Jihane Frangieh: How do you define moral resilience, and how can it help nurses navigate ethical dilemmas and workplace stress?

Cynda Rushton: In our work we define moral resilience as “the ability of an individual to preserve or restore integrity in response to moral adversity”. Nurses are regularly confronted with myriad issues in their work that threaten or violate their core values as a person and as a professional. Moral resilience is a protective resource that nurses can cultivate to reduce the detrimental impact of the moral adversity they regularly face. Moral resilience is a strengths-based approach that presumes nurses are already resilient and the seeds of moral resilience can be amplified and strengthened through intentional investments. Through our research we have identified six pillars of moral resilience. These include personal and relational integrity, buoyancy, self-regulation and awareness, moral efficacy and self-stewardship. Each of these elements can be cultivated and leveraged to restore integrity and wellbeing amid ethically challenging situations. The second edition of our book Moral Resilience: Transforming Moral Suffering in Healthcare was released in August 2024.

Jihane Frangieh: In your opinion, what are the most pressing challenges nurses face today in terms of well-being and moral resilience?

Cynda Rushton: Nurses have always confronted ethical challenges in their work. Since the COVID-19 pandemic, they have become unrelenting occurrences instead of episodic instances that threaten their values and commitments. Now more than ever, nurses are confronted with how to reconcile the balance of benefits and burdens of their work on their patients, their families and themselves. Not having sufficient resources, including time, attention, and people, to provide the care that their patients need and desire, erodes nurses’ integrity and contributes to moral suffering. Nurses are also struggling to address a fracture of their social covenant with the people they serve. As the most trusted and ethical profession for two decades, nurses are now exposed to alarming levels of physical and psychological violence from their patients or families. The dissonance between the requirement of their Code of Ethics to provide respectful care to all persons and the behaviors of disrespect that are leveraged toward them leaves a moral residue that is difficult to overcome. Alongside these ethical conundrums are complex issues that involve patient autonomy to choose treatment options that have harmful consequences, struggles over the boundaries of end-of-life care, challenges to informed consent, how to ethically use technology, the impact of societal inequities and disintegration of historical community safety nets and myriad others that occur daily. Taken together these unresolved ethical issues contribute to alarming levels of burnout, disengagement, mental health outcomes, moral suffering and turnover.

Jihane Frangieh: Can you share the vision behind the R3 (Renew, Resilience, and Retention) Initiative for Maryland Nurses and how it supports nurse well-being, resilience, and retention?

Cynda Rushton: The R3 was conceived before the COVID-19 pandemic to address the alarming trends of burnout and attrition among Maryland nurses. The onslaught of the pandemic created an urgency to stem the tide of these troubling trends. Through funding from the Nurse Support Program II and MHEC, we envisioned that sustaining nurses in the profession over their careers would require a firm foundation of resilience and ethical practice from the first day of nursing school into their chosen nursing roles and beyond. By leveraging statewide academic/practice partnerships, the first phase of the R3 initiative focused on cultivating resilience and ethical practice capacities among nursing faculty in eight schools of Nursing across Maryland. The premise was that nursing faculty, who were also burned out and depleted, needed additional support to restore their wellbeing and integrity. This foundation was necessary to be able to embody and authentically share the resilience and ethical practice skills they were asking students to engage in. Through a series of three workshops faculty champions engaged in exploring their own resilience, implemented a self-stewardship plan, and devised strategies for integrating the R3 content into their existing courses. Armed with 38 multimedia modules developed by the R3 team, they were invited to choose selected modules to integrate into their courses and to use as vehicles for systemic engagement in the topics illustrated in the R3 curricula. The R3 resources apply to nurses in all roles and specialties across their careers, not only at the beginning of their careers. Arming students, faculty and practicing nurses with the tools and skills to restore their wellbeing and integrity along with skills for engaging in system change creates a foundation for greater collaborative solutions to the current workforce crisis. 

Jihane Frangieh: What findings from the R3 Initiative in Maryland surprised you, and what has been the impact of this initiative in the state? Are there plans to expand it further?

Cynda Rushton: One of the biggest surprises was what our team was able to accomplish during a global pandemic (see our team here: https://nursing.jhu.edu/faculty-research/research/centers/r3/about/). We had to pivot in all aspects of our proposal to meet the changing reality of healthcare. Our team innovated and persevered to exceed our projected goals. The impact of the R3 initiative can be measured in a variety of ways. We engaged over 40 R3 Champions from our 8 schools of nursing to participate in the 3-part R3 workshops and communities of practice. Our team created 38 multimedia educational modules focusing on key aspects of resilience, values and integrity You can find it following this link: https://nursing.jhu.edu/faculty-research/research/centers/r3/r3-tools-and-modules/. 

Nearly 3000 students have accessed R3 modules since deployment. Several of our SON’s have integrated them into their curricula. Visits to the R3 website increased from more than 1,500 within the first 6 months after launching to 5220 in 2022-2023, to over 5800 in 2024. Nearly half of our site visitors (46%) engaged with the R3 tools and resources in 2022-2023; and most visitors (more than 50%) engaged with R3 tools and resources in 2023-2024. Engagement with the R3 modules increased from just over 300 people in early 2022 (when the first five modules released) to 1573 in 2023-2024. We launched “stories of resilience” to highlight diverse experiences of nurses in Maryland and developed 10 social media posts that include key R3 messages to engage others in R3 activities and to drive people to the website. A podcast series (13 episodes) was launched in collaboration with the JHUSON “On the Pulse”.  The podcasts average 1500 listeners per episode The Resilient Nurse Podcast – Johns Hopkins School of Nursing (jhu.edu). We developed and disseminated two reports: The Mind the Gap report. Mind the Gap – Johns Hopkins School of Nursing (jhu.edu) and the Slow Talk report https://docsend.com/view/cvcdpq2a79dzt2th.  Since its publication, the Slow Talk report has been downloaded 1540 times. We hosted two statewide conferences with robust attendance from nurses across Maryland. In addition, we had >10,000 participants in The Nurse Antigone series and nearly 20,000 listeners to our podcast series, and >2000 subscribers to our distribution list.

We received 2 years of additional funding to expand our reach and extend our work by focusing on application of it with NRP educators and clinical instructors across the state. We will create 12 new podcasts based on our existing content over the next 2 years that will be tailored to the needs of NRP and clinical educators. We have partnered with Vizient to distribute our R3 modules nationally and will hold another statewide conference in 2026. We also plan to develop an innovative film about nursing and a public engagement campaign. We are partnering with our Slow Talk Colleagues to launch a new series for nurse managers. We invite Maryland Nurse Leaders to participate in this exciting and innovative program. Please register here: http://www.slowtalk.us/linchpin. 

Jihane Frangieh: What strategies, leadership behaviors, and changes can healthcare organizations implement to create a culture that fosters resilience, supports nurses’ moral well-being, and enables them to thrive at all levels?

Cynda Rushton: Nurses are already resilient, and we want to keep them that way. Being resilient does not mean that the onus of responsibility falls solely on nurses. It is a shared responsibility. Accomplishing this goal means that healthcare leaders and organizations must intentionally invest in their nursing staff in meaningful and tangible ways. No longer can organizations assume that nurses will always be willing and able to meet the routine and unexpected challenges that are common in healthcare today without some fundamental changes in leadership and organizational priorities. Nurses must be viewed as vital to the delivery of healthcare and as a scarce resource that is essential for patient and organizational outcomes. This means that organizational budgets must be re-imagined by viewing nursing services not as a budget expenditure to be reduced but as an integral resource that provides value that is not captured in hospital bed rates. Separate budget lines that reflect the actual nursing contribution would go a long way in recalibrating the inequities that are inherent in the current framework. Nurses make an invaluable impact on the safety and quality of patient care, bridge inequities in access to healthcare, provide clinical and policy leadership, and influence many invisible aspects of the healthcare enterprise. Without a sufficient and resilient nursing workforce, current healthcare systems are unsustainable. The long tail of COVID will have an enduring impact on nursing and healthcare. Leaders and organizations must engage nurses in designing new models of care delivery and strengthen communication and shared governance mechanisms. No longer is nursing input “nice to have”; it is vital if we are to create a system that is driven by the needs of patients and is fair and equitable for all. There are no quick fixes. We must take the long view in responding to the aftermath of the COVID pandemic by investing in systemic change to dismantle the barriers to effective and meaningful clinical practice. Healthcare leaders must restore trust and relational connections with nurses who have born a heavy burden of the consequences of the pandemic. Healing these wounds will require humility, mindful listening, forgiveness, and compassion. The time is now!

Disclaimer: This initiative was produced with the assistance of a Nurse Support Program II grant administered by the Maryland Higher Education Commission and funded through the Health Services Cost Review Commission. The opinions, findings, and conclusions expressed herein do not necessarily reflect the position or policy of the Health Services Cost Review Commission, and no official endorsement should be inferred.