- Moral distress is the feeling that one has compromised oneself due to forces beyond one's control.
- Powerlessness is at the heart of moral distress.
- Moral resilience shifts the narrative from powerlessness and helplessness to possibility and choice.
“Moral distress” is a term coined in 1984 by philosopher Andrew Jameton to describe the suffering nurses experience when institutional or systemic barriers prevent them from acting with integrity, particularly when it comes to fundamental moral principles and ethical responsibilities. More recently, the concept has broadened to include other professions, such as medical professionals generally, social service providers, teachers, law enforcement, the military, emergency service providers, lawyers, journalists, and politicians, among others. In our day-to-day lives, this type of suffering can take a serious toll on beliefs, relationships, and affiliations.
Moral distress is the feeling that we've had to compromise ourselves or something we hold dear due to external forces seemingly beyond our control. It is also the sense that others don’t grasp a moral significance or moral imperative that is clear to us. Moral distress is what results from repeatedly not having our values respected, either individually or collectively.
Moral distress causes anger, disgust, fear, and frustration; likewise, feelings of being muzzled, restricted, devalued, unheard, or dismissed. Research (Rushton, 2017) also shows that moral distress has long-term consequences, such as burnout, exhaustion, numbness, disconnection, and diminished moral sensitivity (also called “compassion fatigue”).
The following practices can help you cultivate moral resilience whenever you’re feeling boxed in by a morally distressing situation and struggling to hold onto your integrity.
1. Self-mastery: The art of learning to self-regulate
Self-mastery is the present-focused realization that we can always be in command of ourselves—body, mind, and spirit—even while accepting that we may not be able to control all situations or outcomes. It’s about learning how to struggle well, starting by turning our attention inward or engaging interoceptive awareness. Interoception helps us to be mindful of what’s happening below the surface that might be fueling our feelings, thoughts, and actions.
When going into ourselves, we don’t try to quash unpleasant emotions or judge them as wrong or weak. We give them space to tell us something new about what’s going on. We observe and get curious about what moral values, obligations, or responsibilities are not getting met; what this says about the distressing situation and us; and how we might find other ways to satisfy them.
2. Self-awareness: “To thine own self be true”
Moral resilience is grounded in moral conscientiousness. It reflects a vigilance to live in ways that are aligned with who we are and what we stand for amid situations that appear to be incongruous with integrity (Rushton, 2016, p. 113). This vigilance or desire to be moral requires that we are fundamentally aware of what values, commitments, and imperatives comprise our moral core. This requires regular examination, otherwise, we risk becoming complacent or losing our moral sensitivity. At the same time, we want to avoid becoming rigid or dogmatic.
Being self-aware is an intentional embodied dance that requires continually exploring our feelings, thoughts, and desires—and doing so humbly, carefully, and courageously, with, what I call “benevolent honesty.” We also must do so with transparency, that is being willing to both acknowledge when our convictions have become biased, distorted, shortsighted, or incorrect and being open to change, revision, or alternative outcomes. Self-awareness makes room for us to discover possibilities for responding to morally distressing situations with our head held high, eyes wide open, shoulders relaxed, and grounded confidence in our core, with the least personal cost.
3. Self-expression: Choose and contribute in ethically clear and competent ways
There are many ways to express ourselves, but when it comes to moral resilience, two ways can be particularly helpful: developing ethical competence and speaking with clarity and confidence.
Ethical competence involves ethical embodiment (Rushton, 2016), that is living the values that we espouse by making sure that what we hold to be true and sacred is reflected in our actions. It is about immersing ourselves in the “moral” world by cultivating a moral vocabulary, imagination, attitude, and coherent character, as well as a dynamic moral posture—being patient with, and open and flexible to, others’ values, hopes, and fears.
Speaking with clarity and confidence means giving voice to our concerns by bringing distressing issues to the attention of invested others. Rather than seeing moral distress as a dead-end, consider it an opening to a broader and more substantive conversation about the dynamics of the situation. Speaking with clarity and confidence also includes knowing when to excuse ourselves from a situation, system, or relationship, whether it be for a short time or else permanently because that situation could irreparably harm our conscience.
4. Meaning-making: Don’t demand it, create it
Meaning-making is the process of how we perceive, interpret, and make sense of events in life, relationships, and ourselves. It gives us a way to organize memories and shape the narrative of an experience. Meaning also helps us to reconcile incongruities in our values, beliefs, and expectations and in our attitude toward life. This is especially important in times of moral adversity.
Senseless suffering is a big theme in moral resilience. We often think to ourselves, “Why am I continuing to do ‘this’ when nothing changes?” Or, “I’m doing everything I can to make things better, but nothing I ever do is enough.” And, “I’m fighting against a system that is inherently flawed or damaging.” These umbrages can either fuel a disempowering, dead-end narrative or they can become the foundation for principled and embodied action.
One way to create meaning is to consider alternatives that may not appear obvious or that you have previously rejected. Consider, is there information you have overlooked or misconstrued? Are your grievances cloaking relevant information? How can you look at the situation in a more nuanced way and from multiple stakeholders’ perspectives?
Also, consider how this situation is asking you to grow. What new insights about yourself, others, and life have come to light? What core strengths have you relied on? What weaknesses have reared their head? What values, responsibilities, or moral imperatives have remained constant—and are there any that have shifted? How is all this meaning living inside you?
A mistake often made when it comes to meaning-making is thinking it’s a lesson to be learned or the “moral of the story.” Not so. Meaning-making is not trying to put a happy spin on pain, nor is it necessarily trying to teach us cautionary realities. Meaning-making simply helps us to broaden our thinking and feeling about a morally difficult situation and keeps us moving forward with integrity and principled action.
5. Connectedness: Engage with others
Being connected is one of the realities of life; in fact, recent neuroscience research (Wolpert, 2013) shows that we’re hardwired for it: When we talk to other people, mirror neurons in our brains light up to mimic the emotions and behaviors the other person is conveying. Matthew Lieberman, director of UCLA’s social cognitive neuroscience lab, suggests that humans’ need for connection is even more basic than food and shelter and is the primary motivation of a person’s behavior.
Reaching out and letting trusted others in is an absolute must when it comes to cultivating moral resilience. And note here the word “trusted.” This is also key. Sharing challenges, difficult emotions, and frustrations can make us feel vulnerable. Being in the depths of moral distress is not necessarily the time to test the waters with those who can’t be counted on to be present, to listen and hear, to have empathy and show compassion, and to offer benevolent honesty and grounded hope. Knowing that you are not alone in your moral struggle can go a long way to alleviating a sense of isolation and despair.
We never want to seize control more than when we don’t have it—and when we’re morally distressed, it can really feel as though we don’t have it. Shifting the narrative from one of powerlessness, hopelessness, and helplessness to one defined by possibility and principled choice will help to both assuage the effects of moral distress and cultivate moral resilience.
Rushton, C. H. (2016). Moral resilience: A capacity for navigating moral distress in critical care. AACN Advanced Critical Care, 27(1), pp. 111-119. DOI: http://dx.doi.org/10.4037/aacnacc2016275
Wolpert, S. (2013). UCLA neuroscientist's book explains why social connection is as important as food and shelter. University of California Los Angeles. Retrieved https://newsroom.ucla.edu/releases/we-are-hard-wired-to-be-social-248746