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Moral Resilience as an Antidote to Moral Distress


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Originally appeared in HealthLeaders Media.

Those within the nursing profession are well-aware of the presence of moral distress among nurses.

The reality of healthcare is that the difficult situations that challenge nurses' ethical and moral integrity are part of the job and they are not going away.

Developing moral resilience and creating a culture of ethical practice, however, can provide nurses with the support they need to function in today's healthcare environment. 

"The idea of moral resilience is pointing to this capacity, that I think we all have in varying degrees, to sustain or restore our integrity in the midst of moral complexity, confusion, moral distress, or setbacks that we experience when we really feel like we can't do the right thing," says Cynda H. Rushton, PhD, RN, FAAN.

She is the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University.

So how do nurses develop moral resilience? The American Association of Critical Care Nurses provides resources and Rushton offers a few suggestions of her own:

Be in tune with your body
Don't discount those gut feelings you may have about something, Rushton advises. "Our bodies have a lot of wisdom," she says.

"If you think about what happens in your gut, 'You know it in your gut.' The body is a great sort resource to help us detect there's something here that's challenging or threatening my integrity."

Notice your emotions
Rushton says nurses should identify what emotions occur when they're in a challenging situation. "There's a whole range of emotions. They can be anger and frustration or people could be depressed and totally shut-down in response to these type of situations," she says.

Identify your assumptions and biases
Jumping to conclusions—for example, saying, "I've been here before," or "I know how this ends,"—can limit creative solutions to a problem.

"Immediately, there's a set of assumptions about the people involved and the context of the situation that can lead us down a path where it obscures other possibilities of what might happen in that situation," Rushton explains.

These techniques all contribute to what Rushton calls self-regulation.

"The importance of regulating our nervous system is so we can recognize what's happening. We can pause and reflect and think clearly," she says. "We can't do that if our nervous system has gone bonkers."

Supportive Practice Environments Required

Nurses can't be expected to develop moral resilience without organizational support, says Rushton.

"Being morally resilient individually requires individual capacities, and it requires an ethical practice environment," she says.

Chief nursing officers can support an ethical practice environment by ensuring that decisions are being made and priorities are being set, that reflect the organization's values.

Also, the organization should have mechanisms in place to make it possible for others to speak up about practices that are challenging their sense of integrity without fear of retaliation.

"Another piece of this culture would be to have accountability norms to prevent or remediate instances of reprisal, disrespect, or dismissal of ethical concerns," Rushton says.

"This links to the whole idea of disruptive behavior and creating a culture of civility where everybody's viewpoint is respected and honored. And when it's communicated, it's received in a way that allows people to feel heard and that their concerns are taken seriously."

The bottom line when it comes to developing a culture of ethical practice, Rushton says, is that preserving or restoring integrity is vital for the sustainability of the nursing workforce.

"It is really an urgent issue for us to address as a profession and as a healthcare community because our healthcare system is unsustainable without a healthy nursing workforce," she says.

"I think this has got to be a priority and something that we're all willing to invest in to try to find some really effective solutions at both the individual and the system level."