Building Moral Resilience.

Abstract

Q Maintaining my moral integrity is important to me, yet I have been faced with situations that challenge my ethical compass. How do I develop the internal strength to remain true to my values? How can my organization support efforts by my coworkers and me to speak up when we feel there are ethical concerns? What can I do as an individual and what can my organization do to enhance the environment to ensure ethical practice?A Karen Stutzer, rn, phd, and Mary Bylone, rn, msm, cnml, reply:It is well documented and acknowledged that the critical care environment contains daily challenges to individual nurses in regard to their moral integrity.1–3 Andrew Jameton4 initially described moral distress as when “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”4(p6) Identifying moral distress was the beginning of decades of work that has described and measured the impact of moral distress across multiple nursing specialties.1 The debilitating impact of moral distress on nurses is supported by research and includes burnout, disengagement from patients and families, stress-related illnesses, turnover, and leaving the profession.1A promising approach to addressing situations that challenge one’s ethical compass and the resulting moral distress is to incorporate strategies that promote moral resilience into organizational and individual practices. Moral resilience has been described as “the capacity of an individual to sustain or restore integrity in response to moral complexity, confusion, distress or setbacks.”5(pS13) Developing personal strategies to strengthen one’s approach to ethically distressing situations and seeking organizational strategies to support ethical practice are 2 ways to build moral resilience capacity.At the National Teaching Institute held in May 2017, a panel led several hundred acute and critical care nurses in a discussion about moral distress. Participants were encouraged to “forge a new path”6 and consider strategies to shift the dialogue and experience to those that promote resilience. This column is a reflection of the thinking of these participant experts—acute and critical care nurses who navigate the health care system to advocate for patients and families daily (Tables 1 and 2).Care for the critically ill patients occurs within health care organizations, and the ethical climate of those environments directly affects the ability of the nurse and members of the interprofessional team to provide care ethically.8 Health care organizations can and should provide systemic support to ensure the environment is conducive to ethical practice. The American Nurses Association Code of Ethics requires nursing leaders, in collaboration with nursing care providers, to ensure the practice environment supports the moral integrity of nurses.9,10Policies that support ethical practice are key to creating organizational infrastructure that can mitigate morally distressing events. Nursing leadership and bedside care providers need to identify the policies that are most supportive of ethical practice and develop those policies collaboratively. Among the areas that might be covered are mechanisms for addressing ethical concerns, protection of moral integrity, and organizational priorities for ethical practice. More specific examples include informed consent, withholding and withdrawal of life-sustaining therapies, health care decision-making, and calling an ethics consultation.11Nursing leaders are positioned to influence ethical practice through their words and deeds. Through support of shared governance structures, nurses are able to ensure their voice is included in policy development. It is key that policies and practice reinforce the expectation that nurses will verbalize concerns.12Organizations must provide adequate financial and human resources to support an ethical culture. The presence of effective ethics committees and qualified ethics consultants provides organizational structure for ethical practice.8 There should also be support for nurses who provide care to patients to be part of these committees. Organizations should provide processes, structures, and well-prepared educators to ensure ongoing education to develop and sustain ethical competence. Inquiring daily about potential ethical concerns in concert with the presence of well-prepared ethics resources can provide opportunity for early intervention and perhaps diminish the degree of distress experienced by all members of the team.13The emergence of moral resilience as a strategy to manage and cope with moral distress is a relatively new discussion. As one thinks about personal actions, it is an important step to recognize one’s intrinsic ability to care for oneself, advocate for patients, and work with organizational leadership to address ethically distressing situations. The professional Code of Ethics supports the requirement that nurses must promote personal health and well-being, and advocate for patients and ethical work environments.9Moral resilience comes from a place of intentional actions to build on personal strengths. Knowing one’s personal values and being willing to take courageous action move the experience from one of distress to one of resilience.5 The ability to stay true to oneself, make decisions that are consistent with one’s beliefs, and persevere in addressing concerns are attributes of moral resilience12 and behaviors one can develop and nurture. Additionally, nurses must be willing to support others in these situations, even when the issue is not a problem for themselves. Knowing your colleagues are supportive of what is important to you provides strength for speaking up, which, in turn, improves the dialogue.Maintaining balance and harmony in one’s life needs to be a priority. A healthy diet, proper rest, and time for relaxation can foster the needed energy to cope with distressing situations. Mindfulness practices, exercise, yoga, or other activities that encourage respite from stress can also enhance resilience.Membership in professional organizations should be considered a strategy to promoting moral resilience. Nursing organizations provide a collective voice for nursing concerns and issues, and provide opportunities for networking and supportive dialogue with colleagues. The American Nurses Association has convened a professional issues panel that examines moral resilience with the intention of identifying strategies to strengthen the ethical voice of nurses and, thereby, promote moral resilience.14 In addition to the development and publication of the Healthy Work Environment Standards,7 the American Association of Critical-Care Nurses is an active participant in collaborating with a variety of nursing organizations to promote moral resilience.3 More work is needed to make these documents part of every workplace.Moral resilience moves the internal dialogue from one of disappointment and powerlessness to one of strength and empowerment. Consciously acting to develop moral resilience enhances one’s self-confidence in managing ethically difficult situations.12 Through an ongoing commitment to developing self-awareness and insight when faced with ethical challenges, one can gain a deeper sense of understanding and sense of mastery when faced with ethically distressing situations.5