Caring for tomorrow’s workforce

Introduction: Right, wrong, and what lies behind them

“The most important lesson I have learned is that there is no right nor wrong when talking about ethics.” With this statement, a nursing student closed the final discussion round of an ethics module within a Master’s program in nursing science, just before the noon break. I was definitely not prepared for it, so I simply nodded my head. However, what is wrong with the student’s answer? Maybe it is not too bad, provided we know the assumptions behind it. Healthcare ethics educators may not be the only ones who experience this kind of classroom talk. What is so special about this setting? A closer look at the literature on healthcare ethics education (HCEE) is revealing: In the last four decades, research in HCEE has been enriched by different lenses and methodologies which are helpful in our case. ¹ In what follows, they will be described as the philosophical, the behavioral, and developmental lens.

Moral experts, trustworthy clinicians, or self-reflecting thinkers?

When asked about the essential features of HCEE, educators would most likely first mention objectives within the cognitive domain. ² Through the philosophical lens, HCEE first unfolds with the identification of clinical problems and philosophical aspects that illuminate the ethical dimension (e.g. ethical theories and concepts, ethical decision-making models) and inform principled ethical reasoning. Following established principles of educational science, educators align these contents with the general curriculum. Whether visible or not, curricular issues already imply considerable ethical choices. They are rooted in different theoretical assumptions about normative ethics and its relationship to clinical practice, metaethics, and the question about what constitutes moral expertise. Nevertheless, this is not the sole lens.

Following the title question of Alastair Campbell et al.’s ³ contribution, “How can we know that ethics education produces ethical doctors?”, measuring how students transform cognitive knowledge into practice can be seen as the highest taxonomical level of possible outcomes of HCEE, provided we could reach a consensus on the question what an ethical doctor or an ethical nurse actually is. Here, the moral behavioral lens builds on the consensus of learning theorists generally defining learning as sustainable and visible behavior modification. ⁴ HCEE therefore second unfolds by fostering in students those ethical competencies that make them “ethically fit” for practice. ^5,6 Worrying evidence is given that poor ethical preparedness is associated with an increased risk of professional misconduct. ^7,8 Professionalism expresses and professes that the healthcare professions’ mandate is not only a social or scientific one but also an imminently ethical one.

Third, when considering the moral developmental lens, healthcare ethics educators experience young people living in particular circumstances. Students have to balance not only the intellectual and organizational demands of their studies but also social lives within families and peers, as well as the first clinical experiences. Parallel to their academic studies, they enter the cosmos of the ward as novices. Here, they are progressively socialized into the cultures of healthcare practice, learning that evidence-based knowledge and sound clinical reasoning are not the only driving forces but also gut feeling, intuition, authority, and even abuse of power. They soon become fast learners of the other curriculum, which is informal and hidden, ambivalent, but powerful. ⁹ At one moment, it submits them to the “brute” laws of the “ward jungle,” at another, it protects and directs them by authentic role models whom they will always remember and try to emulate. From starting as peripheral observers, students become more and more actors within the clinical realm. Patterns of cognitive and practical apprenticeship run parallel to their moral apprenticeship. ¹⁰ The latter reflects students’ moral development which is not only seen in terms of assessable cognitive stages or schemes that evaluate moral judgment, ¹¹ but also in terms of psychological, social, and neurobiological determinants of moral functioning. ¹² By adopting this lens, HCEE enhances the moral development in students that results from the interaction of knowledge and experience, may the latter be enactive within the patient encounter or vicarious in discussions within peers and educators in the classroom.

Recent research has highlighted the relevance of the three “lenses” in the delivery of HCEE. However, the coexistence of the underlying paradigms leads to considerable variations in contents and teaching formats of HCEE as well as student assessment. At this point, the hesitation in responding to the “not-right-not-wrong” statement in the introductory part can be explained as a tension concerning the “lens” that should be adopted in order to respond to the student in an appropriate way.

It is unlikely that educators think in terms of “lenses” they wear when planning and implementing an ethics curriculum. They may probably bear in mind some kind of vision how their students as future practitioners will hopefully put into practice what they have heard and learned from textbooks, discussions, direct observation, and experience. At a practical level, these tensions highlighted by the three lenses can be typified by three metaphors: Should HCEE “produce” knowledgeable moral experts (the philosophical lens), trustworthy clinicians (the behavioral lens), or self-reflecting thinkers (the developmental lens)? The relevance of this distinction becomes particularly visible in determining how, what, and when to assess HCEE in students. ¹³ At first sight, the moral expert, trustworthy clinician, and self-reflecting thinker are all justified by the ethical demands of professional practice. Nevertheless, if these models are unstated, combined at random or distributed unequally, they are likely to lead to discrepancies between contents, formats, assessment of student learning, and transferability into practice. ³ Manifestations of such a mismatch reported in the literature are

Cognitive overload of students (as risk of the expert model); ^14,15

Therefore, depending on the “lens” chosen, educators will focus on theoretical problem analysis and moral behavior or make inferences to the moral development. Of importance is that all these conceptualizations have a high degree of intrinsic plausibility. The question, which lens should be the dominating one, has no clear-cut answers. Whereas the majority of authors reasonably propose some combination, the variability of ethics curricula as related to contents, assessment, and reported outcomes ^1,19 bears the risk of fragmentation and randomness. The difficulties in establishing which “lens” should be the dominating one are by no means just of theoretical nature, but a threat to the effectiveness of HCEE, as research on students’ confidence in connecting ethics teaching and practice suggests. ^17,18 As an attempt to overcome these difficulties, moral resilience is proposed as the unitary “lens” of HCEE which departs from the ethical demands of practice and arranges the other “lenses” around this gravitational focus.

Shifting from the complaint about moral distress to the development of moral resilience

To look at education from the perspective of resilience presupposes a conceptual shift from traditional content orientation to experience orientation. ²⁰ It implicates uncovering the different stressors students experience in the classroom and on the ward. Dealing with complexity—as resulting from the novice status of students in science and practice, but also intrinsic to both science and practice—constitutes a major stressor in students’ lives. ²¹ Promoting psychological resilience in the light of this stressor asks from educators and mentors to foster in students self-efficacy and self-control, but also to help them in managing learning, overcoming learning resistances, and coping with learning “failures.” ²² In addition to stressors caused by the demands of their studies, students also experience moral stressors. ²³ Importantly, both study-related and moral stressors can be ascribed to causal or hermeneutic complexity. ^24,25 If psychological resilience has to be strengthened in students in order to help them to manage study-related complexity, then moral resilience helps them in managing moral complexity. Yet, there is a major limitation in trying to “align” psychological and moral resilience which lies in the diversity of the concepts: In general, instruments that measure psychological resilience depart from psychological constructs describing processes, outcomes, or developments of individuals exposed to risk or experiencing adversity. ^26,27 The ethical dimension—albeit present—is not specifically addressed. When looking at the typologies of stressors and vulnerabilities that underlie the psychological resilience construct, there are undoubtedly close similarities between moral resilience and psychological resilience. This holds especially true when considering those stressors that involve witnessed or perpetrated moral injury, understood as the psychological outcome of a morally challenging situation (e.g. nursing students witnessing the force-feeding of patients). Nevertheless, for the purposes of education, it is heuristically useful to maintain the distinction of moral stressors—in terms not of an outcome, but of the underlying etiology—as being triggered on the basis of moral intuitions and values or (by referring to Andrew Jameton’s ²⁸ influential definition of moral distress) moral judgments. Given the difficulty in assessing moral resilience directly with the instruments of psychological resilience, moral resilience seems to be best approached indirectly by referring to measurements of moral distress. Unlike psychological distress, moral distress is a construct with an explicit ethical connotation. Nowadays, an impressive body of empirical research is available to address moral distress in nursing, medical, and allied professions as well as in students of both professions. ^{29 –31} Serious philosophical questions have been raised, marking an important step in the history of this concept. ^{32 –34} Although moral distress serves as the experiential starting point of HCEE, the critiques addressing the normative validity of this construct must not be ignored. This applies especially to moral distress as already implying a moral judgment in a given situation. From an ethical point of view, it is consistent to define moral distress as “a psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both” (p. 7). ³² Yet, the morally challenging situation is never statically given, but results from an interaction of personal intuitions, values, and norms with a given situation, which may also (but does not have to) give rise to moral judgments. In order to preserve this normative caution, the term “perceived moral distress” (PMD) is advocated here as comprising psychological outcomes based on a specific etiology recalling the moral realm.

Moral resilience can therefore be operationally defined as an outcome based on a change in PMD in a given axis of time. In this line of thinking, the goal of HCEE is to enable students to understand and master the moral stressors they experience in practice ³⁵ or they learn about from the experience of others. This goal is seen as the unifying lens that aligns the three lenses mentioned: HCEE provides those knowledge bases (e.g. moral theories, methods in applied ethics, concepts, history of healthcare ethics), trains those relevant skills (e.g. ethical decision-making, communication), and promotes those attitudes (e.g. truthfulness, confidentiality, self-reflexivity, responsible scholarship) that are needed to reach this goal.

Knowing and not knowing: moral transparence and moral opacity

How to start educational activities within a resilience framework? Most students would presumably not care about different lenses or approaches, but expect some clear-cut solution to the situations they witness in practice. ¹⁸

From the author’s experience, the epistemic distinction between morally wrong and morally complex situations offers a good starting point within the context of teaching that allows students to bring in their experiences to the classroom: Both situations, although differing in their normative character, can result in moral distress. Based on this distinction, a first learning objective is that students recognize situations of moral wrongness and name them in terms of malpractice or misbehavior. ¹⁵ Morally wrong situations call for a moral response based on professional values, as in the case of a first semester student witnessing an act of bribery by a head nurse while talking with worried relatives. Here, by following acquired ethical orientations and sharing pertinent knowledge, the professional knows the right thing to do and experiences considerable moral distress by not being able to change the course of action. ³⁶ These situations can be considered as “morally transparent,” as they involve a moral judgment and require an ethical argumentation. Despite this transparence, the psychological outcomes are likely to affect the healthcare professional’s well-being negatively. By contrast, students and later professionals may also be exposed to situations in which different moral judgments can be made, implying a genuine uncertainty about which of prima facie equally plausible ethical principles or orientations apply, which may also result in moral distress (e.g. when caring for a patient with mild cognitive impairment who refuses to drink and to eat). Therefore, a second objective is that students recognize such situations of complexity ²⁴ and frame them by means of ethical theories, concepts, and methods that inform ethical reasoning. ¹⁵ Here, the professional does not [yet] know the right thing to do and experiences moral distress. Importantly, complexity is person and case specific. It may have originated either through a lack of knowledge, a lack of experience, a novice status in moral reasoning, or through the situation itself entailing different ethical principles and professional duties. These factors hinder a clear-cut solution, as in the case of outdated and unclear advance directives in situations of dementia. Here, the resilience perspective enhances a deepened understanding of such “morally opaque” situations. Rather than creating operational solutions, it enhances moral understanding that paves the way for a careful evaluation of different options. ¹⁵ In the teaching context, a morally opaque situation may be transformed into a morally transparent situation through better information, increased orientative knowledge (e.g. about professional values and virtues), skilled reasoning, or a deepened understanding of the circumstances. For example, after the ethics course, the student witnessing bribery feels vindicated and addresses her observation in a confidential talk with her ward preceptor. Conversely, an apparently morally transparent situation may be transformed into a morally opaque situation when the ethical argumentation is proven unstable or resting on false assumptions. For example, a student is claiming that advance directives should be fully respected in the case of a stroke patient she actually cares for. She feels morally distressed when learning that major elective surgery is planned. After the ethics course covering different aspects of patient autonomy and surrogacy, she overcomes her shyness and speaks with the physician in charge. Although she is firmly convinced that advance directives are binding, she shows an understanding for the physician’s doubts as to the validity of the document in the given situation (imprecise formulations, outdated document, and probable reversibility of the clinical symptoms).

Both complexity and wrongness hide moral stressors that are known to have a wide range of adverse outcomes on students, professionals, and patients. Moral resilience as here understood enables students and future practitioners to circumnavigate two “extremes”:

The shallows of moral acquiescence on the one hand in “transparent” situations which require a moral response (in terms of recognizing what is morally wrong, but not changing the course of action and tolerating the adverse consequences at a personal and systemic level);

To start by helping students to make the epistemic distinction between morally wrong and morally complex situations can lead them from not knowing to knowing, but also from pretending to know to not knowing or knowing better. In a developmental perspective, these “shifts” can cause value crises that require a respectful learning climate, as shown in the case of the “not-right-not-wrong” statement. ³⁷ Whatever the direction of learning is, it is transformative and changes the students’ perception not only of the situation, but also of themselves as moral agents perceiving moral distress (or not doing so). The basic assumption is that both “shifts” stand for effective teaching and that such a “reframing” of the situation results in lowered levels of PMD, which is indicative for moral resilience. This assumption is investigated in the next section.

Exploring moral resilience in students

Study conduct and schedule

The study schedule comprised three steps:

First, participants were given four case vignettes inspired by former students’ narratives depicting morally stressful situations (Table 1). The vignettes were not presented at once, but consecutively projected by means of a beamer. After reading the vignette, students were asked to fill out the MDT for each individual vignette, imagining that they were in the given situation (MDT1-MDT4). The tool uses a scale from 0 to 10 (with 0 described as “no distress” and 10 the “worst possible”).

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Table 1.

Vignettes and measurements of moral distress by means of the MDT.

Vignette	Measurements
	Before lecture	After lecture
Baseline (no vignette, actual level of moral distress).	MDT0	MDT5
As a nursing student working in a nursing home, you witness how your preceptor force-feeds an old woman suffering from dementia in a situation of understaffing.	MDT1	MDT6
As a nursing student, you wrongly administer the incorrect dosage of a sleeping pill (twice the prescribed amount) to a young patient you care for in the ICU. You have a good relationship with him.	MDT2	MDT7
As a nursing student working in a psychiatric ward, you witness the involuntary restraint and medication of a psychotic patient you care for. The patient reacts with strong physical and verbal resistance.	MDT3	MDT8
As a home nurse, you visit a woman who suffers from mild dementia. Today, you are accompanied by an official of the guardianship authority. He has to decide if compulsory accommodation in a nursing home is needed. The woman has not been informed about the visit in advance.	MDT4	MDT9

MDT: Moral Distress Thermometer; ICU: intensive care unit.

Data analysis

A total of 166 bachelor students in nursing science participated in the study at three sites. A total of 35 students were enrolled in an extra-occupational program and 131 in a basic education program. One to four data sets per vignette dropped out due to incomplete information. At each site, data were collected by following exactly the same procedure. After collection, SPSS^® statistics software for Windows^®, version 22 was used for analysis. Due to the non-normal distribution and the dependence of the data, a non-parametric test, the Wilcoxon Two-tailed Ranks Test (α = 5%), was chosen for test statistics. A comparison of means was performed in order to show the significance of the data. The test was performed for each site and vignettes individually. The results of the sites matched as related to the significance with the exception of two vignettes measured in one site, which is attributable to the small size of the local sample (n = 16). The same conformity applies for the basic education and extra-occupational education subgroup. Therefore, the data could be pooled (Table 2).

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Table 2.

Descriptive statistics.

	N	Minimum	Maximum	Mean	SD		N	Minimum	Maximum	Mean	SD
Before lecture						After lecture
MDT0	167	0.00	9.00	2.0539	1.9643	MDT5	167	0.00	9.00	2.2156	2.0064
MDT1	168	4.00	10.00	7.6786	1.4655	MDT6	166	0.00	10.00	6.8614	1.8321
MDT2	168	2.00	10.00	5.8155	1.8689	MDT7	166	0.00	10.00	5.3554	1.9603
MDT3	168	0.00	10.00	6.3333	2.2472	MDT8	165	0.00	10.00	5.5818	2.3943
MDT4	168	0.00	10.00	3.6845	1.7685	MDT9	164	0.00	10.00	3.8232	1.8467

SD: standard deviation; MDT: Moral Distress Thermometer.

In three of four vignettes, the data demonstrate a statistically significant decrease in reported levels of moral distress in comparison to the first measurement (MDT1 and MDT6 (p < 0.05); MDT2 and MDT7 (p < 0.05); MDT3 and MDT8 (p < 0.05)). The pair MDT1 and MDT6, which had the most pronounced difference, is illustrated in Figure 1. Although the difference is rather modest in absolute terms, it has to be noticed that the second measurement already took place after a short lecture of 30 min and that a p value of <0.05, which supports significance, emerges in all these pairs. Conversely, no statistically significant difference was given for the fourth pair (MDT4 and MDT9 (p = 0.308)). Also, the baseline measurement with no vignette (M0 and M5) did not show a statistically significant difference between the first and the second measurements (p = 0.409). In addition, these measurements show the lowest levels of distress.

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Figure 1.

Comparison between MDT1 and MDT6 (boxplots).

Discussion

The study aimed at exploring the educational transferability of fostering moral resilience in the context of ethics teaching by adopting an experimental design consisting of vignettes ratings and an educational intervention. In three of four vignettes, a statistically significant decrease in PMD could be shown. By having the knowledge of how the situations in the vignettes can be understood, students’ locus of control over the situation is enforced, ³⁹ which results in lower levels of PMD. Following the operational definition, this tendency is assumed to indicate moral resilience and basically confirms the feasibility of implementing the chosen approach within HCEE.

The fourth vignette (MDT4 and MDT9) was the only one where the lecture did not show a statistically significant effect. At the same time, the absolute levels of moral distress measured here were the lowest of all the vignettes (MDT0 and MDT5 had lower values, but with no vignette). This can be explained by assuming that this situation was neither morally complex nor morally wrong for the students, but just bearing another problem (e.g. the guardianship authority’s duty to announce the visits of its officers) and presumably causing notable psychological (but not moral) distress. The low baseline measurements before and after the intervention (MDT0 and MDT5) show that an influence of the study setting itself on perceiving distress can be excluded. Both the fourth vignette (MDT4 and MDT9) and the baseline measurements (MDT0 and MDT5) show low levels of moral distress with no statistically relevant differences, which speaks against habituation bias.

Conclusion

The importance of promoting psychological and moral resilience in students responds to an urgent need in the healthcare professions’ education and practice. It joins the lenses through which HCEE is seen today. Healthcare professionals increasingly act as providers, managers, and gatekeepers at once. In times of growing global disparities as to the access to healthcare services and effective medical and nursing care, situations that are morally complex or morally wrong are likely to rise. In this perspective, “not-right-not-wrong” statements can demonstrate that students are able to deal with moral complexity. But they should certainly not assuage moral wrongness. Fostering moral resilience in future professionals helps them to circumnavigate both the shallows of moral burnout and moral acquiescence. In order to reach this goal, HCEE has an important contribution to offer by strengthening the knowledge base of moral resilience. This knowledge contributes to the promotion of the mental and physical health of those who give and those who receive care. Training students in transforming this kind of knowledge into practice legitimates HCEE and its costs for societies, faculties, and professional bodies.