A Collaborative State of the Science Initiative: Transforming Moral Distress to Moral Resiliency in Nursing
Repository Posting Date2017-07-25T18:43:28Z
Author DetailsCynda Hylton Rushton, PhD, RN, FAAN; Heidi Kathleen Holtz; Patricia Rodney
Lead Author Sigma AffliationNu Beta
Other Title(s)Nursing Ethics
Level of EvidenceN/A
Background: Moral distress is a pervasive problem impacting health care in numerous settings and at multiple organizational levels (Oh & Gastmans, 2015; Whitehead, Herbertson, Hamric, & Epstein, 2015). First identified in the1980s (Jameton, 1984), 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” (Nathaniel, 2002). The American Nurses Association Code of Ethics for Nurses (2015) delineates 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; threatens core values and moral integrity” (p. 44).
Nurses in all roles, and settings, encounter morally distressing situations. A critical care nurse struggles with implementing invasive interventions for a patient with little chance of survival. A nurse on a medical/surgical unit knows they cannot provide good patient care because of insufficient staffing. A nurse administrator fights for required resources only to face significant budget cuts. Widespread moral distress has been linked with personal (burnout, empathy fatigue, job dissatisfaction), and system(quality of care, staff turnover, poor patient outcomes) consequences (Burston & Tuckett, 2013; Wallis, 2015; Rushton, Caldwell, & Kurtz, 2016). Despite decades of documenting moral distress, few solutions have been proposed for alleviating this problem that is only expected to escalate with increasing health care complexity (Rushton, 2016).
Moral resilienceis an evolving concept that offers promise for helping nurses and other providers manage moral distress. Generally, resilience, refers to “the ability to recover or healthfully adapt to challenges, stress, adversity, or trauma: to be buoyant in adverse circumstances” (Rushton, 2016, p. 112). Specifically, moral resilience has been defined as “the capacity of an individual to sustain or restore, or deepen [his or her] integrity in response to moral complexity, confusion, distress, or setbacks” (p. 112). Moral resilience involves cultivating individual capacities and developing systems to support individual integrity in morally distressing situations by creating a culture of ethical practice.
Purpose: A State of the Science Symposium: Transforming Moral Distress to Moral Resiliency was held to explore promising evidence-based practices and answer three critical questions:
- · What is known about building moral resilience as a strategy to reduce 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 around addressing moral distress and cultivating moral resilience in clinical settings?
The desired outcomes for this project include delineating what is needed to develop individual capacities and systems that will create an environment that will promote ethically grounded, humane, quality care for patients and their families.
Methods: A two day workshop involving forty-six nurse clinicians, researchers, ethicists, organization representatives, and other stakeholders collaborated using several strategies. First, participants were asked to reflect on what each individual’s understanding and beliefs were about moral distress and moral resilience. A background synthesis of moral distress research and interventions were presented to participants to build upon a previous symposium held in 2010. Following that conversation a World Café discussion was held in which group facilitators conveyed emerging ideas for addressing moral distress. To move participants’ discussion beyond moral distress a manuscript was presented on transcending moral distress by building moral resilience followed by a panel presentation describing promising interventions that could developed and implemented to build individual capacities for moral resilience. Succeeding the panel, participants met in small groups to brainstorm and identify essential elements for successful interventions to address moral distress and build individual capacities of moral resilience. These groups focused on what changes and/or additions were needed to move forward in research, education, policy and practice to address moral distress and cultivate individual capacities towards moral resilience.
Day two of the workshop used similar strategies that focused participants towards discussion of promising system and environmental strategies necessary for addressing moral distress and building moral resilience. Small group participation identified key elements needed to build system capacities to support ethical practice; the priorities in research, education, policy, and practice to build systems that support ethical practice; and steps necessary to cultivate systems that support ethical practice.
Results: Participants voted on recommendations for essential elements and next steps necessary for building individual and system capacities to address moral distress, build moral resilience, and support ethical practice. Additionally, participants identified priorities for a research agenda which was formulated into specific research questions to move research forward on addressing moral distress and building moral resilience.
Conclusion: Nurses, other healthcare providers, and administrators can use the results of this workshop to guide discussions, make considerations on how specific ideas can be moved forward, even implemented, through their personal and organizational efforts. With decided action, we can help nurses and other providers mitigate the effects of moral distress, increase the understanding and implications of building moral resilience, improve the ethical environment in which they practice, and improve the quality of health care.