‘Your son has osteosarcoma, or bone cancer,’ the doctor told the parents with their youngster looking on. ‘We will need to do surgery to attempt to remove it. We can’t tell right now how extensive it will be, but it could be significant.’ His words were spoken without emotion, as if he walked in the room to comment on the weather, rather than delivering the most devastating news this family had ever heard. As a nurse on the surgical team, I watched as the parents were consumed with shock, knowing that their disbelief would soon be replaced with worry, sadness and questions. The look on the child’s face spoke volumes. His life would never be the same. Before they could begin to register the news, the doctor turned on his heels and walked out the door into the hallway to continue his rounds.
In dismay, I looked at the parents, and when I saw the helplessness and hopelessness on their faces, I knew I could not stand by and do nothing. These parents deserved an explanation and answers. This young child needed to have his fears acknowledged. They deserved compassion, and I refused to be as cold and insensitive as the doctor who had just abandoned them in their time of need. ‘I know this is a lot to take in. I’ll be right back,’ I quickly told the patient and his parents. While I didn’t have the answers they were entitled to, I knew who did, and quickly darted out the door to find him.
There’s an accepted hierarchy within medicine. Physicians are authorised to make decisions, and nurses are expected to carry them out. Within these role expectations, there are norms for communicating and resolving differences of opinion. Embedded in them are core values that may be given different priority depending on one’s role. I was willing to step outside of the accepted boundaries to confront the doctor and insist he return to the patient’s bedside to continue the conversation he so abruptly ended. I knew that the situation would keep me up at night if I didn’t speak up on behalf of this youngster and his parents. My conscience would not allow me to stand by silently and do nothing. My Code of Ethics as a nurse mandated my advocacy.
When I approached the doctor, I asked him how he thought the parents took his news. He said they seemed fine. I responded by saying: ‘They are not “fine”, you just shattered their world and their son’s future. Did you see the look on their faces? You must go back and help them understand what your news will mean to them.’ Although he initially resisted, I accompanied him as he walked back into the room. As we entered the patient’s room, I made sure he discussed the diagnosis and prognosis, and answered their many questions. I stood in front of the door impeding his departure until all their questions were answered. It was vital to give the parents and their son the care, respect and compassion they deserved. We couldn’t change the diagnosis, but we could reduce the trauma associated with it.
What I later learned – the surgeon was not uncaring. He cared a great deal. Underneath his unskilful interaction, he was struggling with the reality that he couldn’t fix the boy’s cancer. Perhaps his frustration or feeling of ineffectiveness fuelled his response. He felt all he could offer in that moment was his surgical skills when what was needed was deep listening and compassionate communication.
Both doctors and nurses have a set of values and commitments that guide their actions. Their moral compass tells them what is right and wrong, and what they can and cannot accept in the delivery of healthcare. Sometimes our values are aligned and sometimes they are not. In others, the disagreements are among patients, their families and the clinical team or with administrative decisions made by leaders. Each reflects a type of moral adversity. When there are differences in values or in the application of them in a particular situation (such as the case above), moral confusion, conflicts or true dilemmas can ensue.
Our response to situations that involve moral adversity may result in moral compromise, ongoing angst, or moral residue from the unresolved moral or ethical conflicts. The moral residue from troubling cases that are left unsettled or encompass the aftermath of compromised integrity can accumulate and be carried in clinician’s bodies, hearts and minds – sometimes for decades. The moral adversity that produces moral residue can ultimately result in moral distress or more broadly in moral suffering. This is what occurs when we are in a situation we’re unable to sufficiently resolve that threatens our deeply held values and beliefs. We may know what we ought to do but for a variety of reasons are unable to act on what we believe is correct. As a result, we feel a lack of integrity and are subject to stress, anxiety, guilt and even regret. Over time, this can erode our self-confidence, identity and wellbeing. In the case above, I knew I would not be able to live with the image of myself if I walked away, leaving the patient and his parents with no one to turn to in their time of need. But doing so did not guarantee that it would be sufficient to relieve the moral angst I was experiencing or be free from consequences.
While physicians and surgeons are not exempt from moral suffering, nurses are especially vulnerable to it. Due to the nature of their profession, which involves direct care for long stretches of time, it is the nurse who develops a relationship as they provide comfort and care for the patient. Nurses are also, more than doctors, subject to the aftermath – they are at the bedside observing their patients’ pain, fears and reactions to the treatments being provided. Last but not least, nurses are attempting to honour the ethical commitment that they will do no harm, knowing they are, at times, carrying out requests or orders that can make a patient susceptible to harm. Doctors, anaesthesiologists, surgeons and other medical specialists do not have the privilege – or the responsibility – of observing and treating their patients in such close proximity. Bearing witness to a patient’s responses to their treatment and the direct consequences of nurses’ actions to accomplish treatment goals can spawn unanswered questions and persistent moral angst.
Situations like the one above introduced me to the field of bioethics. Lacking a sufficient vocabulary and tools for addressing the moral adversity that was part of everyday practice, I was drawn to learning more. I realised that moral adversity or situations that challenge our values, commitments and integrity were present in nearly every shift I worked. Often, they were not recognised as ethical issues per se, but upon closer examination the source of the angst involved deeply held values and commitments. I saw in myself the heavy weight of carrying unresolved ethical conflicts and dilemmas across my career. There were times when I was unable to release the incessant review of the cases from my clinical assignment as I tried to sleep. Or my disengagement from the humanity of a patient who had no awareness but was kept alive by machines without any hope for recovery. I noticed how the negative memory of certain difficult cases biased the interpretation of new ones. There were times of complete exhaustion, especially when the troubling situations persisted for weeks or months. In others, I noticed my self-censure and the cost of not speaking up when there was a necessity to do so. And in others, I bore the consequences of advocating on behalf of the people I was serving. This was the beginning of my journey into the vortex of moral suffering.
Since the early 1980s, awareness of the causes and consequences of the ethical issues that are inherent in healthcare has evolved. Initially the concept of moral distress, described first by Andrew Jameton, was primarily focused on the nursing profession. It ignited awareness of the sources and consequences of moral distress and the development of tools to measure it. Alongside the early work, I wrote an article on ‘caregiver suffering’. It chronicled some of the myriad cases that create moral suffering, especially for critical care nurses.
At the time, it was embraced with relief and acknowledgement by nurses who heretofore did not have the words or concepts to describe their experience. It was apparent to me that suffering in this way had a significant moral impact on nurses who provide direct care to chronically or critically ill patients. The situations that caused moral suffering were diverse and complex. For instance, you might go home at night knowing that your patient suffered undue pain from a treatment that won’t make a difference, and see yourself as an agent of suffering rather than healing. You might carry out treatment plans that aren’t aligned with your culture or beliefs, and be unable to justify them in your conscience. Or, you might work long hours and then be asked to cover an extra shift, while knowing that exhaustion and stress can cause you to make mistakes that could harm your patient. Moral suffering may involve the helplessness of knowing that there are treatments that can help patients, but you must inform the patient that those treatments aren’t accessible to them. Systemic injustices that advantage some patients over others, or that create barriers to access to basic healthcare or community resources, weigh heavily on nurses who are called to treat each patient with respect, dignity and fairness.
The nurse is the implementer and the person closest to both the dying patient and the distraught family
Over time, we began to realise that moral suffering was a particular type of suffering. Moral suffering is broadly understood as the anguish we experience when we witness, participate in, or cause unfortunate or troublesome negative moral outcomes that imperil our integrity. We began to see that moral suffering, whether described as moral distress or moral injury, is experienced in response to a threat or violation of our core values, commitments and intentions. It involves situations where we know what we ought to do but are unable to translate our moral commitments into action. As I observed the toll it took on myself and the nurses I worked with, I began to conceptualise and research ways to reduce moral suffering in the workplace.
There were no shortages of opportunities to perceive moral suffering. Imagine a family denying their loved one comfort care at the end of life because they are against any medical intervention that influences the timing and circumstances of death due to personal or spiritual reasons. And imagine that, in this instance, the family’s requests are contrary to what the patient would have wanted. When that happens, it is in direct conflict with a nurse’s role, which is to respect the dignity of the patient, prioritise their needs and preferences, and improve their comfort, health and safety. In more extreme forms, our conscience and core values are violated by betrayals of ourselves or others, such as leaders or organisations. Consider having to deny a family member’s anguished request to be present with their dying loved one because of a hospital or government policy prohibiting visitation. While the policy decision was not their own, the nurse is the implementer and the person with the closest proximity to both the dying patient and the distraught family, who is angry and aggressive toward the nurse because they want access to their loved one. Having to defend a policy that is contrary to your core professional values, and be professional in response to a patient or family who is treating you with disrespect, making impossible demands on you, or inflicting blame on you for their loved one’s condition or the policy, creates moral residue that accumulates and intensifies.
Now, with more than 30 years’ experience, I have witnessed the effects of moral suffering in healthcare. It is not unique to clinicians and can be witnessed in patients, their families and other staff. Also, as an ethics consultant and a professor, I have been dedicated to helping nurses and other medical professionals address their moral suffering through education, providing support during troubling cases, and developing resources. Engaging in hundreds of ethics consults and teaching nursing students about bioethics was necessary but not sufficient to address the enlarging prevalence of the most researched type of moral suffering – moral distress.
In 2014, after years of calling out the problem of moral suffering in healthcare, I began to wonder what else is possible. There were now decades of research documenting the problem but there were very few solutions. While a visiting scholar at the Brocher Foundation in Geneva, I finally had the space and resources to begin to conceptualise an alternative. Through my research, I learned about the concept of moral resilience. Based on the work of Viktor Frankl, it launched me into an extended exploration of what it might mean to be able to offer an alternative to the pervasive despair and helplessness that permeated healthcare. Ultimately, our research team defined moral resilience as preserving or restoring a sense of integrity in response to moral adversity. Our purpose is to empower nurses to assess a situation, ask questions, and take action to remove the potential moral residue (shame, guilt, regret, anger, sadness, self-doubt) that causes them stress and threatens their career satisfaction.
By now, working on a book, I began to wonder how to move beyond the despair and depletion that often accompany moral suffering. How could nurses resolve their internal distress when their duties conflicted with their values? Was it possible that they could settle their internal conflicts and reduce the lingering sorrow, frustration or guilt they often experienced? Could they transform the moral residue from unmet obligations and compromised integrity into meaningful acceptance? Even more, I wondered if moral suffering was unavoidable in healthcare.
In my quest for answers, it became apparent that some level of moral suffering in the nursing profession is not only expected, but it is necessary. This is because we all have personal and professional values, and a moral compass, that define what is permissible or not, and moral suffering is an important indicator of our moral conscientiousness or our desire to do the right thing, even in complex, uncertain or conflict-laden situations. Absent that awareness, we risk overlooking important value conflicts that call for specific action, and are in danger of becoming disengaged or complacent with circumstances that should be questioned. Therefore, some degree of unrest or distress is necessary for nurses to recognise, understand and examine what is at stake and to then find the pathways to be able to live with the decisions we make. Nonetheless, even when we have made a conscientious decision, there will likely be a persistent moral residue of unmet commitments or degraded values or integrity.
Ultimately, our research team engaged clinicians in helping us to understand the components of moral resilience in the context of healthcare. Our research team identified six pillars of moral resilience:
- personal integrity;
- relational integrity;
- buoyancy;
- self-regulation and awareness;
- moral efficacy; and
- self-stewardship.
The grounding for moral resilience is personal and relational integrity. As humans, we strive for wholeness in all parts of our lives and work. We begin by adopting and then embodying certain universal values as our moral compass. These might include values such as respect for human dignity, compassion or justice in its many forms. We all have different values and beliefs, many of which have been embedded in us by our families, our places of worship or our worldviews. We have an internal sense of what is right and wrong, what we are willing to accept, and what we cannot tolerate. Persons of integrity engage in a lifelong process of values-clarification to refine their understanding of their values and how they apply in life, especially when there is moral adversity. As part of our character-formation, these values become visible in our words, choices and behaviours. As we become clearer on our values, a commitment to upholding personal values and beliefs, despite challenges or uncertainty, emerges.
From this vantage point, we engage in negotiating our values, commitments and worldviews within our relationships with others. In healthcare, there is a dynamic interplay between a clinician’s personal integrity and their professional values and commitments. Individual clinicians bring their moral compass into their relationships with others. They also have professional values and commitments to which they are held accountable. Relational integrity acknowledges the interdependent connections we have with others. First do no harm, for instance, is a nearly universal professional value among many health professions. Often, our values are aligned with others we work with or the people we serve. But there may also be times when there is conflict or disagreement. This calls us to commit to include diverse perspectives and to respect other’s values and beliefs even when we do not share them. The goal of this process is to leave everyone whole and undiminished rather than compromised in ways that violate their moral compass.
When nurses’ nervous systems are dysregulated, they can’t respond in integrity-preserving ways
Buoyancy is the ability to mitigate feelings of being overwhelmed by moral conflict and return to a state of clarity and stability. It allows clinicians to meet the inevitable ethical challenges they face without being disabled by them. It affords them the resources to gain perspective through moral adversity, and possibly grow and learn. Buoyancy is amplified through cultivating skills and practices that support self-regulation and awareness. These enlarge a person’s capacity to notice escalated somatic, mental and emotional states, and then to shift towards insight, stability and wisdom. Over time, new neural pathways are developed and strengthened in ways that create greater accessibility when it is necessary to maintain or regain balance in response to moral adversity. When nurses’ and others’ nervous systems are dysregulated and reactive, they are unable to clearly see the contours of troubling ethical situations or to respond in integrity-preserving ways. Absent mindfulness practices aimed at stabilising their nervous system, clinicians are vulnerable to the consequences of accumulated or sustained stress or distress.
Moral efficacy – having sufficiently developed moral agency to recognise and respond to ethical challenges and moral adversity with integrity – is a vital pillar of moral resilience. Seeing ourselves as capable of recognising the moral and ethical aspects of clinical encounters supports the cultivation of skills in moral/ethical discernment and analysis. These cognitive and relational skills are what we typically associate with ethical competence. Moral efficacy goes beyond merely possessing skills necessary for analysis to include being able to discern the ethically justified course of action and having properly bounded courage to act with integrity. Enacting ethical decisions engages an expanded repertoire of skills necessary for effective advocacy, diplomacy and strategic action.
Self-stewardship is a key feature of moral resilience, and it reflects having integrity with one’s basic humanity. Instead of reinforcing an expectation of unbounded self-sacrifice, self-stewardship acknowledges that, as humans, we all deserve our investment in our own wellbeing and integrity. Nurses and other clinicians are people first and clinicians second. Self-stewardship is embodied by a commitment to know oneself, and responsibly and mindfully manage one’s personal resources to remain whole and serve without harm to self or others. Importantly, it invites an awareness of personal needs and a compassionate response to one’s limitations. Rather than reinforce the expectation that asking for and receiving support or resources reflects failure or weakness, self-stewardship invites people to choose actions that are wholesome and life affirming. It intentionally shifts the focus from viewing investment in one’s wellbeing or integrity as selfish or self-serving, to being an integrity-preserving act.
Each pillar of moral resilience creates awareness in one’s moral compass, values and beliefs, and shows how to implement them in the decision-making process and how to realign ourselves with them in the aftermath.
Here’s an example. A nurse in a surgical intensive care unit questions the goals of care for a patient who received a liver transplant and had spent months in intensive care. Specifically, experiencing multisystem failure – the patient’s kidneys were failing, the liver was barely functioning, he was tethered to breathing machines and technology to keep him alive – he was miserable. The nurse had tended the patient’s body, attempted to answer his questions about what was possible for him, and supported him during periods of profound stress, fear and sorrow. One evening, during a relatively stable period, the patient had shared with the nurse that he did not want to continue in this state. As he struggled to speak, his message was clear. Even though he knew the course would be difficult, the reality of his life was now obvious to him, and he did not want to continue with the onerous treatments. The culture on the transplant team, however, was focused on patient survival for at least one year, to maintain their status and accreditation. Doubts expressed or questions raised either by patients or others were often minimised or discounted in service of their ultimate goal of demonstrating their patients’ sustained survival. The transplant team often viewed these periods of diminished quality of life as an expected part of the journey, not a reason to abandon it.
Moral resilience begins with the understanding that we can do hard things
The nurse took seriously her commitment to respect the dignity of her patient. Her moral compass as a person and a nurse prioritised respect for everyone. She knew that, while others on the team may value respect for the autonomy of the patient, they may have other values that take precedence. Understanding these differences in perspective expands the foundation for collaboration and, potentially, compromise. Attempting to uphold the integrity of the relationship with her patient and the clinical team, she bravely raised the concern and shared with the team the conversation she’d had with the patient. The initial response was resistance, but she persisted in her resolve to do the right thing by garnering the support of her colleagues, the patient’s family and the ethics consultants, to create a more open space for dialogue. She engaged her inherent buoyancy and self-regulatory capacities so that she was not swept away by the objections of others but rather to stay true to her moral compass. Throughout the process, she accessed internal and external self-stewardship resources to avoid being overwhelmed with the enormity of the situation and the potential harms that could ensue for herself and her patient. She was conscious of her limitations and was aware of signals that she was becoming exhausted or empathically distressed. She engaged her tools for ethical analysis to link her concerns to her professional ethical values and personal moral compass. Through this process, she gained confidence in her ability to advocate for the interests of her patient based on ethical discernment rather than opinion or bias. Concurrently, she connected to her integrity to fuel her moral courage to do the right thing for the patient. Finally, through discussions and negotiations, it was agreed that the goals of care needed to be shifted from all-out medical intervention to a more palliative approach.
The concept of moral resilience presumes that humans are already resilient, that they strive toward integrity, and that there are ways to repair our moral fabric when it is torn or fractured. It begins with the understanding that we can do hard things. We’ve made difficult decisions in the past and likely will be called to do so in the future. Knowing that, we can walk toward moral adversity with compassion, understanding and self-respect. Later, we can engage in the process of moral repair, rather than despair and depletion. These inherent capacities are enabled by a practice environment that supports integrity and ethical practices.
But not all ethical challenges are resolved in an integrity-preserving way. Situations of moral adversity include end-of-life treatment, staffing shortages, inadequate conflict resolution, difficult team dynamics and safety concerns, among others, that affect nurses’ job fulfilment, integrity and emotional wellbeing. In my career, it has been apparent that moral suffering often stems from situations where the stakes are high and there are no good answers. This was certainly the case during the COVID-19 pandemic. Nurses were charged with carrying out decisions made by others who determined who would benefit the most from the only available ventilator. Which person might be saved, and which one would have to wait? Every ethical challenge required sometimes undesirable tradeoffs that created an enduring moral residue of unmet values or commitments, often under conditions of uncertainty and time pressures. But it was the nurse who bore witness to the consequences of those decisions, because it was the nurse who had 24/7 proximity to patients and their families and their intimacy with suffering and death.
Imagine yourself as a critical care nurse during the pandemic. During this time, you were called upon to provide reassurance to critically ill patients and, at the same time, you knew that, sadly, your efforts to improve the health of those same patients were sometimes futile. There was a large gap between the hope that the patients so wanted to hear and the reality that, too often, there was little possibility you would be able to achieve the outcome they desired. Nurses were torn, knowing that they were required to initiate treatment that wasn’t beneficial, while also being aware that there was a lack of equipment to provide treatment that could significantly improve their patients’ health. Their patient numbers increased daily, as did the number of patients who died. With the increased patient load, nurses had to work longer hours and extra shifts under extremely stressful conditions. While emotionally and physically drained, they were called upon to be the final source of compassion for patients who were restricted from seeing their loved ones. Often, it was the nurse who was by their side as the patient took their last breath, which added a level of moral angst that violated the very core of being a nurse.
The pandemic took an incredible toll on nurses across the world. They were fighting an unknown disease, doing the best they could under extenuating circumstances, while knowing their best was not enough. To top it off, they were often without the personal protective equipment that would provide a measure of safety to their own health and that of their families. In addition to the extreme physical and emotional demands placed upon them, they were expected to know and abide by constantly changing policies, restrictions and mandates that exacerbated the nursing shortage. Some nurses lost their jobs, while others chose to walk away from the career they once loved. Underneath these realities were persistent tensions between the moral values they committed to when they joined the nursing profession – to treat every person with respect, compassion and fairness and to put the interests of their patients first. The dissonance and distress associated with the daily moral and ethical choices necessary created degrees of moral suffering that were unrelenting and made it challenging for nurses to cope mentally or physically.
Just how much moral suffering should nurses be expected to endure?
The aftermath of such distressing situations conflicted with their moral compass – their sense of right and wrong – as it relates to their professional duties. In turn, they feel guilt, remorse, shame and even anger that makes it difficult for them to cope and accept their limitations, decisions or outcomes. This tends to weigh heavily on them, especially if these conflicts are not satisfactorily resolved. Before the COVID-19 pandemic, these situations were more episodic but then became unrelenting as the pandemic wore on: the gap between what you knew you should be doing and what you were doing that violates your values, identity and wellbeing, and accumulates over time. The consequences cannot be ignored. There is no denying the escalating numbers of burned-out nurses and doctors, the frightening increase in mental health symptoms and, sadly, death by suicide. The moral adversity was palpable. I, too, struggled to make sense of the inevitable tradeoffs that were required and the feelings of powerlessness to change the course of the reality we were all in. I observed the toll of those decisions on the people who were expected to implement them. It was heartbreaking to see my formerly caring, engaged colleagues reduced to shells of themselves, exhausted, angry and frightened for themselves and their families. We were all suffering in our own ways – sometimes alone and often collectively.
The pandemic called into question just how much moral suffering nurses should be expected to endure, and what might be needed to support them to restore their integrity and moral agency amid these challenges. Due to the nature of our profession, were nurses relegated to accept these conflicts and the moral suffering that ensued? Should moral suffering be thought of as ‘part of the job’? I knew it might not be possible to eliminate all moral suffering and conflict but, as an ethicist, my mission was to discover ways to address or minimise the effects. But, first, we needed to document the relationship of different types of moral suffering and moral resilience.
Armed with a scale based on our conceptual work to measure moral resilience, we embarked on research to explore these questions. One study measured moral injury and moral resilience among healthcare professionals, and the other measured moral distress, moral resilience and mental health outcomes among clinicians, in both cases during COVID-19. In both studies, higher levels of moral resilience were associated with lower levels of moral injury or moral distress. In the second study, it also was associated with better mental health outcomes. We began to see that, although moral suffering could not be eliminated, the detrimental effects of it could be mitigated by cultivating the pillars of moral resilience. The findings suggest that nurses and other clinicians can draw upon the pillars of moral resilience to diminish the negative impact of moral distress and moral injury. By developing moral resilience, they are better able to minimise anxiety, guilt, shame, frustration and the full gamut of emotions experienced in their noble, but demanding, careers. It gives them a firm foundation to preserve, or when needed to restore, their wholeness amid moral adversity.
Secondarily, we were also interested in the interplay of moral resilience, moral injury and organisational effectiveness. In a subsample of nurses from the moral injury study, we found that higher levels of moral resilience were associated with higher perceptions of organisational effectiveness. In our analysis, we learned that both moral resilience and organisational effectiveness were significant in reducing moral injury symptoms. Unsurprisingly, higher levels of moral resilience accounted for a greater improvement in moral injury scores. Our current hypothesis is that we need investments in helping clinicians develop the capacities associated with the pillars of moral resilience as well as investments by organisations in creating healthy workplaces that support the integrity of clinicians.
Moral resilience doesn’t neglect our personal values or integrity; it brings them to the forefront
Moral resilience addresses an unmet need in healthcare, providing nurses and clinicians with a roadmap that reveals how they can invest in their own integrity and wellbeing, regardless of what is happening around them. It offers a vital resource to help neutralise the despair and futility many nurses experience. Moral resilience is not offered to minimise the importance of one’s core values and integrity. On the contrary, its purpose is to help nurses carry out their duties while honouring their values. Nor does it suggest complacency, tolerating unethical situations, or blaming people for systemic problems. In contrast, moral resilience is aimed at creating the conditions to restore one’s moral agency, confidence and skill in being true to who we are and what we stand for in life and work. Building the pillars of moral resilience is a roadmap to support these bright, compassionate professionals become more resilient to the lingering effects. Sometimes, there are no perfect solutions or choices for the situation at hand, but there can be a way to make the best decision possible given the time, information and resources available. Only then can nurses and medical professionals go home at the end of the day, assured that they did the best they could under imperfect circumstances.
Building the muscle of moral resilience doesn’t change what caused the moral adversity or suffering being experienced; it does, however, help healthcare workers come to terms with events and replace their regret or distress with self-compassion and the peace of mind from knowing they did the best they could under trying circumstances. Moral resilience doesn’t neglect our personal values or integrity; it brings them to the forefront, where they can be a resource that guides healthcare workers and nurses toward the best decision under the circumstances. This is a decision they can live with that minimises the internal conflicts, moral residue, anxiety and stress that threaten our careers and our ability to carry out our responsibilities without regret and suffering. Like Frankl’s work, humans have the capacity to meet these challenges in ways that make the realities they find themselves in workable, albeit unacceptable.
Focusing on moral resilience is not a diversion from the systemic contributions to the situations that have caused them. Instead, it is a means to restore moral agency for people within the system to advocate for systemic changes, be involved in the design of healthier workplaces, or decide that they need to reallocate their gifts and talents elsewhere. Healthcare leaders and organisations must meet these efforts with trustworthy investments in dismantling organisational policies and patterns that erode integrity; they must recalibrate priorities and budgets to authentically reflect their core values. For example, policies such as visitation during the pandemic were a source of great moral suffering for nurses. Learning what the impact of implementing them was on the patients and the clinicians provides an opportunity to reconsider the policies’ effectiveness and revise them. Likewise, recalibrating from seeing the nursing workforce as a disproportionate cost, and instead viewing it as an invaluable resource for patient and organisational outcomes, has the potential to drive investment in recruiting and retaining more nurses in the workforce. Without sufficient human resources to meet the needs of patients and their families, nurses and other clinicians are left with an unrelenting exposure to moral adversity that will, over time, compromise the fundamental aims of their work and the economic drivers of healthcare.
We all have different values and beliefs, many of which come to us via our families, our places of worship or our worldviews. We have an internal sense of what is right and wrong, what we are willing to accept, and what we cannot tolerate. When we go against our values and beliefs, we feel a lack of integrity with them, which causes internal conflict that makes it difficult to accept and make peace with the choices we make and their outcomes. Everyone in all walks of life has this moral compass, and they use it in making decisions daily. With the stakes high in health-related matters, our moral compass becomes even more important to guiding us toward decisions that will result in less regret, guilt or uncertainty. It provides us with the reassurance that, while none of the choices before us might be preferred, we can be at peace in knowing we made the best choice given the circumstances at the time. This is all that can be asked of any of us, nurses, clinicians, caregivers and family members alike. Life can knock us down, but when we develop and fortify moral resilience, we can turn toward our strengths if we are feeling helpless, unsure or powerless. Then we can confidently move forward with compassion and grace from knowing we operated with integrity.
More recently, we have observed a need to expand the concept of moral resilience beyond nurses and clinicians. As a nurse, I have witnessed the effects of moral suffering on families and caregivers who are entrusted to make life-changing or end-of-life decisions for their loved ones. Fraught with shock and sorrow, they wrestle with the need to accept a situation that is incomprehensible and are asked to make a decision that is unthinkable at best. They struggle with family dynamics, cultural and religious beliefs and their internal wishes, which might differ from those of their loved one or other family members. As I’ve counselled these families throughout the years in hundreds of ethics consults, it became apparent that they, too, are experiencing intense moral suffering and are in frantic search for answers or guidance that will let them know they are doing the right thing.
Moral resilience can help individuals resolve their feelings of inadequacy, frustration, uncertainty and regret
I am now adapting the concept of moral resilience used by medical professionals to focus on the broader public. It will serve as a resource and tool for families and caregivers, providing them with a pathway to making the best decision they can under imperfect circumstances. This means a decision that will minimise the moral residue they have to live with and replace it with compassion, acceptance and forgiveness. On the other end of the stethoscope are patients or families who are struggling with deciding how to accept the reality of the limits of healthcare to sustain life in ways that are meaningful; how to make these hard decisions on behalf of their loved ones. Others struggle with how to confront the progression of dementia or how to make decisions at the beginning of life where there are no apparent acceptable options. This book discusses the main considerations that go into making healthcare decisions, addressing the patient’s wishes, the relationship between the patient and their decision maker(s), spiritual and cultural considerations, desired outcomes, their core values and beliefs, and their conscience – what can they accept, and what would be impossible for them to live with. It invites them to cultivate the skills and qualities that foster moral resilience.
The more I am exposed to moral adversity and suffering, the more aware I have become of the need to bring attention to moral resilience and help individuals resolve their feelings of inadequacy, frustration, uncertainty and regret.
Nurses and healthcare professionals aren’t alone in the need to strengthen moral resilience, both on the job and in life – we can all benefit. Few are immune to the cultural and societal conflicts that arise in our day-to-day life. Unfortunately, our differences in views and values have become justification for disrespectful or harmful interactions and behaviours. The moral crisis of climate, poverty, human rights and so on are daily reminders of the threat to our core values and our beliefs about humanity and what we owe each other. Moral resilience is a concept that can offer us hope amid this confusion and chaos. It acknowledges our inherent goodness, empowers us to reclaim our wholeness and wellbeing, and offers a path out of the despair and paralysis we experience when confronted with moral adversity. In the end, it is a pathway toward acceptance, compassion and forgiveness, helping us all find a place where we can respect and honour our own values and beliefs, while respecting others with diverse views. Accepting things as they are does not suggest being complicit or agreeing with it. Rather, it reflects a stable awareness to clearly perceive the reality as it is instead of what we wish it to be. It is in this space of possibility that new insights and wisdom reside and integrity-preserving action is enabled.
We all make decisions we don’t want to have to make, and we are not immune to the doubt, guilt, frustrations – you name it – stemming from the decisions we were forced to make. By turning our focus toward our strengths and using them to build moral resilience, we can know that, while we had to do one of the hardest things we were ever called upon to do, we don’t have to live with disabling regret for the decision we ultimately made. Our task is to engage our moral compass and to listen to the promptings of integrity to help us find our way through the complex and uncertain ‘thickets of choice’. Our diligence in the struggle is evidence of our integrity – even when our hand is forced. We did the best we could do at that time, and that is all anyone can ask of us, and it is all we should ask of ourselves. Integrity is not perfection. It is turning toward the hard parts of life by embracing our limitations and our strengths to be whole amid confusion, uncertainty and conflict. Doing so gives us the fuel to stay the course and release the unrealistic expectations we have of ourselves or the situations in which we find ourselves.
