oral Distress has always been an intrinsic yet unspoken challenge within the healthcare industry, particularly affecting the backbone of our organization: our nurses. Defined as a negative psychological phenomenon arising from a nurse's perceived inability to ethically support a patient due to external constraints, moral distress has been exacerbated by the global COVID-19 pandemic.

Nurses, both new and experienced, have faced unprecedented challenges that necessitate an urgent revision of current nursing curricula to better prepare them for real-world ethical dilemmas.

My dissertation reframes the discourse around nurse resilience by positing that organizations must proactively contribute to and safeguard the inherent resilience of their nursing workforce. I surveyed and interviewed nurses across patient care settings and experience levels. A recurring theme was the gaps in nursing training that may help address moral distress.

Let’s take a closer look at three of the largest gaps in preparing nurses to respond to moral distress early in their training and identify ways to help our nurses navigate stressful situations:

Identified Gaps in Nurse Training Programs

Moral Distress and Burnout:

Nursing programs have historically fallen short of preparing students for real-world challenges. Classes frequently focus on teaching to the test and neglect to equip students with the tools they need to prioritize self-care. While many programs offer training modules that mention the availability of resources to combat stress and burnout, they often fail to show students how to access and use those materials. 

This lack of information and training often continues even after nurses enter the workforce. Without proper guidance and support, nurses are left to navigate the emotional and ethical challenges of their jobs alone. That stress has understandably taken a toll, as more nurses are reporting record-high levels of burnout.

Resiliency and Coping:

Another skill that traditional nursing programs struggle to teach is resiliency. Nurses often learn to cope with stress through on-the-job experience, rather than through formal training. The importance of resiliency cannot be understated, as it empowers nurses to reflect on different situations and implement strategies that cultivate moral fortitude at both individual and organizational levels.  

To bridge this gap, we must develop programs that focus on mindfulness techniques, ethical competence and self-care, such as those provided by the Resiliency Center, Organizational Development, and the Joy in Work (Wellness Champions) Program at U of U Health. These concepts have been shown to reduce moral distress by promoting self-reflection and restoring a sense of balance and harmony.  

Incorporating these strategies within undergraduate and graduate courses, as well as professional development programs, will help nurses cope better with the demands of their profession.  

The COVID-19 pandemic overwhelmed the healthcare system, with nurses confronting morally distressing situations more frequently than ever before. Despite the prevalence of moral distress among nurses, both novice and seasoned, nursing programs have historically fallen short of preparing students for these real-world challenges. Classes often focus on teaching to the test, neglecting to equip students with the tools they need to prioritize self-care and manage moral distress effectively.

One nurse in a recent study remarked, "It's something that's not talked about. I'm impressed that they're talking about it now." Another nurse highlighted, "I think we had a lecture about it. I don’t think it was enough." This lack of education is evident, as many nurses expressed that they were either not taught or taught very little about moral distress and burnout while in nursing school. A nurse manager recalled, "I went to school between 2000 and 2004. I don’t think burnout or work/life balance or moral distress were ever mentioned in a single class I took."

High levels of resiliency can increase the chance that nurses will effectively manage moral distress. One participant highlighted the shift in her resiliency over a year, noting significant personal improvement despite ongoing challenges. "I feel like my resiliency has really improved. Whereas a year ago I was really having a hard time, now I don't feel the impact as much." To address this gap, nursing programs must incorporate strategies such as mindfulness techniques, ethical competence, and self-care, as recommended by the American Nurses Association (ANA, 2018). This will help nurses navigate challenging ethical situations within the workplace, ultimately reducing the negative effects of moral distress.

Team Dynamics and Work Environment

Healthcare does not happen in isolation; the dynamics of each team can significantly impact both nurses' and patients' experiences. While a supportive team can make a challenging shift manageable, a poor one can exacerbate moral distress. According to the findings from recent interviews, nurses working in acute-care settings with poor team dynamics reported higher levels of moral distress. One nurse stated, "A nurse’s team can make or break a shift, and team dynamics have shown to have both positive and negative effects."

To improve team dynamics, nursing programs should focus on targeted training that enhances communication skills, embraces team diversity, and fosters shared support among colleagues. This approach not only helps reduce moral distress but also improves the overall quality of patient care. Implementing educational interventions that involve self-directed learning and organized training can help nurses identify moral distress, understand internal and external barriers, and plot a course to initiate change.

Nurse-Patient Communication: A Key Strategy to Managing Moral Distress in Practice

Moral distress comes in all shapes and forms, but patient care is often at the heart of it. Nurses may not be able to directly relate to every patient they see, but our shared humanity provides a common ground for authentic connection. One of the best ways we can encourage our nurses to manage moral distress is through empathetic and honest communication.

Acknowledging the uncertainty of patient outcomes can help alleviate some of the psychological strain that nurses experience. It is critical to avoid patronizing language and to refrain from making promises that can’t be kept, such as guaranteeing recovery or predicting positive outcomes. We can’t promise their cancer will be cured or that they’ll walk again.

Instead, focus on providing support based on connection, not problem-solving. Try to empathetically communicate with patients using phrases that help both of you. An example of this might be, “I can’t even imagine how difficult this must be for you. I respect how much you love your father. I can see that your father is very strong and capable. We are going to do everything we can to provide you the resources you need.”

These phrases center on validation, support, and understanding.

By establishing and respecting these personal, physical, and emotional boundaries, nurses can focus on providing compassionate support for their patients while also reducing their personal moral distress.

Preparing Our Next Generation of Nurses

Despite the past failures of nursing programs to educate students on moral distress, we’re now witnessing a sweeping movement to help nurses build resilience and restore their internal balance. From ethics simulations to case studies and discussions that focus on real-world scenarios, we’re bridging the gap between theory and practical application in healthcare settings.

Conclusion and Future Directions

By raising awareness and implementing new strategies for managing ethical conflict, we aim to better prepare the next generation of nurses to handle the inherent moral distress of patient care. This includes revising nursing curricula to include comprehensive training on moral distress, burnout, resiliency, and effective team dynamics. Our goal is to equip nurses with the skills and support they need to navigate the complexities of healthcare with confidence and compassion, ultimately improving their well-being and the quality of care they provide.

The urgency of addressing moral distress in nursing education and practice cannot be overstated. As the pandemic has shown, our healthcare systems depend on the resilience and well-being of our nurses. It is time for nursing education to reflect the realities of the profession and prepare nurses not just for the clinical challenges they will face, but also for the ethical and emotional ones. By doing so, we can ensure a more resilient, compassionate, and prepared nursing workforce for the future.