In the Covid-19 era, clinicians are stepping outside of their normal roles to help meet patient needs, and at times, are facing new and complex ethical decisions on how to allocate resources when there aren't enough for everyone.

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These ethical decisions can leave clinicians feeling like they're providing care that does not meet their usual standards. As a result, many clinicians now experience moral distress, defined as knowing the right thing to do, but facing constraints that make doing it nearly impossible. It's crucial to help clinicians acknowledge these experiences and find comfort knowing their peers feel the same way.

To learn how organizations can increase support for staff who are navigating ethical challenges, we spoke with Cynda Hylton Rushton, PhD, RN, FAAN. 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, Rushton works directly with frontline staff to build moral resilience and cultivate a culture of ethical practice through virtual Moral Resilience Rounds.

Below we round up the key takeaways Rushton and her team are proactively bringing staff together to have critical conversations about Covid-19—and her advice for how others can do the same.

Getting the conversation started with virtual moral resilience rounds

Rushton and her team rely on virtual moral resilience rounds to proactively bring staff together to have critical conversations about Covid-19.

There rounds are weekly, one-hour sessions with a group of multidisciplinary clinicians who discuss recent ethical challenges. This is not a debriefing. Rather, the goal of moral resilience rounds is to acknowledge the distress caused by the ethical challenge and then pivot to solutions.

In practice, here's how moral resilience rounds work. At the same time each Thursday, Rushton, along with a physician and a philosopher, hosts moral resilience rounds via Zoom. Typically, 25 to 30 participants join, but there have been sessions with up to 50 participants.

Johns Hopkins partners with the Peabody Institute, which provides a musical interlude while participants are joining. Rushton then starts each session in the same way:

1. A mindfulness practice to help everyone ground themselves;
   
   
2. A discussion on participant and patient confidentiality, with a reminder not to violate HIPAA;
   
   
3. A prompt for each person to type a word describing how they feel that day in the chat box. This provides a bit of a barometer for the discussion.

Then, a member of the team invites participants to share their ethical challenges, either verbally or through the chat function. As participants share their experiences or the questions they're wrestling with, others will listen and at times, respond. Sometimes to share answers and other times to acknowledge feelings and share in the comfort of knowing others are experiencing the same thing. As the facilitator, Rushton keeps the discussion solutions focused, acknowledging experiences while pulling out the ways to move forward. At the end of the conversation, participants share what they're taking away from the conversation.

Considerations for implementing moral resilience rounds—virtually or in-person

These sessions are one way to give staff space to talk about their experiences in a safe environment—and they can be done both virtually and in-person.

While facilitating virtually can feel challenging, there are pros to it. Virtual rounds offer more flexibility to staff and an increased sense of confidentiality (and in the era of Covid, it offers a way to touch base while complying with local social distancing rules). For organizations interested in replicating this work, either in-person or virtually, Rushton recommends the following: 

1. Tap into employees with trained facilitation skills to lead rounds. Consider social workers, chaplains, ethics consultants, and clinical psychologists.
   
   
2. Invite a multidisciplinary team to bring needed perspective—but keep this clinical. To create a psychologically safe environment, these sessions should only include frontline clinical staff.
   
   
3. Emphasize the importance of confidentiality. Maintain the standard practices used for in-person forums, such as not sharing discussions outside of the session. But this is one area where virtual facilitation helps! Participants can rename themselves on the virtual platform and remain off camera if they so choose.
   
   
4. Publicize the rounds through multiple channels. Consider channels that clinical staff already use, such as listservs, emails, and department or unit flyers. As with other support forums, word of mouth is also very effective.

For more information on how to build staff resilience and respond to moral distress, Rushton and the Johns Hopkins Berman Institute of Bioethics have put together a resource page. The page provides frontline clinicians with the resources they need to personally and professionally face the unprecedented challenges posed by the Covid-19 outbreak, including:

• Personal Protective Strategies: End of Shift Huddle. These huddles allow members of a shift time to acknowledge each other’s experience and help transition from work to home.
  
  
• Brief Grounding Script for End of Shift Huddle. This resource provides a script for a grounding exercise to use during the end of shift huddle. The exercise uses skills from the Social Resilience Model to decrease the toxic effects of stress chemicals and enhance resilience.
  
  
• Responding to Moral Distress Arising from Covid-19. This video discusses how to apply the social resilience model to the common ethical challenges and address the moral distress caused by the Covid-19 crisis.

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