Ethical challenges are commonplace in critical care settings. Questions about the boundaries of ethically permissible treatment, assessment of decision-making capacity, determining who ought to decide on the ultimate treatment plan, or potentially medically inappropriate treatment are part of everyday practice. Contradictory views can result in lack of consensus or unsatisfactory decisions between patients and family members, within interprofessional teams, or among patients, patients’ families, and critical care teams. Often at stake are each person’s central ethical values, obligations, and commitments. When confronted with these challenges, many clinicians experience moral distress in response to threats or violations of their integrity.1–5 Moral distress ensues when clinicians recognize ethical conflicts and their responsibility to respond to them but are unable to translate their moral choices into ethically grounded action that preserves integrity.5 Although controversies persist regarding the definition and contours of moral distress, the literature is replete with data that documents the pervasive experience of moral distress by critical care clinicians and the profound human costs that accompany it.6–14 Spiraling rates of burnout, turnover, and shortages of critical care clinicians and diminished employee engagement threaten the quality and safety of patient care and the overall stability of the health care system.15–22 Moral distress is not likely to be extinguished, and given the complexities of the health care system, will continue to escalate in the future.
Why is it that some people are able to navigate ethical dilemmas and moral distress without the deep sense of despair and hopelessness that others experience? What individual qualities and capacities do they possess? What is it that supports them to find meaning in situations that appear senseless? How do they transform their experiences into growth-producing transformations?
These are some of the questions to which answers are needed in order to more fully understand how clinicians, particularly critical care clinicians, address moral distress. So far, strategies to address moral distress focused on building skills in ethical decision making, conflict resolution, interdisciplinary collaboration, system reforms, mediation, and ethics consultation have been only partial solutions.23–26 Much of what has been tried has been done on a small scale and has not sufficiently shifted the incidence or consequences of moral distress.27–30 Moreover, while clinicians resonate with data that verifies the existence of moral distress and its negative consequences, the accompanying narrative of disempowerment, despair, and hopelessness may have inadvertently contributed to a culture that undermines lasting and meaningful results.
It is time for a new paradigm for thinking about moral distress that focuses on cultivating moral resilience rather than on the despair and helplessness many clinicians experience.
Resilience as a Way Forward
Resilience is a concept that has been applied in various disciplines and has been used to manage adverse events such as natural disasters, war, and climate change and in business, systems, and other domains.31 Generally, resilience refers to the ability to recover or healthfully adapt to challenges, stress, adversity, or trauma: to be buoyant in adverse circumstances. One definition of psychological resilience “involves the creation of meaning in life, even life that is sometimes painful or absurd, and having the courage to live fully despite its inherent pain and futility.”32 From a community or systems perspective, resilience has been defined as “the ability of an entity— eg, asset, organization, community, region— to anticipate, resist, absorb, respond to, adapt to, and recover from a disturbance.”33(pvii) More broadly, it has been applied to people, systems, and communities as the capacity to “maintain its core purpose and integrity in the face of dramatically changed circumstances”31(p7) Generally it is viewed as a process rather than a trait. Among nurses, resilience can be cultivated through self-efficacy, hope, and coping.34,35
What Is Moral Resilience?
Moral resilience is a concept under construction. There are undoubtedly similarities between psychological resilience and moral resilience. Moral resilience is distinct in its focus on (1) the moral aspects of human experience, (2) the moral complexity of the decisions, obligations and relationships, and (3) the inevitable moral challenges that ignite conscience, confusion, and moral distress. Generic resilience is an important foundation that can be further specified to address specific threats or violations of an individual’s well-being and integrity. The moral domain is interconnected with all dimensions of human beings’ biological, psychological, cognitive, spiritual, and relational resources. Hence, the psychological aspects of resilience are involved in a synergistic web of processes that can also be leveraged to support moral resilience.
Moral resilience has been described as (1) “a distinctive sense that life is meaningful under every condition”36 and (2) the ability to manage moral stressors confronted in clinical practice and to name and frame ethical issues while building moral courage.37 An alternative definition is offered here. Moral resilience is defined as the capacity of an individual to sustain or restore their integrity in response to moral complexity, confusion, distress, or setbacks. Dimensions supportive of moral resilience are reflected in Table 1 and further elaborated in the following sections. In essence, moral resilience involves choosing how one will respond to ethical challenges, dilemmas, and uncertainty in ways that preserve integrity, minimize one’s own suffering, and allow one to serve with highest purpose.
The Contours of Moral Resilience
In considering the definition and application of moral resilience in critical care, several distinctions are useful in deepening our understanding of the concept.
Knowing Who You Are and What You Stand for in Life
The foundation of moral resilience is clarity and commitment to discovering one’s deepest intentions, commitments, and values and discerning what one truly stands for in life. For many critical care clinicians, one of their primary commitments is the relief of suffering. For others, values such as fairness or justice for all predominate. The answers to these fundamental questions evolve over a lifetime and provide a useful anchor when ethically complex and morally distressing situations arise. Knowing oneself in this way requires self-awareness, the ability to be honest with oneself, a commitment to ongoing discernment and reflection, and a willingness to take a stand that is in alignment with one’s integrity. This foundation is necessary for principled moral agency.
Moral resilience is grounded in fundamental moral conscientiousness. It reflects a vigilance to live in ways40 that are aligned with who we are and what we stand for in the midst of situations that appear to be incommensurate with integrity. This stance of desiring to be moral requires a fundamental awareness of our values and commitments and what is at stake in ethically complex situations. It invites critical care clinicians to continually examine their values and viewpoints and to avoid complacency and dampened moral sensitivity that can lead to overlooking or disregarding situations that require principled moral action. Likewise, being resolute about one’s values and moral commitments does not imply being dogmatic and rigid.
Importantly, being morally conscientious also includes the ability to humbly acknowledge the limits of one’s capacity to see things clearly without projection or bias or to bring about the desired outcome. It is a continual process of discernment, examination, and possible revision of one’s position or viewpoint. Moral conscientiousness allows clinicians to navigate inevitable challenges and threats to integrity without abandoning one’s core values and commitments or compromising personal well-being and to be able to rebound in a way that is growth producing and strengthens resolve and capacity to preserve integrity. Similarly, such an orientation fuels confidence and hope in the face of situations that, in the short term, are frustrating and full of impediment and invites the possibility for future change or alternative outcomes.
Cultivating Self-regulatory Capacities
A common misconception is that resilient people are routinely optimistic despite the circumstances and do not experience strong negative emotions. The difference is more likely in their self-regulatory abilities to be able to be with negative emotions in such a way that they are not overwhelmed by them and are able to rebalance their mind and emotions when they experience situations that throw them off balance or provoke strong emotions.5 It may be that morally resilient people experience threats to their integrity more deeply because their moral sensitivity is sufficiently developed. They perceive threats, challenges, or violations of integrity fully rather than repressing them. Instead of denying the distress, “catastrophizing” (predicting a negative outcome and prematurely concluding that the negative outcome would be a catastrophe such as getting fired),41 or engaging in mental or emotional distancing, morally resilient persons are able to fully experience their distress and release its grip on them more easily.
Developing mental and emotional flexibility in these situations does not extinguish the moral conflict or dilemma or the potential consequences of action or inaction but could reduce the intensity of the response to it within a properly bounded zone of moral resilience.
Current neuroscience research suggests that with training in mindfulness techniques, people are able to release strong sensations and emotions more easily. Studies have shown training in mindfulness to result in decreased persistence of emotion aroused by provocative images.42 Evidence also indicates that long-term meditators release from the neural processing of visual stimuli more quickly after mindfulness training,43 conceivably allowing mindful persons to focus more readily on new tasks. Mindfulness practices offer a promising method of supporting the neuropathways to support moral resilience.38
Being Responsive and Flexible in Complex Ethical Situations
Moral resilience is not a static state; rather it is a dynamic, fluid state. As with other forms of resilience, it involves a process of activation and release of the grip of the moral complexity or confusion and the accompanying emotions. It is often in the ebb and flow of the situation and one’s response to it that moral resilience thrives. Acting with integrity may mean recognizing an ethically complex situation or finding an ethically justified compromise. Building on moral conscientiousness, moral resilience includes the ability to make important ethical distinctions, remain open-minded and curious, and resist the conclusion that there is only one way to consider one’s moral obligations in a particular situation or to preserve integrity. Sometimes, for example, moral distress is related to a patient’s or family’s inability or unwillingness to accept the clinician’s appraisal of the situation or their recommendations. Instead of accepting that the patient or family holds a legitimate and conceivably ethically permissible and justifiable point of view, clinicians may respond by escalating efforts to convince the patient or family of their errors in reasoning and decision making. For example, a competent patient with end-stage heart failure with no options for destination therapy or heart transplant is maintained on inotropic support but chooses to continue to live in this condition despite her diminished quality of life. Critical care clinicians involved in the situation may lament—“This therapy is futile!” “Why are we prolonging an inevitable death?”
Although these sentiments have merit, what may be missing is an alternative way to see how integrity can be promoted or restored. Using strategies, such as cognitive reframing to expand possibilities, it is possible to shift the focus from the treatment itself to the patient’s autonomous choice to continue it despite the burdens and thereby open the range of ethically permissible actions. Although some clinicians may view the patient’s quality of life as unacceptable, fully informed patients may legitimately choose differently. Clinicians who are able to view their support of the patient and his or her preferences as meaningful for the patient and within their professional obligations may experience less moral distress intensity or be able to rebound without collateral damage to their own well-being. Such a shift does not deny the clinician’s personal views but expands the possibilities for compromises that preserve integrity.
Being Resolute and Courageous in One’s Moral Action Despite Resistance or Obstacles
Arguably, integrity-preserving compromises are untenable or impossible in some situations. Moral resilience does not imply moral complacency. In other words, a strong and flexible spine supports one to do the right thing even under the most challenging circumstances. This ability, coupled with the stamina to persevere despite one’s inability to act upon one’s moral sensitivity and reasoned judgment, is a hallmark of moral resilience.36 This orientation is the fuel for embodied moral agency—the ability to live one’s values and moral commitments in each moment and engage properly bounded moral courage to address individual and structural impediments to moral action and integrity. When people are morally resilient, they do not crumble under adversity or fear. Likewise, they enact their moral outrage in ways that are constructive, effective, and integrity preserving.44 Consistent with the American Nurses Association’s Code of Ethics, nurses must exercise properly bounded courage and wisdom to discern whether conscientious compromise is possible. It is generally prudent to exercise conscientious voice to identify and examine the ethical concern with patients, patients’ families, and interprofessional colleagues. When ethically grounded actions do not create an occasion for preserving integrity, conscientious objection or refusal to participate may be justified.45 In severe cases, responsible whistleblowing or conscientious exit from the organization may be appropriate if the concerns are not adequately addressed or persist despite concerted efforts to address them.5
Exerting Sufficient Effort and Being Realistic About One’s Limitations
Critical care clinicians may experience moral angst related to a lack of acknowledgment of the factors, outside of their control, that constrain their moral agency. Coupled with this may be a reticence to accept things as they are. Moral resilience includes the ability to shift the relationship with moral distress so that part of the burden is lifted and there is an opportunity to reconcile one’s integrity even when the desired or preferred outcome is not achieved. Thus a morally resilient person would be able to restore or preserve internal stability by using self-regulatory practices and perspective taking to shift thoughts and emotions without denying or suppressing thoughts, perceptions, emotions, or legitimate ethical norms or principles. Rather, moral resilience is an invitation to (1) accept things as they are (including some situations recalcitrant to persuasion or mediation), (2) acknowledge the boundaries of power and influence, and (3) recognize that the evidence of effective moral agency is reflected both in one’s conscientious efforts and in the outcomes produced. Moral resilience also requires the ability to recognize when one has exerted sufficient effort to recognize and address ethical concerns and advocate for effective resolution and to recognize when outcomes are ultimately outside of one’s control. From this stance, it is possible to discern the way forward as a conscious choice of one’s response rather than a decision that has been inflicted upon or mandated by others. This approach includes the exercise of conscientious compromise, voice, objection,45 or exit.5,46 In exercising these options, clinicians regain a sense of control over their situation and over restoring or strengthening their moral agency.
The ability to create meaning out of situations that appear to be senseless is vital to cultivating moral resilience. A theme of senseless suffering often pervades narratives of moral distress.40 The lament of clinicians often takes the form of “Why are we doing this?” Accompanying these protests is an overwhelming sense of futility that one’s efforts are not achieving important goals or the outcomes desired. These protests can either become a disempowering narrative or the fuel for principled and embodied action. One example is when critical care clinicians, especially nurses, perceive that they are administering painful treatments that cause disproportionate suffering or someone other than the patient—a family member, parent, or guardian—is making decisions that are contrary to the patient’s wishes or interests that are perceived to be prolonging unjustified pain or suffering.
For integrity to be preserved in these situations, clinicians need a robust moral sensitivity and the ability to consider alternatives that may not be obvious or may be rejected without careful discernment. In doing so, it is possible to find meaning in situations that cause cognitive dissonance. The source of this dissonance can be a contradiction between what a clinician believes to be true and new information or interpretation of the situation or when clinicians simultaneously hold several conflicting beliefs or values. For example, nurses may perceive that patients ought to be self-determining about care at the end of life. When patients have expressed their preferences but lose decision-making capacity and their families request continuation of burdensome therapies, nurses may experience distress in response to their primary obligation to the patient, their commitment to relieve suffering, and their compassion for the plight of the family.
Creating meaning in such situations does not suggest ignoring the ethical conflict but rather embarking on a process of discovery to understand the moral stakes in a more nuanced, complex way. Is it possible, within the American Nurses Association’s Code of Ethics, to alternatively consider that fulfilling a nurse’s primary obligation to the patient may also include supporting the integrity of the relationships that have been central to the patient’s life? Or that shifting the focus to helping the patient’s family to accept the inevitable death also can have integrity for the nurse, the patient, and the patient’s family members?
The ethical permissibility of, and at times the requirement for, moral acquiescence in such circumstances does not necessarily amount to moral failure. Rather, it may reflect the inevitable regret, sadness, or ambivalence about one’s inability to simultaneously meet other legitimate ethical obligations. Seeking meaning in the most devastating of circumstances is fundamental for human survival and growth.36 Seeking a way of being in relationship with the difficulties beyond what is currently obvious invites critical care clinicians to pause to consider: What is this situation teaching me about myself? About life? About others? Similarly, seeking meaning is also an invitation to connect to our basic goodness and to locate aspects of our life and work that engage our gratitude.
Although moral resilience proposes a positive orientation, one must also take seriously Monteverde’s cautions about the perils of moral resilience.47 These perils include (1) ignoring the systems issues that undermine moral resilience, (2) being unable to distinguish unethical situations from situations of moral complexity that produce apathy and acquiescence instead of principled action, and (3) being rigid in examining one’s personal values and judgments, which leads to a form of moral blindness to other ethically justified responses and risks opportunities for compromise or negotiation.47 Such cautions must be taken seriously to avoid diluting the concept of moral resilience to moral relativism or “anything goes.”
How Do We Cultivate Moral Resilience? Preliminary Thoughts
Currently no established evidence base for specific strategies for cultivating moral resilience exists. Borrowing from literature on resilience in various contexts, a number of promising possibilities can be applied to moral resilience. Some of the elements of resilience (which include self-efficacy, self-control, ability to engage support and help, learning from difficulties, and persistence despite blocks to progress)48 may also apply to cultivating moral resilience. Clearly, interventions at multiple levels—heart, mind, and spirit—will be needed to diversify resources to navigate moral distress. Based on the proposed definition of moral resilience, Table 2 reflects preliminary suggestions to cultivate individual moral resilience. These suggestions will have to be aligned with systems-focused interventions to create a culture of ethical practice that supports individual moral resilience. Each of the elements is discussed in the following sections.
Morally resilient clinicians are likely to be self-effacing and deeply familiar with their strengths, limitations, and moral core. They are willing to explore their thoughts, feelings, and positions, knowing that they may be biased, distorted, or incorrect. This ability to be self-honest and transparent expands the possibilities for responding to morally distressing situations with clarity, confidence, and diminished personal cost.
Develop Self-regulation Capacities
Cultivating the internal capacities to make and uphold moral commitments despite external disapproval or threat is a key element of moral resilience.6 This element supports clinicians to embody an inner integration that conveys calmness, groundedness, and stability in the midst of challenging circumstances. It also supports their ability to recognize when they have become unbalanced, dysregulated, narrow minded, or reactive, which can shift focus away from core values and commitments or obscure ethically grounded action. Being self-regulated does not imply complacency or disengagement. Rather, it is a foundation for clarity, principled choice, and wise action.38,39 Mindfulness practices can support these self-regulatory capacities.38,39,42,43
Develop Ethical Competence
To be morally resilient, one must possess ethical competence. Ethical competence involves (1) ethical embodiment, that is, living the values that are espoused and displaying cohesion between inner character and outward behaviors; (2) moral sensitivity—the ability to perceive the morally salient aspects of circumstances and situations, discern various ways of responding to them and the ability to empathize with the experiences of others; (3) critical reflection based on analysis of ethical values, norms, character, principles, and theories; and (4) robust moral agency to align and enact the ethical behaviors that are congruent with one’s values and support integrity.49,50 Ethical competence also includes cultivating a rich moral vocabulary, moral imagination, attitudes, coherent character, and an openness to understanding the values, motivations, hopes, and fears of others.
Speak Up With Clarity and Confidence
Acting with integrity involves identifying situations that challenge, threaten, or violate integrity.5 To speak up effectively, it is vital to be able to shift from being “mute” or voiceless to finding the words to express the nature of imperiled integrity and ultimately to create meaning in the situation.51 The ability to articulate the nature of the moral problem, examine the ethical justification, explore one’s ethical obligations, and determine the ethically desirable action to take is necessary. Moral resilience supports having a voice that can be heard and understood, is ethically clear and coherent, and enables action.
Morally resilient critical care clinicians are able to speak up with confidence and clarity about overt and insidious threats to their integrity. Giving voice to concerns and bringing issues to the attention of others includes moving beyond the protests of “why are we doing this” to understanding the complete dynamic of the situation. Critical care clinicians can lead by example in discussing their concerns in interprofessional rounds by using clear, compelling, and ethically robust vocabulary. Likewise, they are able to distinguish suffering of patients and their families from their own. These clinicians leverage relationships, support systems, external structures, and evidence to guide solutions, and they know when they need to excuse themselves on grounds of conscience or seek alternative employment.
Find Meaning in the Midst of Despair
One of the vital dimensions of resilience is deriving meaning even when the source of one’s moral distress or moral outrage cannot be changed or removed. Despair implies suffering without meaning.36 Confronted with seemingly senseless situations, there is an opportunity to create meaning out of them. When clinicians are resilient, they are able to stabilize their minds and emotions and recalibrate to a “new normal” that now includes the inevitable residual that accompanies such crises. This process may entail deliberately releasing the residual unmet expectations and regrets through ritual, journaling, or personal or group reflections or debriefings. If clinicians are able to regain a sense of control over themselves, they are able to find insight, value, and meaning in the face of unavoidable suffering.36 From this vantage point, they are able to grow instead of experiencing what Epstein and Hamric52 have called the “crescendo effect”—an accumulation of unprocessed moral distress devoid of meaning and insight that undermines one’s ability to restore integrity and support moral resilience. This residue can be the impetus to potentially reshape the architecture of our minds and hearts to support fundamental coherence, integrity, and meaning. A potent antidote to the powerlessness and despair associated with moral distress is to create meaning by connecting to gratitude for the things that give meaning to working in the critical care setting.
Engage With Others
A key element of moral resilience is the ability to cultivate interconnections with others.34–36 Seeing oneself as part of a larger moral community provides a safety net of support in response to morally distressing or ethically complex situations in the critical care setting.19 The presence of strong social connections enhances physical and emotional well-being. Knowing you are not alone in your struggle to address ethical complexities decreases the sense of despair and isolation that often accompanies moral distress. Intentionally seeking engagement and support of others is a potent contributor to moral resilience. Such engagement may include 1-on-1 conversations with colleagues, facilitated interprofessional discussions, team activities, and connections with family, friends, and external support persons.
Participate in Transformational Learning
Learning from moral crises is a key element in cultivating moral resilience. Resilient clinicians learn from their experiences and are able to shift their responses in subsequent events. Each time a moral crisis is confronted, there is an opportunity to humbly confront our strengths and limitations; reexamine assumptions, positions, and justifications; reconnect with meaning and purpose; and realign with our moral core. Using methods such as routine case reviews, root cause analysis of morally distressing cases, and ongoing quality improvement can support changes in behavior and practice.46
Contribute to a Culture of Ethical Practice
The American Nurses Association’s Code of Ethics specifically states that nurses are responsible for establishing, maintaining, and improving the work environment to support ethical practice.53 It is insufficient to expect that morally resilient individuals will thrive without a supportive culture surrounding them to enable them to be their best in the midst of moral confusion, uncertainty, or dilemmas. Creating a culture of ethical practice will require a multipronged approach that leverages the contributions of morally resilient clinicians and leaders in health care organizations to design structures that enable ethical practice within the complexity of human relationships, systems, and society. Examples, such as the Center for Ethics in the Department of Veterans Affairs, offer useful tools for beginning this process.54,55 Zolli and Healy31(p15) suggest that alignment of “beliefs, values and habits of mind; trust and cooperation; cognitive diversity; strong communities, translational leadership and adaptive governance” are essential elements to bolster resilience. These elements are promising starting points to consider in developing a culture of ethical practice.
Moral resilience is a concept that is gaining prominence and is deserving of our consideration as a way to transform the profound despair and powerlessness associated with morally distressing situations. These preliminary ideas are offered to stimulate further dialogue and refinement. These beginning observations and recommendations can help to stimulate greater conceptual clarity and form the basis of a research agenda to develop an evidence base for interventions aimed at cultivating moral resilience.
I thank Alisa Carse, PhD, Joan Halifax, PhD, Al Kaszniak, PhD, Tony Back, MD, and Monica Sharma, MD, for their contributions to the refinement of the concept of moral resilience and Lukshmi Solos and Peter Young for their assistance in the preparation of this article.
The author declares no conflicts of interest.