How moral distress, courage and resilience impact nursing care

By | 2019-06-17T18:11:39-04:00 June 4th, 2019|1 Comment

Moral dilemmas, decisions and that third ‘D’ in nursing — moral distress — call for courage and resilience

It’s a normal part of life to have some distress. It’s something none of you want, and all of us try to avoid.

Often the cause of emotional and physical pain that can upset and disrupt our lives, distress can occur because of various work situations, financial problems or family issues everyone experiences at times.

Distress can be emotional and make you feel nervous, overwhelmed, worried and even afraid. It also can be physical, causing headaches, GI upsets, respiratory difficulties and more. In your role as a nurse, it can even be worse.

Based on the nature of your work, you often find yourself in situations others never encounter. It can come out of patient care issues related to end-of-life decisions, informed consents or advance directives, or be the result of workplace and staff issues caused by errors, accidents, gaps in communication or poor decisions.

All of those issues are part of nursing and for many people can become moral dilemmas. The decisions they call for move the distress to a different level and cause what is known as moral distress.

Defining moral distress and dealing with it

Moral distress has been a subject of interest and study in healthcare for more than 30 years, and many still ask:

  • How do I know if what I’m experiencing is moral distress?
  • What does it feel like?
  • How does it happen?

Studying it is one thing, but to deal with moral distress you must first define and understand it.

There is a connection between the dilemmas and decisions you deal with, the inner struggle the two can cause and the moral distress that results.

According to the well-known definition from Andrew Jameton, first published in 1984, moral distress occurs when a nurse “knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”

This occurs most often when you believe you know the right thing to do but feel powerless or afraid to do it. Because many patient care situations can be serious, some see suffering moral distress as a predictable part of nursing you need to accept.

According to a report by Johns Hopkins University Nursing’s Cynda Rushton, PhD, RN, FAAN, “moral distress is a predictable response to situations where nurses recognize that there is a moral problem, have a responsibility to do something about it, but cannot act in a way that preserves their integrity.”

Moral distress is when you cannot just accept it when you’re being asked to do something you believe is wrong while organizational rules, regulations or opinions of superiors say it’s not. This is where moral courage comes in.

The power of moral courage

Remember when you were young and your mother told you to “have the courage of your convictions and stand up for what you believe in”?

It wasn’t always easy. Even though you’re all grown up now, it’s still not easy.

It is tempting to say if you have moral courage, you won’t experience moral distress. Sufficient moral courage would enable you to speak up and challenge unacceptable practices and policies. But that’s not always the case.

Speaking up isn’t easy. It helps, but doesn’t always mean your distress will go away. Moral courage takes practice, and “even the most morally courageous staff may fear speaking up,” according to a study published by the American Nurses Association.

The role of resilience in moral distress

Another word we hear in discussions on moral distress and courage is resilience.

“Moral resilience is the ability to deal with an ethically adverse situation without lasting effects of moral distress. … It requires morally courageous action, activating needed supports and doing the right thing,” according to a study in the journal MedSurg Nursing.

So how can you effectively address moral distress as a nurse?

The ANA offers nine recommendations that summarize ways you can develop, work on and strengthen your moral courage and resilience:

  1. Adopt ANA’s Healthy Nurse Healthy Nation strategies to support your general well-being as a foundation for cultivating moral resilience.
  2. Read, review and implement the ANA Code of Ethics for Nurses with Interpretive Statements to gain knowledge and strengthen ethical competence.
  3. Seek opportunities to learn how to recognize, analyze and take ethically grounded action in response to ethical complexity, disagreement or conflict.
  4. Cultivate self-awareness to recognize and respond to your symptoms of moral suffering, including moral distress.
  5. Pursue educational opportunities to cultivate mindfulness, ethical competence and moral resilience.
  6. Develop your personal plan to support well-being and build moral resilience.
  7. Become involved and initiate workplace efforts to address the root causes of moral distress and other forms of moral suffering.
  8. Develop and practice skills in communication, mindfulness, conflict transformation and interprofessional collaboration.
  9. Identify and use personal resources within your organization or community, such as ethics committees, peer-to-peer support, debriefing sessions, counseling and employee assistance programs.

Take these courses about moral distress and ethics:

From ‘Distress’ to ‘De-stress’ With Stress Management
(1 contact hr)
A stress response causes specific biological changes, such as increased heart rate, bronchodilation, horripilation (goose bumps), increased blood pressure, increased sweat production, decreased immune response, decreased insulin and increased blood glucose. The volume of research in this area is growing rapidly, and it is safe to conclude that immune modulations caused by psychosocial stressors or interventions directly affect health outcomes. In the 2011 American Nurses Association survey of health and safety concerns, 74% of nurses reported effects of stress and overwork as their No. 1 concern. This result is up slightly from the 2001 survey. A recent publication reports that nurses experience high levels of workplace stress with negative effects on both individual nurses and the organizations that employ them. This module provides information to help healthcare professionals manage their own stress and patients’ stress.

Nursing Ethics, Part 3: Ethics in Nursing
(1.5 contact hrs)
Nursing is a moral profession. Nurses are charged to do good for their patients and avoid harm. But technological advances in healthcare require that nurses expand their instinctive understanding of ethics into one of reasoned and deliberate knowledge. This course informs nurses about the Code of Ethics for Nurses, nursing ethics committees and nursing advocacy, all of which help maintain the integrity of nursing.

Empathy 101 for Nurses: How to Care for Yourself While Emotionally Supporting Others
(1 contact hr)
Nurses are called to care. You apply evidence-based practice, clinical knowledge and critical thinking with compassion and empathy. Join this webinar to learn the difference between empathy and sympathy, and how to recharge and take care of yourself so you can take care of your patients.


About the Author:

Eileen Williamson, MSN, RN
Eileen Williamson, MSN, RN, continues to write and act as a consultant for Before joining the company in 1998, Eileen was employed by North Shore-Long Island Jewish Health System in New York (now Northwell Health System) where she held a number of leadership positions in nursing and hospital administration, including chief nurse at two of their System hospitals. She holds a BSN and an MSN in nursing administration and is a graduate fellow of the Johnson & Johnson University of Pennsylvania Wharton School Nurse Executives program. A former board member and past president of the New Jersey League for Nursing, a constituent league of the National League for Nursing, Eileen currently is a member of the Adelphi University, College of Nursing and Public Health Advisory Board.

One Comment

  1. Avatar
    Tsosti April 29, 2021 at 4:18 pm - Reply

    Nurse to nurse violence is not only physical, it can be mentally sabotaging you. For instance, when you need help that doesn’t come while trying to save a patient’s life when she’s hemorrhaging. And the very nurses that come to help, eventually, are now reporting that you are unsafe with patient care. The manager has already taken sides and it’s not yours.

    It can be the fear of leaving your home to go to work because you know what you’re up against. HR is useless. They back the managers and the staff making your environment unsafe. It’s definitely a no-win situation here. Having nurses coming into your room to see what you’re doing and more. It never ends because now you have to cover all positions – front, back, and both sides of you.

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