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.
Consensus Recommendations for Addressing Moral Distress and Building Moral Resilience
Essential steps for addressing moral distress and supporting the cultivation of moral resilience in individuals.
- Institution leaders need to value and create a culture of ethical practice and commit resources to support individuals in cultivating moral resilience.
- Nurses and other members of the health care team need education and mentoring to develop such relational skills as motivation, introspection, empathy, communication, mindfulness, and emotional intelligence in order to exercise moral agency in response to moral distress.
- Skilled facilitators or ethics consultants who are empathetic, insightful, ethically grounded, and creative are needed to form safe spaces that encourage conversations—from early discussions about ethical concerns to debriefing following difficult cases.
- Nurse representatives should be present on bioethics committees in health care organizations.
- Institutions should create and disseminate a “toolbox” of best practices to promote ongoing communication among health care providers and facilitate the resolution of ethical issues.
- Existing data must be used to demonstrate the relationship between patient safety, staff turnover, and moral distress in order to boost investment in additional research and foster the development of successful interventions.
Priorities for education.
- Create incentives for more faculty members to develop competency in practical ethics.
- Prepare students and clinicians to recognize ordinary, day-to-day ethical concerns by providing a framework for identifying these concerns and the appropriate language to proactively discuss them—before they lead to moral distress.
- Require that prelicensure curricula include basic ethics content and an understanding of moral resilience.
- Develop continuous professional development programs across all levels of expertise and practice in order to provide the knowledge and skills necessary for recognizing and addressing morally distressing situations.
Priorities for practice.
- Implement a work environment that fosters reflection and communication and rewards staff for raising ethical questions.
- Provide resources designed to address morally challenging issues and include consultants who can facilitate ethics-related conversations.
- Promote collaboration among all members of the health care team to develop an ethical practice environment.
- Develop strategies with interprofessional colleagues to identify and address the root causes of moral distress in the clinical setting.
Priorities for policy.
- Encourage accreditation bodies to mandate that curricula for all health care professions include content addressing ethics, moral distress, and moral resilience.
- Urge the American Nurses Credentialing Center to include programs that promote moral resilience as part of Magnet criteria.
- Advise health care institutions to develop policy through an ethical lens by always asking, “What impact will this policy have on the integrity of this institution and the health care professionals who work within it?”
Essential steps for building systems that support ethical practice.
- Urge the National Academy of Medicine to conduct an analysis of the causes and impact of moral distress and put forth recommendations for pursuing initiatives in practice, education, policy, and research.
- Conduct a cost–benefit analysis of the impact of unaddressed moral distress on such quality indicators as patient outcomes and experience, medical errors, staff engagement, absenteeism and turnover, and financial costs.
- Advocate for a revision of the Joint Commission standard regarding ethical claims, and strengthen mechanisms for addressing requests not to participate in certain actions on grounds of conscience.
- Engage professional associations in recognizing the importance of addressing moral distress and building moral resilience, integrating ongoing ethics education for health care workers, and lobbying for increased funding for clinical ethics research.
- Develop a call to action to nursing and other professional organizations, as well as the public, to raise awareness of the impact of unresolved moral distress on patient care and quality outcomes.
Priorities for education.
- Support efforts by the American Society for Bioethics and Humanities to develop certification in clinical and organizational ethics consultation.
- Advocate the requirement of ethics education for board members of health care organizations.
- Educate the public through public service announcements that clarify the link between moral distress and patient safety to enlist consumer support for institutional policies that sustain ethical practices.
- Encourage nursing and ethics organizations to collaborate on identifying the core components of ethics training for faculty and students.
Priorities for practice.
- Develop benchmarks for such key indicators as patient outcomes, staff turnover, cost, and readmissions as they relate to moral distress and the institutions' ethical culture.
- Develop a system-wide, interprofessional, shared governance initiative to instill ethical values and build capacity and competence to address ethical concerns.
- Identify situations likely to trigger ethical conflicts and develop a process for proactively evaluating and addressing these situations.
Priorities for policy.
- Require that certification for health organization leaders contains content on ethics, including issues related to addressing moral distress and building systems that promote moral resilience.
- Urge regulatory and accrediting bodies to impose more robust criteria for addressing ethics issues that commonly result in moral distress.
- Strengthen incentives for organizations to implement healthy work environment standards such as those developed by the American Association of Critical-Care Nurses.
Recommended Research Agenda
Research needed to address moral distress and support the cultivation of moral resilience in individuals.
- What can we learn from a synthesis of research on resilience in settings other than health care? How can our understanding of what resilience is and how to cultivate it inform our efforts to cultivate moral resilience in health care?
- What strategies can we implement to develop individual moral resilience?
- How do we enhance it?
- How do we support it?
- How do we teach it?
- What measures are needed to assess the effectiveness of moral resilience interventions?
- What is the relationship between individual moral resilience and employee satisfaction and engagement?
- Is there a causal relationship between (preventable) harm and moral distress/moral resilience?
Research needed to build systems that support ethical practice.
- What constitutes a culture of ethical practice in health care?
- What are the promising practices for building a culture of ethical practice in health care?
- What are the similarities and differences in methods and outcomes of various promising practices?
- How do formalized ethics programs impact organizational outcomes?
- What are the key features of formalized ethics programs that contribute to moral resilience and a culture of ethical practice?
- How do we promote moral resilience throughout a health care system?
- What are the system characteristics that promote moral resilience?
- Why do some organizations have greater moral resilience than others?
- What characteristics of an organization foster moral resilience?
- What is the relationship between individual moral resilience and organizational outcomes and patient outcomes?
- Is there a causal relationship between (preventable) harm and moral distress/moral resilience?
- What are the economic costs to a health care organization of measurable moral distress?
- What is the economic impact of implementing practices consistent with a culture of ethical practice?
- What is the experience of moral distress and moral resilience among a national sample of interprofessional executive leaders?