By Peter Young


What should nurses do in the face of adversity and moral distress? Moral distress, the response to situations that imperil the integrity of nurses because of institutional constraints or pressures, is a form of moral suffering.  After nearly 30 years of research into moral distress there are still no clear-cut answers about how to reduce its detrimental impact on nurses, teams and institutions.  In an attempt to rectify this, 46 nurse leaders came together on August 11 and 12 to participate in a State of the Science Symposium entitled “Transforming Moral Distress to Moral Resiliency in Nursing.” This effort, hosted by the American Journal of Nursing, Johns Hopkins School of Nursing, and the Berman Institute of Bioethics and co-led by our own Dr. Cynda Rushton, featured many of the brightest minds within nursing ethics. The two-day meeting, attended by nurse ethicists and leaders in nursing and health care, will help advance effective solutions to address moral distress and build moral resilience. “It is a pivotal time to design solutions to the recalcitrant problem of moral distress in nursing and healthcare.” Says Dr. Cynda Rushton.  “The roadmap for addressing moral distress, focusing on the dynamic interplay between individuals and the environments where they practice, offers promising solutions and hope for the future.”


To better understand the goals of the symposium, imagine a hypothetical ICU nurse, Sarah, who is working with a terminally-ill patient, the family of whom would like to pursue every medical option possible including cardiopulmonary resuscitation (CPR), although it may not be medically indicated. The rest of the clinical team, however, believes that while the patient’s life may be extended by CPR, the patient’s quality of life will not be restored and the patient will never leave the hospital. The team therefore institutes a unilateral Do Not Resuscitate (DNR) order in the event of a cardiac arrest. Sarah, who has been working with the family, feels that although the patient will not leave the hospital, these final moments between the family and their loved one are worth the extra days or hours that CPR can afford. Now Sarah is stuck in a bind between wanting to advocate for a procedure, which she thinks is morally correct based on the surrogate’s goals, but not being able to achieve the outcome because of institutional barriers.


Instead of having Sarah ruminate on the power structures that prevents many nurses from speaking up, or instead of having her build up work-related stress and taking it home, moral resilience focuses on how one can traverse morally difficult situations and preserve integrity. By finding oneself in adversity, what sorts of positive actions can an individual take to restore moral agency and integrity? According to Rushton, it is essential that we acknowledge that moral distress exists and learn to speak up and speaking out about the ethical conflicts nurses confront. She also suggests learning how to regulate somatic and emotional responses, being flexible and seeking meaning in difficult ethical situations and being able to discern when one has done all that is possible, allows nurses to be effective in these otherwise troubling clinical encounters. While these strategies are some ways to cultivate moral resilience, the nursing community needs to be further refine and understand this relatively new concept to be able to fully utilize it in practice.


The State of the Science Symposium therefore focused on effective solutions and strategies to build individual resilience and a culture that supports ethical practice. The two-day discussion resulted in a consensus on different recommendations for practice, education, research, and policy areas to shift to a paradigm of moral resilience by leveraging techniques and attitudes that will help nurses become more confident in themselves and their practice. The future implications of this work could be enormous since adverse patient outcomes have been linked to high nurse burnout and low job satisfaction. If nurses can find ways to address the adversity they are confronted with, the direct effect on patient care could be substantial. The results of the symposium proceedings will be published in the American Journal of Nursing in early 2017.

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Nursing Ethics
Peter Young

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