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Building moral resilience into nursing practice
Jan 20, 2020, By: Hazel J. Magnussen
A nurse looking overwhelmed with his hands pulled to his temples.

Takeaway Messages

  • Nurses are more likely to thrive in workplace settings that support ethical practice.
  • The ability of nurses to exercise their moral agency is a professional priority.
  • Morally resilient nurses are sure of their purpose and mindful of threats to their integrity.

The concept of moral distress has been part of nursing ethics discourse and research for more than 35 years. Often correlated with aggressive treatment, nurse burnout, and attrition, moral distress occurs when a moral event (or events) places constraint on a nurse’s moral agency and results in psychological distress for the nurse (or nurses).

The term moral distress was coined by Andrew Jameton to describe nursing students’ concerns about futile treatments for patients in neonatal and other intensive care settings (Jameton, 1984). Patricia Rodney, University of British Columbia nursing professor and nursing ethics scholar, referred to Jameton’s work in an article about moral distress in critical care nursing (Rodney, 1988).

When I read Rodney’s article soon after completing my Master’s thesis examining power in physician–nurse–patient relationships, the connections between nurses’ experiences of moral distress and power relationships in health care were evident. However, health care authorities do not always recognize nurses’ professional accountability and moral responsibilities—that is, nurses’ role as moral agents.

Since then, other research examining moral distress has added new terms, such as moral injury (“soul wound”) and moral residue, psychological states that linger when a nurse’s core values have been compromised or violated. Moral climate refers to values guiding health care workplaces and affecting practice environments and patient care.

Recent research

A current article, “Moral Agency, Bureaucracy and Nurses,” by Elisabeth Fortier and David Malloy (2019) is particularly relevant to this discussion. In exploring potential barriers to the moral agency and resilience of nurses in bureaucratic health care contexts, the authors conclude: “Learning and gaining experience seemed to be the determining factor in the nurses’ level of moral agency and resilience” (p. 12).

Moral distress and related phenomena can be the impetus for building moral resilience in the nursing workforce. The American Nurses Association seized that opportunity when it developed an action plan following a 2017 symposium on Transforming Moral Distress into Moral Resilience in Nursing (ANA, 2017).

One of the report’s authors, Cynda Hylton Rushton defines moral resilience as: “The capacity of an individual to sustain or restore their integrity in response to moral complexity, confusion, distress, or setbacks.” Her definition is included in the 2017 edition of the Canadian Nurses Association’s Code of Ethics for Registered Nurses. Rushton (2017) encourages nurses to build that capacity by mindfully noticing and responding to “signals from the body, emotions, and thought patterns to restore balance when upsets or ethical challenges occur.”

Moral resilience boosts nurses’ confidence, moral courage, and competence to engage in thoughtful dialogue, ask the moral questions, and take action. Upheld by moral reflection, ethics education, consultation, sound leadership, and interdisciplinary collaboration, nurses find meaning in their work and are empowered to promote and provide safe, competent, ethical nursing care in health care settings fraught with complex clinical and ethical situations.


American Nurses Association (ANA). (2017). Exploring moral resilience: Toward a culture of ethical practice.

Fortier, E., & Malloy, D. (2019). Moral agency, bureaucracy and nurses: A qualitative study. Canadian Journal of Practical Philosophy, 3(1), 1–14.

Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall.

Rodney, P. (1988). Moral distress in critical care nursing. Canadian Critical Care Nursing Journal, 5(2), 9–11.

Rushton, C.H. (2017). Building moral resilience to neutralize moral distress.

Hazel Magnussen is a writer, author of The Moral Work of Nursing: Asking and Living with the Questions, and a retired nurse. She lives in Edmonton, AB.