Archives of Psychiatric Nursing 34 (2020) 391–393

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Incorporating moral resilience into an undergraduate nursing program T

Julie Baker-Townsend, Cynthia Cummings
University of North Florida, 1 UNF Drive - School Of Nursing, Jacksonville, FL 32224, United States

Moral distress experiencing moral distress. Moral resilience has been defined as “the
capacity of an individual to sustain or restore their integrity in response
The concept of the idea of moral resilience training began as a to moral complexity, confusion, distress, or setbacks” (Rushton, 2017).
method to assist those persons experiencing moral distress in a variety In 2016, a Johns Hopkins symposium was presented on “Building Moral
of areas. The concept of moral distress has been conceptualized for Resilience.” The participants noted four areas in which to focus: prac-
many years, and the effects of distress on nurses has been identified as tice, education, research, and policy. The results from the participants
far back as the 1970s with the relationship of moral distress to nursing highlighted the fact that we must first recognize when moral distress
burnout (Benner, 1984; Freudenberger, 1974; Humphrey, 1988; occurs and then develop ways to manage ethically challenging events
Jameton, 1984; Maslach & Jackson, 1981). Jameton (1984) noted that (Rushton, 2017). Moral resilience and the ability of one to exhibit be-
“one knows the right thing to do but is unable to perform the action haviors related to moral resilience stem from the person's own strengths
because of constraints.” Moral distress has been defined as a situation in and belief system. However, they can be enhanced by specific methods
which the ethically appropriate course of action can't be taken (Corley, (Stutzer & Bylone, 2018). Among workplace nurses, strategies for re-
1995). This distress may often take the form of life-saving interventions silience have centered on healthy work environments, relaxation, stress
and treatments performed on a patient without medical benefit. The reduction, and mindfulness practices (Lachman, 2016). Some institu-
concept of moral distress was explored in depth by Jameton (1984) in tions have set up “Moral Distress Consulting Services.” These services
his book entitled Nursing Practice: The Ethical Issues. He noted that allow the staff to discuss the issue and set up strategies to deal with the
there were three main types of moral problems in nursing, those that distress (Epstein & Delgado, 2010).
deal with moral uncertainty, moral dilemmas, and moral distress. Moral
distress was defined as “knowing the right thing, but constraints make it Educating registered nursing students on moral distress and moral
impossible to pursue the right course” (p. 6). The problem stems from resilience
the idea that there are four conventional ethical principles of nursing.
These principles are: Educating students on the concept of moral distress and moral re-
silience while encouraging open dialog is one method to assist students
1. Nurses have an obligation to be competent. in understanding and develop coping patterns. Rushton (2017) dis-
2. The good of the patient is the nurse's primary concern. cussed the need for mindfulness meditation, ethics education, and or-
3. Nurses should not use their positions to exploit patients. ganizational support in the area of resilience training. Suggested
4. Nurses should be loyal to each other. (p. 73) methods for resilience training have included strategies such as simu-
lation experiences on distressing events, mental health first aid courses,
An example is a terminally ill patient who continues to receive in- compassionate mind-training, online stress-management program and
tensive therapy and interventions, such as central line placement or healthy living courses (Beaumont, 2016; Calhoun & Gaba, 2017;
multiple blood draws that do not result in significant improvement. It Crawford et al., 2015; Lang & Schmidt, 2016; Rose et al., 2013).
may be a patient who expresses that they want to die, yet the family
continues to ask for full treatment, or it may be the stress of working Methods
contrary to the wishes of the patient and family because of the desires of
the health care team. In all, multiple scenarios are possible, and many The University of North Florida Bachelor of Science nursing pro-
nurses must deal with these issues on a daily basis. gram admits approximately 142 students per year in a traditional (ju-
nior, senior upper-division education five-semester cohorts), and a post-
Moral resilience baccalaureate accelerated Bachelor of Nursing program (four-semester
cohort). In this convenience sample, resilience methods were in-
Moral resilience is a concept that began as a method to assist those corporated into the undergraduate baccalaureate nursing program

E-mail addresses: jabaker@unf.edu (J. Baker-Townsend), cynthia.cummings@unf.edu (C. Cummings).

https://doi.org/10.1016/j.apnu.2020.06.001
Received 2 December 2019; Received in revised form 27 May 2020; Accepted 2 June 2020
0883-9417/ © 2020 Elsevier Inc. All rights reserved.
J. Baker-Townsend and C. Cummings Archives of Psychiatric Nursing 34 (2020) 391–393

begging in the second semester. The sample (n = 142) characteristics fatigue and moral resilience, which concludes with a class discussion on
such as age, race, gender were not documented. The second semester events they may have seen in the hospital. They were asked to openly
was chosen to begin moral distress and resilience education due to the discuss communication strategies and ways in which they will care for
minimal exposure of the topics during the initial nursing fundamentals themselves after graduation. They also take part in two small- group
training in the first semester. The moral distress and resilience educa- simulated scenarios. In one case scenario, the patient expires, and the
tion started with the addition of a mental health first aid course during group conducts a code blue simulation. In the other situation, a group
the students' second semester. The course was well received and con- of 7 students takes part in a role-play simulation. The students are as-
sisted of an 8-hour course given on the weekend. At the conclusion, the signed the role of the nurse, patient care technician, or patient. Each
student received a mental health first-aid certificate. The curriculum patient has multiple physical, social, and psychological issues, and the
included information on how to deal with stressful events, how to re- “nurse” must deal with the problems promptly. At the end of the si-
cognize signs of mental illness and anxiety, when to seek help, how to mulation, the students discuss how the activity transpired and their
calm an escalating situation, and how to assist patients and others with feelings as a new nurse, a patient care technician, and as patients. The
stressful situations. Presentation methods were videos, scenarios, and main objective was to demonstrate effective communication and stress
group discussions. management.
In the third semester, students were given a discussion board on a
moral distress situation. They reviewed three articles on moral distress
and viewed a PowerPoint on the subject. Following which, they read a Findings
case study on a distressful situation and were asked to answer the fol-
lowing questions: The grounded theory approach was utilized by using case studies,
online discussion groups to introduce students to various moral distress
“What does moral distress in nursing mean?” and resilience situations. Thematic analysis was then used to identify
“What types of patients may cause this feeling?” themes in the data and document findings. Student responses on dis-
“What can you do to help relieve this stress?” cussion boards, through simulation reflections and in-class discussions,
“Was this discussion helpful and how can you use this in your ca- have been overwhelmingly positive concerning the need for moral
reer?” distress and resilience education and training. Reflections have cen-
tered on some major themes:
In addition, as part of their medical-surgical course, students par-
ticipated in a simulation activity involving a young male dying from • Mental First Aid Training created a foundation for interventions in a
AIDS. They were asked to reflect on the comfort measures given, how stressful situation and de-escalating strategies
they could best meet his needs, how did they felt dealing with a dying • Unaware of the concept of moral distress
patient. The simulation also inquired as to which strategies could they • Unaware of coping methods for moral distress
use to help themselves cope with the stress they were experiencing. • Not given any thought to feelings they might experience in these
During the fourth semester, students were assigned a discussion situations
board on compassion fatigue and incivility in their complex nursing • Essential to not become closely attached to their patients
concepts course. They also completed a discussion-based assignment on • No idea that moral distress can lead to physical and emotional
a scenario regarding the use of illicit drugs during pregnancy and the burnout
effects on the newborn in their women's health course. The compassion • Appreciated tools to better care of themselves psychologically, and
fatigue discussion board concerns an elderly patient, who was facing physically
end of life care, and the family had many decisions to address. The • Often thought that when they finished school, patients would be
students were required to read an article on end of life care and moral grateful, they didn't think about anything negative occurring
resilience. Response questions included discussing: what would you say • Thought hospitals would have systems in place for these events.
to the family member, what would you do if the patient asks you to stop
treatment in light that the family wants you to continue. If these end of With these themes in mind, student comments have been things
life situations increase on your unit, what types of behaviors may you such as: “I found the discussion on moral resilience compelling.
see develop among the nursing staff? The incivility discussion involves Empowering ourselves with boldness, risk-taking, and problem-solving
a new nurse in a critical care area, who is treated poorly by another can help immensely.” Other feedback comments included,
nurse. The students view a short video on incivility in the nursing “Desensitizing touchy topics by talking openly can help to relieve stress
workplace and reflect on this issue and how they might cope. The re- on morally distressing areas;” “Taking care of myself is the first step to
flective questions on incivility include: “If you observed this bullying effectively deal with stress;” “As students we tend to overlook the dif-
behavior, what actions would you take?”, “Why might a nurse remain ficulties we may face;” “It seems like working with the elderly and
in an intimidating or bullying workplace environment?” and “What are mentally ill can place a nurse at an increased risk for moral distress”
some solutions to workplace bullying?” The maternal drug abuse ex- and “I had no idea that illicit maternal drug use during pregnancy could
ercise consisted of reading a case study and commenting on how the be so upsetting”.
nurse should support the pregnant patient on illicit drugs. The case Students showed increased awareness of the concept of moral dis-
study also examines neonatal abstinence syndrome (NAS) and the tress when they noted: “It is easy to get caught up in the care of pa-
physical impact on the neonate after delivery. The reflective questions tients, but it is important to remember space. Sometimes you need to
focus on the ethics and support of pregnant patients, ethical dilemmas, take a step back. We can't control the choices patients make, so we
and coping strategies to prevent moral distress. educate them and provide the best care possible and also make sure we
Questions included in the maternal case study include: “What types have a good support system at work and home!” Another student
of teaching should you give Ms. X regarding drug use during pregnancy commented, “Morally distressing events can come from any type of
and fetal outcomes?”, “What types of community resources could you patient and any patient that we feel compassion for. Hospital rules and
discuss with Ms. X during this difficult time?” “How do you maintain lack of resources can prevent us from giving the care that we would
moral resilience after seeing this scenario several times a week in the like”, and “The best way to handle moral distress on the job is to re-
neonatal intensive care unit (NICU)? Please provide examples of coping member the four A's, Ask, Affirm, Assess and Act. Ask and affirm if this
personal and professional coping strategies”. is moral distress, then assess the situation and act on what can be done
In the final semester, the students receive a lecture on compassion to improve.”

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J. Baker-Townsend and C. Cummings Archives of Psychiatric Nursing 34 (2020) 391–393

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