Justice Education

Good Work
May 2024

The Flourishing Nurse: Moral Suffering and Resilience in Healthcare

Wes Siscoe

When Cynda Rushton started her nursing career, she was challenged with the physical, psychological, and ethical challenges that she faced on a day-to-day basis. One case, in particular, was impossible to forget. A young child had experienced severe neurological damage from a lack of oxygen to the brain. They were kept alive on a ventilator and feeding tube, but they would never walk or talk again, and they lacked the ability to interact with people or their environment.

While the child’s parents were in favor of letting them die a natural death, the clinician in charge of the unit didn’t agree that it was a permissible option. The life-preserving interventions would continue. Grief-stricken, the parents stopped visiting, leaving the nurses to care for the child in the ICU for over a year. The situation was heartbreaking, as Rushton and the other nurses could only keep the child’s body functioning at a level just above survival, knowing the whole time that this is not what the parents wanted for their child.

“It was such a painful experience that we didn’t have the words to describe what we were going through. As nurses, we were not the ones making the decisions,” said Rushton, now the Anne and George L. Bunting Professor of Clinical Ethics and Nursing at the Johns Hopkins Berman Institute of Bioethics and School of Nursing. “We were carrying out the decisions of others, and that was a different sort of burden to bear, because no matter how we felt about those decisions, we were the ones who carried them out, 24 hours a day, 7 days a week.”

Looking back, Rushton realized that she and her fellow nurses were experiencing what Warren Reich has called “mute suffering”, which occurs when someone is unable to describe or put into words what they’re going through.

Part of what made the situation challenging was its explicitly moral dimension. Not only was the experience psychologically taxing, but it was also ethically demanding. One concept that helped Rushton express her experiences was that of “moral distress”. According to Andrew Jameton, moral distress occurs when someone recognizes a moral problem and yet they are unable to act on it.

“In thinking about how to capture the many experiences that arose as a pediatric critical care nurse, Reich and Jameton gave me a new vocabulary to describe it,” said Rushton.” “And it really resonated with other nurses as well, because it put into words much of what had been unspoken and unacknowledged. This helped move us from mute suffering to being able to articulate the moral conflicts that were underneath our distress, giving us the chance to address it and potentially transform it.”

In 2016, Rushton started exploring what could be done to help nurses prepare for the moral distress and suffering that they would inevitably face as part of their work in healthcare. And the leadership at Johns Hopkins School of Nursing was on board. Dean Patricia Davidson knew how many nurses leave the profession within their first year of work, making it clear how important emphasizing the role of resilience is in preparing nurses for their careers.

From there, the Mindful Ethical Practice and Resilience Academy (MEPRA) was born. Through MEPRA, nurses learn to be mindful, clarify their values, and exercise self-stewardship, all skills which then strengthen their moral resilience and help them confront the ethical challenges they face in acute care settings.

“We are already resilient as nurses. MEPRA is a strength-based model,” said Rushton, that engages what is already present and amplifies it by strengthening the capacities that allow them to meet the inevitable challenges without so much cost to themselves. The question for us, and what we want our nurses to reflect on, is how our capacity for resilience can be amplified or degraded, depending upon the circumstances that we’re in and the resources we have access to. We know that investments in individual resources must be matched with investments in systemic programs that address the root causes of their moral suffering.”

MEPRA is delivered as an experiential, discovery learning curriculum. From 2016 to 2020, participating nurses were finishing their residency with more experienced nurses who served as on-the-job teachers and mentors. MEPRA then supplemented this mentorship with high-fidelity simulation, using paid actors to simulate situations where nurses would need to put into practice what they were learning about mindfulness, resiliency and ethical practice.

With COVID came a new training protocol, with the curriculum, mentoring, and simulation being delivered virtually. Even though this presented a new challenge, it also revealed an even greater need for the program and demonstrated its scalability.

“We are currently partnering with Corporate Counseling Associates to scale MEPRA and make it available outside the Johns Hopkins ecosystem,” Rushton said. “With a small faculty, we were inherently limited in how many nurses could be participating. Now we are building additional faculty capacity so that others can facilitate this training at their home institutions. We are adapting the current program to include a learning platform to support self-paced learning along with experiential in person or virtual content facilitation.”

Along with making MEPRA more widely available by scaling its programming, Rushton has also worked to get the word out through her research and publishing. An updated edition of her book “Moral Resilience: Transforming Moral Suffering in Healthcare” (Oxford University Press, 2018) will be available in the fall of 2024, and she has published multiple articles with the American Journal of Critical Care on the MEPRA philosophy and the sustainability of its results. For researchers who want to assess whether they are helping nurses build the capacity for resilience, Rushton has also developed the validated Moral Resilience Scale.

“People think that the work we are doing is about resolving ethical dilemmas, but what we are really after is restoring the agency and well-being of nurses. What we’ve heard from our nurses is that this is the first time something has been offered that is just for them, instead of simply another program to help them meet their organization’s goals. This was the first time that they were given the space and support to think about their values, leverage their purpose, and amplify their resilience and strength in ways that contribute to their long-term well-being and ethical integrity.”