Moral resilience in health: A concept analysis

Abstract

Background

Moral distress contributes to serious consequences, and cultivating individual moral resilience has been proposed as a promising approach to mitigating the detrimental impact of moral distress, despite its varying definitions.

Methods

A scoping review of the literature was conducted to analyse the concept of moral resilience in health, following the principles recommended by the Joanna Briggs Institute and the Walker and Avant conceptual analysis method.

Results

From the 39 articles included in this review, six key attributes, nine antecedents and six consequences were identified. A definition of moral resilience is described based on the literature.

Conclusion

Moral resilience is the inherent ability or process to sustain, restore, or deepen one's moral integrity when confronted with moral adversity situations and moral distress. This ability can be challenged or degraded but not extinguished. Understanding the antecedents of moral resilience is crucial for developing effective strategies to promote it. Identifying the consequences of moral resilience can emphasise its importance.

Keywords

Concept formation ethics ethical dilemmas moral distress moral resilience

Introduction

The term ‘moral’, derived from the Latin word mores, refers to the normative domain, customs and rules and is sometimes used interchangeably with ‘ethics’. However, ethics, as a branch of philosophy, involves critical reflection on human actions and the principles that guide them.^1,2 In this way, ethics provides the foundation for morality.¹ To achieve happiness and well-being, a person must fulfil moral duties and personal ideals, which provide meaning to life. Therefore, moral action extends beyond merely meeting legal and socially imposed requirements, encompassing deliberate and principles engagement with the world.³ The inability to fulfil a moral obligation can lead to moral distress.²

The concept of moral distress was first described by Andrew Jameton in 1984 as the experience of knowing the right thing to do while being in a situation where it is nearly impossible to act accordingly due to organizational constraints.⁴ Although any healthcare professional can experience moral distress, this condition has been particularly associated with nurses.⁵ Given the human nature of nursing professionals and the subjectivity of the moral distress phenomenon, it is impossible to eradicate it.⁶ Moral distress can lead to various negative effects, including sadness, anger, anxiety, guilt, frustration, dissatisfaction, hopelessness, burnout and the desire to leave a job or quit their profession. It can also result in negative effects on patients, such as poor patient outcomes and reduced quality of care.^7–9 However, moral distress can catalyse positive outcomes, such as moral resilience and personal growth.¹⁰ According to Rushton, shifting the focus from hopelessness to resilience offers promising opportunities for designing interventions that mitigate the effects of moral distress and foster resilience.¹⁰ Resilience consists of the individual's ability to successfully recover and adapt to adversity.¹¹ Moral resilience, an evolving concept, can help healthcare professionals navigate ethical challenges.⁹ It's particularly important for nurses facing increasing moral dilemmas due to recent health sciences and technology advances.^12,13 According to Young and Rushton's concept analysis of moral resilience, more conceptual work is needed to understand the definition of moral resilience and evaluate the capacity of moral resilience to mitigate moral distress.¹⁴

Since 2017, new theoretical advancements and empirical findings, particularly from ethical dilemmas faced by healthcare professionals during the pandemic, could provide fresh insights into the practical implications of moral resilience. This analysis could offer strategies to enhance moral resilience in professional training and organizational settings.

The analysis and development of concepts facilitate the evolution and expansion of knowledge by standardizing the description of phenomena, thereby contributing to the advancement of the body of knowledge within the nursing discipline.^15,16

The concept analysis method proposed by Walker and Avant is considered a simple, clear and easy-to-apply method, consisting of eight stages, which are as follows: select the concept to analyse; define the aims or purpose of the analysis; identify the possible uses of the concept; determine its attributes; identify the model case; identify related, borderline, contrary, invented and illegitimate cases; identify its antecedents and consequences; and define the empirical referents.^16,17 According to Walker and Avant in concept analysis, the stages do not always occur sequentially, as they are iterative. The iterative nature of the stages can make the process more precise. They also add that a literature review is usually necessary before the concept analysis.¹⁷ Also, scoping reviews seem adequate for concept analysis.¹⁸

Review questions:

How is moral resilience defined in the literature?

What are the attributes, antecedents, consequences and empirical referents of moral resilience?

Method

A scoping review was conducted following the guidelines from the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis¹⁸ and the methodology outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). This conceptual analysis aimed to map the definitions and to identify the attributes, the antecedents and the consequences of moral resilience.

According to the JBI guidelines, the inclusion criteria were as follows: Participants – all types of participants within healthcare settings; Concept – studies related to moral resilience, including at least the definition, antecedents, consequences and empirical referents; Context – all contexts in healthcare; Types of studies – primary studies with qualitative, quantitative or mixed studies, as well as all types of literature reviews, were included. Books, books chapters, editorials, opinion papers, meeting reports and letters to the editor were excluded.

A preliminary search was conducted to identify text words related to moral resilience in the titles and abstracts of relevant articles in PubMed and CINAHL. No MeSH Terms or CINAHL terms related to moral resilience were identified.

The search strategy was developed with the collaboration of a scientific librarian on 16 July 2024, and applied to the following databases: CINAHL Complete, Pubmed and Scopus, presented in Table 1.

Table 1.

Search query.

Databases	Search expression	Results
CINAHL Complete	TI (‘moral resilience’ OR ‘morally resilient’ OR ‘moral resiliency’)	62
PubMed	‘moral resilience’[Title] OR ‘morally resilient’[Title] OR ‘moral resiliency’[Title]	58
Scopus	TITLE (‘moral resilience’ OR ‘morally resilient’ OR ‘moral resiliency’)	68

All articles in English and Portuguese were considered. After the search, the study records were extracted and uploaded to the bibliographic review support software Rayyan. The process of identifying the articles was then carried out, including eliminating duplicates, assessing eligibility and selecting articles. Two reviewers conducted article screening. In the face of disagreements, a final decision was reached by consensus between the reviewers, and there was no need to call a third reviewer.

A total of 37 articles were selected for the review. The bibliographic references of the identified articles were examined to identify additional studies. Two independent reviewers conducted the full-text reading and analysis of the 37 articles and performed the data extraction. Due to the number of papers selected, the reviewers initially created a data extraction tool to capture the following aspects of each study: authors, year of publication, title and key findings relevant to addressing the purpose of this review, such as definitions, attributes, antecedents, consequences and empirical referents of moral resilience, according to Walker and Avant methos for concept analysis. The various stages of the selection of evidence are represented in a PRISMA-ScR flow diagram (Figure 1).

Figure 1.

PRISMA-ScR flow diagram.

Results

The studies included have diverse typologies and focused on moral resilience across various groups, including healthcare professionals (with a greater emphasis on nurses), healthcare students, occupational or social workers, chaplains and young carers. As illustrated in the graph in Figure 2, there has been a considerable increase in the publication of studies on this subject since 2019.

Figure 2.

Publication years of studies.

Definitions

The definition of moral resilience varied across the studies. Rushton's definition of moral resilience, ‘as the capacity of an individual to sustain or restore their integrity in response to moral complexity, confusion, distress, or setbacks’¹⁹ was the most cited and was used in 15 studies.^20–34 In 2018, the first book dedicated to moral resilience (Moral Resilience: Transforming Moral Suffering in Healthcare), was published.³⁵ The definition of moral resilience set out in this significant piece of scholarship has become highly influential, having been cited in 11 papers^36–46 and serving as a cornerstone for subsequent research in the field. Building on this impact, the second edition of the book was published in 2025. Osifeso et al. proposed a different definition to accommodate contemporary research results and to address the team´s components of moral resilience: ‘the ability of an individual or team to develop or implement effective coping strategies that foster, maintain, or restore integrity when faced with potentially morally injurious events’.²¹ Additionally, the concept of ‘collective moral resilience’ emerged during the COVID-19 pandemic, reflecting the shared experiences of moral suffering among healthcare professionals.⁴⁵

All the definitions of moral resilience found in the literature are presented, in chronological order, in Table 2.

Table 2.

Definitions of moral resilience.

Publication date	Authors	Definitions of moral resilience
2005	Oser and Reichenbach ⁴⁷	Moral resilience ‘serves the inhibition of an immoral act which would represent great advantage to the moral subject’ (p.204). It is demonstrated when a person chooses to face potential punishment, loss, or failure for the sake of upholding their moral principles.
2013	Lützén and Ewalds-Kvist ⁴⁸	‘moral resilience – a concept that can be defined as a distinctive sense that life is meaningful under every condition’ (p.320) and ‘a personal and cultural strategy of attributing existential meaning to a dreadful event’ (p.322)
2016	Monteverde ⁴⁹	‘moral resilience operationally as a reduction of moral distress in a given axis of time measured by a validated tool’ (p.104). And can be ‘(understood as the capability to “name” and “frame” ethical issues) can be seen as a necessary condition for moral action’ (p.112).
2016	Rushton ¹⁹	‘Moral resilience is defined as the capacity of an individual to sustain or restore their integrity in response to moral complexity, confusion, distress, or setbacks’ (p.112).
2018	Rushton ³⁵	‘the ability to preserve or restore integrity in response to moral adversity’ (p.125).
2019	Defilippis et al.²³	Moral resilience ‘is best understood as a virtue with two associated vices, faintheartedness and rigidity’ (p.1). This virtue ‘is the character trait, which allow nurses to remain open for compromises with themselves and with the given situation without compromising their own moral integrity’ (p.5). ‘The lack of moral resilience is represented by the vice of faint heartedness’ (p.5) and its excess is described as ‘rigidity or inflexibility, that is to say a lack of readiness for any kind of compromise’ (p.5).
2022	Faraco et al.⁵⁰	‘Moral resilience is the ability to preserve or recover moral integrity through the development of skills that strengthen the connection and commitment to the primary intentions of individuals, in the face of morally complex, ambiguous, or conflicting situations’ (p.1254).
2023	Osifeso et al. ²¹	‘Moral resilience is the ability of an individual or team to develop or implement effective coping strategies that foster, maintain, or restore integrity when faced with potentially morally injurious events’ (p.485).

The majority of authors describe moral resilience as an ability or a process, emphasizing that it can be cultivated or enacted.^21,35,50 According to the literature, an agent is someone who demonstrates moral resilience, which can apply to either an individual^19,21,23,35^47–50 or a team.²¹ Moral resilience is exhibited when confronting ethical challenges, navigating morally complex situations, or from moral distress.^{19,21,35,49,50} Moral resilience is crucial because it preserves or restores moral integrity, enabling individuals or teams to derive meaning from their experiences.^{19,21,23,35,48,50}

According to the previous table, moral resilience seems to be a four-dimensional concept, illustrated in Figure 3: (1 – what?) an ability or a process (2 – who?) where the individual or team endorses their capacity to cope (3 – why?) after experiencing moral distress or facing morally complex situations (4 – what for) to maintain or restore their moral integrity and find meaning in their experience.

Figure 3.

A diagram illustrating the four dimensions of moral resilience.

Attributes

Attributes are defined as the main characteristics of the concept under study.¹⁷ These characteristics distinguish it from other concepts and highlight its uniqueness.^15,17 According to Walker and Avant, an attribute cannot be an antecedent or a consequence.¹⁷ The 39 articles identified six key attributes: personal integrity, buoyancy, self-regulation, self-stewardship, relational integrity and moral efficacy. These attributes align with the domains identified by Heinze et al., Holtz et al. and Rushton et al.^{30,39,41,44,45} The attributes, the antecedents and the consequences of moral resilience are illustrated in Figure 4.

Figure 4.

Antecedents, attributes and consequences of moral resilience.

Personal integrity

Moral resilience depends on an individual's personal strengths, belief system and knowing one's own values.^20,29 Personal integrity, or moral wholeness, is the ability to maintain one's beliefs and values in challenging ethical situations and is an important aspect of moral resilience. It involves staying true to one's values despite adversity, reflecting a state of balance and harmony.^21,30,36,44 An essential aspect of personal integrity is embracing uncertainty and moving forward despite challenging circumstances. This enables nurses to uphold their principles and justify what is morally right. Personal integrity aligns values with actions.^30,45 Moral resilience can also guide an individual in restoring integrity in the face of moral adversity.^42,43

Buoyancy

Buoyancy is characterized as the ability to ‘bounce back’ from situations that threaten one's integrity by using personal strengths to restore it. When facing ethical challenges, a person will show courage and may gain new perspectives or outlooks that will help them respond to future ethical decisions.^30,44 It helps mitigate feelings of being overwhelmed by moral suffering, allowing individuals to navigate distress, learn and grow from the experience.^30,44,51 It reflects the ability to withstand threats to integrity by drawing on inner strength and remaining open to reconsidering one's position in order to preserve or restore integrity.³⁰

Self-regulation

Self-regulation involves being self-aware of one's mental, emotional and physical states and being able to control them.^21,30 It is a crucial biological and psychological mechanism that enables individuals to respond to and adapt in the face of adversity. By observing their somatic, mental and emotional states without becoming overwhelmed or distracted, individuals can maintain flexibility and remain grounded while drawing on their insight and wisdom.^20,30,51 Self-regulation goes beyond self-awareness. It requires individuals to remain flexible, stable and clear when navigating morally complex situations in which their values conflict with others’.³⁰ When a person feels upset or anxious, self-regulation helps shift them toward balance and wisdom.^30,44 Self-care, mindfulness, yoga and meditation are strategies that help foster self-regulation and resilience.^22,23,29,34

Self-stewardship

Self-stewardship involves recognizing and attending to one's well-being while acknowledging personal needs and limitations.^30,44,51 Healthcare professionals must be able to provide care without compromising their own health by placing excessive emphasis on the needs of others.^30,44 Self-stewardship enables professionals to balance the needs of others with their own by taking care of themselves and prioritizing their well-being.^30,44 In this way, healthcare professionals acknowledge their worth and take actions to preserve their health and well-being.^34,39,50

Relational integrity

Relational integrity differs from personal integrity in that it involves balancing personal values with professional commitments to prioritise the interests of those served.³⁰ Stability in relationships with coworkers is a key aspect of this attribute.^36,52 It emphasises regulating work relationships with respect and appreciation as core values. It involves working with others with diverse values while maintaining one's values and well-being through self-stewardship.^45,53,54 Healthcare professionals, leaders, coordinators, social workers, chaplains, occupational workers, families and patients often encounter challenging decisions involving diverse and conflicting opinions, beliefs and values.^{20,21,27,30,33,44} Flexibility and openness to these differences are crucial for maintaining integrity while navigating such situations.³⁰

Moral efficacy

Moral efficacy enables individuals (and teams) to feel capable and confident in addressing morally complex situations while remaining true to their values and convictions despite existing constraints.^{20,22,31,36,39,49,51} In this way, healthcare professionals can communicate their beliefs in a manner that reflects their integrity, advocate for their values and become better equipped to effectively address complex and often persistent ethical issues that arise in clinical practice.^30–32^,37,40,51

Antecedents

Antecedents refer to the events or phenomena that precede the concept, occurring before it.^15,17 The antecedents of moral resilience can be divided into individual characteristics and external factors. The individual characteristics include understanding your values and beliefs, moral sensitivity, moral awareness, self-awareness, self-care and a sense of purpose in life. The external factors include education, especially in ethics, moral adversity and a healthy workplace.

Understanding your values and beliefs

Understanding one's guiding principles and values is essential, as they underpin ethical decision-making and reflect individuals’ moral codes, ethical commitments and core beliefs.²¹ In line with Defilippis et al. grounded theory study, the development of moral resilience requires that nurses have clarity about their guiding values.⁵³ Without this understanding, it becomes easier to compromise or make choices that conflict with one's moral framework, especially in ethically challenging circumstances.²¹

Understanding your values and beliefs is the foundation of personal integrity. When individuals have a clear awareness of what they stand for, they are better equipped to act consistently with those values and beliefs, even when faced with ethically or morally challenging situations.²¹

Understanding your values and beliefs is also essential to relational integrity because it enables individuals to navigate situations that require balancing personal convictions with professional responsibilities, while also respecting clients’ needs.²¹ According to Osifero et al., some occupational workers preserved their personal and relational integrity by leaving their positions or even the profession entirely, as this was the only way they could maintain their values, beliefs and ethical commitments.²¹ Not being able to practice according to one's personal and professional values of what represents good care can compromise well-being, lead healthcare professionals to drop out of the profession, or result in a loss of idealism.²⁰ That is why it is extremely important to understand one's own values, be able to self-regulate, remain flexible in complex ethical situations, distinguish the boundaries of integrity, act decisively in morally challenging circumstances and find meaning when integrity is threatened.²⁰

According to Defilippis et al., moral resilience in nursing practice is best understood as a virtue. Like any virtue, it has two associated vices: deficiency (faintheartedness) and excess (rigidity or inflexibility).²³ When deficient, individuals may recognize the moral dimension of a situation but fail to uphold their integrity under pressure and refrain from intervening.²³ In excess, individuals may become overly rigid and less open to others’ perspectives and preferences and resistant to compromise when making moral decisions.²³ This virtue is properly expressed only when guided by practical wisdom, which enables nurses to discern when firmness is required and when flexibility and openness to others are morally appropriate.²³

If individuals receive work orders that conflict with their own moral values and/or beliefs, it can lead to moral distress if they lack the courage, more specifically, the moral courage, to act upon their convictions.²¹

Moral sensitivity

Moral sensitivity refers to a subjective insight in which nurses recognize the moral implications involved in making decisions on behalf of another individual, as well as an immediate awareness of the vulnerable position of those affected by such decisions.⁴⁸ It represents a positive attribute that enables nurses to perceive the moral nature of encounters with others and to empathize with their experiences.^19,48 When moral sensitivity weakens, the focus may shift from the vulnerable other to self-protective concern.⁴⁸

Jacobs highlights that high levels of moral sensitivity can support emotion regulation, equanimity and compassionate responses.²⁰ However, moral sensitivity may function either as a stressor or as a source of wellbeing, depending on the meaning the individual attributes to it.²⁰

Kovanci and Özbas found in their study that nurses with postgraduate education reported higher levels of moral distress. These findings remain debated, while some argue that advanced education increases professionals’ moral sensitivity and thus their vulnerability to moral distress, others suggest it can reduce distress by strengthening nurses’ confidence, competence and communication skills in patient care.²⁵

Moral sensitivity, defined as an ongoing awareness of ethical implications and others’ vulnerability, contributes to moral resilience by informing moral actions and decisions.²⁰

Moral awareness

Moral awareness is the ability to recognize the ethical implications in a given situation. This requires the capacity to perceive and interpret the moral dimension of a situation, often referred to as moral sensitivity.^23,48 Moral awareness should be cultivated during nursing education through the discussion of everyday healthcare situations that present ethical challenges.⁵³ It further develops with professional experience and personal knowledge.⁵³ Consequently, moral and self-awareness are essential for fostering moral resilience.⁵³

The implementation of programs such as Concentrate, Unrush, Reflect, and Act (CURA), which help healthcare professionals become more aware of moral challenges and reflect on them, significantly increases moral resilience and moral competence among healthcare professionals.³⁸ Moral competences are described as the set of skills that enables an individual to act according to their judgment while remaining morally responsible. These skills include understanding one's own values, perceiving moral conflicts, considering others’ perspectives and having the courage to act.³⁸ Individual moral competences are assessed based on their moral awareness, analytical skills and virtuous attitudes when confronted with morally challenging situations.³⁸

Self-awareness

Self-awareness involves recognizing one's own limitations, physical reactions and feelings, which helps individuals understand moral challenges and make informed decisions.^21,22,53 Cultivating self-awareness allows nurses to face moral challenges with greater clarity, confidence and less personal impact from moral distress.²²

Self-care

Self-care strategies include physical exercise, spiritual practices, mindfulness, yoga, meditation, reading, pursuing recreational interests and maintaining a healthy work–life balance.^{21,39,40,46,50,55} Mindfulness, meditation and yoga offer effective techniques for building moral resilience.²⁹ Longer sleep duration was linked to greater moral resilience.³⁴ Self-care practices can foster self-stewardship, which in turn supports the development of moral resilience.^34,39 Prioritizing self-care in morally distressing situations involves individualized approaches such as stepping away from conflict, taking breaks and pursuing hobbies.²¹ This can help individuals defend their moral principles and maintain their firmness, stability and their well-being during challenging circumstances.⁵⁰

Sense of purpose in life

According to Lützén and Ewalds-Kvist, people have the ability to decide how they respond to events and challenges, including their attitude towards unavoidable suffering. By cultivating a sense of existential purpose, individuals may experience a deeper sense of meaning in life, even under severe stress.⁴⁸ As described by Boyle's study on the moral resilience of young people who care, young carers felt a sense of moral worth and duty from their roles, finding a purpose in unavoidable suffering.³³ Their ability to find meaning in caregiving, adapt their lives to meet their loved one's needs and withstand societal disregard reflected ethical values characteristic of moral resilience.³³ Healthcare professionals who perceive their support of and respect for patients’ preferences as meaningful, both for the patients and within the scope of their professional obligations, may be better able to restore their own moral well-being.¹⁹ Regaining a sense of personal agency enables healthcare professionals to gain insight, recognize value and create meaning from situations that would otherwise seem senseless.¹⁹ The ability to find significance amid morally challenging circumstances is essential for cultivating moral resilience because it fosters gratitude for the aspects of healthcare work that provide purpose and fulfilment.¹⁹ Therefore, one way to foster moral resilience is to encourage the development of a clear sense of meaning and purpose in life.⁴⁸

Education, especially in ethics

Moral resilience can be cultivated through ethics education.^46,55 In agreement with Defilippis et al., health professions educators should encourage nurses to develop a greater understanding of their moral values and boundaries through reflection on their practice experiences.²³ Nursing students should be trained to critically reflect on both their personal and professional values, be acquainted with core nursing values and develop insight into nursing ethics frameworks, thereby fostering a coherent integration of personal and professional ethical perspectives.⁵³ Throughout their clinical practice, nurses should have opportunities to continue their education in nursing ethics and engage in ethical case discussions, potentially under the guidance of clinical ethicists.⁵³ This will enhance their understanding of their colleagues’ perspectives, cultivate their moral and self-awareness and strengthen peer support.⁵³

According to Wald and Monteverde, educators support healthcare students in developing their professional identity, including the internalization of attitudes, values and behaviours that are reflected in the practice setting through their thinking and interactions with colleagues and patients.²⁴ Moral education primarily involves teaching students to apply ethical theories to real-life cases or problems, simplifying complex ethical concepts so they can develop their ethical reasoning.⁵⁴ By equipping healthcare professionals with ethical frameworks and decision-making skills, such education helps them navigate moral challenges and maintain their integrity in the face of adversity.^24,49 The ‘process of naming and framing ethical issues fosters the moral resilience of students through the reduction of ethical complexity and the negative effects of the informal ethics curriculum’.⁵⁴ ‘Through specific case studies and simulated situations, nurses can better understand and address clinical ethical issues’.³¹ Baker-Townsend and Cummings emphasize the importance of incorporating the study of moral distress and moral resilience into undergraduate nursing programs to ensure these concepts are addressed throughout the curriculum.²⁹ This approach aims to foster moral resilience by equipping students with the necessary skills and strategies to navigate morally challenging situations.²⁹ It prepares students for the realities of healthcare practice, reduces moral suffering and distress and mitigates nurse turnover and the intention to leave the profession.²⁹

The articles identified four specific programs designed to foster moral resilience. The Nurse Education and Support Team coach program was created to educate and support nurses facing morally and ethically challenging situations, through education and peer support. To prepare for their coaching roles, nurses participated in conferences and seminars on compassion, paediatric palliative care, ethics, self-care, spiritual care and relational and communication skills. Because if nurses reflect with clarity about moral challenges, they may be able to respond in a way that it congruent with their personal values and beliefs.²²

CURA is a program where healthcare professionals, either in small groups or individually, reflect on morally challenging situations. By encouraging dialogue among participants and promoting openness to exploring others’ perspectives, this program helps them develop moral competencies and manage moral distress. The CURA program invites nurses to reflect on their own values while considering the values of others.³⁸

Moral Case Deliberation is a clinical ethics support approach that fosters moral resilience. It employs three methods: the Dilemma Method, which addresses the tragic aspects of moral dilemmas, and Aristotelian moral inquiry and CURA, which focus on the emotional dimensions of facing moral challenges.²⁶

The Mindful Ethical Practice and Resilience Academy is an evidence-based program for nurses to enhance moral resilience and develop resources like mindfulness, ethical competence, work engagement and confidence to address ethical challenges.^34,41,56

Moral adversity

Reflection on moral issues involves engaging with moral challenges and deliberations, especially when exposed to potentially morally injurious events.^20,21 Adversity is a key aspect of resilience, and learning from these morally difficult challenges is essential for human flourishing.³⁷ Resilience can be cultivated through exposure to risk or adversity, especially when it arises from ethically complex situations that cause unresolved ethical conflicts in which individuals’ moral integrity are challenged or threatened, because they have to cope with various moral adversities.^23,43,49 Moral adversity can lead to various forms of moral suffering, such as moral distress and moral injury.^30,37,43 However, it can also increase an individual's moral resilience.^43,49 In Weissinger et al.'s study, critical care nurses who were able to respond to morally adverse events reported lower levels of traumatic stress and fewer symptoms of moral injury.³⁷ According to Monteverde, healthcare students need to be aware of moral stressors to develop their moral resilience.⁵⁴ To support this, teachers must recognize the moral stressors that exist in healthcare nowadays, such as malpractice or deficiencies in health organizations.⁵⁴ They must also be aware of the contemporary moral complexity inherent in medical and nursing practice, as well as the increasing knowledge and diversity of values among healthcare professionals and patients’ preferences.⁵⁴ This awareness will enable them to help healthcare students develop the skills they need to navigate morally complex situations.⁵⁴ Moral resilience can be a favourable and desirable outcome that is fostered in response to situations of moral adversity.^49,54 The Rushton Moral Resilience Scale has a category titled Responses to Moral Adversity.⁴⁴ This category assesses how a person handles ethical challenges.^43,44

Healthy workplace

Healthcare professionals who frequently encounter moral challenges need individual and organizational support to nurture their well-being and mitigate the adverse effects of trauma and moral injury.⁴⁵ Enhancing collaboration among peers can promote moral resilience by sharing experiences and information in meetings. This process can serve as a form of reappraisal, providing new insights, support and strengthening relationships.^20,21,38 The existing evidence indicates that chaplains can significantly support healthcare professionals dealing with moral distress and moral injury. Spiritual care fosters moral resilience by providing supportive relationships that help individuals manage and integrate moral stress.²⁷

According to the study by Spilg et al., a higher level of support from colleagues and employers during the COVID-19 pandemic was found to be a significant factor associated with moral resilience.³⁴ However, the Brewer et al. study, which explored the relationship between workplace characteristics and moral resilience, found that leadership style did not affect moral resilience scores.⁵² This suggests that moral resilience can exist as an innate trait that cannot be extinguished by the work environment or leaders’ interactions.⁵² This is plausible because moral resilience is shaped by a combination of work-related, societal, environmental and life factors.⁵² Osifero et al. highlight that organizational and leadership support enhances moral resilience by fostering psychological safety through leaders’ genuine recognition of employees’ contributions and well-being.²¹ For this reason, healthcare professionals who perceive greater organizational support also exhibit higher moral resilience scores and lower levels of moral distress.²¹

‘At the organizational level, interventions such as communication programs, strengthening physician-nurse collaboration, involving nurses in clinical decision-making and end-of-life issues, providing social support, using resiliency bundles, fostering interdisciplinary discussions and promoting ethical and communication skills can enhance nurses’ moral resilience’.⁵⁵ Organizational ethical support, through the creation of institutional structures to identify and address ethical concerns, is essential for developing moral resilience, achieved through fostering an ethical workplace environment, that improves the quality of care and develops the moral competence of healthcare professionals.^{30,34,38,39,45} In an ethical work culture, healthcare professionals are supported in making complex ethical decisions and perceive their workplace as prioritizing quality and safety.⁵¹ Additionally, an ethics consultation is proposed as an intervention to mitigate moral distress and further enhance moral resilience by facilitating dialogue and discussion about challenging situations^26,34 since ‘it is difficult for moral resilience to flourish in environments that do not emphasise a culture of ethical practice’.⁵⁷

Healthcare professionals’ resilience, or buoyancy, can be sustained or enhanced when they perceive their organization as supportive, even during challenging care scenarios such as the COVID-19 pandemic.^52,55,56 Organizational decisions, policies and resource allocation shape nurses’ perceptions of organizational effectiveness and can contribute either to symptoms of moral injury or to the development of moral resilience.⁵⁶ Therefore, organizations should invest in support programs that promote and develop moral resilience.^34,41,56

Consequences

Consequences are the situations or phenomena resulting from the occurrence of the concept and can be referred to as the outcomes of the concept.^15,17 The consequences were grouped into six categories: ethical competence; personal and professional growth; finding meaning; improved mental and physical health; decreased moral distress, burnout and turnover; and increased engagement and work satisfaction.

Ethical competence

Yu et al. studied the relationship between ethical climate, moral resilience and ethical competence among head nurses and verified that a positive organizational ethical climate significantly enhances individual moral resilience. They found that ‘nurses’ ethical climate score and moral resilience can be direct predictors of ethical competence, and ethical climate can indirectly predict ethical competence through moral resilience’.³⁹ Moral resilience gives healthcare professionals the skills and knowledge needed for ethical competence.⁵¹

Personal and professional growth

Resilience enables individuals to cope and grow from stressful or negative situations.²⁵ Moral challenges can serve as catalysts for personal and professional growth.^28,51 By nurturing moral resilience, individuals can learn from ethically challenging situations, enhancing their moral confidence and ethical competence.³⁹

Finding meaning

Finding meaning in every experience can transform a negative situation into a hopeful one.^20,40,58 In times of trauma and existential crisis, finding meaning helps moderate unpleasant feelings and explains differences in individuals’ vulnerability to stressors.⁴⁸ Finding a meaning is crucial for human survival and growth.¹⁹ According to the findings of Osifero et al., occupational workers engage in discussions with coworkers to reappraise their experiences and emotional status. They do this by developing a new meaning of a distressing event and focusing on meaningful aspects of their work rather than distressing ones.²¹

Improve mental and physical health

Moral resilience enables individuals to maintain, restore, or improve their physical and mental well-being when facing ethical dilemmas.^{31,40,44,46,51} Spilg et al. examined the relationship between the moral distress of healthcare professionals and their mental health during the COVID-19 pandemic, concluding that higher levels of moral resilience were correlated with lower levels of stress, anxiety and depression. This suggests that moral resilience may be crucial in reducing moral distress during major stressors like the COVID-19 pandemic, which can positively impact overall mental health.³⁴

Decrease moral distress, burnout and turnover

Higher levels of moral resilience were associated with lower perceived stress, anxiety, depression, moral injury and moral distress.^{37,40,41,45,46,52,56} Weissinger et al.'s study examined the relationship between moral injury, traumatic stress and moral resilience. Their findings indicated that most critical care nurses experience significant traumatic stress and/or symptoms of moral injury, both of which contribute to patient-related burnout. However, nurses who scored higher on the Response to Moral Adversity subscale of the Rushton Moral Resilience Scale were at lower risk of experiencing traumatic stress and moral injury symptoms.³⁷ Berdina and Grande's study found that moral courage and moral resilience were negatively associated with moral injury and moral distress.⁴⁰ Kovanci and Özbas examined the effect of moral resilience on moral distress and confirmed that moral resilience reduces the negative effects of moral distress. They also found that younger nurses with less experience have lower levels of moral resilience.²⁵ Katsiroumpa et al. found a negative correlation between moral resilience and moral distress, job burnout, and quiet quitting, suggesting that moral resilience can be a protective factor against work-related problems.⁵⁹ Fostering moral resilience is a key strategy that may help mitigate burnout, poor patient care and turnover, all negative consequences of moral distress.^{26,36,40,51,58}

Increase work engagement and satisfaction

Studies have shown that healthcare professionals with higher moral resilience are linked to greater engagement with their organization,⁵⁵ job satisfaction,^51,58 improve nurse retention rates,^58,59 and positively affect nurses’ compassion satisfaction.⁵²

Empirical referents

Defining the empirical referents is the final step in a concept analysis.¹⁷ Empirical referents are categories or indicators that help measure the occurrence of the concept, making them essential for developing a tool to assess the concept itself.¹⁷ Reliable scales to measure moral resilience can help employers develop programs that better serve their employees.⁴²

The Rushton Moral Resilience Scale is the only tool developed specifically to assess moral resilience in chaplains, nurses, physicians and social workers, aiding researchers in evaluating the moral resilience of healthcare professionals and assessing interventions.^25,43,44 This scale consists of four categories: response to adversity, personal integrity, relational integrity and moral efficacy, based on the six domains of moral resilience.^20,27 The revised Rushton Moral Resilience Scale has improved the personal integrity sub-scale to achieve higher reliability.²⁰

Since cultural values impact the ethical experiences of healthcare professionals, the Rushton Moral Resilience Scale has been translated and validated for use with Chinese and Greek nurses, as well as Turkish healthcare professionals.^25,43,59

Holtz et al. determined the qualities and skills that enable an individual to be morally resilient, including courage, humility, empathy and compassion. Courage involves standing up for one's beliefs without fear. Humility means acknowledging that one does not have all the answers, being open to discovering the best actions in each situation and accepting things as they are without rigidly clinging to one's own viewpoint, which implies flexibility. Empathy helps individuals understand and share others’ feelings, while compassion drives them to take action in response to others’ suffering.^30,36

Figure 5 shows a graphical representation of the concept of moral resilience as described in the literature.

Figure 5.

Concept graph of moral resilience.

Discussion

Resilience is an inherent state, present to varying degrees in all people, that allows individuals to cope with challenges and grow from difficult or negative experiences.²⁵ However, moral resilience is emerging as a concept and an inherent strength that can be nurtured, enhanced and developed over time through the cultivation of specific skills.^14,25,31 It has been suggested as a pathway to mitigate the negative effects of moral adversity³⁹ and can also serve as a protective factor against moral distress and burnout.^31,42,52

True resilience involves accepting situational limitations and recognizing when situations are beyond an individual's control.³² Moral resilience helps individuals gain new perspectives when facing ethical challenges, find meaning, act following their own moral code, remain open and flexible to the beliefs and values of others, and increase their confidence in their ability to respond effectively to ethical dilemmas and uphold fundamental moral commitments.^25,31,36

This conceptual analysis revealed that moral resilience involves both the individual's ability to navigate morally complex situations and the interactive processes that include continuous learning and organizational support.²⁰ These processes aim to strengthen skills and coping strategies so individuals can adapt to and recover from moral challenges.^20,21 However, education alone cannot cultivate moral resilience without prior knowledge of one's moral foundation, such as moral awareness, moral sensitivity and an understanding of one's moral framework (values, beliefs and principles).^48,49,53 Therefore, individuals must develop a clear sense of professional identity, as well as their core values and beliefs, to guide decision-making and uphold moral duties.²⁴ Moral adversity alone is not sufficient to foster moral resilience or personal growth.³⁷ Since morally adverse circumstances are inevitable in the healthcare system, professionals must also develop the necessary skills to navigate them.³⁷

Several antecedents contribute to the development of moral resilience. At the individual level, these include understanding one's values and beliefs, moral sensitivity, moral awareness, self-awareness, self-care and maintaining a sense of purpose in life. Self-care can be defined as all the actions taken to promote an individual's well-being and health.⁶⁰ Self-stewardship transcends that by acknowledging both internal and external resources used to honour and protect one's health and well-being, preserving wholeness and integrity through choices that are right for each individual.⁶⁰ It recognizes that nurses are responsible for their own health in the same way they are responsible for their patients’ health. This requires an understanding of one's values, beliefs and limits in order to recognize how experiences influence well-being, cope with adversity and accept circumstances.⁶⁰ As Rushton emphasize, as ‘nurses, it also includes remembering why we have chosen nursing as our path and why the service that nurses provide matters⁶⁰’ (p.195). Education, particularly in ethics, provides frameworks and skills necessary for ethical decision-making.^24,49 Exposure to moral adversity in supportive and reflective environments can strengthen resilience.^37,49 At the organizational level, a healthy workplace that promotes open communication, acknowledges staff contributions, provides adequate resources and has an ethical climate fosters moral resilience.^34,45 Recognizing these antecedents clarifies the conditions necessary for effectively fostering moral resilience.

Moral resilience is further supported by specific attributes, including personal integrity, buoyancy, self-regulation, self-stewardship, relational integrity and moral efficacy. Integrating these attributes into education, leadership development and organizational strengthens both individual and team capacity to navigate morally complex situations.^21,30,44,61

Cultivating moral resilience has significant consequences for individuals and organizations. At the individual level, it promotes ethical competence,³⁹ fosters personal and professional growth,^28,51 and enables healthcare professionals to find meaning in challenging situations.^21,48 These outcomes improve mental and physical health and reduce the risk of moral distress.³⁴ At the organizational level, higher moral resilience is associated with decreased burnout and turnover^{26,36,40,51,58} as well as increased work engagement, satisfaction and retention.^51,55,58 Recognizing these consequences highlights the importance of investing in strategies that strengthen moral resilience as a key component of workforce sustainability.

Conflicts between personal and professional values, between the values of other healthcare professionals or patients, or those resulting from organizational pressures can trigger moral questions and lead to moral distress.^20,25,27 Healthcare professionals must balance flexible decision-making with a firm commitment to professional values and address situations that threaten ethical practice.⁵¹ Maintaining a high degree of coherence with one's personal beliefs and values may result in unhappiness due to a lack of external recognition or rewards.²³ Organizations must recognize that the retention of healthcare professionals can be negatively affected when their personal values conflict with professional practice. Conversely, greater work satisfaction and engagement is associated with the ability to uphold one's values and beliefs by acting in ways that are considered morally appropriate.⁵¹

Due to the vulnerability of healthcare professionals who frequently encounter moral challenges, there is a need for both individual and organizational support to nurture their well-being and moral resilience.^25,41,45,50 Although it is not possible to eliminate all adverse circumstances, institutions and organizations should systematically identify and address the factors that negatively affecting healthcare professionals in order to improve outcomes.³⁷ Understanding the organizational patterns and processes in healthcare that undermine professionals’ moral resilience and exacerbate moral injury is crucial for fostering engagement and mitigating burnout and staff turnover.⁶¹

It is important to avoid placing the burden solely on individuals to handle stressors while acknowledging the role of hostile and austere systems, often shaped by ideological and political decisions.²⁸ Challenges such as bullying, low staffing and reduced autonomy can create systemic barriers that hinder nurses’ ability to respond to moral adversity.⁵² These issues may lead to feelings of institutional betrayal and further undermine resilience.⁵² During the COVID-19 pandemic, the most recent global public health crisis, nurses who viewed their organization as effective had higher levels of moral resilience.^26,61 Rushton et al. demonstrated that organizational effectiveness significantly impacts the well-being, moral resilience and vulnerability to moral injury of nurse leaders.⁶¹ Higher levels of organizational effectiveness were positively associated with greater moral resilience and negatively associated with symptoms of moral injury. These effects were, in turn, were linked to enhanced work engagement and reduced burnout.⁶¹

During public health crises, nurse leaders must balance achieving organizational goals with safeguarding their own well-being and resilience, as well as that of frontline nurses.⁶¹ This dual responsibility is crucial for addressing the multiple ethical challenges and adversities that emerged during the pandemic while ensuring the provision of high-quality care to patients.⁶¹ Without adequate guidance, clear protocols and sufficient resources, organizations risk creating conflicts between leadership and staff that hinder effective decision-making. This can make nurse leaders feel isolated and betrayed.⁶² Organizational effectiveness influences nurse leaders’ experiences. Some of them felt exploited throughout the pandemic, since their professional responsibilities overtook their personal life.^61,62 However, organizational effectiveness characterized by attentiveness to leaders’ concerns and opinions, recognition of their expertise and provision of adequate support can strengthen moral resilience and enhance work engagement.⁶¹ A workplace where nurse leaders can express concerns, without fear of retaliation, builds respect and trust in the organization and promotes their retention.⁶¹ Organizations, employers and nurse leaders are all responsible for supporting nurses in fostering resilience.⁴⁶

Nursing schools should integrate discussions of moral distress and moral resilience throughout their curriculum, presenting these topics openly and honestly to better prepare students for the nursing profession.²⁹

The Rushton Moral Resilience Scale is a tool developed to measure healthcare professionalś moral resilience.^21,44,50 Focusing on moral resilience enables individuals to find solutions and maintain their integrity.⁴⁵ Heinze et al. reported higher moral resilience is independently associated with being male, older and having more professional experience.⁴⁴ While Spilg et al. found that female workers, younger professionals and those with existing mental disorders may be more likely to have lower moral resilience. Giving that nursing is a predominantly a female profession, nurses may face higher risks of detrimental responses to potentially morally distressing events, particularly among younger professionals.³⁴

Review strengths and limitations

This search revealed significant work in this area in recent years. However, since this is a scoping review, the study has not appraised the quality of the existing studies.

A notable strength of this study is the inclusion of sources beyond the nursing literature, highlighting that the term moral resilience applies not only to healthcare professionals but also to chaplains, soldiers, occupational workers and young carers.

The conceptual analysis was further strengthened by the consensus of two researchers in defining codes and themes.

Nevertheless, the current review has several limitations that should be contextualized. Important results may have been missed due to the inclusion criteria.

For example, the study could not identify the negative consequences of moral resilience, such as unhappiness. According to Oser and Reichenbach, individuals who act morally do not always feel positive about the solutions they reach. Those striving to behave decently may experience negative feelings, such as unhappiness and insecurity. As a result, moral resilience might lead to less happiness and, in some cases, inhibit.⁴⁷

Additionally, the authors acknowledge a limitation in the exclusion of certain articles due to the inability to access the full text or the exclusion of non-English and non-Portuguese language publications, which may have influenced the analysis of the findings.

Conclusion

This conceptual analysis emphasizes the importance of organizations supporting their employees in addressing moral adversity and fostering moral resilience.

Moral resilience helps healthcare professionals maintain their integrity and cope with the stress and emotional burden associated with difficult decisions in their work.

Since moral resilience is a protective factor for work-related problems, fostering it may enhance patient safety and satisfaction by improving healthcare professionals’ ability to manage moral adversity. Further studies are needed to understand how moral resilience specifically influences patient outcomes.

Supplemental Material

sj-pdf-1-cet-10.1177_14777509251401123 - Supplemental material for Moral resilience in health: A concept analysis

Supplemental material, sj-pdf-1-cet-10.1177_14777509251401123 for Moral resilience in health: A concept analysis by Laura Sophia Da Silva and Sílvia Caldeira in Clinical Ethics

Footnotes

Acknowledgements

We would like to thank Dr Maria Perdigão for her assistance in conducting the literature search.

ORCID iD

Laura Sophia Da Silva

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Data sharing not applicable to this article as no data sets were generated or analysed during the current study.

Supplemental material

Supplemental material for this article is available online.

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