The global COVID-19 pandemic tested nurses to their core with unprecedented moral and ethical challenges not seen for a century. While the purpose of this column is not to rehash the collective trauma and moral suffering experienced by our profession, it is important to remember those difficult times to recognize the incredible courage and resilience we demonstrated. Nursing is fundamentally a moral profession defined by our obligations to advocate for the health, safety, rights, and dignity of those under our care—be that individuals, families, or communities (American Nurses Association, 2015). Nurses are called to uphold those moral obligations—not just during extreme times but in daily practice, often in small, quiet ways.

The Relationships Between Moral Distress, Moral Resilience, and Moral Injury

Nursing professional development (NPD) practitioners role model ethical practice and weave professional expectations and norms based on our Code of Ethics into all levels of initial and ongoing education. Due to our internalized moral obligations, nurses are likely to experience moral distress (MD) when we perceive our moral obligations are jeopardized (Morley et al., 2021a; Rushton, 2024). Historically, MD has been seen as a problem to solve with numerous studies reporting and lamenting the high prevalence of MD among nurses and its correlations with psychological distress and negative outcomes for patients and organizations (Salari et al., 2022). However, despite decades of study, little is known about interventions to relieve MD (Morley et al., 2021b; Rushton, 2024). Emerging evidence is suggesting MD may play a more nuanced role in the interplay between positive moral constructs including moral courage and moral resilience (MR) and the negative multidimensional experience of moral injury (MI) that includes physical, psychological, relational, and spiritual responses (Berdida, 2023; Gibson & Alfred, 2020; Rushton et al., 2023a). In fact, MD may be less a problem to be solved than a signal to heed alerting us that the morally distressing situations we experience warrant attention, ethical discernment, and organizational transformation (Rushton, 2024; Rushton & Nelson, 2023; Salari et al., 2022; Spilg et al., 2022).

MD occurs when the nurse knows the right thing to do but is constrained from taking their preferred course of action (Jameton, 1984). However, it also occurs when the correct moral action is less certain – but nonetheless morally distressing (Morley et al., 2021a). For example, nurses report MD when they participate in aggressive life-prolonging treatments for patients experiencing a heavy symptom burden whose likelihood of benefiting from those treatments is limited but who wish to push on despite their suffering. Nurses regularly experience moral suffering related to both structural constraints and exposure to the suffering of others. Not all of those morally distressing experiences have a single “right” course of action.

How we respond to that suffering has consequences for individual nurses, patients under their care, and the nursing profession (Amos & Epstein, 2022; Rushton & Nelson, 2023; Salari et al., 2022). MR is emerging as a complementary phenomenon that when cultivated intentionally, can empower nurses to transform their moral suffering into moral action – moral action that when collectively engaged, can transform institutions (Rushton,2024). MR is the capacity of an individual to sustain or restore integrity in response to moral adversity (Rushton, 2024; Heinze et al., 2021). MR sustains us and enables us to persevere during the darkest of times. By our nature, all nurses have some degree of MR, and evidence suggests MR may be a bulwark against the most damaging outcome of unresolved MD—moral injury (Berdida, 2023; Rushton et al., 2022). For a comprehensive review of MR, readers are invited to read Moral resilience: Transforming moral suffering in healthcare. 2^nd ed. (Rushton, 2024).

MI is the adverse long-lasting physical, psychological, relational, and spiritual  response to actions taken that violate ones deeply held personal or professional moral values or beliefs (Hossain & Clatty, 2021). Nurses may develop MI acutely after a sudden and severe breach of our moral obligations to patients, or we may develop MI after prolonged exposure to unrelieved and unrelenting MD (Griffin et al., 2023).

Studying Our Nurses

To explore these concepts, in the summer of 2023, we conducted a multisite, cross-sectional survey study to examine the relationships between MI, MR, and the work environment among ICU nurses working at 22 Providence sites in Alaska, Montana, Washington, Oregon, California, and Texas. That study, led by Dr. Sumner with the support of 15 RN site investigators (NPD practitioners, ICU clinical nurses, nurse scientists) recruited 304 participants who completed a demographic questionnaire, the Moral Injury Symptom Scale – Healthcare Professional, the Revised Rushton Moral Resilience Scale, and the Healthy Work Environment Assessment Tool 1.0 (Connor et al., 2018; Mantri et al., 2020; Rushton et al., 2023a).

Below is a brief summary of the key findings which were presented during a podium presentation titled Moral Injury, Moral Resilience and the Work Environment: Associations and Implications for Nurses  at the 2024 American Association of Critical Care Nurses (AACN) National Teaching Institute in Denver, CO (Sumner & Shemwell, 2024). Additional information will be forthcoming in a future publication.

• MI and MR had a strong inverse correlation (r=-.58, p≤.001)
• MI and the work environment had a moderate inverse correlation (r=-.40, p≤.001)
• MR and the work environment had a weak positive correlation (r=.26, p≤.001)
• MI symptom scores were highest (worse symptoms), and MR scores were lowest (less MR) among the youngest (Generation Z, and Millennial nurses) and nurses with five years or less of experience
• 1/3 of participants reported they had never had ethics education
• 75% of the participants agreed or somewhat agreed that difficult ethical situations left them feeling powerless
• Nurses who interacted with hospital chaplains daily had the lowest MI scores

What NPD Practitioners Can Do

MD may emerge from a range of experiences—from caring for patients receiving potentially non-beneficial care, to missed nursing care due to inadequate staffing, to causing patient harm from medication errors. How nurses respond to MD – and their risk for MI depends on the interplay between their appraisal of the situation, their personal coping resources, their skills to navigate the situation, and the support systems available to them at their institutions (Berdida, 2023; Griffin et al., 2023; Hossain & Clatty, 2021; Rushton et al., 2022; Spilg et al., 2022). Bolstering those factors may enhance nurses’ MR.

NPD practitioners can prepare nurses for the moral and ethical challenges they are likely to encounter by providing education and training for how to respond. Younger, newer nurses may be particularly vulnerable to MI, and structured activities may help those nurses to cultivate MR as a protective and empowering resource (Rushton et al., 2021). NPD practitioners should facilitate introductions to ethics committee members during onboarding and ensure nurses understand how to request their support. NPD practitioners may also advocate for additional resources as needed to debrief difficult ethical cases and ensure nurses have adequate psychological and emotional support (Morley et al., 2021b; Rushton et al., 2022). That may include access to chaplains or moral distress debriefs (Morley et al., 2021b).

Most organizations have chaplains, and many nurses are unaware that the chaplain scope of practice encompasses caring for staff. Chaplains may be particularly adept at helping nurses to process their morally distressing experiences (Colorafi et al., 2024; Klitzman et al., 2022). It is possible regular interactions between nurses and chaplains—perhaps as embedded members of the interprofessional team—can help to relieve MD and reduce the risk for progression to MI.

NPD practitioners interested in MR are encouraged to look at the outcomes from the Mindful Ethical Practice and Resiliency Academy (MEPRA) (Rushton et al., 2021). That six-session program aimed at developing ethical competency and mindfulness practices demonstrated robust improvements in ethical confidence, moral competence, resilience, work engagement, mindfulness, emotional exhaustion, depression, and anger, with effects sustained at three and six months (Rushton et al., 2023b). NPD practitioners should assess the structures and processes available in their institutions to promote MR and support ethical practice

Since conducting our study, several of the study team members at different sites across our system have taken action locally to promote MR including the recommendations below:

• Consider implementing MEPRA or similarly focused program
• Integrate ethics education appropriately, especially during transition into practice and annual skills updates
• Ensure nurses understand what resources are available to support ethical practice in your institution and how to access the support
• Ensure nurses are aware of existing organizational well-being resources
• Create and support ethics resource specialist roles
• Advocate for nurses serving on ethics committees
• Leverage professional governance structures to promote and support access to ethics resources
• Facilitate formal or informal mentorship opportunities at all levels
• Advocate for assessment of the work environment using a validated tool like the AACN Healthy Work Environment Assessment Tool
• Introduce chaplains and the role of chaplaincy during transition into practice
• Advocate for integration of chaplains into clinical teams

Nurturing Moral Resilience as an NPD Practitioner

While the COVID-19 pandemic tested our profession to its core, it also revealed our strength—individually and collectively. We are a moral profession, and we are resilient. We demonstrate that every day in big and small ways. NPD practitioners can nurture MR and co-create the conditions for it to thrive. Acknowledging our strength and MR does not diminish the real suffering nurses have experienced and continue to endure, nor does it magically transform our institutions (Rushton & Nelson, 2023; Rushton, 2024). But it does give us a path forward, and a shared mental model to strive for and celebrate when we see it in action.

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