Many health professionals on the front lines of COVID-19 care have stepped outside their normal roles. They have been worried about how to allocate already scare resources and about contagion for themselves, their patients, and their families. Many have also been faced with professional conflicts of how to provide care when basic personal protective equipment is not available.
These new and complex ethical challenges during the COVID-19 pandemic can cause moral distress. To address this, Johns Hopkins Hospital and Berman Institute of Bioethics in Baltimore launched the Moral Resilience Rounds program.
“We started moral resilience rounds in response to COVID-19 in recognition that a lot of our colleagues felt isolated and distressed,” said Cynda Hylton Rushton, PhD, RN, the Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics and the School of Nursing in Baltimore. “It came out of the concern that people needed a place that was safe and supportive to share their concerns.”
“They could bring some of their concerns not to be fixed or be given the answers, but to have a chance in the context of community to at least acknowledge and explore them and learn from each other,” said Rushton.
These are the six core components included in the Moral Resilience Rounds at Johns Hopkins to address moral distress in physicians and other health professionals.
Musical interlude
The Moral Resilience Rounds at Johns Hopkins occur twice a week for an hour using Zoom, which allows physicians and other health professionals to join from anywhere. Each session has seen between 5 and 30 participants who have experienced some form of moral distress since the pandemic began.
To begin the virtual session, musicians from the Peabody Institute of the Johns Hopkins University perform a five-minute interlude to set the tone as participants join the call.
Create a safe space to share
The session then moves to speaking about being together while stressing confidentiality. It is also the opportunity to emphasize the importance of creating a safe space for people to share.
“We want people to share, so we need to make sure it’s psychologically safe,” said Rushton, adding that they give people the option to not have their name on the Zoom list or they can change their name to something else that doesn’t identify them if they want to. They are also not required to turn their camera on unless they want to when they speak. If they don’t want to speak out loud, there is also the option to share their thoughts in the chat box.
Mindfulness practice and purpose
For about five minutes, participants in the session practice mindfulness to help them find a place of rest in the midst of their day. After the mindfulness practice, everyone is asked to write a word in the chat box about how they are doing. This is to gain a better understanding of what people are carrying that day.
“From there we talk about the purpose of the rounds and we usually do a little bit of cognitive content,” said Rushton. “We talk about the definition of moral resilience, the trajectory of response to crisis or the zone of resilience.”
Review of the themes of the week before
Each week, the sessions also review the themes from the previous week to give people a sense of what topics were discussed.
“A number of the themes have to do with the changes in visitation with families, particularly the distress around patients dying alone or not being able to have their family members there, and family members and patients being upset about that,” said Rushton. “There has been a very clear theme about worrying about their own health and worried about their family.”
Learn more about how doctors can keep their families safe after providing COVID-19 care.
Open discussion of concerns and struggles
The session then opens to the community. Physicians and other health professionals can share what is staying with them or what ethical concerns are on their minds.
“We leave it very open and facilitate the discussion,” said Rushton. “We want it to be not about us having answers or having the expertise but being able to get insights from people in the group.”
Leave feeling supported
At the end of every meeting, participants are asked to use the chat box to share what they are going to take away from the session.
“We generally try to have an arc of the session so that we’re leaving people in a resourced state—we don’t want to end it on some big, complex, emotional issue,” said Rushton. “We try to help people to not ignore that, but to really honor it and then try to move toward how we can resource ourselves and what we can draw upon so that when we leave, people are feeling supported, not devastated.”
“One of the things that distinguishes moral resilience rounds from a support group or a debriefing is that it really is focused on addressing the ethical challenges that people are experiencing,” she said. “Part of our goal is to create a space for that, but also to give people vocabulary to name the things that they're struggling with.”
The AMA has created an ethics resource page, "Obligations to protect health care professionals,” that offers expert advice on supporting and protecting staff at health care institutions during a public health crisis. Citing numerous opinions from the AMA Code of Medical Ethics, the page provides a comprehensive guide to the ethical questions in play.
Additionally, the AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center. Also check out pandemic resources available from the AMA Code of Medical Ethics, JAMA Network™ and AMA Journal of Ethics®, and consult the AMA’s physician guide to COVID-19.
