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.
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.
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.
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.