The American Nurses Association (ANA) recently published a draft call to action on cultivating moral resilience as an antidote to nurses’ and other clinicians’ “moral suffering and distress.”

The ANA paper further asks healthcare organizations to “create the conditions where moral and ethical practice can thrive.” (See table after this article for ANA’s actions for nurse leaders.)

ASCs can act to make ethical practice a priority, and a first step is to recognize what moral suffering and moral failing look like. An example of moral suffering or moral failing can be found when ASC nurses fail to report potentially dangerous practices, situations, or medical errors, says Dana Bjarnason, PhD, RN, NE-BC, vice president and chief nursing officer, Oregon Health & Science University (OHSU) in Portland.

“They don’t report it for a variety of reasons,” she says. “Maybe they didn’t want to get somebody else in trouble.”

The most overwhelming reason why people fail to report errors is because they fear punishment, according to safety surveys, Bjarnason says.

“At OHSU, I wanted to respond to this by taking a leadership stand and developing a culture of safety statements,” she says. “We formed a culture of safety steering committee, and the first task was to develop a position statement for the organization.”

They developed the position statement within six weeks, basing it on four principles. Then, the statement was circulated to various stakeholder groups for their endorsement.

“We took this around to professional boards, nursing leadership groups, and a hospital administration team, and we received a 100% endorsement for it,” Bjarnason says. “Shortly after it was endorsed, it was entered into the OHSU code of conduct. Then, we developed a speakers bureau and went out to speak with large groups of people about the activities and how we were changing the culture at OHSU to be just a culture where we were encouraging reporting.”

Because of these and additional changes and actions, there were positive outcomes: a 29% increase in patient safety incident reporting and a 13% increase in near-miss reporting, she says.

ASCs could employ similar strategies to improve safety and increase team and staff error reporting. Here’s how OHSU made it work:

  • Put safety first.

The OHSU culture of safety position statement is one sentence: “OHSU’s executive leadership team is committed to improving patient safety at OHSU by fully engaging OHSU leaders and employees in a culture of safety.”

That simple directive is amplified in one page that provides context and the culture of safety’s four principles. (See table on the four principles after this article.)

In a preamble, the culture of safety paper refers to the Institute of Medicine and other regulatory agencies, noting they have urged healthcare organizations to create a culture of safety in which safety is a core value and high reliable systems of care are the core strategy.

To transform into a culture of safety, an organization must shift from the pattern of reacting to errors by blaming individuals or teams to an environment in which error reporting is valued as a performance improvement effort, the preamble notes.

“In 2014, an OHSU safety survey validated that many of our healthcare workers underreport errors due to concerns about being blamed, having a colleague blamed, or suffering punitive action from management,” the culture of safety position statement preamble says. “We are committed to achieving a ‘culture of safety’ at OHSU by addressing all aspects of that culture, including creating an environment in which it is easy and desirable for anyone to report an error.”

  • Create a “good catch” program.

The good catch program celebrates people who report errors, either after one occurs or “near misses,” which are errors that were prevented from occurring.

“We have one of our executive team members go to the area where the person works,” Bjarnason says.

The recognized employee receives a baseball hat and glove to wear. Then, the executive team member, supervisor, and a staff member pose for a photo that is turned into a poster. The poster, measuring 16 inches by 20 inches, is placed in the employee’s unit and in a conference area. The image also is published on the facility’s intranet.

“Some people do blush, but we explain the whole thing to them,” Bjarnason says. “We tell them the reason we do it is because our staff said they weren’t reporting errors because they would be punished, and so we wanted to make a big scene about thanking people who report errors in our organization.”

The culture change and good catch program have become so integrated in the organization’s culture that celebrants have come from unanticipated groups. For example, recognition recently went to a student nurse who saw that a nurse he was following had missed a count. He asked, “Are you supposed to do a count at this point? And the nurse said, ‘Thank you for noticing. Yes, we should do a count,’” Bjarnason recalls.

“I said to the student nurse, ‘Wow! That took courage to speak out,’ and he said, ‘Are you kidding?’ That’s the OHSU culture,’” she says.

The nurse who heard his question also has internalized the culture, carrying out her duties in this circumstance, saying “thank you,” and then reporting the near miss to the charge nurse, faculty, and Bjarnason, who then could celebrate the student nurse with a good catch award.

  • Adopt and disseminate the ARCC method.

After launching the culture of safety program, they soon realized that some staff members do not engage in difficult safety conversations because they lacked the skills to make their voices heard.

They adopted the ARCC method:

- A: Ask a question;

- R: make a Request;

- C: voice your Concern;

- C: engage in the Chain of resolution.

The chain of resolution provides nurses and other staff with a fallback if they are unable to succeed using the first three steps of ARCC. If they are unable to speak with or get through to their immediate supervisor or the person who could address the error, then they can let someone else in the organization know what they saw, and that person can handle it.

“We recognize that not everybody will have the courage, authority, and scope to deal with every issue, so we only ask that you let someone know about the error,” Bjarnason says. “Don’t keep it a secret.”

So far, issues have been resolved using ARCC, and the organization’s staff recognize that the current culture is one of transparency and open communication, she notes.

“We’ve been really focused on how the key to being engaged in difficult conversations with others is through developing relationships and influence,” she explains.

It also derives from both parties in a difficult conversation recognizing that it’s not about either of them, but about the patient and patient safety. Keeping the focus on patients can lead to calm, collected conversations and solutions that move the issue forward and prevent problems from recurring, she adds.

“We developed a 15-minute, mandatory module for all nursing team members about ARCC, and we took it to the school of nursing to have students do the module, too,” Bjarnason says.

“We rolled it out, hoping it would be another great tool for our team members as they enter into difficult conversations,” she explains. “It should help them talk about problems in a way that prevents people from getting upset or lashing out. We realize it’s all about patients and keeping employees engaged.”

The module contains a video fireside chat between Bjarnason and the chief medical officer. It drives home the point that employees should always speak up, abiding by the motto of “if you see something, say something.”

  • Measure results.

The culture shift has resulted in people expecting problems to be reported and followed up on. They no longer fear punishment when reporting an error. The organization will collect and analyze results, including following the percentages of incident reporting and near-miss reporting.

“We’ll do a national validated survey about the safety environment next year,” Bjarnason says.

The ARCC method and culture of safety have been popular with staff, she says.

“People were waiting with open arms for something to help them develop a system for addressing issues in a way that is accepted within the organization,” Bjarnason explains. “People were hungry for a systematic way to know and do the right thing.”


  1. American Nurses Association. Draft: A call to action: Cultivating moral resilience and a culture of ethical practice. Available at: Accessed Aug. 28, 2017.

American Nurses Association’s Ideas for Cultivating Moral Resilience

The American Nurses Association (ANA) recently published “A call to action: Cultivating moral resilience and a culture of ethical practice.” The 27-page paper offers the following eight steps that nurse leaders can take to help improve moral resilience and ethical practice:

  1. Ensure that every individual has access to resources to mitigate moral distress and cultivate moral resilience.
  2. Participate in institutional mechanisms to form and support ethical issues such as ethics committees or consultation services to bring the nursing perspective into the dialogue and decision-making process.
  3. Develop strategies to support nurses’ moral resilience, based on evidence applied from other contexts of resilience.
  4. Continue to systematically document and study the effect of individual interventions on nurses’ and other clinicians’ ability to address moral adversity, such as moral distress.
  5. Support your team in ANA’s “Healthy Nurse, Healthy Nation” strategies to foster clinician well-being as a foundation for cultivating moral resilience.
  6. Become skilled at recognizing, analyzing, and taking ethically grounded action in response to ethical complexity, disagreement, or conflict.
  7. Nurse leaders should adopt a standardized screening and intervention tool to recognize and address moral distress and build moral resilience.
  8. Incorporate programs aimed at developing capacities and skills in moral resilience, including mindfulness and self-regulation, ethical competence, and self-care into pre-licensure, graduate, and doctoral programs, nursing residency programs, and continuing education.

OHSU’s Four Culture of Safety Principles

The Oregon Health & Science University (OHSU) has developed a culture of safety position statement that lists the following four principles:

  • Just Culture. We recognize that most mistakes come from systems failures. We are committed to a nonpunitive and transparent response to error reporting. We maintain individual accountability for actions in a manner that reflects overall patterns of behavior and performance.
  • Reporting Culture. We continuously dedicate ourselves to promoting open reporting of errors. We commit to a response that is objective, timely, reliable, and transparent.
  • Learning Culture. We develop highly reliable systems and teams by engaging in process improvement efforts, using internal and external sources to guide our learning, and being transparent about lessons learned with patients, families, and all team members.
  • Engaged and Informed Culture. We are mindful and respectful of the ideas and perspectives of all OHSU employees. We honor the courage of those who raise concerns and foster the development of trusting relationships that enhance our community.