Facing Moral Distress: Why We Need to Enhance Moral Resilience in Palliative Care Nursing

The quiet crisis of moral distress in palliative care

Palliative care clinicians operate at the intersection of suffering, dignity and decision-making. Ethical conflicts often arise when institutional constraints, conflicting values, of limited resources prevent clinicians from acting in accordance with their moral convictions.^[1] This phenomenon, termed moral distress, is distinguished from general occupational stress by its roots in ethical dissonance and integrity compromise.^[2,3] In palliative care settings, moral distress can arise from various ethically challenging situations, such as the provision of non-beneficial or futile treatments, family demands that conflict with patient needs and ambiguities in end-of-life decision-making.^[4,5] Other contributing factors include a lack of informed consent, experiences of discrimination, acts of negligence and adherence to incorrect or ethically questionable medical orders, all of which can undermine healthcare professionals’ moral integrity and compromise the quality of care.^[6]

The consequences include significant moral discomfort, which not only jeopardises practitioners’ emotional and psychological health but also reduces care quality, increases turnover and weakens institutional ethics.^[7,8] Esmaeili et al., in their qualitative study in Iran, highlighted the specific coping strategies employed by intensive care unit (ICU) nurses, emphasising the importance of organisational support, ethical discussions and fostering moral resilience.^[6] Addressing this phenomenon requires a systemic, forward-looking response that acknowledges the complexity and emotional depth of ethical care at the end of life. As highlighted by Alanazi et al., implementing targeted education, developing ethical decision-making frameworks and fostering organisational support are crucial strategies to mitigate moral distress, promote nurses’ moral resilience and ensure the delivery of compassionate, ethically informed end-of-life care.^[9]

Furthermore, Selvakumar and Kenny (2023) contend that fostering a culture rooted in care ethics, characterised by relational responsibility, empathy and person-centeredness, plays a crucial role in enhancing clinicians’ moral resilience.^[10] According to their findings, incorporating ethics of care principles into organisational processes may operate as a safeguard, allowing healthcare personnel to better negotiate moral hardship, keep their integrity and provide ethically based palliative care in the face of adversities.

Moral resilience and ethical empowerment

In response to the pervasive effects of moral distress, the concept of moral resilience has emerged as a transformative paradigm. Defined as the capacity to sustain or restore integrity in the face of moral adversity, moral resilience embodies traits such as ethical confidence, emotional regulation and a commitment to principled action.^[11,12] It is not only an individual trait but also a dynamic interplay of personal agency, institutional support and relational ethics. Research underscores that moral resilience allows palliative care professionals to process ethically complex situations without psychological fragmentation or burnout.^[13,14] It fosters a sense of purpose and coherence in morally charged environments, empowering clinicians to act meaningfully even when ideal solutions are out of reach.

Moral resilience is not about stoicism or emotional suppression but about adaptive capacity rooted in values and reflective reasoning. It encourages professionals to engage ethically, even in distressing circumstances, while preserving their sense of moral identity and professional purpose.

Key components of moral resilience

Emerging literature has refined the understanding of moral resilience into several core components. These include self-awareness, moral efficacy, relational integrity, self-regulation and moral agency.^[15,16] Defilippis et al. further emphasise ‘harmonised connectedness’ and ‘moral well-being’ as integral to resilience in intensive and palliative settings.^[17]

During the COVID-19 pandemic, integrity and self-stewardship helped critical care nurses navigate overwhelming moral adversity.^[18] Moreover, moral resilience was shown to mediate the effects of secondary traumatic stress among ICU nurses^[19] linking internal resilience capacities to professional sustainability. Rushton identifies moral resilience as a process requiring self-reflection and meaning-making, especially in response to complex moral conflicts.^[11]

These components are not static attributes but dynamic skills that must be cultivated and supported through continuous professional development and ethical engagement.

Individual level: Cultivating inner ethical capacities

At the individual level, cultivating moral resilience begins with self-awareness, ethical competence and the ability to critically reflect on one’s values and actions. Nurses who possess strong moral self-regulation and personal integrity are better equipped to navigate ethical adversity.^[15,16]

Studies by Hu et al. and Galanis et al. show that higher levels of personal moral resilience correlate with reduced moral distress and moral injury.^[19,20] According to Barbosa et al., developing moral resilience involves engaging in personal and self-awareness strategies, such as participating in team meetings for reflection and support, which foster recognition of personal limits and promote self-care.^[21] These strategies enable nurses to critically assess their experiences, consider alternate approaches and support their emotional well-being behaviours, which are crucial to maintaining moral integrity. Individual solutions include self-reflection, emotional management and mindfulness activities.^[14]

Interventions such as acceptance and commitment therapy have also been explored for their role in enhancing personal resilience to moral stressors.^[13] Interventions that actively involve nurses in assessing and communicating patients’ palliative care needs can reduce moral distress and enhance perceptions of empowerment, highlighting the importance of empowering clinical practices to mitigate moral distress.^[22]

Developing personal resilience also requires safe spaces to process moral experiences. Reflective writing, peer support groups and supervision can support clinicians in making sense of difficult choices and maintaining moral clarity.

Organisational level: Creating ethical work environment

The workplace environment plays a pivotal role in shaping moral resilience. Supportive leadership, ethics infrastructure (e.g., ethics committees), and structured opportunities for moral reflection are essential. Organisational cultures that promote open communication and prioritise ethical concerns foster a psychologically safe space for moral dialogue.^[23,24]

Implementing ethical frameworks and providing institutional support can foster better decision-making and reduce moral distress among nursing staff. For instance, integrating palliative care principles throughout healthcare systems enhances symptom management and aligns care with patient values, which is vital in ethical decision-making at the end of life.^[9] Furthermore, tools such as structured communication strategies and decision aids can improve transparency and shared decision-making with patients and families. The review emphasises that addressing these systemic and educational needs is essential to support nurses in ethical practice and to promote high-quality, patient-centred palliative care.^[9]

Tools such as the Concentrate, Unrush, Reflect, and Act (CURA) model, an ethics support instrument for nurses, have been shown to improve moral clarity and support ethical reflection in palliative decision-making.^[25] Moral case deliberation (MCD), explored by Metselaar and Molewijk, empowers teams to collaboratively reflect on ethical dilemmas and build shared moral agency.^[26] Jacobs underscores that volunteer coordinators, too, benefit from institutional support when navigating moral challenges.^[27]

Organisations that embed ethical reflection into their operations contribute to stronger team cohesion, ethical awareness and reduced moral injury. Creating a culture of openness, where ethical challenges are acknowledged and supported, is crucial for long-term moral sustainability.

Policy level: Addressing structural barriers

Policy-level interventions are vital to mitigate the systemic sources of moral distress, such as nurse-patient ratios, access to palliative resources and institutional protocols that restrict ethical decision-making. These organisational changes can foster a culture of ethical practice and support nurses in managing moral challenges.^[28]

Policies that protect whistleblowers, uphold ethical standards, and mandate ethics consultation services are critical to safeguarding clinicians’ moral agency. Furthermore, moral resilience should be integrated into national nursing frameworks and workforce well-being strategies.^[20] Policymakers must ensure that the ethical dimension of care is not sidelined by efficiency-driven mandates.

Legal and regulatory reforms should support not only ethical care delivery but also the moral development of professionals through protected time for ethics training and discussion.

Education level: Forming the ethical professional identity

Undergraduate nursing students gain important benefits from ethics-based curricula that help align their personal values with professional nursing practice.^[29] Introducing ethics early in nursing education supports the development of moral resilience, which strengthens students’ ability to handle ethical challenges in their future roles. However, teaching ethics should go beyond classroom lectures. It should be actively integrated into practical experiences such as simulations, clinical mentorship and reflective exercise. This approach helps students apply ethical principles in real-world settings and develop a strong professional identity grounded in ethical practices.^[29]

Educators must help students develop emotional intelligence, moral sensitivity and ethical courage to navigate future dilemmas. Institutions that invest in values-based education prepare nurses to remain grounded in their moral convictions amid the pressures of real-world care settings.^[12]

Continual professional education should also reinforce moral resilience by linking theory to practice. Workshops on moral conflict resolution and leadership can ensure that moral resilience evolves as clinical experience deepens.

Relational and community level: Supporting ethical dialogue and belonging

Moral resilience is deeply relational. Teams and communities that validate moral experiences and promote open dialogue foster stronger ethical strength and collective moral capacity. Interprofessional collaboration and mutual respect serve as critical buffers against moral distress, isolation and burnout. ^[12,30] Specifically, Amin et al. emphasise that fostering environments where nurses feel supported through shared moral reflections and collaborative practices enhances their moral resilience, enabling better handling of complex ethical situations in home care settings.^[30]

Relational integrity, or an alignment of personal and professional ethical beliefs, has been demonstrated to be an important component in reducing traumatic stress among nurses. Hu et al. highlight that maintaining this integrity reduces moral distress and trauma^[19] which aligns with findings by Amin et al., who demonstrate that moral resilience is strengthened through relational support mechanisms in collaborative team environments.^[30] In community-based or home care contexts, volunteers and family caregivers also require structured support mechanisms to navigate and process moral complexity effectively.^[27]

To promote collective resilience and ethical competence, healthcare teams should consider encouraging regular ethics rounds, shared decision-making processes and inclusive ethical reflections across disciplines. Such practices foster a culture of mutual respect, understanding and shared moral responsibility, ultimately enhancing the collective moral resilience necessary for delivering ethically informed care in home and community settings.^[30]