We recently co-hosted a webconference along with Cynda Hylton Rushton, PhD, RN, FAAN. Dr. Rushton currently serves as an Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics and the School of Nursing. In her role, she works directly with frontline nurses to build moral resilience and cultivate a culture of ethical practice.

Read on to learn about the Mindful Ethical Practice and Resilience Academy (MEPRA), an educational program Dr. Rushton created to help alleviate moral distress among frontline nurses.

What is moral distress?

Moral distress is when you know the right thing to do, but individual or institutional constraints prevent you from doing so. In health care, moral distress can occur when clinicians feel their ethical values are being compromised when providing care. For example, nurses who feel their unit is short-staffed may feel like they are making inappropriate tradeoffs in the care they are providing, which often results in moral distress.

Why is moral distress an issue for health care leaders?

Ethical issues are a daily occurrence for clinicians, especially nurses. When we can’t translate our moral values into action, moral distress can ensue. If unaddressed, moral distress undermines resilience, which can increase burnout and turnover.

Conversely, helping clinicians address their moral distress and feel empowered to act in accordance with their values in complicated ethical situations can have a positive impact on resilience and engagement.

How can leaders identify moral distress in the frontline?

There are validated tools to measure moral distress. Leaders may also use a number of proxy measures readily available through routine staff surveys. For example, many engagement surveys include questions such as, “Over the past year I have never been asked to do something that compromises my values.”

For this project, we used a screening tool to measure resilience, ethical confidence, and ethical competence, and work engagement, in addition to a variety of other instruments before and after the foundational MEPRA training.

How is Johns Hopkins addressing moral distress and building moral resilience?

We created an educational program called the Mindful Ethical Practice and Resilience Academy, or MEPRA. This program is designed to help individual nurses reduce their moral distress by building their own moral resilience and ultimately contribute to a culture that fosters ethical practice.

Can you explain the MEPRA model?

To guide the workshop, we created a model called “The Five Pillars of Moral/Ethical Competency.” The base of this model is moral resilience, which is the ability to maintain personal integrity in the face of morally difficult situations. The other four pillars are:

• Moral agency, including self-regulation
• Moral sensitivity
• Moral discernment and reasoning
• Moral action

What does MEPRA look like in action?

The program consists of six, four-hour workshops conducted over 12 weeks. We designed the content to be experiential and practice-based rather than a didactic lecture series, to encourage participants to come to their own conclusions about the moral dilemmas they’ve encountered and to discover their own inner resources in dealing with moral adversity. We also have staff practice the skills we teach at our simulation center, where we have actors interact with participants to model ethically complex situations. I’ve included more detail about each of these six workshops below:

• First session: Participants explore and define their own values and moral compass, as well as evaluate their resilience. We also introduce the concept of mindfulness and help participants develop their own mindfulness practice.
• Second session: We discuss how the nervous system influences individuals’ response to morally complex situations. Though we address strategies to help staff bounce back after difficult situations, we also discuss how to build resilience long-term using skills of mindfulness, self-reflection and self-regulation. We then apply skills in moral sensitivity to a clinical case.
• Third session: We explore empathy and perspective taking and offer context on how our individual perspectives and biases affect our assessments of morally complex situations. With this foundation, we begin to examine the impact on how we communicate in morally complex situations and apply skills in moral discernment and reasoning to a clinical case.
• Fourth session: We discuss the role of moral distress in clinical practice—its sources and consequences and typical ways clinicians respond to it. We help participants explore the morally distressing cases from their own practice. They also learn how to use their emotional and mental resources strategically and the importance of self-stewardship. We’re intentionally offering this content in a later part of program so the participants have the skills to discuss moral distress in constructive ways.
• Fifth session: This is an integrative session and takes place in the simulation lab. Specifically, we use high fidelity simulation to allow participants to practice the communication and mindfulness skills talked about in previous MEPRA sessions.
• Sixth session: In our final training, we discuss how the individual skills participants build throughout MERPA contribute more broadly to moral resilience, and encourage staff to think about how they can contribute to a culture of ethical practice at their organization. They use a template to identify and think about how to change an aspect of their practice that is contributing to their moral distress. We focus on opportunities that are both changeable and within their sphere of influence. We engage them to share their skills with their colleagues and see themselves as unit leaders and coaches.

Throughout the program, we also encourage staff to stay mindful and find ways to create pauses in their workday. Specifically, participants receive a daily email with a mindfulness reminder and an exercise to help them build positive emotions such as gratitude, which is an important step in building resilience.

What were your results?

Preliminary results suggest improved engagement and moral competence and confidence as a result of the training. We’re also trending toward significance in moral resilience. We will be conducting our full data analysis this summer.

Based on anecdotal evidence from participants, MEPRA has made a significant difference in their engagement at work, and we’ve also heard participants find these skills valuable outside of their professional life.

Who participated in this training?

We had almost 150 participants in our first six cohorts. They spanned many different specialties and ages, from new graduates to seasoned nurses. There are now a critical number of MEPRA graduates in several of our intensive care units and we are beginning to see benefits of nurses who share a common language around moral distress equipped with strategies, skills and tools to participate in change initiatives.

How were nurses recruited for this training?

We initially recruited in areas with high levels of moral distress, such as critical care units. After the first cohort, we expanded our pool of nurses to include the entire hospital in order to include more new graduates nurses—because we know if we can keep a new nurse past their two-year mark they are more likely to stay committed to the hospital setting. We also spoke to the nurses in our nurse residency program to encourage new graduates to participate, and reached out to nurse managers to encourage their staff to participate. One thing we learned is that the best learning occurs when people volunteer to participate rather than being “voluntold.”

Were they compensated?

While financial compensation was at the discretion of the nurse leader, we are looking to explore more consistent financial compensation in the future. However, we’re looking into offering CNE credits to participants.

What’s next for MEPRA?

We’re currently wrapping up our last cohort’s training sessions, and are running an analysis of the results. We plan to offer additional cohorts of MEPRA to expand the MEPRA community of practice at Johns Hopkins, which will include an annual MEPRA renewal retreat. We’re looking at the possibility of designing a MEPRA coach or champion role. Along the same lines, we’ve made efforts to work with nurse managers in thinking through how they can develop these skills in new graduates.

Finally, we’re developing a moral resilience tool that we will be evaluating over the coming months; exploring how the content might be adapted for interprofessional moral resilience; and thinking about how to adapt this content for nurse managers, as we know that they also struggle with moral distress. We are also exploring the feasibility of a MEPRA Facilitator Training Program. Stay tuned!

If another organization is interested in addressing moral distress among staff, what first steps do you recommend?

I encourage leaders to start by recognizing that ethical issues can cause moral distress and contribute to burnout. Acknowledging the distress and committing time and resources to address it sends a powerful message to frontline staff. Next, explore the root causes of moral distress at your organization—which can help focus the design of effective and sustainable solutions. It’s also important to recognize which contributors to moral distress we don’t have control over, so we can better target the root causes we can change.

For example, we know that there’s a relationship between end-of-life decision-making and moral distress. Clinicians will always witness suffering and death first-hand. But we can better prepare staff to do so without burning out by acknowledging that these complex cases can cause moral distress and systematically examining the patient, family, clinician, team and organizational factors that both contribute to the distress and are fixable. For example, we can proactively identify and address end-of-life concerns for patients receiving high risk therapies with uncertain benefit or who have intermittent decision making capacity before it becomes a complex problem. In helping clinicians address challenging situations, we can help move them from feeling helplessness to being empowered to take action.