The Mindful Ethical Practice and Resilience Academy: Sustainability of Impact

MEPRA was developed, implemented, and evaluated through an academic/practice partnership to address moral adversity by cultivating skills of mindfulness, ethical competence, and resilience among front-line nurses.¹⁶  The content of the 24-hour, 6-session MEPRA foundational curriculum is shown in Figure 1. The curriculum was developed by experts in nursing, bioethics, education, communication, mindfulness, simulation, and evaluation. It draws on social learning theory, experiential and discovery learning practices, and high-fidelity simulation.¹⁶  Methods used in the sessions included facilitated discussion, role play, guided mindfulness and reflective practices, embodied movement, case analysis, videos, simulation, and a breakthrough project initiative. The conceptual framework for MEPRA was adapted from previous work addressing moral distress,^17,18  scholarship in moral resilience,⁵  and a targeted literature review. Additional details of the curriculum have been provided elsewhere.¹⁶ 

The MEPRA curriculum was delivered to nurses working in a variety of roles and settings in 2 acute care hospitals within a large academic medical system.¹⁶  The longitudinal impact of the curriculum was measured by administering surveys to participants at baseline, immediately after the intervention, and at 3 and 6 months after conclusion of the intervention.¹⁶  Nurses practicing in diverse clinical areas were recruited through email and short in-person educational sessions. Online survey software (Qualtrics) was used, and data collected included demographics and scores on several validated tools specific to program outcomes. An electronic link to the survey was emailed to participants before and immediately after delivery of the curriculum and at 3 and 6 months after completion of the program. Reminders were sent weekly, and whenever practical, the study team visited the clinical units of participants in person to encourage survey completion. All study procedures were approved by the Johns Hopkins University institutional review board.

The following measures were used at all time points: Perceived Ethical Confidence Scale,¹⁹  Moral Competence Questionnaire,²⁰  Brief Resilience Scale,²¹  Ilfield Psychiatric Symptom Index measures of depression, anxiety, anger, and cognitive disturbance,²²  work engagement,²³  Mindful Attention Awareness Scale,²⁴  Multidimensional Emotional Empathy Scale,²⁵  single-item turnover intentions,²⁶  2-item burnout screening scale (emotional exhaustion and depersonalization),^27,28  Moral Distress Thermometer,²⁹  and Moral Sensitivity Questionnaire.³⁰  Descriptions of the measures are provided in Figure 2.

Analyses were conducted using SPSS, version 27.0, using generalized estimating equations (GEEs) to test for differences in change over time.³¹  All measures were evaluated at 4 time points: baseline, immediately after the intervention, 3 months after the intervention, and 6 months after the intervention. All available data were included in analyses. In GEE analysis, missing data cases are not dropped in computation of estimates.³¹  Before our main analyses, we examined the difference in demographic variables at baseline between participants who had data collected at all 4 time points and participants who missed 1 or more time points for data collection. The only significant difference was in age, which was included as a covariate in the final analyses. In a previous analysis, we found differences between the 2 hospitals participating in the study in marital status, shift worked, and race/ethnicity.¹⁶  These variables were included as covariates in the GEE analysis.

From 2016 to 2019, 249 nurses participated in the foundational MEPRA curriculum. Only 245 completed the majority of the baseline survey. Of the participants, 88.9% were female; 68.3% were White, 11.1% were Asian/Pacific Islander, and 9.0% were Black; and the average age was 33 years. The majority of participants (91.8%) worked full time, and 46.6% worked rotating 12-hour day and night shifts. Although 95.5% of participants reported that they encountered ethical situations at work, only 15.1% had previously received formal ethics training. Detailed demographics are presented in Table 1.

Preliminary analyses using 1-way analysis of variance compared participants who had data collected at all 4 time points with participants who missed 1 or more time points for data collection (Table 2). We divided participants into 4 groups: 119 participants completed all 4 time points, 64 participants completed only baseline and immediately after the program, 51 participants completed all but 6 months, and 11 participants completed all but 3 months. The only significant difference between these 4 groups was in age; those who completed only baseline and immediately after the program were significantly younger than those in the other groups. To address this difference, age was added as a covariate in the main analyses.

We previously reported that immediately after program completion, participants showed improvements in mindfulness, ethical confidence, ethical competence, work engagement, and resilience.¹⁶  Using GEE analyses, we found sustained improvements at both the 3- and 6-month time points for most measures: Perceived Ethical Confidence Scale, Moral Competence Questionnaire, Brief Resilience Scale, work engagement, burnout as measured by emotional exhaustion, Ilfield Psychiatric Symptom Index: depression and anger, and Mindful Attention Awareness Scale (Table 3). Participants had significantly lower turnover intention scores after the intervention, which were sustained at 3 months. Turnover intention scores were higher at 6 months but not as high as at baseline.

The Multidimensional Emotional Empathy Scale is a measure of emotional empathy on a scale of 1 to 5. Using GEE analysis, we found that participants’ scores improved marginally immediately after the intervention, further improved at 3 months, and regressed at 6 months. There was no significant difference in burnout, as measured by depersonalization, at the time point immediately after the intervention; scores decreased significantly at 3 months, but the improvements were not sustained at 6 months. The Ilfield Psychiatric Symptom Index measured 4 domains: anxiety, depression, anger, and cognitive disturbance. Scores for anxiety and cognitive disturbance showed no difference immediately after the intervention but significant improvement at both the 3-month and 6-month time points. Depression and anger scores improved significantly at all time points.

The Moral Distress Thermometer measures moral distress using a scale from 0 (none) to 10 (high). Using GEE analysis, we found that scores were low at baseline and remained low, with no significant changes over time. The Moral Sensitivity Questionnaire measured moral decision-making on a scale of 1 to 6, with higher scores indicating increased difficulty in moral decision-making. The baseline score was 4.38, with no significant difference over time. A summary of the changes in scores on the various measures over time is shown in Figure 2.

Nurses working in diverse clinical settings are experiencing moral adversity and ethical challenges in their work setting. In our sample, 95.5% reported confronting ethical challenges in their workplace. Studies have repeatedly demonstrated that when ethical issues are not addressed, various forms of moral suffering, including moral distress and moral injury, ensue.^32-34  Our findings indicate that MEPRA was effective and that most improvements were sustained 3 and 6 months after conclusion of the foundational program. The most robust effects of the intervention were improvements in ethical confidence, moral competence, resilience, work engagement, mindfulness, burnout as measured by emotional exhaustion, anger, and depression. Turnover intentions were significantly decreased from baseline to immediately after the intervention, and these changes were sustained at 3 months but not at 6 months.

Some of the outcomes, namely scores on the Ilfield Psychiatric Symptom Index subscales of anxiety and cognitive disturbance, showed no significant differences immediately after the intervention but significant improvements from baseline at 3 and 6 months. These findings suggest that some effects of the curriculum may take time to manifest. Participants may need time to apply the principles and skills learned in the day-to-day work setting and gain confidence in their ability to handle ethically challenging situations. Similarly, burnout as measured by depersonalization and empathy scores were unchanged from baseline to immediately after the program but were improved at 3 months; however, the improvements were not sustained at 6 months. Moral distress scores remained low.

Although a measure of moral resilience had not been developed when MEPRA was initiated, improvements in overall resilience were sustained. Since the initiation of MEPRA, moral resilience has been confirmed to be a distinct category of resilience.³⁵  Moral resilience has been shown to be a protective strategy when nurses experience moral distress or moral injury.^34-37  In a study examining the relationship among moral resilience, moral injury, and organizational effectiveness in nurses, for every 1-unit increase in moral resilience, moral injury symptom scores decreased by 1.14 points.³⁷  Components of moral resilience include personal and relational integrity, moral efficacy—the confidence and competence to address ethical concerns in ways that embody integrity—self-regulation and self-awareness, buoyancy to respond mindfully to ethical challenges, and self-stewardship to invest in one’s own well-being.^35,38  Thus, using a moral resilience scale may allow more specific interpretation of the results of interventions.

Sustaining results of any intervention is challenging. Although most of the impacts of the MEPRA intervention were sustained, some of the improvements were not sustained at the same level throughout the study period (namely, the depersonalization sub-scale of burnout, empathy, and turnover intentions). Beyond the foundational curriculum, the MEPRA program includes communities of practice meetings and annual retreats. Although these are opportunities to reinforce foundational content, build community, and apply program teachings to clinical practice, our finding that changes in depersonalization and turnover intentions were not sustained at 6 months suggests a need for more robust booster sessions to help solidify initial progress. The contribution of these ancillary parts of the MEPRA program to the overall results of this study is unknown. The fact that some of the initial progress was not sustained raises the challenge of controlling for the impact of the complex and rapidly changing environments in which nurses practice on key variables of interest. Burnout and turnover intentions are affected by a complex set of workplace factors including workload, workplace resources and support, and individual nurses’ coping skills and resources.³⁹  It is plausible that improvements in these variables would be facilitated by a multi-pronged approach combining MEPRA with structural changes to the workplace such as reduced workload. Another study indicated that higher moral resilience scores combined with improved organizational effectiveness are associated with lower moral injury scores.³⁷  These findings provide evidence that a program with a multipronged design that includes primary, secondary, and tertiary interventions may have a more sustained impact.

As far as we know, MEPRA is the first program to integrate this unique combination of elements to address the complex moral and ethical issues confronted by nurses at the point of care. A systematic review of interventions to mitigate moral distress identified MEPRA as the only program to combine education and mindfulness.¹⁴  This review also described MEPRA as 1 of 2 robust educational interventions.¹⁴  The other intervention, Clinical Ethics Residency for Nurses, is a 98-hour program designed to increase knowledge, skills, and competencies in clinical ethics. The program is proposed to mitigate moral distress by enhancing nurses’ ability to bring about change but does not measure moral distress. It uses lectures, classroom discussions, simulations, and a clinical practicum to teach clinical ethics and train nurses to apply this knowledge in their workplace.¹²  The program developers have not reported results beyond an initial pre- and postcurriculum evaluation. In a study to determine an early action ethics protocol intervention in 6 intensive care units, nurses and physicians were surveyed at baseline, 3 months, and 6 months to examine moral distress, ethics self-efficacy, and ethical climate.⁴⁰  The intervention involved a team approach to daily ethics assessments and early interventions. Over time, nurses’ moral distress scores and frequency of moral distress decreased significantly, while ethics self-efficacy scores and ethical climate improved.⁴⁰ 

Among 3 recent reviews of moral distress interventions,^14,41,42  only 1 other mindfulness-based intervention was identified. A 6-week mindfulness program was offered to nurses working on an inpatient hematology/oncology unit, as one component of a “bundle of mindfulness interventions.”⁴³  The authors reported that attendance at these sessions ranged from 1 to 8 nurses. Other components of this intervention included critical debriefing, establishment of a work-life balance committee, and yoga classes.⁴³  Another intervention¹¹  included mindfulness reminders through cell phone applications as part of a “moral resiliency bundle” to address moral distress but did not specify whether any mindfulness training or resources were provided. A quality improvement project involving hospital clinical nurses examined the impact of 60-minute monthly sessions that included guided meditation and open discussion sessions to decrease moral distress.¹³  The findings were not statistically significant, but the authors concluded that the intervention improved camaraderie and coping skills among nurses.

Few studies of interventions for moral distress use longitudinal data to demonstrate sustained improvements among health care workers. Among studies that measured outcomes at multiple time points, the second follow-up assessment ranged from 2 weeks⁴⁴  to 2 months after the intervention.⁴⁵  One study measured outcomes of an ongoing intervention involving weekly meetings every 2 months for 1 year.⁴⁶  A Nurse Education and Support Team coaching model was evaluated for 18 months to determine feasibility of the model and satisfaction of nurses experiencing ethical concerns.⁴⁷ 

Taken together, these findings offer a promising path forward in strengthening the skills, tools, and resources that nurses already possess to address moral adversity. Future refinement of the MEPRA program could focus on primary and secondary prevention strategies to amplify components of moral resilience as resources to enable nurses to meet the inevitable ethical challenges that arise in clinical practice. Future studies should address the impact of the MEPRA program in post-pandemic environments, where solidarity within a clinical unit and continuity of nurse staffing have been disrupted, and the impact of different content delivery systems (eg, in-person delivery vs self-directed and immersive modules) on program outcomes. We postulate that the relational and social connections that develop within each foundational program cohort and within the broader MEPRA community are strengthened by other program elements including retreats, communities of practice, and unit-based champions. Further investigation is needed to understand the relationships among these components and their combined impact. Also required is further refinement of outcome measures, including measures of the ethical practice environment and moral resilience, and the development of “train the trainer” programs to scale delivery of content.

Studies involving repeated measures for 6 months are historically difficult to sustain. To limit attrition, we sent weekly email reminders to participants encouraging them to complete the follow-up surveys and also made in-person visits to clinical units to reinforce this message. Because of organizational constraints, it was not feasible to include a control group in the study. It is not possible to rule out the impact of multiple survey completions on the results. Investigators conducting future studies may consider incorporating an experimental research design.

In addition, a global measure of resilience may not be sufficiently sensitive to detect the moral dimension of resilience. When this program was initiated, there was no validated measure of moral resilience. Since then, the Rushton Moral Resilience Scale has been validated in clinicians representing various professions; this instrument offers a more precise measure of the moral dimension of resilience.³⁵  Measures such as the 2-question burnout scale and the Moral Distress Thermometer are better suited as screening tools than as secondary outcome measures to evaluate the impact of interventions.

The current delivery method of MEPRA is labor-intensive and requires ongoing leadership investments of time and funding to sustain it beyond the initial foundational program. Institutions that adopt MEPRA must take a long view of the program and consider the high costs of nurse turnover compared with the relatively small investment involved in developing a robust and sustainable program. Organizations can demonstrate their commitment to frontline nurses by offering programs such as MEPRA with paid time during the workday to participate in various elements of the program and by creating unit-based opportunities to share and practice skills developed through program participation.

Collaborative academic/practice partnerships are essential to create multifaceted experiential programs that support nurses’ ability to effectively address ethical challenges that arise in the clinical setting. MEPRA is effective in improving key outcomes that are important in cultivating nurses’ moral efficacy, mindfulness, and resilience and in sustaining these improvements over time. Given the current threats to the nursing workforce, programs such as MEPRA offer organizations targeted interventions to address moral adversity and ethical challenges that are ever present in the acute care setting. Investments in sustainable programs such as MEPRA can enhance nurses’ resilience, improve burnout, increase work engagement, and improve staff retention. Because ethical issues involve values that may be contested or in conflict, programs must feature a multipronged design that includes primary, secondary, and tertiary interventions. Such efforts should be coupled with systemic interventions designed to detect and counter the modifiable patterns in health care organizations that contribute to moral suffering of nurses.

This work was performed at the Johns Hopkins Hospital, Baltimore, Maryland, and Sibley Memorial Hospital, Washington, DC.

We appreciate the contributions of Peter Young and Michelle Prizzi in the initial phases of the program and our entire MEPRA team who helped create it. We are deeply indebted to and inspired by all of the participants in the MEPRA program, who remind us of the purpose of our work and their integral role in health care delivery.