Transforming Moral Suffering by Cultivating Moral Resilience and Ethical Practice

As a nurse in the pediatric intensive care unit (PICU), I felt strained by evolutions in technology that began overwhelming treatment for critically ill children. Early in my career, we used new methods of mechanical ventilation to restore breathing and health but also to sustain bodily functions when young brains had been devastated by lack of oxygen or injury. In the early 1980s, I cared for a young child who survived an anoxic brain injury and was left in a persistent vegetative state and whose biological life was sustained by a ventilator and feeding tube.¹  They lived in our PICU for more than a year, despite their parents’ requests that life-sustaining treatment be withdrawn. Every day we tended their body, wondering “why are we doing this?” It felt wrong, undignified, and unjust; at that time there was no name for what we were experiencing. The prevailing message was grin and bear it. Ethics committees and staff support systems were nonexistent. The expectation was to take care of business ourselves and not let visible evidence of our distress accompany us to the bedside.

The residue from that case and others persisted. It became the grist for finding a way to create meaning from what seemed to be a meaningless attempt to sustain a life devoid of awareness, even when the parents had the courage to declare it was not a life they would choose for their child. I became a pediatric clinical nurse specialist to advocate for parents and children confronted with unresolvable ethical trade-offs, which catapulted me into the emerging field of bioethics. As I pursued doctoral work to expand my skills in bioethics and research, I returned to the residue from that early PICU case and wrote a 1992 article on caregiver suffering as my first foray into the largely uncharted territory of moral suffering.²  I finally had words and concepts, informed by the early writings of Andrew Jameton in one of the first nursing ethics textbooks.³  He created a typology of ethical concerns that included moral distress to point to the frustration, anger, and powerlessness that nurses experienced as they attempted to sustain their integrity within health care institutions’ constraints and pressures.³  Moral distress was slowly emerging within health care but had already taken hold, especially within nursing.^4-9  At times, the term has been contested with various definitions of moral distress, emphasizing a range of perspectives. Concerns were leveraged that the term had become an umbrella term^10-13 ; others called for refinement,^11,14  substantial reconceptualization,^15,16  or abandonment of the term.¹¹  Despite these objections, moral distress became the most prominent form of moral suffering reflected in the literature.

Tools were developed to measure moral distress by focusing on common sources, especially in the acute care setting.^17-19  Data consistently demonstrated that various sources and intensities of moral distress exist, and nurses consistently reported higher levels of moral distress than physicians.^9,20,21  Interest in physician burnout emerged in the early 1980s, and that narrative became dominant in medicine, while moral distress took hold within nursing.²²  Over time, the moral distress scales were refined for different contexts.¹⁹  My colleagues and I contributed to the field by synthesizing literature, proposing evidence-informed strategies, and engaging in qualitative research to refine our understanding.^8,23-26  We partnered with interprofessional groups to address conditions that contribute to moral distress^23,27,28  and led a National Nursing Ethics Summit in 2014 to create a strategic agenda for addressing ethical practice in nursing.^29,30 

Around 2018, the concept of moral injury— originally described in the military³¹ —emerged in health care literature. Although related to moral distress, moral injury involves distinctive features that include a profound threat or violation of one’s moral foundation and conscience, which occurs in response to severe personal, collective, organizational, or leadership transgressions or betrayals.³²  It can lead to erosion of one’s moral identity and ignite feelings of guilt, shame, or unworthiness.³³  Concurrently, we began exploring moral injury while writing our book; moral injury became more widely acknowledged during the COVID-19 pandemic.^34-38 

After decades of focusing on the problem of moral suffering, I kept coming back to the nagging question: what else is possible?¹  We began exploring this question with moral philosopher Dr Alisa Carse. What emerged was an awareness that along with the detrimental aspects of moral distress, there was an alternative orientation that embraced the role moral distress plays in alerting clinicians to violations of their values and integrity. Moral distress was not a symptom of clinician deficiency or failure but rather a signal of their moral conscientiousness.¹⁴  “Moral distress signals fidelity to and investment in moral commitments one believes are threatened or compromised.”^14,38(p26)  It is reflected in a “troubled call of conscience.”^38(p26) 

Responding to this call requires clinicians to sustain connection to their core values and commitments within a work environment that fosters their basic goodness and resilience. This orientation does not imply ignoring the real suffering clinicians experience but rather that embedded in the suffering is evidence of unacknowledged integrity and strength that can be amplified at both the individual and system levels of intervention.³⁹  During our initial literature review,⁴⁰  we noted that Kim Lutzen called for the cultivation of moral resilience in response to the morally challenging situations nurses confront and as a means for addressing their moral distress.⁴¹  Moral resilience was described as (1) “a distinctive sense that life is meaningful under every condition”^41(p320)  and (2) “the ability to manage moral stressors confronted in clinical practice and to name and frame ethical issues while building moral courage.”^42(p392)  This launched an exploration to further understand and clarify the concept.⁴⁰ 

Our formative conceptual work evolved and culminated in our book in 2018.³⁸  A critique on work that others have written on this topic is beyond the scope of this article.

Generic resilience is an important foundation that can be specified to address threats or violations of an individual’s well-being and integrity in response to adversity.⁴³  The moral domain is interconnected with all dimensions of human beings’ biological, psychological, cognitive, spiritual, and relational resources. Hence, the psychological and moral aspects of resilience are involved in a synergistic web of processes that can also be leveraged to support moral resilience. We proposed a definition of moral resilience that specified the moral domain within general resilience.⁴⁰  Moral resilience focuses on “(1) the moral aspects of human experience, (2) the moral complexity of decisions, obligations and relationships, and (3) the inevitable moral challenges that ignite conscience, confusion, and moral distress.”^40(p112)  Moral resilience is fundamentally grounded in personal, professional, or collective integrity. Our initial definition of moral resilience was, “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.”^40(p112) 

Consistent with generic resilience concepts, we view moral resilience as a capacity that humans possess to be whole or to restore their wholeness or integrity when it has been tarnished. It encompasses an inherent resilient potential that can be amplified or degraded but not extinguished. Essentially, moral resilience involves knowing who you are and what you stand for, choosing how you will respond to ethical uncertainty, challenges, or dilemmas in integrity-preserving ways by minimizing your own suffering, thereby allowing yourself to serve in alignment with your highest purpose.⁴⁰  Moral suffering inevitably changes us and must be integrated into our current experience, meaning making, identity, and worldview. It goes beyond a temporary bouncing back to an ongoing process to transform the experience and, as Viktor Frankl embodied, find meaning amid adversity.⁴¹  Transforming the experience involves a complex interplay of factors, resources, and capacities that can be individualized and amplified to create the conditions for new learning, growth, and social progress.

We conducted a concept analysis to solidify our conceptualization of moral resilience using the methods of Rodgers and Knafl to identify antecedents, attributes, and consequences.⁴⁴  Scant literature was available on the concept; we concluded that further conceptual work was needed to refine the definition and ascertain how moral resilience mitigates consequences of moral distress or moral adversity.⁴⁴  Next, we gathered definitions from interprofessional clinicians and conducted a thematic analysis to identify elements of moral resilience.⁴⁵  The 6 pillars of moral resilience were defined through a qualitative study of health care workers’ definitions. These included personal integrity, relational integrity, buoyancy, self-regulation, self-stewardship, and moral efficacy.⁴⁵  We then refined the definition of moral resilience after undertaking further conceptual analysis and gathering iterative feedback from interprofessional clinicians.^46-49  Our current working definition is “the capacity of an individual to preserve or restore integrity in response to moral adversity.”^38(p68)  Central to this definition is a robust understanding of integrity that encompasses personal, professional, and relational integrity. In our definition, moral resilience is not defined by external circumstances but rather invites individuals to return to the fundamental state of wholeness as the basis for identifying their responses, choices, and actions. Moral resilience thrives in a practice environment where the modifiable factors that cause moral adversity and moral suffering are systematically addressed. Figure 1 reflects our typology of moral resilience and ethical practice.

In the book Moral Resilience: Transforming Moral Suffering in Healthcare, we proposed a continuum of responses to imperiled integrity that reflects differences in intensity, sources, and consequences.^38(pp52-76)  The continuum begins with moral adversity and includes moral stress,⁵⁰  moral distress, moral injury, and moral decline (Figure 2). Although these conceptual distinctions are important in conducting research, they do little to relieve the distress many clinicians experience in their day-to-day lives. A recent study highlighted the work physicians are now doing to locate themselves along this continuum.³⁸ 

Next, we developed a scale to measure moral resilience—the Rushton Moral Resilience Scale (RMRS)—among interprofessional health care workers (N = 702).⁵¹  Psychometric analysis yielded overall α = 0.84, convergent validity with the 10-item Connor-Davidson Resilience Scale, and criterion validity with the Maslach Burnout Inventory—Human Services Survey. The RMRS contains 17 items spread over 4 factors: responses to moral adversity, personal integrity, moral efficacy, and relational integrity.⁵¹  Since its creation, it has been translated into several languages, including Dutch and Portuguese, and others are in process. The RMRS is available for free at https://nursing.jhu.edu/rmrs. To date, more than 200 people have downloaded the scale, and it has been used in several studies; findings are summarized in Table 1.

Throughout my career, I was aware of the dynamic interplay of clinicians’ integrity and the work environment.⁵⁸  As a member of the American Association of Critical-Care Nurses (AACN) Ethics Committee, I was acutely aware of the need to build a robust infrastructure for ethical practice. Simultaneously, I was examining how organizational ethics aligned with efforts to address individual moral suffering. Therefore, I considered the broader context of organizational ethics and implications for integrity. As such, my colleagues and I engaged in multipronged efforts to create an ethical practice environment that allows caregivers to practice with integrity.⁵⁹ 

We used a model developed within the United Nations for large-scale change⁶⁰  and first applied it to the development of the University of Virginia Compassionate Care Initiative⁶¹  and later to the context of resilience and moral suffering in health care.³⁸  This culminated in a 3-part initiative, Toward a Culture of Ethical Practice in Healthcare, that originated before the COVID-19 pandemic. Participants were recruited in teams from various health systems across the United States. The 3-part series with intersession practice offered a promising application to address the ethical issues that undermine integrity, teamwork, and organizational effectiveness. The full-spectrum approach is described elsewhere.^38,60  The interplay of these interpersonal and organizational factors has been widely reflected in our research, as shown in Table 1. Furthermore, we partnered with AACN on a policy focusing on addressing moral distress,⁶²  collaborating with the American Nurses Association and the American Journal of Nursing to advance the dialogue around these promising concepts and create momentum for change.^48,49,63 

We postulated several possible strategies to build the requisite capacities and skills needed to confront the inevitable ethical challenges embedded in clinical practice.^40,46,49,64 

We began implementing a promising intervention for nurses aimed at building mindfulness, resilience, and ethical practice. It incorporated many of the elements described in Table 2. In 2016, we launched the first cohort of the Mindful Ethical Practice and Resilience Academy.⁶⁵  The academy became the “learning laboratory” for examining ways to engage nurses in building the requisite components of moral resilience. We used a pre/post design measuring impact via a generic resilience scale because the RMRS was not yet developed. Results have shown substantial improvements in ethical confidence and competence, mindfulness, resilience, and work engagement and decreases in depression, anger, and intent to leave.⁶⁵  Most results were sustained at 3 and 6 months after the intervention.⁶⁶  Others have focused on nurse education and support to build moral resilience.⁶⁷  Many of these skills and tools are reflected in our statewide R3: Renewal, Resilience and Retention of Maryland Nurses Initiative. (Visit https://nursing.jhu.edu/faculty_research/research/centers/R3 for details.)

Moral resilience is continuing to evolve in its application and relevance. Our initial conceptual instincts have been empirically validated. Our recent studies focusing on moral injury, moral distress, and moral resilience during the COVID-19 pandemic validated our hypothesis that moral resilience is a protective resource. Furthermore, when combined with organizational effectiveness, moral resilience has the greatest potential to reduce moral injury symptoms⁵³  and the intensity of moral distress.⁵⁶  Measurement of moral resilience continues to be refined and applied in different populations such as nurse leaders, physicians, and other workers outside health care.

We are refining the RMRS (version 2) to improve reliability and validity of the overall scale and the personal integrity subscale (unpublished data, April 2023). Evidence was added to the construct validity via confirmatory factor analysis on the sample of health care workers. Overall, the scale was shortened to 16 items to improve usability of the scale for other contexts. Additionally, the team is conducting a cross-sectional survey of nursing leaders regarding their experiences in preparing for public health emergencies (eg, COVID-19) and prevalence of moral injury symptoms and moral resilience. Insights will provide context for harnessing the resilient potential of leaders and designing organizational strategies to support integrity and ethical practice.

Interventions that combine moral resilience and system-level interventions appear to have the greatest potential to proactively address sources of moral adversity. Further scientific inquiry on moral resilience should prioritize exploring relational integrity as an element of moral resilience and expanding the concept to encompass collective moral resilience.⁶⁸  Additionally, various concepts that are related to, but distinct from, moral resilience should be explored further to better align conceptual understandings. Further refinement will be reflected in the forthcoming second edition of our book.

In our conceptualization of moral resilience, we applied existing research to inform our definition.³⁸  We initially adopted the analogy that resilience can be like a rubber band that bounces back to its original shape. Some authors have argued that the construct is limited by selectively highlighting partial elements, placing the focus on bouncing back.^37,69,70  These interpretations have overemphasized traditional notions of resilience at the expense of understanding that integrity (personal, professional, and relational) is the core feature of moral resilience. As our inquiry deepened, we recalibrated our understanding based on the elements that emerged from clinicians’ definitions of moral resilience, which included buoyancy as 1 among 6 pillars of moral resilience. Buoyancy goes beyond bouncing back, incorporating the ability to stay in the flow of adversity without being overwhelmed by it. It signifies a capacity to meet ethical challenges with flexibility without abandoning integrity.

This led us to use the metaphor of kintsugi, the Japanese practice that uses golden paint and cement to put pieces of broken pottery together in a new and perhaps stronger, more beautiful vessel.⁷¹  This metaphor acknowledges that our moral adversity and suffering inevitably changes us. Beyond simply recovering to where we were, moral adversity can transform us to preserve or restore our integrity. In this context integrity is not perfection, nor is it turning away from our brokenness. Rather, integrity allows us to harness our inner strength and resilient capacities to propel us forward amid adversity and learn from it. It does not mean that we are free of wounds but that we are capable of posttraumatic growth and moral repair. The process is congruent with how complex adaptive systems function. They may break down, but they also have the potential to reorganize themselves and learn from the experience to create new or better systems.

Despite the trend toward embracing moral resilience as a concept to address moral adversity, resistance persists, based on the inaccurate use of the term by some,^69,70  the erroneous suggestion that moral resilience implies a state of oblivion or avoidance of enacting immoral acts,⁶⁹  complacency, tolerating or putting a “positive spin” on unethical or unhealthy situations, or that the concept places disproportionate burden on individuals to address the moral adversity and thereby “blames the victim.”^69,72-74  Pivoting toward a more life-affirming possibility does not overlook or minimize the adversity that is present. Focusing on preserving or restoring individuals’ integrity does not deny the influence of the systems in which clinicians practice or imply that the goal is to fortify people to tolerate unacceptable conditions. Well-intentioned efforts to separate individual agency from the cultures in which clinicians practice creates a false dichotomy with either/or framing that limits focus onto either the individual or the system. Individuals are members of systems by choice or circumstance and are embedded in systems that support or degrade their integrity. Although there is no question that keeping the pressure on the system to change is vital, it is not the only way to make progress. In fact, doing so can inadvertently leave those in the system abandoned, waiting for large-scale changes to be implemented. We advocate for an inclusive both/and approach that leverages interventions at both the individual and system levels. Whether one engages in integrity-preserving actions or what Morley et al⁷⁵  have termed critical resilience to address systemic issues of austerity, change requires that the people who engage in these efforts have the requisite skills, capabilities, and structures that enable effective action and “wise hope”⁷⁶  rather than despair. We argue that the foundation for both types of resilience begins with a robust notion of integrity and must include investments to create a culture of ethical practice. Aligning the polarities of the individual and the system is needed to avoid overemphasis on either component or to avoid strengthening unintended consequences.

Clinicians may view moral distress as an inevitable reality in health care today that they are powerless to change or a condition that should be extinguished altogether because suffering serves no purpose. This position animates despair and a victim narrative that is devoid of moral agency or power to change one’s responses or the circumstances. It breeds cynicism that nothing can change or there is nothing a single person can do and further incapacitates and disempowers people in the system. Such attitudes and beliefs have been exacerbated during the COVID-19 pandemic and have intensified cynicism and despair. These characterizations overlook the power of individuals to choose in accordance with their values and denies their inherent capacities for integrity and resilience that are not defined by external circumstances but can be influenced or degraded by them. Moral resilience is fundamentally about restoring agency and empowering individuals to choose integrity-preserving responses rather than be victims to the realities they find themselves in. Repeating a disempowering narrative only solidifies the despair rather than transforming it and intensifies suffering rather than relieving it.

Terms like resilience and moral resilience have the potential to be used in ways that are incongruent with their meaning. How they are interpreted depends on intention and tone of their communication—either as a demand that conveys a sense of deficiency or as an invitation to harness the basic goodness and inherent resilient potential everyone possesses. Just as in some institutions, the moral distress narrative can be misapplied in some contexts and used as an imprimatur of threat to others’ authority or decision-making, so, too, can terms like moral resilience be corrupted.⁷⁷  These insidious patterns can cause leaders to view addressing moral adversity and moral suffering solely as an individual responsibility that requires more education or training to withstand the workplace pressures, ignoring the broader systemic factors that contribute to moral suffering and erode well-being. In both cases, it is vital to understand the power of creating and repeating a narrative that animates fear and resentment rather than engagement. When we continually activate the threat system in our nervous system, we undermine our flexibility, creativity, and collaboration. By aligning individual and system interventions, we amplify the impact by taking a social ecological approach.⁷⁸  Changes in one area impact the whole; designing interventions that account for these interrelationships has the greatest potential for lasting and meaningful change.

Moral resilience is an evolving concept that offers a promising direction for preserving or restoring integrity of clinicians. Moral resilience is a strengths-based model that acknowledges the inherent resilient capacities of all people and, in the moral context, their capacity for preserving or restoring integrity. It is one element of a complex and multifaceted approach to dismantling the conditions within health care and the professions that create moral adversity and moral suffering. Moral resilience is likely insufficient alone to heal the depth of psychological wounds that result in severe burnout, posttraumatic stress disorder, or moral injury. It may be a complementary resource when an accurate diagnosis of the nature and degree of moral suffering is made. Although further research is needed, moral resilience is likely to be most beneficial for people who retain some capacity to engage in practices aimed at restoring moral agency, fostering self-stewardship, moral efficacy, and self-regulation.⁶⁵  More specific tools are needed to distinguish among psychological symptoms that do not resolve on their own, self-harming behavior that becomes intensified or chronic, or persistent demoralization or self-limiting attitudes that undermine a person’s positive experiences or breed futility.⁷⁹  These more extreme states will require targeted, often multipronged interventions.⁷⁹  Moral resilience has the greatest potential for benefit when it is combined with organizational strategies aimed at dismantling the modifiable factors that degrade integrity and create moral adversity.⁵⁵ 

Sometimes integrity requires us to stand alone when others object or resist. At times the journey has proceeded beyond the velocity of others’ readiness to join in it. Whether you call it moral comfort,⁸⁰  moral resilience, moral strength,⁸¹  or posttraumatic growth⁸² —all of these concepts point to the possibility that there is more to our reality than our suffering.⁸³  Moral resilience offers a vision of hope and the alternative to despair and futility as an invitation to embrace the power each person has in the system to bring about a different reality. Together, individuals and health care organizations can align their efforts to create the conditions in which integrity is fostered and, when integrity is threatened, systems and resources exist to restore it.

I would like to acknowledge Warren Reich, STD, Alisa Carse, PhD, Roshi Joan Halifax, PhD, Anthony Back, MD, Monica Sharma, MD, Katherine Heinze, PhD, Heidi Holtz, PhD, and my research team—Ginger Hanson, PhD, Danielle Boyce, DPA, Katie Nelson, PhD, and Deb Swavely, DNP—for their passion and support in this work. I am forever grateful for the space to do this work that was created by Anne and George Bunting’s generosity to establish an endowed chair in their names and the support and collaboration of the Johns Hopkins University Berman Institute of Bioethics, School of Nursing, and Johns Hopkins Hospital. I am deeply indebted to the patients and families I have been privileged to serve, my incredible network of nursing colleagues, and the hundreds of nurses I have worked with—all of whom have trusted me to share in their journeys with them.