mindfulness and active engagement in ways that allow us to embody stability and clarity in challenging circumstances and to reflect our values in our choices, behavior, and character. Methods such as mindfulness based stress reduction (MBSR), meditation, and movement practices such as yoga and tai chi are effective and accessible.

Develop ethical competence

Live the values you hold and align your inner character with your outward behaviors. Cultivating your ability to perceive ethical issues in complex cases can help you explore ethical values and principles and exert robust moral agency. Ethical competence encompasses skills in moral reasoning, habits and patterns of behavior that reflect our character, ongoing reflection, and principled, responsible action. When we attain new levels of ethical competence as nurses, we can achieve a new openness to the values, motivations, hopes, and fears of others.

Speak up with clarity and confidence

Find your voice of wisdom and clarity. Go beyond the protests of “why are we doing this” to state your concerns in inter-professional encounters using a clear, compelling, and ethically robust vocabulary. Courage, the ability to befriend your fears when confronted with a situation that requires you to act to preserve integrity, is often needed. Self-regulatory skills and self-awareness can be essential to differentiate your suffering from the patient’s and to clearly articulate the nature of the ethical conflict or concern.

Identify situations where you are able to act with integrity and when you must excuse yourself on grounds of conscience. Begin to notice when you are acting in ways that are aligned with your character and conscience. These patterns can be useful when confusion or uncertainty arise to help re-orient us toward integrity preserving action and inform how we communicate our concerns. Within our practice settings, we have access to relationships, systems, and structures that we can—and should—leverage for guidance and support.

Find meaning in the midst of despair

When confronted with seemingly senseless situations, meaning can be an antidote to despair. If the source of your moral distress is unmovable, stabilize your emotions to neutralize reactivity. Articulate your regrets and unmet expectations by journaling, debriefings, or reflections. Release, to the extent possible, the moral residue and re-calibrate to a “new normal” that restores your mind and heart to wholeness and makes space for the moral disappointment, sense of moral failure, or moral harm that was produced.

Create a potent antidote to powerlessness and despair by reconnecting with your core values and intentions. For all of us, reaffirming the values and purpose that originally drew us to the nursing profession can sustain us in the midst of ethical conundrums. Similarly, the practice of connecting to what we are grateful for—in ourselves, our patients, our colleagues, and our profession—is a powerful antidote to despair.

Engage with others

You are not alone. People with moral resilience leverage connections to themselves and others to support their integrity and well-being. Strong social connections can act as a safety net when you struggle to address ethical complexities and the isolation that often accompany moral distress. Become part of a moral community by talking one-on-one with colleagues or trusted advisors, connecting with family and friends, or reaching out to leaders within your institutions or professional organizations. Within our practice environment, we should look to and seek support from team activities such as facilitated inter-professional discussions or ethics consultation.

Participate in transformational learning

Seize the opportunity to learn from moral crises and the situations that produce moral distress. Confront your limitations, re-examine your positions and realign them with your moral core. We can change our behavior and practice by participating in professional activities including routine case reviews, root cause analysis of morally distressing cases, and ongoing quality improvement.

Contribute to a culture of ethical practice

The American Nurses Association Code of Ethics tells us that we are responsible for creating and sustaining a culture of ethical practice. As nurses, we can actively contribute to and leverage interprofessional efforts to design structures that bolster resilience. We can, for instance, find useful and tested tools in the work of the Center for Ethics in the Veteran’s Administration and by other ethics initiatives. And we can benefit from ongoing research into the nature of resilience for starting points in developing a culture of ethical practice, such as the work of Zolli, who suggests the alignment of “beliefs, values and habits of mind; trust and cooperation; cognitive diversity; strong communities, translational leadership and adaptive governance.”

Commitment to moral resilience

Moral resilience is an evolving concept in response to moral distress. Like physical exercise, moral resilience requires dedication, discipline, and compassion toward our limitations and inevitable setbacks. Creating a regular time and commitment to cultivate the elements of moral resilience and engaging resources to resist distractions and flagging will, are essential for robust moral resilience. As an ongoing practice, nurses will have regular opportunities to return to three core questions.

  • Who am I being in this moment?
  • How do I want to be known?
  • Am I choosing to act or not act in a way that I can live with?

These questions ground our intentions, character, choices, and behaviors to reduce the exhaustion that arises when we are out of alignment with our values and obligations. Regularly committing to specific actions to support your moral resilience upholds the 5th Provision of the ANA Code of Ethics: “The nurse owes the same duties to self as to others, including the responsibility to…preserve wholeness of character and integrity.” Being morally resilient is not optional; enact your moral resilience plan toda

The author would like to acknowledge Judy Douglas and Peter Young for editorial assistance and to note that this article is based on Rushton C. Moral resilience: a capacity for navigating moral distress in critical care. AACN Advanced Critical Care. 2015;27(1):111-9.

Cynda Hylton Rushton is the Anne and George L. Bunting Professor of Clinical Ethics and a professor of nursing and pediatrics at Johns Hopkins University, School of Nursing & Berman Institute of Bioethics, Baltimore, Maryland.

Selected references

American Nurses Association. Code of ethics for nurses with interpretive statements.

Foglia M, Pearlman R, Bottrell M, et al. Ethical challenges within Veterans Administration healthcare facilities: perspectives of managers, clinicians, patients, and ethics committee chairpersons. Am J Bioethics. 2009;9(4):28-36.

Helft PR, Bledsoe PD, Hancock M, et al. Facilitated ethics conversations: a novel program for managing moral distress in bedside nursing staff. JONA’S Healthc Law Ethics Regul. 2009;11(1):27-33.

Nelson HL. Damaged Identities, Narrative Repair. Ithaca, NY: Cornell University Press; 2001.

Oh Y, Gastmans C. Moral distress experienced by nurses: a quantitative literature review. Nurs Ethics. 2015;22(1):15-31.

Rushton C. Moral resilience: a capacity for navigating moral distress in critical care. AACN Adv Crit Care. 2015;27(1):111-9.

Rushton CH, Caldwell M, Kurtz M. Moral distress: empowering nurses to restore integrity. Am J Nurs. In press.

Rushton CH, Kaszniak AW, Halifax JS. A framework for understanding moral distress among palliative care clinicians. J Palliat Med. 2013;16(9):1074-9.

University of Kentucky, College of Medicine. The Moral Distress Project.

Varcoe C, Pauly B, Webter G. Moral distress: tensions as springboards for action. HEC Forum. 2012;24(1):51-62.

Zolli A, Healy A. Resilience: Why Things Bounce Back. New York: Free Press; 2012:15.

87 COMMENTS

  1. Awesome information to remind us that we need to care for ourselves before we are truly able to care properly for others.

  2. This is a great overview of the issues of moral distress and I gave this assignment to RN>BSN completion students and the array of moral issues that they must deal with, and be resilient to, was daunting. This provides a framework for helping them achieve their resilience, but I would like more strategies for them to safely address these moral dilemmas. THey are not in positions of power.

  3. how can a nurse also have empathy for the patient which allows insight for beneficial and productive ways of being a positive advocate for each patient?

  4. I believe I take better care of my family, friends, patients and staff. Whatever is left, is mine. This has been going on FAR TOO long and I prescribe to doing better beginning today.

  5. I love my job. There’s just too much of it and higher acuity patients. I arrive early work, skip all breaks everyday, and work through lunch almost everyday. The first thing I think about is retiring early. Second thought is I have to pay the bills. Then I get to work and repeat the same thing day after day. I am praised for my ability to handle the case load and precept students and interns even on the worst of days. My job partner does the same thing. We discuss our retirements together and know that the light is now closer to the end of the tunnel than we thought. Right now stocking shelves or working retail looks like a happier place to be.

  6. I have to sell this to myself almost every day. I MUST take care of myself-please get the walk in on the greenway… you need it SOO much & so does the puppy 🙂

  7. We have experience a lot of this in the work place. Sometimes we are so busy taking care of others that we tend to ignore our own self care. Thank you for the strategies and tips to help us as nurses maintain our moral resilience

  8. I enjoyed this article very much! We as nurses are so busy taking care of others that we forget we must also take care of ourselves.

  9. This is very useful information in life in general, not just pertaining to the nursing field

  10. very informative. good information and thought provoking. self care is very important and a lot of nurses do not do this, including myself! thank you

  11. This article is spot on. Meeting with other nurses to discuss relevant issues and journaling can be beneficial to understanding situations that require us to question how we perceive ethical issues.

  12. Good article, we all need a moral boost, redirection and positivity to stay engaged in our jobs.

  13. Excellent strategies given for nurses to be more resilient in better caring for themselves, co-workers which eventually helps in care of the patients.

  14. Everything goes back to yourself, an answer to the question, a self reflection.. What made me decide to become a nurse? As a nurse, a strong foundation the reason behind why you what to be a nurse, eventually will make you morally resilient.

  15. Years ago nursing was built on moral resilience, in the 80’s we continued being taught that it was expected. Today, many students and new grads stray far from this, it is our duty to practice this and be examples for the new generation of nurses.

  16. Moral distress happens frequently in mental health with coming to terms with other’s beliefs in their practice. This article is a reminder of what can be done to care for others and ourselves.

  17. Very well said and relatable. I feel as being a leader, one of my priorities is to constantly being on watch and identify when the team starts to pull back and become less engaged, using it as a warning sign. That is when I bring them in and switch up their assignment, giving them redirection to focus on new tasks positively versus the repetitive duties creating negatives. This article is very helpful!

  18. Interesting, informative article. Ethical principles and actions are such a daily practice in every nurse’s life.

  19. Very good, thought provoking and great ideas to help the staff nurse before they get burned out

  20. I think there should be more opportunities for nurses to “debrief” or “unload” after particularly distressing days.

  21. reaffirming why we became nurses will help us to refocus. We never said we became nurses to take care of ourselves, but how can we effectively care for others if we don’t care for ourselves?

  22. This article gave good pointers on dealing with issues we are faced with in healthcare that conflict with our personal beliefs. We must remind ourselves why we joined this profession, but also remain true to who we are as we go through our day. We should not feel compelled to do something that violates our personal beliefs because at the end of the day we have to be happy with our choices.

  23. Moral resilience vs moral stress
    A lot of information packed in this article, some old, but a lot of it is new to me

  24. I can see how moral resilience is important in many situations where you question what you are doing. I love the questions to ask yourself for the commitment to moral resilience because it gives you a way to reflect on yourself.

  25. I LOVE this article and the fact that ANA has included statement 5, which speaks to self care.
    It is a personal quest of mine to achieve self care.

  26. Very informative article that will help me to continue to improve my moral resilience and become a better nurse by doing this which will give my patient’s the best care that they deserve.

  27. Developing and checking the self-regulation “muscle” is important for every nurse in order to continue to learn, educate, and maintain a healthy, professional status.

  28. Refocusing on the important things in life, and why I am a nurse is something I always have to remind myself of.

  29. If everyone works together and is willing to help out fellow co-workers, it will help to eliminate some of the stress

  30. Who am I being in this moment? How do I want to be known? Am I choosing to act or not act in a way that I can live with? Great questions to ask yourself when you’re feeling overwhelmed or need to re-center yourself

  31. I think it’s very important to have a regular “re-set” button that reminds us why we became nurses in the first place and that is to take care of other people. When we break it down to this basic insight, many of the other issues that we deal with on a daily basis seem to resolve themselves. I think it’s very important that we take time when outside of work to participate in calming activities and also share experiences with our fellow staff members.

  32. Good food for thought:)
    Who am I being in this moment?
    How do I want to be known?
    Am I choosing to act or not act in a way that I can live with?

  33. I think all nurses should read this to remind us to take care of ourselves s that we can be the best nurses for our patients.

  34. I thought this was a very thought provoking article that made practical suggestions of how to prevent burnout

    It emphasized the importance of team support

    Its focus on the mind, body spirit aspects of nursing was a reminder of the importance of maintaining a balance in order to be an effective health professional

  35. It is important for nurses to be able to respect and honor others values and morals. Nurses play an exceptional role in people’s everyday lives.

  36. It is important for a nurse to reaffirm and/or recall why becoming a nurse was important in the first place. Remember the defining moment when an individual realized that being a nurse was the most important goal in his or her life.

  37. Building Moral Resilience can be a team effort. Spirituality in the workplace makes staff calmer and able to handle emerging situations with tact and professionalism.
    Sometimes, a five minute huddle in the middle of a busy work day to pray touches the entire group and has a ripple effect on the rest.

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