Phases of Suffering: A Roadmap for Moral Repair

The ethical conundrums that arise in the care of critically ill people are diverse, complex, and challenging. They can involve value conflicts around goals of care or inadequate informed consent, allocation of scarce resources including staff, inequities in access to critical care interventions, and myriad others. Often there are no clear or satisfying resolutions to these complex issues. The vestiges of them remain as moral residue even when we have done our best—all things considered. The moral residue can manifest in a variety of ways including physical, emotional, spiritual, and moral consequences. We may be unable to name the source of our moral suffering or identify the moral adversity that produced it. Or we may be stuck in an endless cycle of questions or grievances that leave us powerless and exhausted. We often wonder: How do I restore my integrity and wholeness in response to the persistent moral residue? How do I see myself as a “good” nurse amid these challenges?Whether expressed as moral stress, distress, or injury, moral suffering is but one response to moral adversity. Broadly defined, moral suffering is “the anguish experienced in response to moral harms, wrongs or failures and unrelieved moral stress.”2(p12–13) It can occur through witnessing, participating in, or directly precipitating situations that produce a wide range of negative moral outcomes that in some way imperil integrity. The suffering can be episodic or sustained, manifest with varying degrees of intensity, and have short- or longer-term consequences. An unavoidable element of our human condition, moral suffering can degrade well-being or fuel learning and transformation. Working with it mindfully and skillfully allows us to address the modifiable factors and to extend compassion and grace to ourselves and our human limitations. Moral resilience, “the ability to preserve or restore integrity in response to moral adversity,” has been proposed to support integrity in response to moral suffering.2(p68) Research has shown it to be a protective resource that nurses and other clinicians can draw upon to meet the inevitable ethical challenges embedded in clinical care.3 Moral repair is an important element in cultivating and sustaining moral resilience. When coupled with systemic investments to create the conditions for restoring moral wholeness and well-being, true healing is possible. See an illustration in the case example.Angela has been a critical care nurse for 2 years, starting in the middle of the COVID-19 pandemic. Her learning curve was steep, and she has been involved in many ethically complex cases. She noticed that she was developing a pattern of responses to these cases that troubled her. Initially, she ruminated about the cases on her way home from work, often second-guessing her actions and castigating herself for being unable to shake the recurrent thoughts.Her sleep patterns were disrupted, and she vacillated between irritability and exhaustion. She felt responsible for the situations she found herself in and was overwhelmed with emotion but could not explain the source of her distress. She became withdrawn and lonely, often lapsing into extended periods of silence or apathy in her personal life.After a while, she noticed that she was becoming more vocal about her concerns at work; she frequently engaged with other nurses to complain about the physicians or family members whom she viewed as “the problem.” She had occasional outbursts on rounds when it appeared that her concerns were being discounted. Her advocacy for certain patients intensified and her reputation in the unit became as a “troublemaker.”Recently she has begun to feel disconnected from the clinical cases and like she is “going through the motions” while she is at work. She feels numb to the consequences of the cases and lacks interest in attempting to find solutions. It scares her that she has lost her sense of identity as a nurse. She wonders what is happening and how she can regain her vigor for being a nurse. Some days she does not know if she belongs in nursing or her unit.Critical care nurses like Angela are intimately familiar with the experience of moral suffering. Moral suffering can be understood as a continuum, so an initial step in working with moral suffering is to locate where you are within that continuum. It often begins with moral stress that alerts us to the presence of moral adversity and its common sources of moral confusion, conflict, or uncertainty and actual or potential imperiled integrity.2,3 At times, these sources of moral stress can be skillfully addressed and resolved. At other times, the moral residue of these situations accumulates. Even though the intensity of emotional turmoil may decrease somewhat following a distressing event, there often remains a lingering sense of moral suffering, known as moral residue. This unresolved distress can encompass feelings of uncertainty, guilt, frustration, and anxiety, leaving health care providers susceptible to what Epstein and Hamric4 call the crescendo effect—a gradual accumulation of moral distress over time. The resulting moral residue may stem from regret or guilt, sometimes arising from the acknowledgment that one’s integrity has been compromised due to external pressures.5 In other instances, it may result from navigating challenging situations where any decision made would fail to fully uphold important moral values or commitments, despite efforts to act in the best possible manner within constrained circumstances.6 Repeated instances of moral suffering can extend beyond the individual to others. In some instances, a collective moral residue can result in relational integrity becoming compromised among groups or teams.7,8 When moral suffering occurs in the form of moral distress or more recalcitrant or corrosive moral injury or moral decline, it can be accompanied by moral outrage, apathy, or disengagement.2,3 See Figure 1 for a typology of moral resilience and ethical practice. Other sources go into more detail.2,3 Once it is clear where nurses like Angela are on the continuum, using a framework such as phases of suffering can offer a useful roadmap for moral repair and healing.In a general sense, “moral repair involves the restoration or establishment of trust and hope in a shared sense of value and responsibility.”9(p28) A range of techniques for moral repair can help restore personal integrity, alleviate individual distress and moral anguish, and reinstate a sense of meaning, significance, and completeness. In clinical settings, the process of moral repair encompasses interventions designed to promote well-being, moral autonomy, and self-confidence; foster mental and emotional equilibrium; tap into inherent resilience; and enhance communication, ethical judgment, and dialogue. The effective alignment of diverse methods necessitates careful assessment and planning. There is no universal solution for moral repair, and often, a multifaceted approach is required. Walker9 provides a detailed framework for devising strategies of moral repair applicable to both individuals and organizations. It is essential to tailor individual, group, and systemic interventions according to the specific needs of clinicians and the underlying causes of their stress or moral suffering.In his seminal work, Warren Reich10 outlines phases of suffering that can be applied to moral adversity and imperiled integrity. He defines suffering as “an anguish experienced as a threat to our composure, integrity, and the fulfillment of our intentions and … as a frustration to the concrete meaning of our personal existence.”10(p85) He describes 3 phases of suffering: (1) voiceless or mute, (2) expressive, and (3) transformative. Reich’s categorization into 3 phases serves as a helpful framework for structuring the support systems and procedures required to tackle moral suffering.10 It is important to note that these phases are not always sequential; individuals might undergo multiple phases concurrently or fluctuate between them, and their duration can vary. Consequently, methods for moral repair need to be tailored to each phase and adjusted according to the distinct requirements and capacities of the individuals involved. Figure 2 illustrates Reich’s phases of suffering.When nurses like Angela experience moral suffering, their initial response may be devoid of language, rendering them mute or voiceless. There may be a “preconscious, inchoate awareness of distress, anxiety, or negative emotions.”2(p196) The inability to articulate and communicate one’s suffering or even to name it leaves vague unrest or discomfort, which can lead to uncertainty or confusion about one’s identity, motivations, or decisions. Without words or concepts to name the source of their suffering, nurses may find the distress becomes an unwelcomed companion undermining their integrity, moral agency, and self-esteem. As depicted in Angela’s case, silence represents one possible reaction to preconscious suffering. In such instances, individuals may be unaware of the signals of their distress, which they potentially interpret as denial, avoidance, indifference, or apathy. Being temporarily speechless—literally or figuratively—according the Reich, differs from simply “suffering in silence”; rather, it involves a profound awareness of suffering that renders one unable to articulate it.10(p86) This does not imply a loss of voice; individuals may be vocally or internally expressing their pain without finding the words to articulate it. Their expressions of distress may seem disconnected from the actual source of their suffering, leading to misinterpretation by observers. Yet, beneath these behaviors lies an expression of the indescribable nature of their suffering. To cope, individuals might adhere to rules and routines or seek solace in familiar structures to avoid directly confronting their distress.Unspeakable and unnamed, the moral suffering becomes isolating and lonely. In the absence of language to articulate the suffering, it is difficult for Angela to describe what she perceives at a deep level. Adopting an attitude of resignation or moral apathy can cause a person to remain immobilized in voiceless suffering. Alternatively, some people respond aggressively, using angry, cynical, or demeaning language and constructing a wall of defensiveness. The discomfort of a person’s suffering can overwhelm other aspects of living and undermine their capacity to exercise their moral agency, develop understanding, or create meaning.10 Physical symptoms or sleep disruption can signal preconscious manifestations that can go undetected, dismissed, or attributed to other factors. Nurses like Angela may also experience physical symptoms such as irritability or being shut down or exhausted. Others may turn to addictive behaviors to relieve the distress or avoid the uncertainty or meaninglessness. Cynicism, withdrawal, or sadness may appear without explanation. Since these are also common signs of burnout, it is important to discern the roots of the feelings and responses.When nurses find themselves unable to articulate their thoughts and emotions, their suffering becomes voiceless and remains submerged in their subconscious. During this phase, nurses such as Angela may struggle to verbalize their suffering, comprehend it, discern its significance, or empathize with it or share to their experiences with others. They might lose touch with their core identity as individuals or professionals or find it challenging to alter their perspective or experience with their reality. This state of voicelessness may indicate a profound sense of hopelessness, unprocessed collective suffering, or personal anguish stemming from historical, cultural, or institutional factors.This voiceless phase persists until the individual reaches a threshold of tolerance and becomes sufficiently liberated from suffering to explore avenues for expression. Interventions at this stage aim to identify subtle signs of distress and establish safe, supportive, nonjudgmental environments for introspection, inquiry, and dialogue. Above all, offering compassionate presence, actively listening, and bearing witness to the experience, without attempting to offer immediate solutions or consolation, can facilitate the individual’s journey toward finding a path forward. To transition beyond this phase, the individual must believe in the possibility of change and be capable of shifting from resignation or apathy to a mindset of possibility. Creating conditions conducive to this shift in readiness is essential to initiating the process of moral repair. Sometimes people like Angela will be able to make this transition on their own; for others, skilled counselors, mental health professionals, or trained facilitators are needed. Being able to ask for and receive support and resources is a vital component of this phase of suffering.The acquisition of language to express suffering leads one out of the uncomprehending phase of mute suffering. Reich10 describes the initial phase of expressive suffering as lament or complaint, story or narrative, and interpretation.The gradual emergence of conscious awareness and the search for language to describe the sources and consequences of their moral suffering punctuates the second phase of suffering. As awareness emerges, nurses such as Angela struggle to discover a voice to express their search for meaning in their suffering. Initially, the vocabulary to express one’s suffering can be quite impoverished, lacking insight or clarity. Giving voice to it, in whatever form, begins the process of reconfiguring the experience that was formerly unspeakable. If Angela chooses to share her thoughts and feelings, she can bring what was once incomprehensible into conscious awareness by verbalizing it with others. This is possible when others can create a safe container for listening to and holding the content shared without attempting to console the sharer or to reinterpret the experience. Having compassionate others share in the exploration of our experience and bear witness to it can fuel our sense of moral agency, diminish isolation, and enable new insights. It can propel the person toward the hopeful possibility of being able to make sense of the experience or possibly transform it. Even when language is accessible, the capacity for insight and reflection may be disabled by the degree of suffering nurses are and have to This is true when moral suffering the form of moral facilitators or mental health professionals are to support a person through the moral injury process in a way that does not the distress or leave the person or unable to the ability and language to articulate what was serves as a to the and experienced by us to describe express thoughts and emotions, and establish initial response to suffering as a such as are we and as they seek to be comprehend the or or make sense of As by Angela’s case, this expression can be quite When nurses their suffering, through or complaint, they often a of their the story of their suffering can facilitate a understanding, and of experience to it with or a new and potentially alleviate the distress it Nurses sometimes detailed of their moral suffering or even the In such instances, or the story serves as a of the experience and it in a way that renders it and It also the to reinterpret the experience, shifting from a of to one of moral and the expressive phase of suffering, moral repair can manifest through including or other of This may involve at times, the familiar or we our ethical moral anguish, or methods enable nurses to their distress, with it in a manner that allows them to and the and reinterpret or the experience in a more or with specific and between the individuals in the and the a of the experience of suffering into a form that nurses to fully and in some instances, it may facilitate the of a new that us into a phase of with our This process is by a of and in navigating both the and our and as for challenging and meaning and In certain nurses can their to moral agency, lingering distress, and facilitate have that nurses from expressive as a of the of stress and about such as the experienced by Angela a healing process through (1) to difficult their intensity and them more over (2) the distress with moral challenges by new on and (3) the ability to and alleviate their this process for and personal there are instances where experiences of moral suffering can potentially the presence of skilled facilitators and professionals capable of such situations is to that might from At times, the experience of moral adversity and compromised integrity may a sense of that constructing meaning from our is the of suffering, when an or finding meaning it is essential to create a where nurses can and with their negative or without to or when nurses are for and capable of a and for this process to compassion toward our and exploration to for repair and to restore personal and relational integrity involves what has been to with that individuals or groups to often and about themselves and their repair to shift and these with new or that and describes a process for repair. Once a like Angela’s is the step is to identify the and that have been to create a identity as a nurse and to discern how these have individuals or The second step involves the story about an individual or in such a way that that were in the It might the form of the of nurses to more of their and The is to make moral sense of the by the that it in a way that moral agency, and the narrative, according to involves 3 (1) to it, its to one’s identity without that others will the (2) to other people the to and (3) and its in a repair process can be useful for restoring relational integrity when the source of the moral distress, outrage, or injury involves and a that has or It can also be useful in and the and patterns that have to moral suffering. and the of patients or for may offer a path to to shift the the second phase of suffering, like the it is to create where nurses can explore their experiences with compassion and on the and of their moral anguish, nurses may find solace in individual methods that their well-being, or they may to in by in moral repair. to and in response to the physical signals of their moral suffering nurses with new to themselves when with ethical Some nurses may find that offer or to strategies at well-being and moral resilience. Others may in that their with their suffering in a manner that with their In cases where moral distress or injury is persistent and clinicians may from by mental health professionals, counselors, or in individuals of distress and diverse manifestations the phase, suffering can undergo as the act of constructing new meaning to a sense of This is by nurses like Angela the of their suffering into their personal narrative, identity, and through a and process with compassionate individuals and with The of the of a and the with and as a how it is possible to transform our suffering and it into our identity, and We can our moral suffering and the while them into a new The new will encompass the but the is not but transformation. During this phase, there is an to and the and resources that have It also allows for the of a and possibly voice to articulate the of one’s does not or it involves a acknowledgment of moral suffering without its and consequences. The process can as a for personal awareness and for cultivating and compassion toward and others. upon and the strategies in the phases of suffering, this phase may and external to interpret and the experience and meaning from moral suffering by with questions that clinicians the Reich10 provides into the that health care professionals may need to to comprehend both their suffering and the suffering they witness or to in they seek to sense of such as can I myself as a in the presence of profound suffering and an to shift one’s and an story that more one’s and integrity. When nurses can the person they have through this process of suffering and make sense of the of the suffering, integrity can be It is to explore for situations that have compromised or one’s integrity, including methods for the and with moral suffering and the systemic to moral suffering can offer can be by and using inquiry, and dialogue. such known as the is a framework of into the of suffering within the and of the where and from the from offering or and whatever as true to be and may be able to transform their suffering into but the potential for like are to their with compassion and The of this on including one’s readiness and the of and external nurses into a of necessitates in resources that support their in such with a shared sense of and factors such as the of and individual experiences must also be and addressed in the healing the journey to healing the possibility that the moral residue can be and the experience is possible for nurses such as Angela to through these phases of suffering and transform it into and Walker9 that there is a shared for the and that imperil integrity and create moral adversity and suffering. The and ethical and and in for of in this are for that the ethical including when the support the person integrity has been imperiled and the is This occur until nurses like Angela are to bring their mute suffering into expression and structures within health care create the and for moral repair and