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Challenges in the Critical Care Workplace
©2021 American Association of Critical-Care Nurses
doi:https://doi.org/10.4037/ajcc2021359
Background Ethical challenges in clinical practice signifi-
cantly affect frontline nurses, leading to moral distress,
burnout, and job dissatisfaction, which can undermine
safety, quality, and compassionate care.
Objectives To examine the impact of a longitudinal, expe-
riential educational curriculum to enhance nurses’ skills
in mindfulness, resilience, confidence, and competence
to confront ethical challenges in clinical practice.
Methods A prospective repeated-measures study was
conducted before and after a curricular intervention at 2
hospitals in a large academic medical system. Interven-
tion participants (192) and comparison participants (223)
completed study instruments to assess the objectives.
Results Mindfulness, ethical confidence, ethical compe-
tence, work engagement, and resilience increased signifi-
cantly after the intervention. Resilience and mindfulness
were positively correlated with moral competence and
work engagement. As resilience and mindfulness improved,
turnover intentions and burnout (emotional exhaustion and
depersonalization) decreased. After the intervention, nurses
reported significantly improved symptoms of depression
and anger. The intervention was effective for intensive
care unit and non–intensive care unit nurses (exception:
emotional exhaustion) and for nurses with different
years of experience (exception: turnover intentions).
Conclusions Use of experiential discovery learning prac-
tices and high-fidelity simulation seems feasible and effec-
tive for enhancing nurses’ skills in addressing moral
adversity in clinical practice by cultivating the components
of moral resilience, which contributes to a healthy work
environment, improved retention, and enhanced patient
care. (American Journal of Critical Care. 2021;30:e1-e11)
M
indful Ethical
PracticE
and
rEsiliEncE
acadEMy: EquiPPing
nursEs to addrEss
Ethical challEngEs
By Cynda Hylton Rushton, PhD, MSN, RN, Sandra M. Swoboda, MS, RN,
Nancy Reller, BS, Kimberly A. Skarupski, PhD, MPH, Michelle Prizzi, BA,
Peter D. Young, MBE, and Ginger C. Hanson, PhD
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 e1
1.0 Hour
C E
This article has been designated for CE contact
hour(s). See more CE information at the end of
this article.
This article is accompanied by an AJCC Patient Care
Page on page 10.
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Ahealthy nursing workforce is integral to the delivery of health care services. Data
from national surveys and other sources indicate that nurses are stressed; many
are burned out and leaving their jobs or the profession.1-3 Increased patient acuity,
the demands of a high-intensity work environment, and limitations of staffing,
time, and resources contribute to moral distress and burnout.4-7 Repeated expo-
sure to morbidity, mortality, ethically challenging situations, and prolonged patient suffering
exacerbate moral distress and burnout.4-7 Subsequently, job performance, work engagement,
communication, and teamwork all suffer, negatively influencing patient care and quality out-
comes. This situation threatens nurses’ well-being and leads to high turnover rates, impacting
organizations’ bottom line.4,6,7
The American Nurses Association Code of Eth-
ics mandates that nurses have an obligation to pro-
tect and foster their own well-being and integrity to
serve patients.8 Resilience, the ability to be buoyant,
flexibly adapt, or poten-
tially grow in response to
stressors or adversity,9-12
can be a protective factor
to support nurse well-
being. Many nurses lack
the skills and tools to
be resilient in the com-
plexity of the health care
environment and to effec-
tively confront ethical
challenges they regularly
face.13 Less-experienced nurses are thought to be more
vulnerable because they report increased stress asso-
ciated with greater exposure to ethical conflicts.13 When
job demands exceed resources, burnout can ensue.14
In a study of emotional exhaustion (EE), a key ele-
ment of burnout, nurses with burnout reported
lower levels of resilience, whereas their resilient
counterparts were more protected from EE.15
Nurses report gaps in ethical competence and
confidence to recognize and skillfully address ethical
issues with effective communication and advocacy
skills.16 (In this article, we use the terms ethical com-
petence and moral competence interchangeably.)
Many feel powerless to implement ethically justi-
fied actions for fear of reprisal, ridicule, or shame,
producing an array of negative emotions and physi-
cal consequences.17-21 This distress leads to patterns
of silence, avoidance, lack of self-awareness, and
lack of self-regulatory skills needed to navigate high-
stakes, emotionally charged ethical situations.18,19
Nurses may conform to the decisions of others, cre-
ating dissonance by acting contrary to their ethical
standards under conditions of constraint or duress.18,20
When nurses are chronically stressed or morally dis-
tressed, their ability to remain engaged, constructive,
and nonreactive may be diminished.18,22
Nurses who confront ethical challenges in their
work are also carrying job-related stress and work-
load fatigue.2 The combination of these types of
adversity and stress likely compounds the impact
on their already taxed nervous systems. Mindfulness,
the practice of being aware of what is happening in
the present moment somatically, emotionally, and
cognitively, develops new neuropathways to support
self-regulation and awareness.23-26 Mindfulness prac-
tices can enable clinicians to downregulate their
nervous systems and create conditions for insight,
discernment, and action.10, 27-29
Developing skills to mitigate the detrimental
effects of ethical challenges and moral distress and
to foster moral resilience can help nurses confront
the moral adversity in everyday practice.30-32 Com-
prehensive programs are needed to reverse these
About the Authors
Cynda Hylton Rushton is the Anne and George L. Bunting
Professor of Clinical Ethics at Berman Institute of Bioethics
and a professor of nursing and pediatrics, Johns Hopkins
University School of Nursing and School of Medicine,
Baltimore, Maryland. Sandra M. Swoboda is the Depart-
ment of Surgery research program coordinator and pre-
licensure masters entry program simulation coordinator/
educator, Johns Hopkins University School of Nursing
and School of Medicine. Nancy Reller is president of
Sojourn Communications, McLean, Virginia. Kimberly A.
Skarupski is associate dean for faculty development at
the School of Medicine, associate professor in the Divi-
sion of Geriatric Medicine and Gerontology, and associ-
ate professor of epidemiology at Bloomberg School of
Public Health, Johns Hopkins University. Michelle Prizzi
is research and educational program coordinator at Ber-
man Institute of Bioethics, Johns Hopkins University.
Peter D. Young is a DPhil candidate in population health
at Ethox Centre and Wellcome Centre for Ethics and Human-
ities, University of Oxford, England. Ginger C. Hanson is
an assistant professor at Johns Hopkins School of Nursing.
Corresponding author: Cynda H. Rushton, PhD, MSN,
RN, 525 North Wolfe St, Box 420, Baltimore, MD 21205
(email: crushto1@jhu.edu).
When nurses are chron-
ically stressed or morally
distressed, their ability
to remain engaged, con-
structive, and nonreactive
may be diminished.
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troubling trends and to build the needed capacity
within the profession to address ethical challenges
and meet the needs of complex clinical patient care.33-35
Methods
Through an academic/practice partnership, the
Mindful Ethical Practice and Resilience Academy
(MEPRA) was developed to nurture a culture of mind-
fulness, ethical competence, and resilience among
frontline nurses. The program curriculum addressed
moral adversity by cultivating moral resilience through
knowledge, skills, and practices in self-regulation,
mindfulness, moral sensitivity, discernment and
action, targeted communication skills to enhance
moral efficacy, and methods for translating new skills
into everyday practice. MEPRA includes the founda-
tional curriculum, a community of practice, annual
retreats, and a champion program. Experts in bio-
ethics, education, communication, mindfulness,
simulation, and evaluation developed the experien-
tial discovery learning curriculum.
The conceptual framework was adapted from
prior work addressing moral distress, scholarship
in moral resilience, and a literature review regarding
interventions to build ethical competence, mindful-
ness, and resilience.9,22,32,36 The curriculum draws on
social learning theory, experiential and discovery
learning practices, and high-fidelity simulation. We
hypothesized that an experiential educational curric-
ulum would enhance nurses’ skills in mindfulness,
ethical confidence, ethical competence, and resilience
to recognize, respond to, and confront ethical chal-
lenges in clinical practice. Secondary outcomes
included changes in empathy, psychiatric symp-
toms, burnout, moral distress, work engagement,
and turnover intention.
From 2016 to 2018, a longitudinal preintervention-
postintervention design tested the impact of the cur-
riculum on frontline nurses from 2 hospitals in a
large academic medical system. A convenience
sample of nurses was recruited from diverse clinical
areas through brief in-person educational sessions
and email invitations.
The program included 6 experiential sessions
totaling 24 hours of face-to-face, interactive training
based on a variety of educational and evaluative
methods. Five sessions incorporated didactic experi-
ential practices, role play, video review, mindfulness
practices, and group activities; 1 session involved
high-fidelity simulation with trained actors and a
facilitated reflective debriefing. Didactic content
provided scaffolding to support program outcomes
(Figure 1). Participants received 10 minutes of daily
technology-enabled, guided mindfulness practices
(breathing, loving-kindness, difficult emotions, letting
go) and reflective questions to reinforce content and
engage prosocial attitudes and emotions.
Eleven survey instruments specific to program
outcomes, demographics, exposure to ethical experi-
ences, and well-being were used (Table 1).37-48 Online
survey software (Qualtrics)
was used for preintervention
and postintervention surveys,
each of which took less than
30 minutes. We verbally
explained research activities
to participants and obtained
consent. Participants also
provided consent when
completing the electronic
surveys. A unique acrostic
code created by participants
was linked to longitudinal surveys. The institutional
review board provided expedited approval.
We administered a 1-time comparison group
survey to nurses who did not participate in the MEPRA
program at 1 of the study hospitals. The purpose of
this survey was to help identify differences between
nurses who enrolled in MEPRA and the general
nursing workforce at that organization to adjust for
possible selection bias.
Results
The 192 MEPRA participants completed preinter-
vention and postintervention surveys; 223 non-MEPRA
participants completed the comparison survey. Ninety-
four percent of participants attended MEPRA sessions,
and 88% completed the simulation session. We did
not collect data on use of guided daily mindfulness
MEPRA was developed
to nurture a culture
of mindfulness, ethical
competence and
resilience in response
to moral adversity.
Figure 1 Elements of the curriculum of the Mindful Ethical
Practice and Resilience Academy.
• 6 experiential
workshops
(4 hours)
• Daily technology-
enabled mind-
fulness and
reflective practice
• Pre- and
postcurriculum
assessment
• Self-report
Moral compass, mindfulness, resilience
plan
Autonomic nervous system activation,
self-regulation, moral sensitivity
Empathy, perspective taking,
assumptions, bias, communication
Ethical competence, moral adversity,
self-stewardship
High-fidelity simulation: integration
session
Moral resilience, culture of ethical practice
© Cynda Rushton 2019
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Tool
Table 1
Survey instruments
Perceived Ethical
Confidence Scale37
Moral Sensitivity
Questionnaire38
Moral Competence
Questionnaire39
Brief Resilience Scale40
Multidimensional
Emotional Empathy
Scale41
Work Engagement42
2-Item burnout
questions43,44
Single item: turnover
intentions (modified)45
Moral Distress
Thermometer46
Ilfeld Psychiatric
Symptom Index47
Mindful Attention
Awareness Scale48
This tool is a modified version of the 9-item perceived ethical confidence scale to assess the ability to rec-
ognize, understand and manage ethical situations. Several of the questions (fiscal responsibility, informed
consent, reproductive health) were not relevant to frontline nurses and therefore were not included. The
score was computed according to the mean of 3 items on a scale of 1 (very low) to 5 (very high). Example
questions included “confidence in the ability to recognize genuine ethical problems” and “reach sound
decisions when facing a problem in clinical ethics.” The a coefficient was .77.
This survey tool measures moral decision-making. The score is obtained by calculating the mean of 9 items
measured on a scale from 1 (completely disagree) to 6 (completely agree). Example questions included
“I find it difficult to deal with my feelings that are aroused when a patient is suffering” and “when caring
for patients, I am always aware of the balance between the potential of doing good and the risk of caus-
ing harm to them.” The a coefficient was .56.
This tool is a self-measure of moral competence in nursing practice. It measures moral reasoning and
moral judgement and is computed as the mean of 3 items measured on a scale ranging from 1 (strongly
disagree) to 5 (strongly agree). Based on the factor analysis of this 15-question survey for public health
nurses, our survey questions focused on the will of the individual to face difficult situations. Questions
included “I have the courage to directly face problems or opposition,” “I have the persistence to directly
face problems or opposition,” and “I can convey my views frankly without faltering in front of any person.”
The a coefficient was .83.
This tool is a validated scale that measures the ability of an individual to “bounce back after stress.” It is
computed by the mean of 6 items, 3 of which are reverse scores. The scale of the items ranges from
1(strongly disagree) to 5 (strongly agree). Questions included “I tend to bounce back quickly after hard
times” or “I usually come through difficult times with little trouble.” The alpha coefficient was .88.
The scale is a general measure of emotional empathy with subscales. It is computed as the mean of 30
items measured on a scale of 1 (strongly disagree) to 5 (strongly agree). Six items are reverse coded.
Questions included “The suffering of others deeply disturbs me” and “When I’m with other people who
are laughing I join in.” The a coefficient was .85.
This validated 9-item tool measures fulfillment at work related to vigor, dedication, and absorption. A scale
ranging from 0 (never) to 6 (every day) is used. Example questions included “I am enthusiastic about my
job” and “I am proud of the work that I do.” The a coefficient was .86.
Two items derived from subscales of the Maslach Burnout Inventory focused on emotional exhaustion and
depersonalization measured on a scale ranging from 0 (never) to 6 (every day). The emotional exhaustion
question describes the individual stress component of burnout and the feeling of emotional and physical
depletion (“I feel burned out from my work”). The depersonalization question describes the interpersonal
response (callous, negative, or detached) to characteristics of the job (“I have become more callous
toward people since I took this job”). The a coefficient was .69.
A 1-item question measured turnover intentions: “In the past week, I have seriously thought about looking
for a new job.” The score ranged from 1 (strongly disagree) to 5 (strongly agree). The time frame for consider-
ing this question was condensed to better capture experiences over the 3 months between data points.
This tool is a visual analog scale ranging from 0 (none) to 10 (worst possible) that measures moral distress
in the work environment. The question was “Moral distress is a form of distress that occurs when you
believe you know the ethically correct thing to do, but something or someone restricts your ability to pur-
sue the right course of action. How much moral distress you have been experiencing related to work in
the past week including today?”
This validated survey measures psychiatric symptoms. The tool includes 29 items measuring negative
mood, which are rated from 0 (never) to 3 (very often), and 4 subscales measuring cognitive disturbance
(4 items, a = .83), anxiety (11 items, a = .83), depression (10 items, a = .81), and anger (4 items). The score
was computed by mean of all items and each subscale was transformed to a 0 to 100 scale. Example
questions included “During the past week how often did you have tension in your neck, back or other
muscles?” (anxiety) and “During the past week how often did you feel downhearted or blue?” (depres-
sion). The a coefficient was .81.
This validated 15-item scale assesses the state of attention and awareness of what is occurring in the pres-
ent moment (a core component of mindfulness). Items are rated on a scale ranging from 1 (almost always)
to 6 (almost never). Example questions included “It seems I am ‘running on automatic,’ without much
awareness of what I’m doing” and “I find myself doing things without paying attention.” Scores are com-
puted by taking the mean of all items. The a coefficient was .89.
Description
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practices. Longitudinal results are not reported.
MEPRA participants were 90% female, their mean
age was 33.09 years, and most were White (70.6%)
and single (55.9%). Most participants (90.8%)
worked full-time, 46.1% worked 12-hour day and
12-hour night shifts equally, 32.5% worked only day
shifts, and 18.8% worked only night shifts. Although
16% reported prior ethics training on the preinter-
vention survey, 96% had encountered ethical situa-
tions at work.
We used independent t tests or χ2 tests to deter-
mine differences between the 2 organizations (hos-
pital A and hospital B) whose nurses participated in
MEPRA and the comparison group from hospital A
(Table 2). We found significant differences between
the 2 MEPRA groups. Hospital A nurses were younger,
more likely to be single, and more likely to work both
day and night shifts rather than a fixed shift. Hospital
A had a greater percentage of nurses who experienced
ethical situations and higher scores on the frequency
of ethical situations. Compared with nonparticipants
in MEPRA, participants in MEPRA from hospital A
were younger, more likely to be single, and more likely
to work both day and night shifts rather than a
consistent schedule. We used variables with signifi-
cant differences (work shifts, marital status, age, and
regularity of ethical situations) as control variables
in the main analyses.
We evaluated the impact of MEPRA with repeated-
measures analysis of covariance with a significance
level of .05 (Table 3). Scores that increased significantly
after the intervention included ethical confidence,
ethical competence, resil-
ience, work engagement,
and mindful awareness
and attention. Participants
had reduced symptoms
of depression and anger
(subcategories of the
Ilfeld Psychiatric Symp-
tom Index). Turnover
intentions (TI) also decreased after the curriculum,
with a trend toward significance. We found no sig-
nificant changes in moral sensitivity, empathy, burn-
out, or moral distress.
We conducted bivariate correlations of resil-
ience and mindfulness with other intervention out-
comes (Table 4). Resilience and mindfulness were
Variable
Table 2
Demographic characteristics by sample
Age, y (range, 22-67 y)
Regularity of ethical situationsa
Female
Race/ethnicity
White
Black
Other
Marital status
Single
Married
Divorced or separated
Employment
Part-time/as needed
Full-time
Shift
Day
Night
Both equally/other
Encountered ethical situation
Ethical program participation
<.001
.08
.31
.21
<.001
.92
<.001
.08
.65
7.86
−1.77
1.0
3.1
37.2
0.0
36.4
3.1
0.2
216
218
215
221
221
221
222
222
221
.002
.03
.94
.29
.008
.09
<.001
.005
.73
−3.34
2.18
0.0
2.5
9.8
2.9
25.6
7. 9
0.1
163
160
162
162
163
162
163
163
163
29
26
29
29
29
29
29
29
29
41.15 (12.36)
5.05 (2.38)
93.0
77.4
4.5
18.1
29.9
57.5
12.7
7. 7
92.3
56.3
19.8
23.9
93.7
13.1
40.17 (12.15)
4.46 (2.27)
89.7
62.1
1 7. 2
20.7
27.6
69.0
3.4
7. 4
92.6
79.3
6.9
13.8
86.2
1 7. 2
32.21 (9.80)
5.47 (2.17)
90.1
70.4
8.0
21.6
58.9
38.7
2.5
1 7. 2
82.8
30.1
1 7. 2
52.8
97.5
14.7
PP tt Mean (SD)Mean (SD)
Hospital A (n = 163) Hospital B (n = 29)
Non-MEPRA comparison
group at hospital A (n = 223)
MEPRA participants
Mean (SD) nn n
PP χχ2
χχ2%% % nn n
Abbreviation: MEPRA, Mindful Ethical Practice and Resilience Academy.
a Regularity of ethical situations is rated from 0 = never to 10 = all the time.
MEPRA improved nurses’
ethical confidence, moral
competence, resilience,
and work engagement.
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positively correlated with perceived confidence,
moral competence, and work engagement and were
negatively correlated with EE, depersonalization, TI,
Moral Distress Thermometer, and the Ilfeld Psychiat-
ric Symptom Index subscales of
cognitive problems, anxiety,
depression, and anger.
We examined unit specialty
(intensive care unit [ICU] vs non-
ICU) and years of nursing expe-
rience to determine if these
factors moderated the effect of
MEPRA on the main outcomes
included in Table 3. Unit specialty was not a signifi-
cant moderator of change in any outcome except
EE (P = .04). MEPRA was more effective at decreas-
ing EE for nurses in non-ICU units than for those
in ICU units. Turnover intentions decreased the
most in nurses with less than 10 years of experience
(Figure 2). Nurses with less than 10 years of experi-
ence and higher TI at baseline had a greater decrease
in TI than did nurses with 10 or more years of expe-
rience and a lower TI at baseline.
Discussion
The MEPRA curriculum increased participants’
ethical confidence, ethical competence, resilience,
work engagement, and mindful attention and aware-
ness. MEPRA also decreased reported symptoms of
depression and anger and turnover intention.
Mindfulness
The MEPRA curriculum enhanced the skills of
mindful awareness. Self-regulatory and awareness
skills engage biological and psychological mecha-
nisms important for responding to various types of
adversity.49,50 Cultivating mindfulness-based skills is
important in the process of moral discernment and
helps clinicians address moral adversity and develop
mediation pathways for emotional competency, cog-
nitive function, and ethical action.15,49-52 Cultivating
mindful awareness and cognitive skills aimed at rec-
ognizing, analyzing, and responding to ethical chal-
lenges and at fostering moral resilience holds
promise for nursing ethics education.53
Moral/Ethical Competence and Confidence
Moral/ethical competence has been defined as
embodiment (being ethical), perception or sensitiv-
ity, reflection, discernment based on ethical knowl-
edge, and behavior/action.54 Each element is reflected
in the MEPRA curriculum. Moral competence and
perceived ethical confidence improved significantly
after participation in MEPRA. Baseline scores for per-
ceived ethical confidence were significantly lower in
ICU nurses than in non-ICU nurses, yet ICU nurses
scored significantly higher in moral sensitivity at onset.
These findings could be explained by the greater fre-
quency of exposure to ethical issues in the ICU and
such factors as avoidance in identifying and address-
ing ethical concerns.19 Many frontline nurses have
limited formal or informal ethics education beyond
basic prelicensure training.13 In our study, only 14.7%
to 17.2% of MEPRA participants reported receiving
formal ethics training, suggesting an opportunity to
strengthen ethics education in academic and practice
settings. We found no differences between new grad-
uates and experienced nurses in ethics preparation.
Programs aimed at enhancing moral agency and
moral efficacy and at reducing moral distress have
demonstrated similar efficacy in increasing ethical
competence and or confidence in both groups.20,21,55
Table 3
Change from before to after the interventiona
Variable
Perceived Ethical
Confidence Scale
Moral Sensitivity
Questionnaire
Moral Competence
Questionnaire
Brief Resilience Scale
Multidimensional
Emotional Empathy Scale
Work engagement
Burnout
Emotional exhaustion
Depersonalization
Turnover intentions
Moral Distress Thermometer
Psychiatric Symptom Index
Cognitive
Anxiety
Depression
Anger
Mindful Attention
Awareness Scale
<.001
.32
<.001
<.001
.13
<.001
.19
.85
.05
.85
.10
.79
.02
.02
.03
73.27
0.98
28.32
18.20
2.34
17.53
1.77
0.04
3.83
0.04
2.77
0.07
5.78
5.82
4.78
164
165
164
164
168
166
166
166
149
156
166
166
166
166
166
3.94 (0.53)
4.44 (0.52)
4.00 (0.77)
3.66 (0.70)
3.99 (0.42)
5.28 (0.82)
3.61 (1.19)
3.03 (1.35)
2.48 (1.41)
3.49 (2.26)
31.88 (18.55)
23.07 (13.88)
22.39 (13.15)
31.04 (15.52)
3.90 (0.81)
3.49 (0.66)
4.39 (0.56)
3.57 (0.91)
3.39 (0.72)
3.92 (0.44)
4.97 (0.95)
3.76 (1.34)
3.05 (1.56)
2.75 (1.44)
3.53 (2.39)
34.69 (21.48)
22.75 (14.08)
25.26 (14.37)
34.69 (18.90)
3.76 (0.79)
P
F
n
Postinter-
vention
Preinter-
vention
a Control variables included age, marital status, shift, and regularity of ethical situa-
tions. Confidence was coded 1 (very low) to 5 (very high). Sensitivity was coded
1 (completely agree) to 6 (completely disagree). Competence, resilience, empathy,
and turnover intentions were coded 1 (strongly disagree) to 5 (strongly agree).
Engagement and burnout questions were coded 0 (never) to 6 (every day). Moral
Distress Thermometer was rated from 0 (none) to 10 (worst possible). Psychiatric
Symptom Index was coded as 1 (never) to 4 (very often). The score was computed
by mean of all items and each subscale was transformed to a 0-to-100 scale. Mind-
ful Attention Awareness Scale was rated from 1 (almost always) to 6 (almost never).
Score, mean (SD)
Further exploration is
needed to measure
the moral dimension
of resilience.
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Resilience
We used a general measure of resilience to gain
insight into the elements of global resilience that
may be harnessed in response to the adversity asso-
ciated with ethical challenges in clinical practice.
Resilience scores significantly improved after MEPRA
participation. Of the 10 characteristics of resilience
that can be fostered through targeted interventions,
MEPRA included the following: (1) developing a
personal moral compass; (2) cognitive flexibility,
the ability to face one’s fears; (3) being optimistic
in the face of adversity; (4) altruism; and (5) active
coping skills, mentoring, and a supportive social
network.56-59 MEPRA participants appeared to engage
their resilient potential in new and expanded ways.
Other studies have shown an inverse relationship
between resilience and burnout symptoms in
nurses.2,15,60-63 More targeted and refined measure-
ments are needed to understand the relationship
of resilience, especially moral resilience, with burn-
out symptoms.11, 62-64 Further exploration is needed
to measure the moral dimension of resilience.11
Work Engagement
Work engagement, a measure of fulfillment in
the workplace, is characterized by “vigour, dedication
and absorption”65 and is positively related to work
performance.65-67 Although participants demonstrated
relatively high work engagement scores before MEPRA
participation, scores improved significantly after the
program. Turnover intention scores were relatively low
initially and further decreased after MEPRA participa-
tion. The MEPRA content broadened nurses’ repertoire
to exercise moral agency and expanded their commit-
ment to contribute in the work setting. These trends are
important in making the financial case for health care
organizations to invest in programs such as MEPRA,
particularly when coupled with systemic structures
that dismantle the factors undermining well-being
and nurse engagement.14,68,69
Turnover Intentions
MEPRA participants, specifically nurses with
less than 10 years of experience who reported higher
TI before the program, reported decreased TI after
training. This result demonstrates that the curricular
intervention was more useful in lowering TI among
participants who had worked as nurses for less than
10 years and had higher TI at baseline than among
participants who had worked as nurses for 10 or more
years and already had lower TI at baseline. MEPRA
may be most effective as a retention intervention for
nurses with less than 10 years of experience.
Table 4
Correlations of moral resilience and
mindfulness with other outcomes
Variable
Perceived Ethical Confidence Scale
Moral Sensitivity Questionnaire
Moral Competence Questionnaire
Multidimensional Emotional
Empathy Scale
Work engagement
Emotional exhaustion
Depersonalization
Turnover intentions
Moral Distress Thermometer
Psychiatric Symptom Index
Cognitive
Anxiety
Depression
Anger
Mindful Attention Awareness Scale
0.21b
0.05
0.36a
−0.03
0.38a
−0.33a
−0.41a
−0.20b
−0.31a
−0.63a
−0.53a
−0.50a
−0.52a
−0.56a
0.31a
0.09
0.33a
−0.04
0.33a
−0.35a
−0.27a
−0.18c
−0.26a
−0.50a
−0.34a
−0.51a
−0.38a
−0.36a
0.31a
Mindful Attention
Awareness Scale
Resilience
a P < .001.
b P < .01.
c P < .05.
Correlation, r
Mean turnover intentions
4.00
3.00
2.00
1.00
0.00
Preintervention Postintervention
<2 (n = 64) 2-4 (n = 55)
5-9 (n = 27) ≥10 (n = 45)
Years of tenure
Figure 2 Plot of means for change in turnover intentions from
preintervention to postintervention according to years of expe-
rience as a nurse (P = .004). Turnover intentions were measured
by responses to the item “In the past week, I have seriously
thought about looking for a new job.” Values represent scores
ranging from 1 (strongly disagree) to 5 (strongly agree).
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Psychiatric Symptoms
The Ilfeld Psychiatric Symptom Index is a self-
reported measure of an individual’s feelings of spe-
cific symptoms, not a diagnosis of a psychiatric
illness.47 Participants in MEPRA reported a signifi-
cant decrease in symptoms in the subcategories of
depression and anger. Intensive care unit nurses
reported decreased symptoms of anxiety. These find-
ings mirror those of studies that linked resilience
to lower levels of depression and anxiety in critical
care nurses, associated increased mindfulness with
reduced anxiety and depression in practicing nurses
and nursing students, and tied burnout to depres-
sion in nurses.3,29,70-73 Because the prevalence of
depression among nurses is twice the national aver-
age, reducing depression is an important adjunct to
supporting nurse well-being and performance.74-78
Moral Sensitivity, Empathy, and Moral Distress
Moral sensitivity is the capacity to identify moral
conflicts and the morally salient aspects of a situa-
tion, including how actions affect others.38 MEPRA
participants consistently experienced ethical issues,
and their moral sensitivity scores remained high both
before and after MEPRA partici-
pation. Frontline nurses, partic-
ularly in critical care settings,
face ethically challenging situa-
tions that require them to iden-
tify moral conflicts and their
moral responsibilities. Nurses
are highly attuned to ethical sit-
uations in practice but lack the
confidence and competence to
address them in ways that pre-
serve their integrity.79 The lack
of variability of the scale items
may have contributed to the low
reliability and inability to demonstrate a change in
this measure as a result of MEPRA. Moral sensitivity
may be embedded in the measurement of ethical
confidence and competence.
Participants consistently showed moderately high
levels of empathy, with a modest but not significant
increase after the intervention. Empathy involves the
ability to be attuned to the experience of another
person, to partially feel the emotions of the other
person while regulating one’s own response (affective
empathy), and to take the perspective of another
person in understanding their experience (cognitive
empathy).80 Higher empathy and lower moral dis-
tress scores suggest that nurses, confronted with
ethical challenges, were able to maintain empathy
and regulate their emotions in response to distress-
ing situations, avoiding empathic overarousal and
nervous system dysregulation.22,81 Developing these
skills enables participants to accurately identify the
source of their ethical tension, confusion, or unrest
and respond to it in a way that reflects their profes-
sional values.81
More than 96% of participants indicated that
they had experienced an ethically distressing situa-
tion in their clinical practice. Although a significant
number of participants worked in critical care settings,
where levels of moral distress using other measures
are reported to be high, Moral Distress Thermome-
ter scores in this study remained low and unchanged
after MEPRA participation.46,82 Future research is
needed to understand the relationship between
moral distress and moral resilience.
Burnout
Contrary to reported burnout data in nurses,
participants did not report high levels of EE or deper-
sonalization at baseline.2,83-85 Emotional exhaustion
decreased modestly but not significantly, and deper-
sonalization remained unchanged after MEPRA par-
ticipation. Compared with ICU nurses, non-ICU
nurses had a greater decrease in EE after MEPRA par-
ticipation. Other factors could have influenced these
findings; ICU nurses might have become more aware
of their EE or needed more focused strategies to spe-
cifically address the sources of EE. Studies suggest
that nurses who experience moral distress also expe-
rience symptoms of burnout, especially EE.15 Find-
ings from this and other studies have shown that
mindfulness-based interventions are inversely cor-
related with burnout, particularly EE and deperson-
alization.86-88 Developing mindfulness skills offers
nurses protective tools to modulate burnout.
The 2-item burnout screening questions (EE
and depersonalization) derived from the Maslach
Burnout Inventory were selected to reduce survey
burden.43,44,89 It is unclear whether the longer Maslach
Burnout Inventory, which is used primarily in a phy-
sician population, would have revealed significant
differences in nurses.44,89 Single-item scales are prone
to lower reliability than are multi-item scales. The
2-item survey may not have been sensitive enough
to detect a change in burnout in nurses. Further inves-
tigation is needed to assess the efficacy of the 2-item
burnout questions in comparison with the longer
Maslach Burnout Inventory or other validated burn-
out measures among nurses.
Health care organi-
zations must invest
in individual and
systemic solutions
so that ethical prac-
tice is routine and
not the exception.
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Limitations
Ethical and financial constraints precluded a
randomized controlled trial that could confirm and
strengthen the study results. A voluntary program
might recruit a skewed sample of highly engaged
nurses. Nurses who participated in MEPRA were
compared with a general sample of nurses from the
same institution. The few differences found were
used as covariates in the analyses. All measures were
self-reported. Without a formal control group, the
effect of repeat testing could not be independently
assessed. The positive results, consistent across mul-
tiple cohorts, offers evidence that MEPRA affects key
outcomes. Frequency of ethical challenges occurring
in a single large academic medical system may not
be generalizable to other hospital settings.
Conclusions
Nurses are leaving their jobs and the profession at
alarming rates.90 During the coronavirus disease 2019
crisis, a nationwide survey of 1200 nurses showed that
67% were planning to leave their organization.91
Health care organizations cannot afford to lose tal-
ented nurses or continue to expect high-quality
performance without an investment in building
individual and collective resilience and an infra-
structure to support ethical practice. Investment by
health care organizations in individual and systemic
solutions is needed to build a culture where ethical
practice is routine, safe havens for raising ethical
concerns are used and safeguarded, and a healthy
work environment is sustained.14,35,92 Individual-
focused solutions such as MEPRA must be aligned
with unit-based and systemwide reforms to sustain
progress and change practice patterns.9 Future research
may consider evaluating the effect of adapting the
MEPRA format to determine if differences in session
length, frequency, cohort composition, and online
modalities can reproduce these results or improve
the effectiveness of the interventions used. Further
research is needed to fully understand the unique
moral domain of resilience and the complexity that
influences individual and team responses to ethical
challenges. Delivering high-quality patient-centered
care and retaining the best and brightest nurses in
the profession is an ethical mandate we must uphold.
ACKNOWLEDGMENTS
The MEPRA team is deeply grateful for the philanthropic
support of Dean Patricia Davidson to develop the MEPRA
program through a Dean’s Award and dissemination
through funding from Sibley Memorial Hospital and
Maryland Health Services Cost Review Commission,
Nursing Support Program I grant from Johns Hopkins
Hospital. We are grateful to Meredith Caldwell for her
excellent editorial support. We are inspired by all the
participants of the MEPRA program, who remind us
of the purpose of our work and their integral role in
health care delivery.
FINANCIAL DISCLOSURES
None reported.
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