A post in reply to a reader’s question on the Moral Governance series.
A reader’s comment on the three-part Moral Governance series (see links below) arrived recently with a question the series had not answered. While the diagnosis for their workplace was uncomfortably recognisable, what they wanted to know was what one person, without authority, could actually do about it, and whether the advice simply to leave was the only honest answer.
The three Moral Governance posts, as written, offered a diagnosis. Two later posts on The Dimensionality of Thought and Ethical Leadership described a way of thinking – moral imagination – that helps people see past the binary options a difficult situation presents. While neither set out to describe treatment, this post does.
Its premise is that if moral distress is a condition, it needs more than a diagnosis, and more than a resilience programme. It needs practices that a person can begin without permission, without a budget, and without putting their livelihood at risk.
The diagnosis, in brief
In Part 1 of the Moral Governance series, I defined moral distress, following Jameton (1984), as occurring “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action“. It is not the same as a moral dilemma, where two or more valid courses compete, or moral ambiguity, where the right course is unknown.
In Part 2, I drew on Fourie’s (2017) distinctions between constraint distress, uncertainty distress and conflict distress. The distinctions matter for treatment, because the remedies differ: a workload that makes good practice impossible is not fixed by a conversation about values, and a conflict with a directive is not fixed by more resources.
Moral distress is also cumulative. Left unaddressed – without acknowledgement, voice or repair – it can harden along the continuum described in Part 1 towards moral injury. And because it is shaped by the moral climate, it is not simply an individual ailment. It is a condition of the organisation, which is why Parts 1–3 treated the moral climate as a governance responsibility, and why Part 1 described the result as ‘doing the right things the wrong way’.
What the Moral Imagination posts added was a way of thinking that resists the narrowing that distress produces. Under moral distress, the field of action collapses into two unsatisfactory choices: stay and suffer, or leave and abandon. Moral imagination reopens the field. It asks what else might be true, what else might be possible, and what a wise person would do here. Treatment begins with that reopening – and with the recovery of moral agency, the capacity to recognise, deliberate on, and act on one’s moral responsibilities.
Three Treatment Levels
The chart below summarises three levels of treatment for a diagnosis of moral distress – the person, the group, and the system. The text which follows explores these three levels in more detail, along with some additional tools.
First, treat the person
The first treatment level is personal – not because moral distress is a personal failing, but because the instrument of any change is the person attempting it.
Name it, and share it. The person should be able to share what they are experiencing with someone: a trusted colleague, a friend, a GP or counsellor, a union or professional association. In Part 2, I warned that a ‘resilience bundle‘ offered in place of root-cause work can amount to victim blaming. That warning stands, but the opposite error is also a mistake: treating the person as nothing more than a symptom of the system, and offering them no care at all. Self-stewardship – safeguarding one’s own health and judgment in order to serve – is a duty, not an indulgence.
Keep a record. Private, factual notes: dates, what happened, what it affected. Observations recorded separately from interpretations. The purpose is not to build a case but to build clarity – and, if the situation sharpens, protection.
Protect your capacity. Boundaries, rest, relationships with the people one serves, and a life outside work are not distractions from the problem; they are the conditions that make it possible to keep responding to it. It also helps to keep one’s options quietly alive with a current CV, a referee, and some financial room. A person who could leave but chooses to stay is a different kind of actor from one who cannot leave.
Use moral imagination on yourself. The 6D Reflective Governance Cycle set out in Part 2 of the series on The Dimensionality of Thought and Ethical Leadership (see link below) was written for boards and leadership teams, but its discipline scales down to a single practitioner: return to the facts, test the assumptions, consider the perspectives not yet considered, and only then decide what to do.
A Self-care Scaffold
The practices above are habits rather than a sequence; where a sequence helps, a well-established scaffold is the 4 A’s, developed by the American Association of Critical-Care Nurses in 2004: Ask, Affirm, Assess, Act. It was designed for clinical settings but translates readily to any organisation whose moral climate has become corrosive. The chart below enlarges the person panel from the three-level chart. It is not a second framework, not a summary of the treatments, and not something to read on its own: read in isolation, the 4 A’s would imply that the answer to a climate problem is a personal one – precisely the error Part 2 warns against when it describes a ‘resilience bundle’ offered in place of root-cause work as a form of victim blaming. The 4 A’s is where a person begins. It is not where the organisation’s obligations end.
Then, Treat the Group
The second level of treatment recognises that while a single person is rarely able to shift a moral climate alone, a small group sometimes can.
This is not a rhetorical flourish. It is the practical observation behind Margaret Mead’s much-quoted line: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”
Each word in that sentence does work. Thoughtful: the group reasons together rather than merely complaining. Committed: it persists through discouragement. Citizens: its members act as people with responsibilities, not as subjects waiting to be directed. Small group: the unit of change is not the individual and not the crowd, but a handful of people who trust one another enough to act together constructively.
In practice, this begins with relationships that already exist. Talk with colleagues about the work and the people it serves, not about personalities. Find two or three steady people whose judgment you trust. Define a shared purpose – what would ‘good’ look like here? – and choose small, concrete improvements you can actually deliver. Each success does two things: it improves something real, and it builds the credibility that makes the next conversation possible. It also does something less visible: replacing the experience of powerlessness with the experience of agency, which is what moral distress most needs.
It is important that the group is defined by what it is for, not by whom it is against. A group organised around a grievance becomes a faction; a group organised around a purpose becomes a resource – including for the people it is trying to influence.
Three bodies of work sit behind the practices described in the last two sections, and they are worth naming. Cynda Hylton Rushton’s (2018) account of moral resilience describes the capacities that keep a person a moral agent when under pressure – integrity, self-regulation and self-stewardship – while insisting that individual resilience must be matched by efforts to change the conditions that cause the harm. Debra Meyerson’s (2001) ‘tempered radicals’ are the insiders who stay, keep their legitimacy, and push the system through openings, alliances and small wins. Karl Weick’s (1984) ‘small wins’ explain why those moves work: each is a concrete, complete outcome that tests the ground and recruits the next ally. The chart below sets the three out as capacity, standing and scale. All of them deepen the person and group levels; none of them reaches the system level though.
The third of these disciplines – Weick’s small wins – has since acquired a motivational account. In a study of nearly 12,000 daily diary entries from 238 employees in 26 project teams, Amabile and Kramer (2011) found that the strongest influence on what they call ‘inner work life’ – the blend of emotion, motivation and perception that carries a person through a working day – is making progress in meaningful work. Setbacks, unfortunately, can register more strongly than wins; a sense of lost ground can undo the lift of a run of small gains.
The implication is not simply to celebrate more. It is to make progress visible, protect the work that matters, and remove what blocks it. The win also has to be real – a small, complete improvement in something that matters, not a quick win that leaves the underlying problem untouched. Their progress principle is the motivational counterpart to Weick’s small wins: not only a tactic for changing organisations, but the daily fuel that keeps the people doing the changing well enough to continue. The chart below turns that implication into three practical moves.
Then, treat the system
The third treatment level uses the machinery the organisation already has.
In Part 2, I listed the governance mechanisms that shape the moral climate: strategy and values, the code of conduct, governance standards, policies on human rights, discrimination, bullying and grievance, the risk management framework, and stakeholder and service standards. These are not ornamental. Each is a commitment the organisation has made about how it will behave, and each can be used legitimately by a person without authority.
‘Small-wins’ research (Termeer and Dewulf, 2019) has since shown that wins accumulate only when the surrounding system energises them, connects them, learns from them and protects them. A single person can start one; only the organisation can make them add up.
The core move is to stop arguing about character and start testing consistency. A useful discipline is to state the concern in the organisation’s own language: what is happening (observed), what effect it has on the people served and the work (the evidence), which commitment it touches (the standard), and what specific change is being asked for (the request). Focus on one issue at a time; privately before publicly; and do so in the right room (i.e., not the corridor or staff room).
The organisational structures matter because they are documented and legitimate: staff meetings, consultative committees, staff surveys, safety and wellbeing consultation, accreditation or quality self-study. Used well, they turn an individual concern into a matter of record – and record is the only form in which organisations reliably learn.
And because moral climate is a governance responsibility, the audience for a concern is not only the manager. Boards and committees exist to ask whether the organisation is achieving its purpose within its values and its appetite for risk; staff wellbeing – moral distress included – belongs inside that question. Reaching them through the proper channel is not disloyalty; it is using the accountability structure the organisation already has.
It also helps to understand what is acting on the people whose behaviour troubles you. Leaders under external scrutiny, carrying directives they did not design and consequences they did not choose, often pass the pressure downwards. Seeing that does not excuse harm – some behaviour has no defensible explanation, and it should not be given one. But where a real pressure is visible, naming it can locate the actual problem and produce a question the other party can answer. That too is moral imagination: understanding another’s position without surrendering one’s own judgment.
Staying, or leaving
No treatment plan is honest unless it includes the possibility that the right course is to leave.
Leaving is not a betrayal of the people one serves, and staying is not proof of loyalty. What matters is that the decision is deliberate, made against criteria, and owned by the person making it – not extracted by exhaustion. A quiet checkpoint helps: a date, and what one would need to see by then. If leaving becomes the decision, leave well – references, handover, relationships intact, and an exit that tells the truth calmly. A governance system may learn more from a well-explained departure than from years of quiet endurance.
Staying can be the right treatment too, but only if it is sustainable. A person worn down to cynicism serves no one, least of all the people the work is for.
In an echo of the advice that a group should be for something, it is also important your job search is framed as moving toward a meaningful role rather than escaping the present one.
In summary
The treatments described above are not dramatic or magical. Care for the person; build the small group; use the system’s own commitments; and decide, deliberately, whether to stay or to leave. None requires authority, and all of them protect the person who attempts them. Nor are the three levels stages to be completed in order: they are worked at together – capacity, standing and scale – with visible progress as the daily fuel. Together they are how moral agency is recovered: not in a single act of courage, but in a practice of small, deliberate, shared ones.
What we call moral courage can therefore be seen less as a personality trait than a practice – supported by other people, sustained by visible progress, and protected by care for oneself.
The diagnosis of moral distress was never sufficient on its own. It is helpful though, to the extent that it shapes what thoughtful, committed people do next.
References
Amabile, T. M., & Kramer, S. J. (2011). The progress principle: Using small wins to ignite joy, engagement, and creativity at work. Harvard Business Review Press.
American Association of Critical-Care Nurses Ethics Work Group. (2004). The 4 A’s to rise above moral distress.
Fourie, C. (2017). Who is experiencing what kind of moral distress? Distinctions for moving from a narrow to a broad definition of moral distress. AMA Journal of Ethics, 19(6), 578–584.
Jameton, A. (1984). Nursing practice: The ethical issues. Prentice-Hall.
Meyerson, D. E. (2001). Tempered radicals: How people use difference to inspire change at work. Harvard Business School Press.
Rushton, C. H. (Ed.). (2018). Moral resilience: Transforming moral suffering in healthcare. Oxford University Press.
Termeer, C. J. A. M., & Dewulf, A. (2019). A small wins framework to overcome the evaluation paradox of governing wicked problems. Policy and Society, 38(2), 298–314.
Weick, K. E. (1984). Small wins: Redefining the scale of social problems. American Psychologist, 39(1), 40–49.
See also:
- Moral Governance – Part 1
- Moral Governance – Part 2
- Moral Governance – Part 3
- The Dimensionality of Thought and Ethical Leadership – Part 1 (Theory)
- The Dimensionality of Thought and Ethical Leadership – Part 2 (Praxis)
- Foundational Thinking for Nonprofit Leaders
