Moral distress and positive experiences of ICU staff during the COVID-19 pandemic: lessons learned.

BACKGROUND: The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. METHODS: A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. RESULTS: All 178 respondents (response rate: 25-32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to 'team cooperation', 'team solidarity' and 'work ethic'. Lessons learned were mostly related to 'quality of care' and 'professional qualities'. CONCLUSIONS: Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals' dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. TRIAL REGISTRATION: The trial was registered on The Netherlands Trial Register, number NL9177.

Moving From Moral Distress to Moral Resilience Using Acceptance and Commitment Therapy

Moral distress (MD) is a problematic experience for healthcare workers, with career engagement implications includ-ing burnout, job turnover, and career turnover. Instances of MD have been increasing since the start of the COVID-19 pandemic, threatening greater problems for the healthcare system. Although a range of interventions have been explored, no evidence-based treatment has been identified. Be-cause of how embedded ethical decision-making is in the health-care field, it is unlikely that MD will be eradicated;however, it is suggested that MD can be learned from and transformed into moral resilience. Some evidence indi-cates that healthcare workers could benefit from mindfulness-based and emotion regulation skills, alongside values-based and action strategies, to support the devel-opment of moral resilience. This article proposes the applicability of Acceptance and Commitment Therapy (ACT) and its six core skills-acceptance, cognitive de -fusion, mindfulness, self-as -con-text, values, and commitment-to the work of career practitioners as a means of developing moral resilience skills among healthcare workers.

"Sip & Share": Building Resilience in Surgery Residency Through Moral Distress Rounds.

OBJECTIVE: Resident moral distress rounds were instituted during the COVID-19 pandemic to provide a safe zone for discussion, reflection, and the identification of the ethical challenges contributing to moral distress. The sessions, entitled "Sip & Share," also served to foster connectedness and build resilience. DESIGN: A baseline needs assessment was performed and only 36% of general surgery residents in the program were satisfied with the current non-technical skills curriculum. Only 62% were comfortable with navigating ethical issues in surgery. About 72% were comfortable with leading a goals-of-care discussion, and 63% of residents were comfortable with offering surgical palliative care options. Case-based discussions over video conferencing were organized monthly. Each session was structured based on the eight-step methodology described by Morley and Shashidhara. Participation was voluntary. The sessions explored moral distress, and the ethical tensions between patient autonomy and beneficence, and beneficence and non-maleficence. SETTING: Large general surgery residency in an urban tertiary medical center. PARTICIPANTS: General surgery residents. RESULTS: A post-intervention survey was performed with improvement in the satisfaction with the non-technical skills curriculum (70% from 36%). The proportion of residents feeling comfortable with navigating ethical issues in surgery increased from 62% to 72%. A survey was performed to assess the efficacy of the moral distress rounds after eight Sip & Share sessions over ten months. All thirteen respondents agreed that the discussions provided them with the vocabulary to discuss ethical dilemmas and define the ethical principles contributing to their moral distress. 93% were able to apply the templates learned to their practice, 77% felt that the discussions helped mitigate stress. All respondents recommended attending the sessions to other residents. CONCLUSIONS: Moral distress rounds provide a structured safe zone for residents to share and process morally distressing experiences. These gatherings mitigate isolation, promote a sense of community, and provide a support network within the residency. In addition, residents are equipped with the vocabulary to identify the ethical principles being challenged and are provided practical take-aways to avoid similar conflicts in the future.

Evaluating a brief mindfulness-based self-care intervention on critical care nurses' resilience and well-being during the COVID-19 pandemic

Background: Critical care nurses faced unprecedented challenges during the pandemic, exacerbating stress, burnout, and moral distress. Despite the significant implications of moral distress, few effective interventions exist. Shifting the focus from mitigating moral distress to strengthening moral resilience may help to address this gap and provides an opportunity to shape future research. Mindfulness practices have been shown to reduce distress and burnout, improve well-being and resilience, and may provide a useful tool in mitigating the negative effects of moral distress. Objectives: To determine the efficacy and feasibility of a brief mindfulness-based self-care program on critical care nurses' resilience and well-being during the COVID-19 pandemic. Methods: A single-group pretest-posttest design was utilized. From an adult critical care unit in an academic hospital, a convenience sample of nurses working during the pandemic were enrolled. The four-week intervention was offered through a free online application. Participants were asked to complete five assigned guided practices per week at a location and time convenient to them. Pre-and-postintervention surveys were available through Qualtrics and utilized the 10-item Connor-Davidson Resilience Scale, Rushton Moral Resilience Scale, and Nurse Well-Being Index to evaluate outcome measures. Practice frequency was automatically tracked by the application. Demographic data and feasibility measures were included. Statistical analysis included descriptive statistics, Wilcoxon signed rank tests, nonparametric permutation tests, and nonparametric bootstrap analyses;a regression analysis evaluated relationships between variables. Results: Thirty nurses completed pretest data, and twenty-three participated in practices and the postintervention survey. Significant changes in resilience, moral resilience and well-being scores were noted. There was no significant correlation between practice frequency and changes in outcome measures. A positive correlation was found between resilience and moral resilience. Resilience measures were negatively correlated with at-risk well-being scores. Participant responses lent support to the acceptability and feasibility of the intervention. Conclusion: Participation in a brief, online MBSC intervention appeared beneficial in fostering resilience, moral resilience, and well-being in a sample of critical care nurses during the COVID-19 pandemic. Future studies are warranted. Interventions that offer room for personal and collective growth may be an important next step, particularly as we look forward. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Supporting people with intellectual disability at end of life: Moral distress among staff caregivers during COVID-19

COVID-19 is likely to have compromised the management of end-of-life care. Disruptions include the inability to respect advanced care planning, offer support to the person dying, and the failure to celebrate the person's life within local customs. Where people work to deliver high-quality care, such disruption can lead to carers experiencing moral distress, which can have behavioural and physical consequences if unresolved. This chapter describes the leading theories of the causes, experiences, and prevention of moral distress for carers. We then utilise data from eight end-of-life interviews that supply evidence for carers experiencing moral conflict distress, moral constraint distress, moral uncertainty distress, retrospective moral distress, and moral residue to underpin three case stories about the disruptions to end-of-life care in the intellectual disability community. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

The adaptive moral challenge of COVID-19

This author offers of narrative of hope in response to the coronavirus pandemic by viewing it as a wake-up call to lean into the adaptive moral challenge of stewardship for the future of humanity and the planet. Acknowledging the many material and social benefits of a global regime of free market urbanism built on advances in science and technology, this is a point in geohistory, the Anthropocene, when the impact of human activities on the Earth has begun to outcompete natural processes. The coronavirus has illuminated systemic moral failures and new moral challenges of the Anthropocene that call for adaptive response if we are to build a hopeful future for humanity and the planet. Pointing to millennia of human adaptive response to threats and disasters, the author asserts an evolutionary hardiness attributable as much to moral capacities as rational intelligence as a singularly defining trait fueling millennia of human adaptive learning and thrival. The current pandemic is the latest point in humanity's moral evolution of adaptive response to moments of urgent threat that have tested, expanded, and defined our character and moral capacities as a species. Rather than falter under the moral burden of the coronavirus threat and its consequences, the author views this pivotal point as an opportunity to stretch human moral horizons by taking responsibility for the urgent moral challenges we have created and inventing new ethical frameworks and tools that will lead us to new moral understandings and solutions to the moral challenges we face.

The Long Tail of COVID-19: Implications for the Future of Emergency Nursing.

INTRODUCTION: COVID-19 has led to exacerbated levels of traumatic stress and moral distress experienced by emergency nurses. This study contributes to understanding the perspectives of emergency nurses' perception of psychological trauma during COVID-19 and protective mechanisms used to build resilience. METHOD: The primary method was qualitative analysis of semistructured interviews, with survey data on general resilience, moral resilience, and traumatic stress used to triangulate and understand qualitative findings. Analyses and theme development were guided by social identity theory and informed by the middle range theory of nurses' psychological trauma. RESULTS: A total of 14 emergency nurses were interviewed, 11 from one site and 3 from the other. Almost all nurses described working in an emergency department throughout the pandemic as extraordinarily stressful, morally injurious, and exhausting at multiple levels. Although the source of stressors changed throughout the pandemic, the culmination of continued stress, moral injury, and emotional and physical exhaustion almost always exceeded their ability to adapt to the ever-changing landscape in health care created by the pandemic. Two primary themes were identified: losing identity as a nurse and hopelessness and self-preservation. DISCUSSION: The consequences of the pandemic on nurses are likely to be long lasting. Nurses need to mend and rebuild their identity as a nurse. The solutions are not quick fixes but rather will require fundamental changes in the profession, health care organizations, and the society. These changes will require a strategic vision, sustained commitment, and leadership to accomplish.

Moral distress in carers for people with an intellectual disability who died during the COVID-19 pandemic, a template analysis extending the Barlem and Ramos model of moral distress.

BACKGROUND: This article aims to understand moral distress in carers of people with an intellectual disability during the COVID-19 pandemic. METHOD: Nine staff carers of seven people with an intellectual disability, who had been participants of the IDS-TILDA study in Ireland, who died during the COVID-19 pandemic participated in in-depth, semi-structured telephone interviews. Template analysis was used to analyze the interviews. RESULTS: Obstructions in performing their duties left carers feeling powerless and experiencing moral conflict distress, moral constraint distress and moral uncertainty distress. Most managed to connect to the moral dimension in their work through peer support, understanding they fulfilled the wishes of the deceased, and/or thinking about how they or others did the best they could for the person they were caring for. CONCLUSIONS: This research demonstrates that while restrictions may have been effective in reducing the spread of COVID-19, they were potentially damaging to carer wellbeing.

Perceived Stress and Its Relationship to Moral Resilience Among Nurses in the Hail Region, Saudi Arabia

Background: This study aimed to determine the relationship between perceived stress and moral resilience among nurses. Methods: The researcher used a quantitative-comparative correlational study design that utilized a self-administered questionnaire with 393 nurse participants in the Hail Region, Saudi Arabia. Adapted questionnaires were distributed through Google Form survey. Data collection was conducted between October and November 2021.Results: The nurses were moderately stressed (21.69/30) but morally resilient (2.74/4). Perceived stress scale (p < 0.033) and moral resilience (p < 0.25) were found to be significantly associated with gender. The designated ward and age were not significantly associated with perceived stress and moral resilience. Conversely, the years of experience showed a significant association with perceived stress (p < 0.038) but not with moral resilience (p > 0.255). Finally, no relationship was observed between perceived stress and moral resilience (p > 0.248).Conclusions: The nurses were perceived to be moderately stressed but morally resilient. Gender was found to have a significant association with perceived stress and moral resilience but not with designated ward and age. Conversely, the years of experience had a significant association with perceived stress but not with moral resilience. Meanwhile, perceived stress had no significant relationship with moral resilience. Therefore, being morally robust allows nurses to respond to challenging, frequently intractable ethical issues that arise in clinical practice and during pandemics, regardless of the underlying stress at work.

Supporting people with intellectual disability at end of life: Moral distress among staff caregivers during COVID-19

COVID-19 is likely to have compromised the management of end-of-life care. Disruptions include the inability to respect advanced care planning, offer support to the person dying, and the failure to celebrate the person's life within local customs. Where people work to deliver high-quality care, such disruption can lead to carers experiencing moral distress, which can have behavioural and physical consequences if unresolved. This chapter describes the leading theories of the causes, experiences, and prevention of moral distress for carers. We then utilise data from eight end-of-life interviews that supply evidence for carers experiencing moral conflict distress, moral constraint distress, moral uncertainty distress, retrospective moral distress, and moral residue to underpin three case stories about the disruptions to end-of-life care in the intellectual disability community. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

‘Have They Talked About Us At All?’ The Moral Distress of Healthcare Social Workers during the COVID-19 Pandemic: A Qualitative Investigation in the State of Texas

Amid the ongoing pandemic, as overburdened and underfunded health systems are requiring health care social workers (HSWs) to assume responsibilities beyond their scope of practice, institutional constraints have undoubtedly heightened encounters of moral distress (MD). MD is the psychological disequilibrium that arises when institutional factors obligate an individual to carry out a task that violates their professional and/or personal ethics. Our qualitative study investigated HSWs' (n = 43) MD in Texas during the 2019 COVID-19 pandemic. Findings from our study indicate that MD occurs across five levels: (i) patient care decisions;(ii) personal care decisions;(iii) team/unit decisions;(iv) organisational decisions;and (v) social justice decisions. MD is rooted in systems that disproportionately impact historically excluded populations, including social inequities such as financial instability, homelessness and substance use. Organisations need to explicitly consider social justice initiatives that seek to identify growing disparities in care that have been at the forefront of the pandemic;macro-level perspectives that expand MD must address social and health inequities that impede daily tasks of all health care workers. MD encounters that are rooted in social determinants of health can inform supervision, education and practice to ameliorate HSWs' value conflict. The pandemic has heightened encounters of moral distress (MD) among health care social workers (HSWs). MD occurs when institutional factors constrain an individual in performing a task that violates their professional and/or personal values. MD is a leading cause of burnout, job dissatisfaction, patient disengagement and turnover. Limited research on HSWs' MD during the pandemic indicates a need for evidence-based data to inform intervention strategies. This qualitative study aimed to identify the triggers of MD among a sample of HSWs in Texas during the COVID-19 pandemic. Findings from our study show that MD is rooted in: (i) patient care decisions, including rushed and unsafe discharge plans and poor end-of-life practices;(ii) personal care decisions, including safety precautions that reduce care;(iii) team/unit considerations, including poor interdisciplinary collaboration and power imbalances;(iv) structural factors, including inconsistent visitation policies and unethical hierarchies;and (v) social injustice, including social inequities and the politicization of the pandemic. Importantly, as all health care workers are being impacted by macro-level constraints, health care organisations ought to explicitly consider incorporating social justice initiatives to enhance health and well-being. Our findings have implications for social work practice, education and supervision.

Evaluating a brief mindfulness-based self-care intervention on critical care nurses' resilience and well-being during the COVID-19 pandemic

Background: Critical care nurses faced unprecedented challenges during the pandemic, exacerbating stress, burnout, and moral distress. Despite the significant implications of moral distress, few effective interventions exist. Shifting the focus from mitigating moral distress to strengthening moral resilience may help to address this gap and provides an opportunity to shape future research. Mindfulness practices have been shown to reduce distress and burnout, improve well-being and resilience, and may provide a useful tool in mitigating the negative effects of moral distress. Objectives: To determine the efficacy and feasibility of a brief mindfulness-based self-care program on critical care nurses' resilience and well-being during the COVID-19 pandemic. Methods: A single-group pretest-posttest design was utilized. From an adult critical care unit in an academic hospital, a convenience sample of nurses working during the pandemic were enrolled. The four-week intervention was offered through a free online application. Participants were asked to complete five assigned guided practices per week at a location and time convenient to them. Pre-and-postintervention surveys were available through Qualtrics and utilized the 10-item Connor-Davidson Resilience Scale, Rushton Moral Resilience Scale, and Nurse Well-Being Index to evaluate outcome measures. Practice frequency was automatically tracked by the application. Demographic data and feasibility measures were included. Statistical analysis included descriptive statistics, Wilcoxon signed rank tests, nonparametric permutation tests, and nonparametric bootstrap analyses;a regression analysis evaluated relationships between variables. Results: Thirty nurses completed pretest data, and twenty-three participated in practices and the postintervention survey. Significant changes in resilience, moral resilience and well-being scores were noted. There was no significant correlation between practice frequency and changes in outcome measures. A positive correlation was found between resilience and moral resilience. Resilience measures were negatively correlated with at-risk well-being scores. Participant responses lent support to the acceptability and feasibility of the intervention. Conclusion: Participation in a brief, online MBSC intervention appeared beneficial in fostering resilience, moral resilience, and well-being in a sample of critical care nurses during the COVID-19 pandemic. Future studies are warranted. Interventions that offer room for personal and collective growth may be an important next step, particularly as we look forward. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Moral distress and moral injury and their interplay as a challenge for leadership and management: The case of Croatia.

AIM: We aim to investigate the interplay between moral distress and moral injury among nurses working in palliative and oncology wards and to assess its impact on nursing leadership. BACKGROUND: The past 2 years have been particularly challenging for nurses and nursing leaders in Croatia. The coronavirus disease pandemic and the subsequent earthquakes in the country significantly impacted the work of nurses. Moral distress has been well-known to nursing professionals, but recent studies warn about cofounding it with moral injury and their possible intercorrelation, deserving more attention from an empirical perspective. METHODS: We conducted quantitative cross-sectional research in palliative and oncology wards in 11 Croatian health care facilities on 162 nurses, using a questionnaire and paper/pencil method over 6 months (1 January 2021 to 1 July 2021). The questionnaire consisted of three parts: sociodemographic data, a Measure of moral distress for health care professionals and Moral injury symptoms scale for health care professionals. The research protocol was approved by the Ethics committee of the Catholic University of Croatia under no. 1-21-04. RESULTS: The findings of our study demonstrated that the current average levels of moral distress might be characterized as low, but the moral injury symptoms are severe. The results of our study bring interesting novel insights, such as the strong correlation between moral distress and moral injury, but also in terms of nurses' decision to leave or consider leaving their position. The nurses who experience higher levels of moral distress experience severe symptoms of moral injury, while nurses who score higher in moral distress and moral injury have left, considered or consider leaving their positions. CONCLUSIONS: This study highlighted the need to pay attention to the emerging phenomenon of moral injury that has been unaddressed and overshadowed by moral distress, their intercorrelation, and the importance of addressing them timely and adequately within health care organizations with their leadership and management. IMPLICATIONS FOR NURSING MANAGEMENT: These findings provide a significant insight that may assist nursing managers and leaders to act and respond in time to develop various prevention and mitigation measures and help resolve situations leading to moral distress or moral injury.

RESPONDER: A qualitative study of ethical issues faced by critical care nurses during the COVID-19 pandemic.

AIMS: To identify and understand ethical challenges arising during COVID-19 in intensive care and nurses' perceptions of how they made "good" decisions and provided "good" care when faced with ethical challenges and use of moral resilience. BACKGROUND: Little is known about the ethical challenges that nurses faced during the COVID-19 pandemic and ways they responded. DESIGN: Qualitative, descriptive free-text surveys and semi-structured interviews, underpinned by appreciative inquiry. METHODS: Nurses working in intensive care in one academic quaternary care centre and three community hospitals in Midwest United States were invited to participate. In total, 49 participants completed free-text surveys, and seven participants completed interviews. Data were analysed using content analysis. RESULTS: Five themes captured ethical challenges: implementation of the visitation policy; patients dying alone; surrogate decision-making; diminished safety and quality of care; and imbalance and injustice between professionals. Four themes captured nurses' responses: personal strength and values, problem-solving, teamwork and peer support and resources. CONCLUSIONS: Ethical challenges were not novel but were amplified due to repeated occurrence and duration. Some nurses' demonstrated capacities for moral resilience, but none described drawing on all four capacities. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers would benefit from greater ethics training to support their nursing teams.

Research Progress on Moral Injury of Foreign Medical Staff under the Background of COVID-19 Pandemic

This paper reviewed the research on moral injury among foreign medical staff in the background of the COVID-19 pandemic. It was found that foreign medical staff bore multiple moral pressures and impacts in the face of the epidemic, including the collision between medical practice and utilitarian policy, the inability to meet personal needs, the rapid transformation of medical mode, and a variety of comprehensive factors. Therefore, the moral injury of foreign medical staff is particularly prominent. In order to avoid and reduce the occurrence of moral injury, it is necessary to strengthen the cultivation of moral resilience, provide psychological and social support, and carry out personalized treatment for medical staff. © 2022, Editorial department of Chinese Medical Ethics. All rights reserved.

Moral Injury and Moral Resilience in Health Care Workers during COVID-19 Pandemic.

Background: The 2019 coronavirus (COVID-19) pandemic placed unprecedented strains on the U.S. health care system, putting health care workers (HCWs) at increased risk for experiencing moral injury (MI). Moral resilience (MR), the ability to preserve or restore integrity, has been proposed as a resource to mitigate the detrimental effects of MI among HCWs. Objectives: The objectives of this study were to investigate the prevalence of MI among HCWs, to identify the relationship among factors that predict MI, and to determine whether MR can act as buffer against it. Design: Web-based exploratory survey. Setting/Subjects: HCWs from a research network in the U.S. mid-Atlantic region. Measurements: Survey items included: our outcome, Moral Injury Symptoms Scale-Health Professional (MISS-HP), and predictors including demographics, items derived from the Rushton Moral Resilience Scale (RMRS), and ethical concerns index (ECI). Results: Sixty-five percent of 595 respondents provided COVID-19 care. The overall prevalence of clinically significant MI in HCWs was 32.4%; nurses reporting the highest occurrence. Higher scores on each of the ECI items were significantly positively associated with higher MI symptoms (p < 0.05). MI among HCWs was significantly related to the following: MR score, ECI score, religious affiliation, and having ≥20 years in their profession. MR was a moderator of the effect of years of experience on MI. Conclusions: HCWs are experiencing MI during the pandemic. MR offers a promising individual resource to buffer the detrimental impact of MI. Further research is needed to understand how to cultivate MR, reduce ECI, and understand other systems level factors to prevent MI symptoms in U.S. HCWs.

The new frontline: exploring the links between moral distress, moral resilience and mental health in healthcare workers during the COVID-19 pandemic.

BACKGROUND: Global health crises, such as the COVID-19 pandemic, confront healthcare workers (HCW) with increased exposure to potentially morally distressing events. The pandemic has provided an opportunity to explore the links between moral distress, moral resilience, and emergence of mental health symptoms in HCWs. METHODS: A total of 962 Canadian healthcare workers (88.4% female, 44.6 + 12.8 years old) completed an online survey during the first COVID-19 wave in Canada (between April 3rd and September 3rd, 2020). Respondents completed a series of validated scales assessing moral distress, perceived stress, anxiety, and depression symptoms, and moral resilience. Respondents were grouped based on exposure to patients who tested positive for COVID-19. In addition to descriptive statistics and analyses of covariance, multiple linear regression was used to evaluate if moral resilience moderates the association between exposure to morally distressing events and moral distress. Factors associated with moral resilience were also assessed. FINDINGS: Respondents working with patients with COVID-19 showed significantly more severe moral distress, anxiety, and depression symptoms (F > 5.5, p < .020), and a higher proportion screened positive for mental disorders (Chi-squared > 9.1, p = .002), compared to healthcare workers who were not. Moral resilience moderated the relationship between exposure to potentially morally distressing events and moral distress (p < .001); compared to those with higher moral resilience, the subgroup with the lowest moral resilience had a steeper cross-sectional worsening in moral distress as the frequency of potentially morally distressing events increased. Moral resilience also correlated with lower stress, anxiety, and depression symptoms (r > .27, p < .001). Factors independently associated with stronger moral resilience included: being male, older age, no mental disorder diagnosis, sleeping more, and higher support from employers and colleagues (B [0.02, |-0.26|]. INTERPRETATION: Elevated moral distress and mental health symptoms in healthcare workers facing a global crisis such as the COVID-19 pandemic call for the development of interventions promoting moral resilience as a protective measure against moral adversities.

COVID-19 era healthcare ethics education: Cultivating educational and moral resilience.

The COVID-19 pandemic crisis has had profound effects on global health, healthcare, and public health policy. It has also impacted education. Within undergraduate healthcare education of doctors, nurses, and allied professions, rapid shifts to distance learning and pedagogic content creation within new realities, demands of healthcare practice settings, shortened curricula, and/or earlier graduation have also challenged ethics teaching in terms of curriculum allotments or content specification. We propose expanding the notion of resilience to the field of ethics education under the conditions of remote learning. Educational resilience starts in the virtual classroom of ethics teaching, initially constituted as an "unpurposed space" of exchange about the pandemic's challenging impact on students and educators. This continuously transforms into "purposed space" of reflection, discovering ethics as a repertory of orientative knowledge for addressing the pandemic's challenges on personal, professional, societal, and global levels and for discovering (and then addressing) that the health of individuals and populations also has moral determinants. As such, an educational resilience framework with inherent adaptability rises to the challenge of supporting the moral agency of students acting both as professionals and as global citizens. Educational resilience is key in supporting and sustaining professional identify formation and facilitating the development of students' moral resilience and leadership amid moral complexity and potential moral transgression-not only but especially in times of pandemic.

How Does an Oncology Nurse Increase Moral Resilience During a Pandemic?

As an oncology advanced practice nurse, I find myself asking, "How can I continue to provide the same level of competent, quality care while meeting the unique, holistic needs of this population leveraged with self-care during the COVID-19 pandemic?" In talking with colleagues, we find ourselves torn between providing fluid oncology care that is compassionate and comprehensive while managing our uncertainties with our family since the beginning of this pandemic. I practice in a state that is known nationally to have the worst rates of cancer-associated deaths and comorbidities, which predisposes patients to poor outcomes with COVID-19 (Centers for Disease Control and Prevention, 2020). Providers grasp that patients are at higher risk, yet patients with active cancer must be seen in person regularly and providers are tasked with how to protect them.