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Building moral resilience and healthy environments

By: Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN

This effort requires everyone’s support.

“That which does not kill us, makes us stronger,’’ so proposed German philosopher Friedrich Nietzsche back in the 19th century and reiterated since then by countless others when facing adversity. Having to relentlessly confront moral dilemmas and other stressors without institutional support and effective individual coping skills is not healthy for anyone. Unfortunately, it can be the reality for RNs in workplaces across the nation.

Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN President, American Nurses AssociationSince its inception, the American Nurses Association (ANA) has led efforts to improve the health and well-being of nurses. And through our 2017 “Year of the Healthy Nurse” initiative, we’ve emphasized the importance of self-care and a healthy work environment. Looking at both of those components is critical when we’re trying to solve the many issues we face, including the conditions that lead to moral distress.

Nurses experience moral distress when they know the right thing to do in a given situation but feel powerless to intervene because of organizational or other constraints. Significant contributors to this phenomenon include staffing issues and conflicts over decision-making among patients, families, and healthcare team members.

This past year, we’ve led and participated in major efforts aimed at alleviating moral distress and strengthening clinicians’ moral resilience and overall well-being. Recently, an ANA professional issues panel completed A Call to Action: Exploring Moral Resilience Toward a Culture of Ethical Practice, which offers specific, practical guidance for individual nurses, nurse leaders, and organizations, as well as a toolkit featuring promising practices from around the country to strengthen clinicians’ moral resilience.

The document speaks to the importance of everyone working together at all levels to foster ethical practice environments and moral resilience, which our colleague Vicki Lachman, PhD, MBE, APRN, FAAN, defines as “the ability and willingness to speak and take right and good action in the face of an adversity that is moral/ethical in nature.” Specific recommendations for individual nurses include developing and practicing skills in communication, mindfulness, conflict transformation, and interprofessional collaboration. We also urge nurses to adopt ANA’s Healthy Nurse, Healthy Nation™ strategies to enhance their overall well-being and to use the ANA Code of Ethics for Nurses with Interpretive Statements to strengthen their ethical competence.

Recommendations outlined for nurse leaders and organizations include raising awareness and studying interventions around moral distress, burnout syndrome, compassion fatigue, and secondary trauma. They also call for implementing healthy work environment standards if needed, as well as testing strategies that address the root causes of moral distress and adversity. Nurses and other care team members are not expected to shoulder the responsibility for addressing the root causes alone; it must be a shared responsibility.

External stakeholders, such as national accrediting agencies and researchers, also are asked to do their part to ensure health professionals can practice in a supportive, ethical environment. Currently, abundant research on moral distress exists, but less so on effective ways to deal with it.

In another effort, I’ve been representing ANA on the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience. This multiyear initiative is focused on better understanding the challenges to clinician well-being and promoting evidence-based, multidisciplinary solutions to support health professionals and halt the growing epidemic of burnout. We’ve already accomplished much in our first year. Nurses can access a webcast from a July 14 public meeting that summarizes key goals from our workgroups so far; details the scope of the issue; and features promising approaches to reduce burnout and improve well-being, including an effort at Johns Hopkins to build moral resilience developed by Cynda Rushton, PhD, RN, FAAN, who also was the co-chair of ANA’s moral resilience panel.

Finally, ANA’s call to action document points to research indicating that moral resilience is built in response to adversity. As we take better care of ourselves, we call on the greater healthcare community to improve healthcare environments and strengthen workforce resilience.


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Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN
President, American Nurses Association


ant12-ANA President-1116
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