Four R’s and Resilience Approach Help Oncology Nurses Respond to Morally Distressing Challenges

March 14, 2023 by Elisa Becze BA, ELS, Editor

Disparity. Inequity. Futility. Barriers. Miscommunication. Unacceptance of the inevitable. Ethical and moral challenges perpetuate throughout practice for today’s healthcare workers, particularly oncology nurses in cancer care. As those burdens build up, nurses struggle to sustain their resilience and risk developing burnout or even leaving the profession entirely.

Nurses can use evidence-based strategies to respond to morally distressing events. In an article for the February 2023 issue of the Clinical Journal of Oncology Nursing (CJON), Joaquin Buitrago, PhD, MS, RN, OCN®, outlined how oncology nurses can take a resilience approach to anticipate and manage moral distress ( in their cancer care practice.

What Moral Distress Looks Like

Anticipating situations that may produce moral distress can help you prepare with the tools to proactively respond. Buitrago cited examples ( such as:

Respond With Resilience

Mitigating moral distress is a two-factor process, Buitrago said ( The first part takes place in the moment, when you can respond cognitively using the four R’s:

Through a detailed case study, Buitrago illustrated how an oncology nursing team applied the four R’s ( to respond to an unsafe staffing situation (read it in the CJON article) (

After you’ve alleviated any preexisting moral challenges, Buitrago advised adopting a resilience approach ( to prevent future moral distress and maintain, enhance, and restore your moral integrity. The strategies and factors you’ll want to consider for your resilience approach include:

“Moral distress negatively affects oncology nurses,” Buitrago concluded ( “Incorporating strategies to prevent or manage moral distress can strengthen resilience in managing ethical and moral dilemmas. Strategies such as practicing self-care and using ethics committees and support systems may empower a resilience approach and sustain and restore integrity during ethical dilemmas.”

Learn more and earn 1.0 NCPD contact hour by reading the full CJON article ( and completing the evaluation as directed in the instructions in the box at end.

Copyright © 2023 by the Oncology Nursing Society. User has permission to print one copy for personal or unit-based educational use. Contact for quantity reprints.