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There is a persistent and growing need to educate and retain nurses who are prepared to competently address patient care needs within complex health care systems. Though recruitment efforts are strong, workforce attrition remains problematic. Approximately 17.5% of newly Registered Nurses (RN) leaves the profession within the first year of practice [1]. Moral distress, and its deleterious effects, contributes to workforce attrition [2,3]. Moral distress, or feeling constrained from acting upon one’s ethical knowing, is associated with powerlessness, compassion fatigue, apathy, and burnout [4,5]. One may recover from adversity and attenuate moral distress, via personal, social and professional capabilities associated with resilience.

Resilience Protective Factors (RPFs) enable effective adaptation and coping amidst distress [6-9]. Per Monteverde, resilience is associated with the capacity to identify ethical issues, justify moral actions, and effectively cope with adversities inherent in health care practice [10]. Concerns about nurse workforce attrition and moral distress should motivate nurse leaders to develop and evaluate educational strategies that strengthen RPFs, preparing the future nursing workforce to thrive amidst ethical challenges. Through educational interventions, it may be possible to equip nurses with capabilities that reduce the deleterious consequences of moral distress.

In this review article, we will first explore literature that clarifies the prevalence of moral distress across healthcare settings and research on RPFs. Second, we synthesize Organizational Communication literature in order to establish why distress is a difficult organizational and professional issue. In reviewing literature across disciplines, we provide a rich understanding of moral distress as a difficult nursing issue and what organizational factors lend to a lack of empowerment. By understanding the factors that lend to distress, the review also establishes the exigencies that call for a new model that promotes a nurse’s capacity to effectively navigate contextual ethical issues within complex health care workplace cultures. Thus, in the third and final portion of the manuscript, we propose and develop a new model, the Nelson-Marsh F.A.C.E heuristic model to enhance resilience and reduce moral distress. Each letter of the acronym represents a step in the process. We explicate each part of the model and offer the Nelson-Marsh Conflict-Risk Assessment Modes and communication strategies for each risk assessment scenario in order to provide nursing educators and post-licensure practicing nurses with effective communication and conflict management strategies. We argue that the Nelson-Marsh F.A.C.E. model and corresponding Nelson-Marsh Conflict-Risk Modes developed in this article will strengthen RPFs and empower one’s ability to act on moral convictions during distressing situations.


Originally published in Global Journal of Health Science and Nursing, Vol. 2, No. 1, (2019).