First identified in the 1980s,1 moral distress occurs in situations where “the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; yet, as a result of real or perceived constraints, participates in perceived moral wrongdoing.”2 The American Nurses Association's Code of Ethics for Nurses with Interpretive Statements defines moral distress as “the condition of knowing the morally right thing to do, but institutional, procedural, or social constraints make doing the right thing nearly impossible.”3 Moral distress, the code emphasizes, “threatens core values and moral integrity.”
Moral distress is pervasive in numerous health care settings and at multiple organizational levels.4, 5 Nurses in all roles encounter morally distressing situations. Examples include a critical care nurse who struggles with implementing invasive treatment in a patient with little chance of survival; a nurse on a medical−surgical unit who is unable to provide compassionate care to her patients because of insufficient staffing; or a nurse administrator who fights for required resources only to face significant budget cuts.
The concept has been associated with negative consequences for both people and systems. At the individual level moral distress may cause burnout, lack of empathy, and job dissatisfaction, while at the organizational level it may lead to reduced quality of care, increased staff turnover, and poor patient outcomes.6-8
Despite decades of research on moral distress, few solutions have been proposed for alleviating a problem that is only expected to escalate as health care becomes more complex.9 Recent scholarship has suggested, however, that instead of being a purely negative experience, moral distress can become a catalyst for positive action.9-11
Moral resilience is an evolving concept that may help nurses and other providers to respond to moral distress and other ethical challenges. Generally, resilience refers to “the ability to recover or healthfully adapt to challenges, stress, adversity, or trauma: to be buoyant in adverse circumstances.”9 Specifically, moral resilience has been defined as “the capacity of an individual to sustain or restore [her or his] integrity in response to moral complexity, confusion, distress, or setbacks.”9 Health care workers can learn to respond positively to ethically challenging situations by building their capacity for moral resilience, and organizations can support them by creating a culture of ethical practice.
To examine promising practices for addressing moral distress, a collaborative project was developed by the Johns Hopkins Berman Institute of Bioethics, the Johns Hopkins School of Nursing, the American Journal of Nursing (AJN), and the Journal of Christian Nursing, along with the American Association of Critical-Care Nurses and the American Nurses Association, to identify strategies that individuals and systems can use to mitigate the detrimental effects of moral distress and foster moral resilience. This project builds on the recommendations of the 2014 Blueprint for 21st Century Nursing Ethics: Report of the National Nursing Summit (see www.bioethicsinstitute.org/nursing-ethics-summit-report).
Desired outcomes for the project included identifying what is needed to help individuals develop moral resilience and what organizations can do to create environments that provide ethically grounded and humane care to patients and their families.
After four years of planning, an invitational symposium, State of the Science: Transforming Moral Distress into Moral Resilience in Nursing, was held on August 11 and 12, 2016, at the Johns Hopkins School of Nursing in Baltimore, Maryland. Funding support was provided by the Johnson and Johnson Campaign for Nursing's Future, the Heilbrunn Family Foundation, and Nurses Christian Fellowship/USA, with in-kind support from the Johns Hopkins School of Nursing and AJN. Forty-five nurse clinicians, researchers, ethicists, organization representatives, and other stakeholders worked together to explore promising evidence-based practices and to answer these critical questions:
- What is known about building moral resilience as a strategy for reducing moral distress?
- What is known about individual and organizational strategies for reducing conditions that give rise to moral distress and for supporting moral resilience?
- What are the recommendations for practice, education, research, and policy for addressing moral distress and cultivating moral resilience in clinical settings?
The symposium began with remarks from the host and conveners: Cynda Hylton Rushton, the Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics and professor of nursing and pediatrics at the Johns Hopkins School of Nursing; Patricia M. Davidson, professor and dean of the Johns Hopkins School of Nursing; Jeffrey Kahn, the Andreas C. Dracopoulos Director of the Johns Hopkins Berman Institute of Bioethics; and Maureen Shawn Kennedy, editor-in-chief of AJN.
Following the opening remarks, participants reflected on what they knew and believed about moral distress and moral resilience. Patricia A. Rodney, associate professor at the University of British Columbia (UBC) School of Nursing and faculty associate at the W. Maurice Young Centre for Applied Ethics at UBC, offered a summary of existing research on moral distress to propel the group to build on the work accomplished at a 2010 Canadian symposium on the subject.11 A World Café−model discussion followed, during which participants broke off into small groups to deliberate on interventions for mitigating moral distress. Afterward, facilitators shared each group's suggestions with all the participants.
Rushton presented a paper on transcending moral distress by building moral resilience. This was followed by a panel discussion on interventions designed to cultivate individuals’ capacity for moral resilience. Participants next met in small brainstorming groups to identify the essential elements to any successful moral distress intervention program; the changes needed in research, education, policy, and practice; and the steps to take to help individuals become morally resilient. At the end of the brainstorming session, facilitators once again reported their groups’ top suggestions.
The second day opened with a recap of the previous day's activities and accomplishments. A panel discussion followed, during which panelists shared promising strategies that systems and organizations can implement in order to address health care workers’ moral distress. Participants again broke off into small brainstorming groups to identify the elements needed to encourage ethical practice in systems; determine priorities for research, education, policy, and practice; and offer suggestions for future initiatives. As before, facilitators reported their groups’ recommendations.
All participants then voted on recommendations for essential elements in building individual and system capacities to address moral distress, increase moral resilience, and support ethical practice (see Consensus Recommendations for Addressing Moral Distress and Building Moral Resilience). Participants also identified priorities for a research agenda, and a small team—comprising Heidi Holtz, Lisa Lehmann, and Christine Grady—formulated these priorities into specific research questions (see Recommended Research Agenda). Many participants committed to disseminating the work accomplished at the symposium within their work circles.
The result of the two-day symposium was group consensus on recommendations for addressing moral distress and building moral resilience in four areas: practice, education, research, and policy. Participants and the organizations represented were energized and committed to moving this agenda forward.
Nurses and other health care professionals and administrators are encouraged to review the recommendations from this symposium and consider how specific ideas can be moved forward—even implemented—through their personal and organizational efforts. Educators can think about ways to incorporate content on moral distress and moral resilience into curricula. Policymakers must engage to remediate the root causes of moral distress and the barriers to moral resilience and ethical practice by including appropriate standards in accreditation and licensing of health care institutions. Researchers and graduate students can examine the research recommendations and conduct exploratory and experimental studies.
With determined action, we can help nurses and other providers mitigate the effects of moral distress, enhance the ethical environment in which they practice, and improve the quality of health care.
1. Jameton A Nursing practice: the ethical issues
. Englewood Cliffs, NJ: Prentice-Hall; 1984. Prentice-Hall series in the philosophy of medicine.
2. Nathaniel AK Moral distress among nurses
. Washington, DC: American Nurses Association 2002.
3. American Nurses Association. Code of ethics for nurses with interpretive statements
. Silver Spring, MD; 2015.
4. Oh Y, Gastmans C Moral distress
experienced by nurses: a quantitative literature review Nurs Ethics 2015 22 1 15–31
5. Whitehead PB, et al. Moral distress
among healthcare professionals: report of an institution-wide survey J Nurs Scholarsh 2015 47 2 117–25
6. Burston AS, Tuckett AG Moral distress
: contributing factors, outcomes and interventions Nurs Ethics 2013 20 3 312–24
7. Rushton CH, et al. CE: Moral distress
: a catalyst in building moral resilience
Am J Nurs 2016 116 7 40–9
8. Wallis L Moral distress
Am J Nurs 2015 115 3 19–20
9. Rushton CH Moral resilience
: a capacity for navigating moral distress
in critical care AACN Adv Crit Care 2016 27 1 111–9
10. Aburn G, et al. What is resilience? An integrative review of the empirical literature J Adv Nurs 2016 72 5 980–1000
11. Pauly BM, et al. Framing the issues: moral distress
in health care HEC Forum 2012 24 1 1–11