Although the consequences of moral distress are sobering, Hiler’s study showed there are factors that decrease this form of stress among nurses, such as increased participation in hospital affairs like shared governance. Nurses who experienced support from nurse leadership and collegial relationships with physicians also reported less moral distress.

The data from the study also revealed nurses employed in a Beacon-recognized unit — an honor awarded by the American Association of Critical-Care Nurses to hospitals that have a positive and supportive work environment — experienced less moral distress. Although there are a variety of ways organizations can attempt to decrease moral distress, Rushton’s experience as an ethics consultant informed her decision to tackle the issue by developing a program that focused on building moral resilience in nurses. During six four-hour sessions taken over the course of three months, nurses from Johns Hopkins enrolled in the learned self-regulation, moral discernment and how to take action by voicing concerns.  “One thing that is very different about this program is that it is experiential, not a passive didactic course in which an expert does most of the talking,” said Rushton, who launched the program in 2016. “The participants engage in reflective practice and discover their own solutions rather than being told what to do.” Nurses every day and learn to pay attention to their minds and bodies throughout the day. In one of the sessions, participants spend time exploring their personal values and beliefs and learn how to recognize opportunities to bring their voices into an ethics conversation. They also practice communication strategies that will promote productive conversations about difficult topics and enhance their advocacy skills. “What we’ve noticed is that nurses often lose track of their sense of purpose and meaning, and then discount the value of their contribution,” Rushton said. “We invite them to recognize the incredible value they bring to patients and families, and how to see themselves as effective moral agents that belong in these difficult conversations.” Rushton also encourages nurses to avoid statements like “Why are we doing this?” when talking to physicians about interventions, and instead start with affirming their shared commitment to the patient. Then they can offer their perspective on the situation and suggest new questions or directions. More than 100 nurses have completed the program, with preliminary data showing participants trending toward improved work engagement, ethical confidence and competence. “The feedback from the participants has been overwhelmingly positive,” Rushton said. Nurses often enter the program depleted, discouraged and questioning their decision to become a nurse and they leave with renewed enthusiasm and connection to their work, she said.

Debriefing meetings is another strategy that can help nurses cope with stress after difficult cases, especially because the discussion gives caregivers an opportunity to hear the perspectives of doctors, nurses or other specialists who were involved in the case, said Abigail Butts, MS, RN, CCNS, CCRN, a medical intensive care nurse at MedStar Georgetown University Hospital in Washington, D.C.

“Sometimes we discover that we may not have known the whole story as we learn about conversations others had with the family or patient,” she said. A physician and nurse on her unit also are pioneering a training that will help caregivers broach difficult topics with families around end-of-life care. The daylong training, called into the ICU, focuses on a clinician’s role in a family meeting and communication skills related to prognosis and goals of care.  The program, offered three times a year, has been popular among nurses and resulted in improved job satisfaction, Butts said. “As much as people hate role playing, it is helpful because the scenarios simulate these discussions accurately,” she said. “There are so many things that we can do in medicine now, but we need to get better at asking what should we be doing, and this helps us do that with families and doctors.”