Ethics in Practice: From Moral Distress to Moral Resilience

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Nurses have been dealing with ethical issues and dilemmas in practice for years, and many of have experienced moral distress along the way. Moral distress is the condition of knowing the morally right thing to do, but institutional, procedural, or social constraints make doing the right thing nearly impossible and threaten our core values and moral integrity (American Nurses Association [ANA], 2015, p. 44). Much has been written about moral distress, especially regarding the impact that it has on individual health care providers as well as on patient care quality. In a synthesis of the literature, McAndrew, Leske, and Schroeter (2016) found inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions.
From a personal perspective, the experience of moral distress can develop into something that is emotionally painful, with associated feelings of one's personal and professional integrity being compromised. There is an accompanying need to bring resolution to the issue so as to be able to move on from it, which brings me to the concepts of moral residue, moral courage, and moral resilience. My previous description of my experience is an example of moral residue. Moral residue as defined by Epstein and Hamric (2009, p. 330) describes lingering feelings after a morally problematic situation has passed; in the face of moral distress, the individual feels as if seriously compromising himself or herself, or allowed others to be compromised, resulting in loss of moral integrity.
Moral courage is the capacity of an individual to overcome fear and stand up for his or her core values; the willingness to speak out and do what is right in the face of forces that would lead a person to act in some other way; it puts principles into action (Lachman, 2007, p. 131). Moral courage supports nurses as advocates, both for themselves and for their patients. Acts of conscientious objection are acts of moral courage (ANA, 2015, p. 21). The act of advocacy implies taking some sort of action on behalf of some person, some principle, some belief, some policy, and so on. It means putting yourself on the line, so it is important to be able to articulate your position effectively. When nurses have difficulty articulating the reasons why they object to something, it can impact their moral courage. It becomes imperative for nurses to have knowledge and support for their arguments. This is where the ANA Code of Ethics for Nurses can help (ANA, 2015). The provisions in the code serve as the information, direction, and support for nurses when composing a moral stand. The Code is there to support and guide our practice—We just have to read it and use it.
However, even if we have moral courage, we may still feel emotionally exhausted from dealing with ethical issues in practice. We are familiar with the resiliency of our patients as they cope with disease and injury. However, we, as nurses, also need to develop a type of resiliency when dealing with ethical issues and dilemmas. We need a type of moral resiliency. Moral resiliency has been defined as the ability and willingness to speak and take right and good action in the face of an adversity that is moral/ethical in nature (Lachman, 2016, p. 122). Our work environment needs not only a culture of safety but also an ethical culture—a culture of civility and respect.
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