American Nurses Association Ethics and Human Rights Advisory Board

Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L. Associates, a consulting and coaching firm, Avalon, NJ, and Sarasota, FL. She is Chair, American Nurses Association Ethics and Human Rights Advisory Board, and serves on a hospital ethics committee.

Moral Resilience: Managing and Preventing Moral Distress and

Moral Residue

P racticing nurses need confidence in confronting morally complex situations to reduce the poten- tial for moral injury, and thus prevent moral dis-

tress and burnout (Rushton, Batcheller, & Schroeder, 2015). To gain this self-confidence, nurses need to iden- tify appropriate levels of moral responsibility in situa- tions of moral ambiguity or complexity. Understanding the concept of moral resilience will be helpful in creat- ing prevention and intervention strategies. An illustra- tive case, table of definitions, and attributes of moral resilience are described, with discussion of how leaders can support resilience by building an ethical workplace.

A Case of Moral Injury and Moral Distress This case example exemplifies the profound impact

of futile intervention on the mind of a nurse who was able to write the narrative for a research project 30 years later (Ferrell, 2006). This case will be used in this article to illustrate the definitions (see Table 1) and examine how moral resilience strategies could have helped.

I was working on a medical-surgical floor with a pat ient with end-stage liver cancer. The oncolo- gist decided to do a bone marrow biopsy. There was no benefit to the patient; he just wanted to see what was happening with her. He was not going to change any treatment. My sense was he just wanted to satisfy his curiosity. I was a relatively new nurse and I questioned him some but then let it go. (p. 927)

In this case, the nurse’s action was insufficient to pre- vent an unnecessary, futile procedure. As a result, the nurse experienced lingering feelings over the personal loss of moral integrity (i.e., moral residue).

What Is Resilience? The Merriam-Webster Dictionary (2015a) defined

resilience as “the ability to become strong, healthy, or successful again after something bad happens; an ability to recover from or adjust easily to misfortune or

change” (para. 1-2). By the nature of their work, all nurs- es have had the opportunity to see human resilience in clinical specialties – oncology, neurology, cardiology – and trauma survivors, as well as post-combat experi- ences of traumatic brain injury and post-traumatic stress disorder. Nurses need resilience to thrive in these inti- mate and complex clinical situations. What are the characteristics of those who are resilient?

A concept analysis of resilience by Earvolino-Ramirez (2007) resulted in helpful descriptive parameters. Her research defined six attributes that repetitively appeared in the literature. The first characteristic was rebounding/ reintegration. “A quality of bouncing back and moving on in life after adversity is present in resilience” (p. 76). Reintegration describes an individual’s desire to return to a normal routine in an improved way. High expectancy/ self-determination was the second characteristic. This involves having a sense of purpose in life and an internal belief an individual will persevere no matter what life brings. The third characteristic was positive relationships/ social support. In nine studies with children and adults, the presence of at least one social support and meaning- ful relationship with one significant adult was consistent with resilient outcomes. Flexibility was the fourth charac- teristic and encapsulated the crux of adaptability – the ability “to roll with the punches,” be accepting, and have an easy temperament. The fifth characteristic was “hav- ing a sense of humor about life situations and about one’s self…” (p. 77). Being able to make light of the adversity and the intensity of personal emotional reac- tions helps individuals keep a realistic perspective. We have all laughed with patients as they navigated through awkward movements in their recovery. The sixth and final characteristic was self-esteem/self-efficacy. These terms often are recognized as the answer to “why some people snap and some people snap back” (p. 77). Earvolino-Ramirez concluded adversity was the single most recognized variable that discriminated resilience from other personality traits (e.g., hardiness) or social management processes (e.g., support groups).

What Is Moral Resilience? The Merriam-Webster Dictionary (2015b) defined

moral as “concerning or relating to what is right and wrong in human behavior; considered right and good by most people: agreeing with a standard of right behav-

Ethics, Law, and Policy Vicki D. Lachman

March-April 2016 • Vol. 25/No. 2122

ior” (para. 1). Though the term moral resilience was used in numerous publications, no definition was offered (Monteverde, 2014; Rushton et al., 2015; Rushton & Kurtz, 2015). This author defines moral resilience 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. Lessons learned from military combat situations are instructive in further understanding the application of moral resilience to nursing clinical situations (American Nurses Association [ANA], 2015a; Litz et al., 2009).

Why Is Moral Resilience Key in Dealing with Moral Complexity?

Litz and colleagues (2009) defined moral injury as an injury suffered as a result of “perpetrating, failing to pre- vent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” (p. 296). The harm done by moral injury comes from its ability to “shatter an individual’s beliefs about the purpose and meaning of life, challenge belief in God, induce moral conflict, and even precipitate an existential crisis” (p. 296). Service members, as well as nurses, may experience moral injury from two sources. First, they may witness or do something that violates their moral code. For example, the nurse failed to prevent the intervention in the futility case, creating a moral conflict that left her with moral residue. Second, individuals may become so

Ethics, Law, and Policy

entrenched in the culture in which they work that their moral code begins to incorporate elements of their host culture (Markus & Kitayama, 2003; Monteverde, 2014; Snow, 2009; Zimbardo, 2007). What becomes normal clinical practice can violate compassionate, evidence- based care of patients in some unit/organizational cul- tures. Extensive arguments have been offered by situa- tional philosophers and social psychologists that moral character will be traded for situational acceptance. Monteverde (2014) and Erdil and Korkmax (2009) called for new ethics education for nurses; both identified the influence of the so-called hidden or informal curricu- lum to which students are exposed during clinical prac- tice. Practicing nurses are exposed to the same organiza- tional culture that deals compassionately with difficult patients, confronts patient safety issues, supports patient advance directives, or does not.

Resilient people employ transformational coping strategies of understanding and contextualizing the cir- cumstances of the situation. They see the reality of the culture in which they work and sometimes must take action that does not support the cultural norm. They couple this with situation-focused problem solving to reframe the event in terms of a challenge over which they have some level of control. Resilience is cultivated when nurses are able to frame their experiences contex- tually in environments with different, even competing moral systems while maintaining a healthy sense of commitment, control, and challenge. Van Den Berg

TABLE 1. Terms and Definitions

Term Definition Source Moral complexity Emerges when events do not fit within learned rules. Monteverde, 2014, p. 393 Moral ambiguity The possibility of interpreting an expression in two or more distinct

ways; vagueness or uncertainty of meaning [lack of clarity as what is the right and good thing to do].

The Free Dictionary, 2003

Moral injury Perpetrating, failing to prevent, or bearing witness to acts that trans- gress deeply held moral beliefs and expectations.

Litz et al., 2009, p. 296

Moral distress The condition of knowing the morally right thing to do, but institu- tional, procedural, or social constraints make doing the right thing nearly impossible; threatens core values and moral integrity.

ANA, 2015b, p. 44

Moral residue Lingering feelings after a morally problematic situation has passed; in the face of moral distress, the individual has seriously compro- mised himself or herself, or allowed others to be compromised, resulting in loss of moral integrity.

Epstein & Hamric, 2009, p. 330

Moral courage Capacity 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 resilience The ability and willingness to speak and take right and good action in the face of an adversity that is moral/ethical in nature.

This article

Prestige resilience The set of reactive attitudes that allow a person to cope with the permanent public presence of cultural others, without harming or denying his or her identity.

Van Den Berg, 2004, p. 197

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Moral Resilience: Managing and Preventing Moral Distress and Moral Residue

(2004) defined prestige resilience as “the set of reactive attitudes, which allows a person to cope with the per- manent public presence of cultural others, without harming or denying her own identity” (p. 197). According to Litz and co-authors (2009),

…the idea is not to try and fix the past, but rather to draw a firm line around the past and its related associations, so that the mistakes of the past do not define the present and the future and so that a pre-occupation with the past does not prevent possible future good. (p. 704)

Do morally resilient nurses manage moral distress sit- uations in clinical practice differently, avoiding moral residue that erodes their moral integrity? As Epstein and Hamric (2009) noted in their research, the answer to this question is unknown. Mealer and colleagues (2012) commented, “…future research is needed to better understand coping mechanisms employed by highly resilient nurses and how they maintain a healthier psy- chological profile” (p. 292). This author believes research on the development of resilience could yield promising ways to combat moral distress and moral residue, as well as better understand the development of moral courage and moral resilience (Mealer et al, 2012; Monteverde, 2014; Moore, 2014; Rushton et al., 2015; Wagnild, 2014). Because resilience can be learned, an individual needs to understand what characteristics are most important to develop.

What Other Attributes Are Needed to Build Moral Resilience?

Using the work of Conner and Davidson (2003) from the development of their resilience scale (CD-RISC), Wagnild’s (2014) work on the True Resilience Scale Survey (TRS), and other references in this article, this author adds to the Earvolino-Ramirez (2007) concept analysis of resilience six attributes most relevant to moral resilience. Considerable overlap exists in characteristics, and the fol- lowing statements from the resilience scales address the importance of clarity of beliefs: • “I stay true to myself even when I’m afraid to do so.”

(TRS) • “My deeply held values guide my choices.” (TRS) • “I make decisions that are consistent with my

beliefs.” (TRS) • “I know what’s most important to me and this

knowledge guides my life.” (TRS) • “Make unpopular decisions.” (CD-RISC) • “Can handle unpleasant feelings.” (CD-RISC) In the case, the nurse did not stay true to the personal belief of patient advocacy and was left with the moral residue of guilt.

All authors on resilience address the importance of perseverance. Below are three quotations from the two scales and a book that reflect its importance for moral resilience. • “Even if I don’t feel like it, I do what I need to do.”

(TRS)

• “Best effort no matter what.” (CD-RISC) • “Perseverance means you don’t give up easily on any-

thing.” (Wagnild, 2014, p. 13) These behaviors, plus the six attributes mentioned by Earvolino-Ramirez (2007), are the traits that should be developed by nurses for moral resilience.

What Can Leaders Do to Increase Moral Resilience in the Workplace?

The resilience of leaders influences the resilience of the people they lead. Allison-Napolitano and Pesut (2015) created a model for resilient leaders and dis- cussed the subject in depth. What follows are three ways leaders can influence moral resilience in a constantly changing, morally complex health care system. 1. Engage in interprofessional dialogue in truly com-

plex cases in a seminar format. This allows members to explore their peers’ methods for engaging in the case. The focus of this effort is on enabling members to revisit past trauma to develop appreciation of the appropriate context in which trauma occurred by countering the tendency to universalize, and regain a sense of themselves as competent moral agents.

2. Leaders and staff formulate policies and priorities that reinforce the requirement to verbalize concerns in morally complex cases, without the possibility of retribution.

3. Leaders routinely consider the directives they give. Their talk and actions need to be synchronous with a culture that supports an ethical work environment. The advice and counsel they offer, the stories they tell, and perhaps most importantly the examples they provide may indeed alter the manner in which individuals interpret and make sense of their experi- ences in morally complex cases.

Summary Moral resilience is the ability to deal with an ethically

adverse situation without lasting effects of moral dis- tress and moral residue. This requires morally coura- geous action, activating needed supports and doing the right thing. Morally resilient people also have developed self-confidence by confronting such situations so they can maintain their self-esteem, no matter what life delivers. Finally, the ability to adapt to changing circum- stances with a sense of humor is at the heart of their flexibility. Morally resilient nurses are not naïve about the price of moral integrity. They know it does not come without pain of dealing with adversity, but they believe the virtue of moral courage is necessary to meet the eth- ical obligations of their profession (ANA, 2015b).

REFERENCES Allison-Napolitano, E., & Pesut, D.J. (2015). Bounce forward: The

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