About

Dr. Cynda Hylton Rushton is the Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics and the Johns Hopkins School of Nursing. She is an international leader in bioethics and nursing, with a focus on moral distress, moral resilience, and ethical practice in healthcare. Dr. Rushton co-chairs the Johns Hopkins Hospital’s Ethics Committee and Consultation Service and is a founding member of the Berman Institute. Her work includes co-leading national initiatives such as the first National Nursing Ethics Summit and the State of the Science Initiative on transforming moral distress into moral resilience in nursing. She has contributed to the development of frameworks and tools to support ethical practice, including the Rushton Moral Resilience Scale and the Mindful Ethical Practice and Resilience Academy (MEPRA). Her research emphasizes cultivating resilience among clinicians, addressing moral suffering, and fostering a culture of ethical healthcare. Dr. Rushton is also recognized for her expertise in palliative and end-of-life care, having led various national projects and served on influential committees, including the Institute of Medicine’s Committee on Increasing Organ Donation. She has received numerous awards for her leadership and research, including the Marguerite Rodgers Kinney Distinguished Career Award and the Milestone Award for Bioethics Leadership. Her academic background includes a doctorate in nursing with a concentration in bioethics from the Catholic University of America, a Master’s of Science in Nursing from the Medical University of South Carolina, and a Bachelor of Science in Nursing from the University of Kentucky.

Research topics

• Medicine
• Nursing
• Clinical psychology
• Political Science
• Computer Science
• Virology
• Psychology
• Business
• Pediatrics
• Intensive care medicine
• Law
• Medical education
• Internal medicine
• Economics
• Pathology
• Social psychology
• Family medicine
• Economic growth
• Environmental health
• Psychiatry

Selected publications

• Navigating Right to Try, Expanded Access, and Ethics in Intensive Care Unit Practice

  AACN Advanced Critical Care · 2026-02-27

  articleSenior author

  Kai, a seasoned intensive care unit (ICU) nurse who recently transitioned into a nurse practitioner role, is working a weekend shift in the medical ICU of a large academic medical center. The hospital regularly participates in clinical trials and is familiar with US Food and Drug Administration (FDA) pathways for investigational drug use, but Kai has never personally been involved. Although he has heard about these pathways in ethics rounds and staff meetings, the practical steps—and risks—feel more uncertain now that he is the one being asked to act.At the beginning of the shift, Kai admits David, a 42-year-old man with relapsed acute myelogenous leukemia (AML), who presented to the emergency department the previous night with a severe nosebleed, dizziness, and confusion. Laboratory test results show profound neutropenia, anemia, thrombocytopenia, and coagulopathy. David is experiencing fever and hypotension and requires vasopressors, broad-spectrum antibiotics, and multiple transfusions. An ear, nose, and throat specialist places nasal packing, and the interventional radiology department is on standby for potential embolization.As Kai reviews the medical record, he learns that David has nucleophosmin (NPM1)–mutated AML, a rare and aggressive subtype. Despite months of chemotherapy, David’s disease has progressed rapidly. The concern now is that he may be experiencing sepsis, compounding his already fragile state.While Kai and Jordan, the bedside nurse, work to stabilize him, David’s wife Ana approaches, gripping a folder of papers. She pushes them toward Kai, her voice urgent: “Please, call Dr Chan, the oncologist. We’ve been talking about this medication. We’re not giving up. We have the right to try. It’s all here!” Kai gently acknowledges her urgency and reassures her that he will follow up, but only after David is stabilized. She adds, “Please, hurry—the doctor said this might be his only chance.”Hours later, with David slightly more stable, Kai reviews Ana’s documents: a product insert for revumenib,1 a drug he is unfamiliar with; an article about phase 1 trials for the drug; and a 2018 press release announcing the passage of the federal Right to Try law.2,3 Kai is unsure how this information applies—or if it applies—to David’s situation. He is also concerned that starting a new, unproven treatment when sepsis might be present could make David worse.Kai consults the hematology/oncology physician, Dr Chan; briefs the attending physician; and reassesses David throughout the day. David is looking better, drowsy but arousable; the transfusions, fluids, and antibiotics are working. Kai approaches David to assess his decision-making capacity. He seems to understand why he is in the hospital, the severity of his disease, and his treatment options. He admits—this looks bad. “David,” Kai says, “your wife shared some information about a medication she’s hoping we can try. It’s not an approved treatment yet—but we’re going to speak with your oncologist, Dr Chan, about whether it’s an option. Do you want us to look into this for you?” David looks over at Ana, then slowly nods yes.That afternoon, the oncologist returns Kai’s call and confirms her plan to pursue the investigational drug. She explains that the manufacturer has agreed to provide revumenib1 for David through the FDA’s Expanded Access4–7 pathway, since he is not eligible for the ongoing phase 2 study. With David’s signs of sepsis improving, she hopes to move quickly. She plans to submit the emergency Expanded Access request that day using the FDA’s Project Facilitate8,9 program, which helps oncologists complete and expedite these applications, often in under an hour. Because David is now an inpatient, she asks Kai to help with institutional review board (IRB) notification, pharmacy coordination, and ethics team consultation in accordance with the institution’s Expanded Access policy.Kai listens but remains uneasy. “He’s pretty sick,” he says. “I don’t want to give something that might make things worse—just because his wife is asking.” He is also worried about differentiation syndrome,10 a serious adverse effect that can mimic sepsis and complicate care. The oncologist acknowledges Kai’s concerns, emphasizes the urgency of treating David’s aggressive AML, and offers to co-manage any complications. She also offers to guide him through the Expanded Access process to ensure all approvals, consents, and pharmacy coordination follow policy.Kai notices that he is feeling more unsettled as the process is unfolding. He finds it difficult to avoid thinking about the case on his way home and keeps coming back to the question, “Am I doing the right thing?” He feels torn as he assesses the benefits and potential burdens of the treatment and wonders, “What am I responsible for?”Kai’s uncertainty is not a flaw—it reflects his moral sensitivity to recognizing an ethical issue and appreciating the complexity and consequences for everyone involved. As a newly transitioned acute care nurse practitioner at an academic medical center, he is taking on new clinical and ethical responsibilities. His concern about initiating investigational treatment for a patient who is unstable reflects both his clinical competency and his ethical discernment. His questions and actions are embodied expressions of his ethical commitments, as outlined in Provisions 1 through 5 of the 2025 American Nurses Association (ANA) Code of Ethics for Nurses.11 The code provides a foundational framework of ethical principles and professional standards to guide nurses in delivering compassionate, safe, and equitable care while upholding integrity and accountability in practice. It is the definitive resource for nurses practicing at all levels and in all settings. The following examples demonstrate the application of the code’s provisions.Although David was admitted with critical illness and confusion, Kai assesses his decisional capacity and honors his autonomy to choose for himself. He slows down, explains the situation, and asks David directly if he would like to proceed, ensuring the patient’s voice in the plan of care.Although Kai’s primary obligation is to David, he appreciates that respecting David also includes respecting the relationships that are most important to him—in this case, his wife. Ana’s desperation is palpable. Kai responds with respect and compassion, serving as a bridge between Ana’s concerns, the clinical team, and institutional processes.Kai carefully weighs the potential benefits and risks of both current and proposed treatments. He clarifies the difference between Right to Try and Expanded Access to ensure institutional procedures are correctly followed. He confirms IRB approval is in progress and engages the pharmacy to coordinate safe drug storage, dispensing, and administration. Recognizing lingering concerns, he requests an ethics consultation to support the team’s deliberation. Although the institution has an established Expanded Access pathway, the team remains cautious about administering an investigational drug with an incomplete safety profile and wants to balance their ethical duty to respect David’s autonomy with their duty to protect him from harm. This caution is essential to prevent the use of unproven or inadequately monitored interventions.Kai consults the oncologist, raises concerns about David’s medical stability, and seeks confirmation that all necessary approvals will be in place. These actions mean he is practicing with integrity amid uncertainty. He advocates within his scope of authority and takes steps to clarify his role and responsibility.Kai feels the weight of his decision to support moving forward with the experimental treatment through the Expanded Access pathway. He wants to help without causing harm. Instead of ignoring that tension, he seeks support and clarity, demonstrating self-stewardship through reflective, values-guided practice.These provisions serve as practical guide-posts. Kai’s actions illustrate how ethical practice is built in everyday actions: pausing to reflect, asking questions, following up with colleagues, and engaging in honest conversations at the bedside.Kai’s uncertainty is understandable, especially as a new NP. Two federal pathways—Expanded Access and Right to Try—offer legal routes to experimental therapies but differ in oversight, ethical safeguards, and institutional requirements (see Table 1).4–7,12–17 Academic centers typically have formal processes in place, whereas community hospitals may have less experience or clear policy for handling these requests.Right to Try, passed federally in 2018,3,6 was designed to reduce regulatory barriers by allowing patients to request access to investigational drugs directly from manufacturers. However, the law does not guarantee access—manufacturers are not required to provide the drug, and physicians are not obligated to prescribe it. The lack of oversight and institutional support has made many clinicians and hospitals hesitant to use Right to Try, especially in complex inpatient cases. By contrast, Expanded Access7—sometimes called “compassionate use”—offers a regulated, team-based approach. It includes IRB notification, informed consent, and FDA coordination, helping to protect patients and clinicians alike. In oncology, the FDA’s Project Facilitate9 provides real-time support to help providers complete Expanded Access requests efficiently.In David’s case, the oncologist had already secured manufacturer agreement to make the drug available and was planning to submit an Expanded Access request for revumenib through Project Facilitate. Of note, the cost of the investigational drug outside clinical trials may be passed on to the patient and will not be covered by insurance.13–16 This is an important consideration when pursuing investigational drugs through either Right to Try or Expanded Access. Because David was an inpatient, Kai was asked to help coordinate with the pharmacy, IRB, and institutional leadership to move forward safely and legally. But he has some reservations. His recommendations about starting or delaying the investigational drug in collaboration with Dr Chan may have significant consequences. While the legal pathways—Expanded Access and Right to Try—offer procedural direction, the deeper work lies in clinical and ethical discernment.The ANA Code of Ethics asserts that nursing practice is inherently principled, accountable, and relational. Building upon this foundation, Rushton’s model of moral resilience offers a framework for clinicians to preserve integrity and effectively navigate moral adversity.18 A core tenet of moral resilience is self-stewardship, which involves knowing oneself, managing personal resources with awareness and responsibility, acknowledging one’s limitations with compassion, and making choices that support integrity and well-being.19Responding to the signals of moral distress is central to Kai’s experience and shows his commitment to maintaining integrity even when the situation is ethically uncertain. By acknowledging his moral uncertainty, seeking support from colleagues, and taking time to reflect before acting, he is practicing self-stewardship. These actions are not self-indulgence but an ethical responsibility,19 helping nurses continue to provide care with clarity, compassion, and moral integrity. When clinicians do not address the moral and ethical dimensions of their work, moral residue can accumulate over time, creating a heavy and sometimes unsustainable burden.20In this context, the E-PAUSE model becomes a practical expression of these commitments, a way for clinicians like Kai to reflect, engage, and act with clarity, and courage grounded in ethical principles.21 Table 2 demonstrates the E-PAUSE model, a structured approach grounded in moral resilience that helps clinicians pause, reflect, and act ethically under pressure. Table 2 also shows how the ANA Code of Ethics integrates with E-PAUSE and guides Kai’s response as a nurse and developing advanced practice provider learning to lead with integrity in ethically complex situations.By Tuesday evening, David’s condition is improving. His bleeding stopped, his fevers are resolving, blood pressure is stable off vasopressors, and he is alert and oriented. From the hallway, Kai overhears the oncologist speaking with David and Ana. Her tone is calm but direct: “David is recovering, which gives us a chance to consider this next step. But the drug has risks.” She explains that revumenib has shown promise in early trials but carries the danger of differentiation syndrome, a potentially life-threatening reaction causing fluid overload, hypotension, and organ dysfunction (Table 3).1,10 “If we catch it early, we can treat it—but you’ll need close monitoring. Do you want to try this?” David nods: “Yes.” Kai feels the weight of the moment. As a new NP, this is his first experience with Expanded Access. While IRB paperwork and pharmacy preparations are underway, he remains uneasy about whether introducing the drug now, while David is still recovering from sepsis, might do more harm than good. Knowing the possibility of inducing a potentially fatal syndrome in a recovering patient heightens his ethical concern.It turns out that others on the ICU team are unfamiliar with the investigational drug use process and are feeling ethical tension about the justification for proceeding. At the request of the ICU team, an ethics consultation is convened. The nature of the conflict is not between the patient and the team but among the clinical team. As is typical, the ethics team met with the clinical team to more fully understand the facts of the case and their ethical concerns. Around the table are representatives from palliative care, pharmacy, medical oncology, a clinical ethicist and other ethics committee members, Kai, and David’s direct care nurse. The question the clinical team wishes to explore is whether it is ethical to offer an investigational drug under these circumstances. The team plans to carefully weigh the moral, clinical, and relational dimensions of the investigational treatment. First, they hear the ethical concerns from various team members. Then they review the case according to traditional principles of biomedical ethics: From the nursing perspective, the conversation shifts to the relational context of the decision. Kai speaks candidly: “I don’t want to be part of something that gives false hope. But I also don’t want to close a door if there’s even a small chance.” A palliative care social worker echoes him: “This isn’t just about the drug. It’s also about how we walk with this family through uncertainty in a way that is sensitive to their hopes and fears.” An ICU resident wonders, “How will we address the ethical concerns of our team who may not be confident about the path forward?”After thorough deliberation with the clinical team, the ethics team reaches consensus: they support the clinical team’s recommendations to proceed with the investigational drug through the Expanded Access pathway as an ethically permissible option. They also acknowledge that ethical permissibility does not mean it is ethically required, and additional discernment may be needed by the clinical team. The ethics team acknowledges that even though there was consensus among the clinical team to proceed with revumenib, there may still be team members who were ethically challenged or experiencing moral distress. They encouraged the team to keep the lines of communication open and to have regular team meetings to assess the impact of the decision to proceed on team members. They offered to continue to be available for support or re-engagement if the facts change as the Expanded Access process is implemented. Although no one questioned David’s decisional capacity or his perspective, the ethics team offered to answer any questions that David and his wife might have.Kai leaves the meeting with greater clarity about the ethical trade-offs and the reasons that supported the recommendation to offer the medication despite the risks. But he noticed that he was still feeling unsettled. He wondered whether it was because he was new to his role or if there were lingering ethical issues to be addressed. He reaches out to the nurse manager and another NP to gain some perspective. His conversations with them make him realize that he needs to intensify his efforts to take care of his physical and emotional well-being to support his ability to act with integrity.Later that day, Dr Chan takes Kai aside. Although they work in different specialties—intensive care and oncology—they share the challenges of caring for patients at the edge of life and death. She thanks him for trusting her expertise and collaborating to stabilize David so treatment could continue in line with his wishes. She also encourages Kai to consult ethics representatives, formally or informally, when cases feel especially complex, noting that structured ethical analysis and looking at complex cases from multiple perspectives have helped her manage her own moral distress when her decisions felt especially consequential.Following the ethics consultation, the care team moves swiftly. The oncologist submits Form FDA 3926 to request emergency use of revumenib under the Expanded Access program.8,9 The hospital IRB reviews the proposal, and the pharmacy confirms the protocol for safe storage and administration. Within hours, the approval is granted. The drug will be delivered later that day. Kai double-checks the consent documentation and discusses the plan with the nurse at the bedside. The first dose is administered before Kai goes home that night. David is monitored closely for signs of differentiation syndrome for 48 hours.David to from the ICU to the the Kai by the Ana says, I this She then adds, “I still we to use the Right to Try Kai then was the FDA’s Expanded Access program, with hospital and IRB But I felt like a and we all to support Ana gives a you call you helped us Kai leaves the uncertainty He still if it was the right decision. He differentiation potentially life-threatening still in the coming he also David’s would be These questions have no David was improving. the team established But Kai remains his new role as an advanced practice nurse, Kai that his decisions now greater accountability and only for but for the of David’s He acknowledges that even when you do the moral residue can that moral residue is a of he recognizing the ethical David’s autonomy and Ana’s with the oncologist to expedite and the ethical with the team while taking steps to support his own well-being and care nurses regularly moral and uncertainty that are and can be This moral in self-stewardship, By using like E-PAUSE to reflect, and act with clinicians like Kai to preserve the integrity needed to care for others with clarity and case the ethical complexity ICU clinicians when legal and emotional investigational treatments. While the Right to Try may to the the FDA’s Expanded Access often provides a more ethical experience how the ANA Code of Ethics and the practice of moral especially through self-stewardship, can guide clinicians through these Provisions 1 through 5 the duty to respect patient and care for and In structured like E-PAUSE help clinicians pause, reflect, and act with is not it is an ethical By acknowledging uncertainty, seeking and grounded in core nurses the moral resilience needed to navigate the of critical care while delivering compassionate, ethical care.

  PublisherDOI

• Evaluation of standardized emotional intelligence modules in prelicensure nursing curricula

  Teaching and learning in nursing · 2026-01-02

  articleSenior author
  PublisherDOI

• Implementation and evaluation of mindfulness modules for promoting resilience and well-being among nursing students: The R3 initiative for Maryland nurses

  Teaching and learning in nursing · 2026-03-01

  article
  PublisherDOI

• Preserving Our Ethical Foundations: The Future of Nursing Is Now

  Journal of Advanced Nursing · 2026-04-15

  article1st authorCorresponding
  PublisherDOI

• Changing the narrative

  Nursing Management · 2026-04-28

  articleOpen access1st authorCorresponding

  ABSTRACT: Reframing nurses' core relational abilities from "soft skills" to "power skills" is essential to transforming health care. These capacities-such as effective communication, empathy, self-regulation, ethical grounding, and relational presence-aren't secondary to technical expertise but foundational to healing, trust, and professional identity. Power skills enable nurses to mitigate suffering, strengthen connections, and lead effectively across education, practice, and policy. This article calls on nurses in all roles to embrace, model, and structurally embed this narrative shift to reclaim nursing's authority, purpose, and enduring impact.

  PublisherDOI

• Mindful Ethical Practice and Resilience Academy (MEPRA)

  Nursing Management · 2025-08-27

  article1st authorCorresponding

  FigureNurses face complex ethical challenges in the clinical setting that impact their integrity and their personal and professional values. Challenging interactions with patients, family members, and the healthcare team can undermine relational integrity and lead to conflict or moral suffering. As patient acuity and the stress and demands of the healthcare environment increase, novice and experienced nurses may have difficulty with self-regulation, sustaining moral resilience, and confronting ethical challenges. Lack of self-regulatory capacities contributes to decreased empathy, perspective-taking, collaboration, and creativity, and degraded well-being. The evidence suggests gaps in nurses' ethical competence and confidence to effectively and skillfully navigate ethical challenges, speaking up with colleagues, patients, and families.1-7 Nurses lack skills in exercising moral agency and recognizing and enacting ethical actions.8,9 Repeated exposure to ethical situations can lead to moral distress and contribute to nursing burnout, which is estimated at 35% to 47%.10-13 In a cross-national study, estimates of nurses' psychological distress range between 40% and 80% and intent to leave is 20% or higher.14 These persistent patterns of degraded well-being and integrity require leaders' urgent attention. Despite the ethical mandate for nurses to preserve integrity and well-being as described in the American Nurses Association Code of Ethics for Nurses (ANA COE) Provision 5, many lack the skills and tools to invest in their integrity and well-being.15,16 Self-stewardship—seeing yourself as worthy of investment in your personal health and well-being and leveraging self-knowledge to enact healthy actions—has been proposed as a more robust concept than self-care, which is often viewed as a selfish, self-serving process.17 Taking responsibility for your integrity and well-being doesn't relieve organizational responsibility to support nurses in developing their well-being and resilience.17 Individual responsibility is vital to well-being, and organization-based initiatives are critical to stem the tide of nurse turnover and attrition.18-21 Comprehensive and focused interventions are crucial to address these gaps. Nurse leaders are responsible for fostering environments that include processes, structures, and opportunities for professional growth, empowerment, and practice consistent with the American Nurses Credentialing Center's forces of magnetism.22 The Mindful Ethical Practice Resilience Academy (MEPRA), through an academic practice partnership, was developed to provide nurses at the point of care with the opportunity to develop skills, cultivate moral resilience, and confront daily ethical challenges.23,24 Details of the integration and impact of the MEPRA curriculum and sustainability outcomes were previously published. Participants had improved mindfulness, ethical confidence and competence, work engagement, and resilience, along with decreases in turnover intention and burnout following completing the program.23,24 Many of the outcomes persisted for 3 and 6 months after participation.24 This paper describes the educational pedagogy (teaching), design, content, and delivery of the MEPRA foundational curriculum to nurses practicing in high-intensity settings. THE MEPRA CURRICULUM The MEPRA curriculum, developed and delivered 4 years before the COVID-19 pandemic, was based on a targeted literature review, the adaptation of previous curriculum development, and consultation with education and communication specialists.25,26 MEPRA aligns with the recommendations of a leadership blueprint to decrease burnout and moral distress, advocate an ethics infrastructure, and expand strategies to support well-being.27 Likewise, it aligns with the ANA COE values of respect for all people (including nurses), and nurses' obligations to advocate for patients, provide just patient care, engage in interprofessional collaboration, uphold the ethical mandate to preserve nurse integrity and well-being, and contribute to healthy work environments. Program objectives The curriculum's overall objectives were to equip nurses with practical skills to address daily ethical challenges (see Table 1). Developing skills and capacities builds nurses' ethical competence and confidence in the clinical setting to face ethical challenges, equips them with moral resilience tools and practices, and serves as a foundation for spreading a culture of ethical practice within the organization. TABLE 1: - MEPRA session topics and learning objectives Overall MEPRA objectives Learn and apply mindful practices to ethical issues in clinical practice Learn and demonstrate ethical competence by applying tools and skills to ethical issues in clinical practice Cultivate moral resilience in response to ethical challenges and moral distress MEPRA content Learning objective 1. Moral compass, mindfulness, self-stewardship Engage in values clarification Reflect on personal values to create a personal moral compass Practice mindfulness Develop, implement, and refine a self-stewardship plan 2. Autonomic nervous system activation, self-regulation Recognize the neurobiology of distress triggers and responses Learn self-regulation methods, including mindfulness, embodiment, and other skills to regain balance 3. Cultivate moral sensitivity and empathy; recognize assumptions and biases; communicate strategies Apply moral sensitivity to clinical cases Discover barriers and enablers of empathy Reflect on implicit/explicit biases and identify strategies to recognize and address those biases Employ a variety of constructive communication strategies to foster respect and understanding 4. Ethical competence, responses to moral adversity; moral suffering and moral resilience Identify and apply an ethical framework such as E-PAUSE to clinical cases Recognize symptoms of moral suffering Apply various moral resilience elements as protective resources to morally troubling situations Explore the impact of moral residue Engage in actions to restore integrity 5. High-fidelity simulation: integration session Demonstrate the elements of moral resilience in response to ethically complex scenarios Demonstrate effective communication skills in high-stakes clinical situations Receive feedback to enhance demonstration of MEPRA skills 6. Culture of ethical practice; becoming agents of change Apply pillars of moral resilience to daily practice Describe how moral resilience contributes to an ethical practice environment Develop a feasible plan to spread MEPRA skills and tools at the unit level Devise a sustainability plan to retain and deepen MEPRA skills, including a self-stewardship plan, self-regulatory practices, and frameworks for ethical discernment Engage in ongoing communities of practice with MEPRA graduates ©2017 MEPRA. Reprinted with permission. Educational pedagogy The MEPRA educational framework integrated principles from social learning theory (SLT) and experiential and discovery learning with immersive, interactive, and simulation-based methodologies to actively engage nurses in the learning process. Unlike passive didactic approaches, MEPRA emphasized experiential learning, encouraging nurses to directly experience content. Grounded in neuroscience and mindfulness practices, MEPRA fostered present-moment awareness, nonjudgment, and caring intent.28-30 SLT highlights learning through observation and modeling in a social context, rather than solely through consequences.31 Effective modeling requires attention, retention, reproduction, and the motivation of participants, supported by a conducive learning environment.31,32 This approach leverages neuroscience, the role of mirror neurons, vicarious learning, and self-regulation to deepen understanding and promote behavioral change.33 SLT principles were reinforced through small group settings for observation and modeling, active participation, and self-reflection to enhance insight into thoughts, emotions, and behaviors. The program incorporated discovery and experiential learning, immersing participants in content and fostering self-discovery and knowledge retention.34,35 Experiential learning cycles—concrete experience, reflective observation, conceptualization, and active experimentation—were used to explore values, attitudes, assumptions, and alternatives. Real-life problem-solving encouraged participants to adopt new perspectives. Leveraging participant experiences, the program enhanced meta-cognitive skills, engagement, and relational connections across specialties and levels of experience. Facilitated group discussions, dyad inquiries, storytelling, guided explorations, reflective discussions, and writing practices further enriched engagement and learning. DESIGN The MEPRA Foundational Curriculum consists of six 4-hour experiential sessions (24 hours) of tools, templates, ethical skills, and competencies to help transform ethical challenges and moral adversity into moral integrity and well-being by cultivating moral resilience. Specific objectives and summary content are included in Table 1. Skills in constructive communication and values-based, integrity-preserving action were highlighted. Consistent with SLT, the MEPRA curriculum enhances cognitive and reasoning skills using case studies, group inquiry, reflective practices, observation, demonstrations, and multimedia platforms. The sessions were designed to foster psychological safety and trust to create community and belonging, vital elements to reducing isolation and fostering self-awareness, collaboration, and self-regulation. MEPRA sessions were sequenced every 2 weeks to allow reflection and application of insights and foster continuous learning throughout the program. Repetition and ongoing practice of mindfulness, the embodiment of values, alignment with their moral compass, and adoption of self-stewardship skills required intentional timing and spacing to invite new awareness in the moment and prevent skill decay. Ongoing feedback and rapid cycle quality improvement, with refinement and reiteration of each exercise or practice, fostered the evolution of the curriculum and customization to meet learner needs. The MEPRA program was open to nurses from all clinical areas of the acute care setting, including adults, pediatrics, wards, ICUs, psychiatry, and ambulatory care. The program sessions occurred in conference rooms away from the clinical care area. Building community among participants and securing stakeholder buy-in of the unit managers and leaders of the institutions contributed to point-of-care nurses' engagement and the sustainability of the program. The MEPRA curriculum is the foundation for unit-based and system interventions to leverage culture change toward a culture of ethical practice. Graduates of MEPRA shared common experiences, vocabulary, skills, and practices that organically created a learning community and model for culture change. Rather than a one-off program, the foundational curriculum is part of a broader vision to build capacity and sustain and disseminate tools and skills. Key curricular elements scaffolded content to build skills and achieve the program outcomes of using mindfulness practices, demonstrating ethical competence in ethical situations, and cultivating moral resilience in response to ethically challenging situations. The pillars of the MEPRA curriculum include mindfulness, cultivation of ethical competence/confidence, self-stewardship, amplifying resilience and moral resilience, addressing moral suffering, high-fidelity simulation, and ways to contribute to a culture of ethical practice (see Table 1). 1) Mindfulness The foundation of MEPRA was steeped in the core concept of mindfulness, the ability to be nonjudgmentally present in the moment. Mindfulness includes focused attention, noticing what is happening (body, heart, and mind), using skills to foster self-regulation and potentially reduce the detrimental effects of stress and improve well-being.36 A series of seven short videos focusing on the core concepts of the program and relevant neuroscience were created to reinforce and develop mindfulness skills. These 10- to 12-minute videos were coupled with guided mindfulness practices. The neuroscience of mindfulness was highlighted with emphasis on skills to regain stability and composure when confronting ethical challenges. Practices were integrated into each session of MEPRA to reinforce skills. Daily technology enabled 10-minute guided meditations, and reflective practices—with access to a collection of related resources and articles—were provided. This foundation of mindfulness and self-regulatory capacities were necessary to perceive the contours of moral/ethical adversity, reason and deliberate about the range of ethical options, and enact decisions that reflect personal and professional values and commitments. 2) Cultivation of moral/ethical competence The framework for ethical competence builds on the foundation of mindfulness. It includes clarification of core values, development of a moral compass, and cultivating moral sensitivity. Content included bias/assumptions and perspective taking, and applying ethical frameworks to clinical scenarios.37-40 These skills and frameworks extended cognitively focused moral reasoning to explore the interplay of psychological processes in responding to moral/ethical challenges.37 Ethical competence is grounded in nurses' ability to identify their personal and professional moral compass and use it as motivation and guidance for moral action in the context of the ANA COE.15 Specific strategies to support this process and reinforce this foundation throughout the program included examining how participants were living their values, rather than merely discussing them, while exploring what properly bounded moral agency requires. Cultivating moral sensitivity is crucial for recognizing and understanding the ethical dimensions of a clinical situation—appreciating its complexity, competing ethical obligations, commitments, and one's biases, assumptions, and frames of reference. This approach encourages empathy to understand various stakeholders' perspectives and to attune to the emotional dynamics of clinical situations.40 Using case studies, participants practiced moral reasoning and analysis, enhancing their ability to navigate ethical aspects of clinical practice with integrity. By applying their core personal and professional values (ANA COE) to case studies, participants clarified their relevance and heightened awareness of their central role in everyday ethical practice. This foundation aligned their moral commitment and motivation to do the right thing with an ongoing exploration of personal and professional integrity, moral agency, and the embodiment of their moral compass. Moral action combines these dimensions to determine a course of action that reflects nurses' values and commitments, serving as an effective mechanism for moving from analysis to integrity-preserving action. Program participants gained experience in communication skills and conflict resolution strategies, including mindful listening, appreciative inquiry, constructive dialogue with feedback, and the application of E-PAUSE (a systematic framework to address ethical issues).41 Participants explored how to apply their new skills and practices in daily clinical work, proactively and effectively engaging others in identifying and addressing ethical concerns and establishing themselves as unit-based clinical leaders. They examined how to ground their actions in core personal and professional values, recognize patterns that support or hinder ethical practice, and take effective steps to address unit-based challenges within their sphere of influence. A key component to sustaining and spreading unit-based MEPRA content was participants claiming their moral authority to be agents of change in day-to-day clinical practice. This approach helps integrate practices that support a culture of ethical practice and moral resilience that can be sustained.42 3) Resilience and moral resilience Resilience content included global and moral resilience.43 Resilience generically refers to the ability to confront adversity in healthy, wholesome ways.44 Resilience “is a process to harness resources to sustain well-being.”45 Generic resilience content was introduced in the first session and reinforced throughout. This included the neuroscience of nervous system activation and skills and tools to restore stability when events occur that catapult people into dysregulation. Noticing when they were outside of their “zone of resilience” and adopting new skills to restore stability were reinforced throughout the curriculum. These skills were synergistic with foundational mindfulness practices and other self-regulatory skills and the elements of moral resilience. Moral resilience—the ability to preserve or restore integrity in response to moral adversity—is a particular type of resilience grounded in the moral domain.46 Moral resilience was guided by the six pillars of moral resilience, which were integrated throughout the curriculum: 1) personal integrity, 2) relational integrity, 3) buoyancy, 4) self-regulation, 5) self-stewardship, and 6) moral efficacy.46 The concept of moral resilience and a corresponding measurement tool evolved alongside the development and implementation of MEPRA.47 Emphasis was placed on cultivating a stable, nonreactive nervous system through mindfulness practices, especially in response to moral adversity. By linking responses to nervous system activation and noticing common response patterns, participants gained insights into their experiences. The exploration of moral suffering, moral distress, using a reflective model elements of moral resilience, understanding and new skills and The process of cultivating self-stewardship is a key of moral resilience that was at the and throughout the program. is as a commitment to to and one's personal to recognize and respect one's and to actions that are wholesome and Participants a to identify personal and professional that supported or their and moral resilience, which the development of a self-stewardship plan the session participants to reflect on the of their plan, and necessary The and of their self-stewardship plan was and tools for refinement were These tools included daily practices to cultivate what and their challenges or adversity. 4) High-fidelity was to practice and reinforce skills as an component of the curriculum. scenarios designed using the of Practice focused on ethically challenging clinical and Facilitated reflective occurred after each were to and family in Nurses were by and each had the opportunity to and The enabled nurses to apply the skills in focusing on self-regulation ethically and This approach participants to demonstrate mindfulness, ethical competence, and communication skills, their moral resilience. CURRICULUM created tools that aligned with program and These included process that were at the and of the program. These were crucial for program and and that outcomes be to the program. Overall program were at These included of confidence in program of nursing practice, and motivation to achieve the program By the of the program, participants with on a from at to at the the of the program, participants the and impact of program and those with the impact (see Table a program content and were effective program on a Participants that the program and had the and writing practices were the effective with the Participants were with the program range and were to the program to others range and change their nursing practice range skills to face ethical challenges, decrease and impact others at work with participants (see Table TABLE - MEPRA and of confidence and motivation of program are that at all and 1: Apply mindful practices to ethical issues in clinical practice Demonstrate ethical competence by applying tools and skills to ethical issues in clinical practice Cultivate resilience in response to ethical challenges and moral distress are at all and 1: Apply mindful practices to ethical issues in clinical practice Demonstrate ethical competence by applying tools and skills to ethical issues in clinical practice Cultivate resilience in response to ethical challenges and moral distress TABLE - to and with stress from work of the skills, tools, and resources have gained from the tools to those and situations that and up at to face ethical issues and take in that are other nurses with the how to to work and to be a more effective skills help be a nurse and in all aspects of This program a change on the leaders to and their nurses may gaps in their program that all the gaps. A of the MEPRA curriculum was that it was designed for nurses serving at the point of care face challenging ethical situations. A for learning the content, and the of SLT, and discovery learning with mindfulness practices, the intention and impact of the program. The content is scaffolded and throughout all educational including dyad role and simulation, application of content and skill are and the of experiential learning. The the that how knowledge is in that the activation of knowledge is to the and of new to learning using reflection and discussing of and integration of new High-fidelity was to be an to enhance of skills and practices in the moment. Developing relevant and using and tools enhanced the and a small to a for learning and experiential experience with the MEPRA program suggests that in moving one-off to investment in that build capacity and include elements that sustain learning and engagement, such as exposure to content and the of learning the impact of a critical of MEPRA graduates on a unit the impact and a with a model for content and contributes to learning experience and is necessary for challenges included and participant engagement with reflective practices and improved with of and leadership the of MEPRA and the global pandemic, guided and mindfulness practices have been encouraged and is an ongoing for MEPRA. may that such are experience suggests the investment in nurses to in such as MEPRA is small with the of burnout and in the was a MEPRA graduates to their and by more and grounded decisions about their in their others opportunities within the and others leadership or educational nurses in the is vital when gaps in the The MEPRA program is effective in to ethical practice by capacity within the nursing The impact of the MEPRA curriculum ethical ethical competence, resilience, work engagement, and mindful and MEPRA decreased symptoms of and and turnover In this of burnout, and ethical in the healthcare for nurses are vital to develop integrity-preserving skills, self-stewardship, and mindfulness to promote overall well-being and work Nurse leaders may adopting MEPRA as in their nursing Unlike other participants that their leaders them the to as an investment in their well-being and integrity. in people and the to support the new skills are vital for healthy that levels of moral resilience among nurses are with organizational it was the of moral resilience and organizational that had the impact on moral in to skills and nurses to care delivery and have the to transform the practice environment and ethical care.

  PublisherDOI

• Evaluation of a program to build resilience, renewal, and retention in nursing faculty

  Teaching and learning in nursing · 2025-11-16

  articleSenior author
  PublisherDOI

• Critical care nurses' perspectives on organizational betrayal by health systems during the COVID-19 pandemic

  Nursing Management · 2025-02-19

  articleSenior author

  FigureThe COVID-19 pandemic hit many healthcare systems incredibly hard. Many direct care nurses, especially those working in critical care (CC) and EDs, were particularly challenged by their experiences. Since the height of the pandemic, healthcare systems and nursing are rebounding, but, like those recovering from the virus itself, recovery in the nursing workforce has been uneven. Experiences with patients impacted nurses, but difficult experiences involving coworkers, management, and leadership of healthcare systems may be even slower to heal.1 Nurses have expressed a loss of trust in healthcare systems and employers, which has been linked to organizational betrayal and poor communication.2,3 Organizational betrayal describes the actions, or lack of actions, by an organization that disregards the health and safety of its employees, violating the terms of their relationship.2-4 Inadequate actions by leadership can contribute to negative feelings about work and, potentially, negative impacts on mental and physical well-being.2 Nurses require active support from healthcare organizations to fulfill many of their duties, so they're particularly vulnerable to organizational betrayals like inadequate provision of protective equipment, ineffective or hostile management, and diminishing of their experiences and concerns after negative events.2 In addition to supporting nurses, leaders need to provide transparent and effective communication. Ineffective communication skills and lack of transparency can diminish trust, which is vital to successful, sustainable working relationships.3 Building trust within an organization is a mutual act, but actions taken by leadership can weaken or even break trust in an entire organization. Lack of trust can give rise to resentment, as employees feel despondent and skeptical.2,4-6 Research finds that many direct care nurses from CC and the ED continued to express a loss of trust and feelings of betrayal toward health systems even after the pandemic waned.4,7 What exactly causes these feelings of betrayal and distrust is still unknown. The purpose of this study was to explore direct care nurses' perceptions, and to answer the following questions: 1) For CC and ED RNs, what are the causes of organizational mistrust and betrayal? and 2) How did these nurses or their organization restore the “personal self?” Findings will guide leadership efforts to better support direct care staff, especially in times of uncertainty. THEORETICAL FRAMEWORK The Reina Trust and Betrayal Model, which focuses on interpersonal relationships exhibited by actions and emotions, guided this study. This model describes how trust, an essential aspect of the relationship between individuals and organizations, can be grown, maintained, or damaged. It asserts that trust is acquired gradually through reciprocity in interactions and relationships and consists of three dimensions: Trust of Communication, Trust of Character, and Trust of Capability.8 Trust of Communication is demonstrated with openness and transparency regarding the provision and reception of information, including feedback and mistakes. Trust of Character reflects clear expectations, fulfilling promises, and consistency. Trust of Capability signifies confidence in another's ability to perform tasks, interact with others, learn new skills, and make decisions. These lay the foundation for trust and mutual respect and provide a behaviorally focused framework for assessing where and how trust is built and broken, including practices to bolster a positive work environment.8,9 The authors selected sensemaking theory as a leadership model to provide recommendations for addressing the themes that would emerge from the study. Sensemaking is the initial step in a larger leadership model proposed by Ancona to create more effective leadership in a changing world.10 It's a dynamic process of using open-minded inquiry, setting aside entrenched ideas about problems and solutions, to categorize available data.11 This categorization into themes guides communication and future actions, enabling leaders to translate the unidentified, chaotic, and complex into a coherent phenomenon that can be understood, explained, and worked on collaboratively to improve the work environment. METHODS Design This study uses secondary data collected during 2021-2022 from two nursing-focused intervention research studies. See Box 1 for brief descriptions of the studies, including inclusion/exclusion criteria. Prior to observation and data comparison analysis, the study was reviewed and approved by the organization's institutional review board. All participants provided informed consent before participating in the original studies. A qualitative descriptive approach was used, allowing for exploration of events or experiences related to the primary topics.12 Sample and setting Data included responses from 29 RNs employed as direct care nurses in two Magnet®-designated, acute care, academic hospitals located in Pennsylvania and Missouri. Qualitative analysis The analysis used templating, a flexible thematic analysis approach that can use both a priori ideas and themes drawn directly from the data to organize coding.14 The a priori template was developed utilizing the Reina Trust and Betrayal Model for the initial data organization. Researchers independently reviewed participants' deidentified data from the two referenced studies and coded for content themes. The template was modified to include subsequent codes identified during analysis. Codes were further refined utilizing inductive analysis. Formal discussion regarding emerging themes, facilitated by another researcher within the group, followed and centered on coding similarities and differences. Discussion continued until consensus on coding and data saturation was reached. RESULTS Findings demonstrate that direct care nurses perceive ongoing mistrust and organizational betrayal. The following themes were identified as contributing factors to these feelings: inconsistent leadership in response to uncertainty and constraints, financial and human resource challenges, and persistent residue of perceived ongoing organizational betrayal (see Table 1). Direct care nurses also conveyed enhanced emotional self-awareness and self-appreciation regarding care for COVID-19 patients that reflected a distinct theme: professional growth and gratitude in a challenging situation. TABLE 1: - Themes, illustrative quotes, connections with models, and leadership recommendations Theme 1: Inconsistent leadership in response to uncertainty and constraints (Definition: Nurses' reciprocal relationship with administrators/managers during the pandemic resulted in feelings that administration wasn't worthy of trust anymore.) Subtheme(s) Quotes Link to Reina Trust and Betrayal Model Potential leadership adaptative responses/Sensemaking interventions Missteps in communication “Whether it's trusting the information she's bringing back to us, or that she's not bringing information back at all. I know that's been a huge dissatisfier right now is just kind of there [sic] are expecting and wanting more...” “These concerns have been expressed to management over and over again and continuously fall on deaf ears.” “But there's no one answer. No action. So, you know... like, what's the next step and then just hearing.” Communication trust—Trust of Disclosure Be transparent and receptive to information. Involve others (including staff themselves) in discussions on decisions that directly affect the micro-, meso-, and macrosystem in which they're employed. Not feeling valued “Very little was done to improve things to prevent similar safety situations from occurring, coworkers are resigning every day... it's defeating.” “To be one of the people labeled an ‘essential worker’ and being forced to show up to work every shift and take care of the dying COVID-19 patients was more than overwhelming. There were nights that my coworkers and I had to put 5+ patients in body bags just to fill their rooms up again with the same type of patients. All this while having limited resources, minimal staff, worrying about myself or my loved ones dying, and the hatred I felt towards others who claimed COVID wasn't real or those who got to ‘work from home’ who laughed about just moving their computer mouse every couple of hours and not actually working.” “The overwhelming sadness and loneliness of being the only living person to comfort the dying. Standing as a pillar when so many left and we did not get a raise or the COVID money those other facilities got while paying travelers twice our wages.” Contractual trust—Trust of Character Listen and encourage staff to be forthcoming and share information. As a result, staff will be respected, valued, and felt heard. Acknowledge and reward staff for their contribution(s). Abandonment by leadership “I don't feel like I'm getting the support that I need.” “There have been several situations where I feel hung out to dry with no support, when our charge nurse and management did nothing. I feel like that is the worst part of the last few years. Nor did they show me how to support the patient or help me to be safe. They watched it all happen and did nothing.” “As a preceptor and facilitator, I am expected to do certain things and have these things completed by a certain time. I complete the tasks because it is my job and it's what is expected. However, the management and education teams here have been nowhere to be found.” Contractual trust—Trust of Character Recognize that actions speak louder than words. Be visible, available, and approachable. Identify and revise hazardous processes within the micro-, meso-, and macrosystem. Theme 2: Challenges with financial and human resources (Definition: The pandemic stressed the financial stability of healthcare organizations. Direct care nurses vacated the inpatient acute care setting at a rate outpacing replacements.) Impact on preparing and supporting nurses to work in the clinical environment “My facility has found a way to cut orientation time and limit resources during the process. I have seen nurses and because they do not feel like is a to seen so many nurses and because they don't feel for the the is and we are expected to do so with little How can we nurses to to to at the when we have limited no and a “I and other have to our management and nurse and the and ideas we need to be or that we need more resources and to staff and these resources and are Contractual trust—Trust of Character Be with of staff and care in complex clinical with and processes that are and that Be and the of in the environment in which the to nursing and for patient “I a and it is again to direct patient care because the this the feeling that to back to me is the feeling of I that there was that I have done or have had more on how to help the “I felt like I was to provide care to both of my patients. I wasn't to give care or their to prevent between there wasn't time in the to provide the care that the patient It's to that as a I'm there to provide and care to the patients because that's what they trust—Trust of Capability and staff and of me were a were a I need to to help me or to do their and did “I that this has me and It has me that actions or lack in a professional setting directly impacts patients and their “The and of the staff me for the future of The only more than the and is the complete and of Contractual trust—Trust of Character in the work environment in a Theme residue of perceived ongoing organizational betrayal (Definition: Direct care nurses expressed continued mistrust and perceived organizational and “I still have not management for their and for their during one of the of my “The distrust for management I still I they do not have my in and that my coworkers and I need to out for and I to answer with was when how my shift I don't know that will I am and people make the decisions that they How many times do we have to about How many times do we have to how this I feel as I am concerns to a Contractual trust—Trust of Character with the the future the of how staff the actions they Theme growth and gratitude in a challenging (Definition: The for growth by direct care is on and an of the back on this I do feel like I have I have more in my care of the work more in with the nurses than to the pandemic, the staff is more of a working I can the positive things that did out of the I am for being to learn from that I do feel like I from those two years. I was challenged COVID has me a both and has I am to that I am a COVID was for a in but it also my need to help Listen and the direct and actions of care and support, and back on these I am of the as as the from These were what me and the that we were all in this were a difficult time for of the I would to work and the of in my I would of to in of feel just a little nurse are only with so many they are used up it's So, I to use that as my when I No to because you do and the still I am still critical of but I now give myself to not of it as having situations that are complex and into for skills “I and the of time the of the I have had a I to only you only have so and I to only or I will to as it me things that I need to and things that to me “I make all are I to know what the is like, the is I the to into the I in here even the I'm not the only one who the another and my are in the with me to make and more at “I wasn't people about so I my I out a of in that and time for staff to process events and encourage for and Theme 1: Inconsistent leadership in response to uncertainty and constraints Direct care nurses' relationships with leadership during the pandemic resulted in feelings that their to trust organizational Direct care nurses in response to data and resource constraints as a lack of respect and “The did so many They to They to up all of the that we had on all of the as as I can our were of and in all of the entire of and I back the next and the staff was It like had our was that they had the of trust resulted from staff not feeling valued for their and trust to feelings of perceived or on leadership decisions and Direct care nurses about how is and don't feel by other in the or communication by leadership negative feelings direct care nurses who felt and during a vulnerable time. They perceived that leadership contribute in a and way to their safety and as they put at was at a of where the entire our charge nurse and management, both of which did nothing. They They support They the patient or to the situation. Nor did they show support to the patient or help me to be safe. They watched it all happen and did nothing.” to create a working environment and and expectations, with Trust of Theme 2: Challenges with financial and human resources The COVID-19 pandemic stressed the financial stability of healthcare organizations. Nurses for patients while in human and resources in to and of nurses who the in nursing and that were difficult and to The of staff impacted the and support of nurses to work within their clinical environment. in this expressed feelings of and continued with the and of nurses, which their Trust of Character, and They that nurses, and they were nursing care while being for patient during this time of resource about the they had “There wasn't time in the to provide the care that the patient and it's to that as a I'm there to provide and care to the patients because that's what they As a result, direct care nurses to their and of care provided to patients. This to provide care was a Theme residue of perceived ongoing organizational betrayal as the pandemic loss of trust and feelings of organizational betrayal expressed continued and regarding leadership the perceived to patient care, and the of interventions to They about still there as I still feel with the and the way they These feelings A of trust is a of people to and their participants their professional and reflected on the of nursing as a valued in and to ongoing feelings of betrayal as direct care nurses for the future of would have I followed is What to critical Be The problems they but into the Theme growth and gratitude in a challenging Direct care nurses that they were active participants in and addressing the challenging they and the entire healthcare They worked to restore their growth and gratitude where about the of I am a better is that we to the respect we from our our and our their challenges, nurses about how they felt gratitude for from and others and emotional support from and they also had regarding the They developed to difficult as and allowing to the emotional they were nurse up their experiences and I to on one at a time. I will to take every as an of my and not a events are to process than a of I am that I can make the of my over the next This study and of CC and ED direct care nurses, allowing the to explore the feelings on organizational mistrust and betrayal. demonstrated that and a lack of to their experiences of perceived betrayal and ongoing with the lack of expected leadership in a time of had and to their health and the nurses also expressed that they of these experiences but were in a of and skills to the from other research studies that healthcare have organizational betrayal to the COVID-19 For a found that only of direct care trust organizational leadership to in for only trust organizational leadership to and in a just toward The Nurses research on the of professional nursing the pandemic a on nurses' mental health and to with leadership for the of Findings from this study on these as they provide more descriptions of experiences to feelings of organizational betrayal and mistrust and to leadership In this nurses expressed that all of the Trust and Betrayal model were Trust of Communication was to Nurses felt communication was or the situations they they felt that they trust what they were by Trust of Character was as leadership actions were Nurses felt as leaders worked or within a in and of for patient and organizational were by or inconsistent and to Trust of Capability as nurses felt that they the of they were and that leaders to or of addressing their These of trust were by leadership which nurses perceived to that it's to leaders regarding financial and human resources, especially the inadequate education and of new resulted in concerns for the of care and patient a of nurses' of the COVID-19 pandemic has negative as direct care nurses expressed and reflected a time. Sensemaking for of complex data into actions for leadership and may use sensemaking to the and the using this and actions and and revise further actions on their This research that direct care nurses' of organizational betrayal and mistrust are with actions, and so leaders then to the that are contributing to this that trust be built between direct care nurses and their As a trust that all to in a process of betrayal has and to a future that the and of A of trust is where trust has been and on a of In this it's vital that leaders the that trust was and, be for their communication and clear with nurses' health and of leadership In the of the COVID-19 pandemic, about organizational trust and support when employees that organizations care about their through a process of sensemaking that a to both and leaders can in that on the three of the Reina Trust model a for behaviorally focused 1 recommendations developed from this work using a sensemaking For of the of trust in leaders can to the feelings of betrayal that nurses Trust in Communication will require that leaders in and who in a and and use of and a can and Trust of Character of and communication that that the organization's and actions with this be during difficult have expectations, and demonstrate respect for and Trust of Capability to involving direct care nurses in decisions that their to give people the and skills to their and their and to what's to do their Nurses who perform their and have trust in the of These recommendations are and a process of sensemaking with available data in organizations can to more for a This study has for leadership and nurses, but there are the from only two healthcare organizations. may not be and may including and The is the use of secondary where directly focused on organizational betrayal and to or in the data also that the data may lack the that would have been in an participants were and about their experiences The the lack of and from a leadership leadership and and sensemaking a of the themes exploration is to leadership during the COVID-19 The of this study are also to They include of the skills and and by direct care nurses for and in in complex This that direct care nurses are and skills and practices that can be this for leadership to of interventions that only but that may and and of interventions may the nursing and those direct care nurses who are the that can be and refined leaders a for trust and it during for further research on the subsequent research on how direct care nurses their to trust certain leadership actions and to trust have been identified through the of the Reina Trust and Betrayal Model and sensemaking that will the trust of direct care nurses in their leadership of this can interventions valued by direct care nurses to relationships not only in times of but also in of this study is that direct care nurses a of professional growth and the challenges, direct care nurses employed to health and during the COVID-19 can to these to restore health and by in that and that and In an of healthcare and the future of direct care nursing is leadership to As they the of their organizations, nurse leaders their of the that break trust and out the skills and to and have the to restore trust in their and organization will require a approach to this process. of the Reina Trust and Betrayal Model and sensemaking leaders can to improve communication to make it and of direct care staff as and their and be with their their and be in times of to better their and support Box 1: descriptions 1: of on in Nurses in and to a in nurse Data used in this study from that nurses to about difficult experiences they had at were nurses working at hours in CC or an ED at participating Data were drawn from a of about difficult or experiences at 2: of on the and Organizational Trust in the use of for staff to share were and included a for staff to and emotional in direct patient in discussions by and their were nursing leaders and clinical staff working in CC who at one Data for this secondary analysis were drawn from with clinical nurses about their experiences with as as the and emotional in direct patient

  PublisherDOI

• Evaluating Nurse Conscientious Objection: Application of a Novel Framework

  HEC Forum · 2025-08-09 · 1 citations

  articleOpen access

  Certain moral beliefs and/or values about what is good or harmful can cause nurses and other healthcare professionals to object to participating in some clinical actions. Such objections are also called conscientious objections. Invocation of a conscientious objection (CO) can produce complexities in patient care and health care delivery and must be mindfully evaluated for its soundness. In this manuscript, a recently developed framework, The Ethical Evaluation of a Nurse's Conscientious Objection (EENCO), is applied to expose hidden elements and nuances in a proposed or actual CO by nurses or other healthcare professionals, thereby illuminating strategies that can lessen associated harms. The EENCO is utilized to explore two types of situations where a nurse makes a CO claim. Scenario 1 involves a nurse's reluctance to follow provider medication orders intended to relieve pain and suffering at the end-of-life. In scenario 2, nurses object to a visitation policy during the COVID-19 pandemic. Additionally, we provide a summary of the necessary elements of institutional policy to address claims of CO using the EENCO. Drawing on the EENCO, the two scenarios were analyzed for their ethical implications. This framework contributes to the exposure, scrutiny, and clarification of potentially unappreciated aspects of CO claims. Steps for developing institutional policy are identified. Application of the EENCO guides the analysis of the two scenarios. CO claims are explored more deeply, thereby revealing implications for those involved. Additionally, the EENCO provides guidance for the development of institutional CO policies.

  PublisherOA PDFDOI

• Applying E-PAUSE to Ethical Challenges in a Pandemic

  AACN Advanced Critical Care · 2025-02-25

  article1st authorCorresponding
  PublisherDOI

Frequent coauthors

• Gail Geller

  Johns Hopkins Medicine

  90 shared

• Douglas B. White

  University of Pittsburgh

  68 shared

• Sam D. Shemie

  Montreal Children's Hospital

  65 shared

• Thomas A. Nakagawa

  University of Florida

  65 shared

• Thomas P. Bleck

  New York Medical College

  64 shared

• Susan L. Bratton

  64 shared

• Mudit Mathur

  64 shared

• Sandralee Blosser

  64 shared

Awards & honors

• Hastings Center Fellow
• Fellow of the American Academy of Nursing
• Marguerite Rodgers Kinney Distinguished Career Award
• Distinguished Researcher award from American Association of…
• American Association of Critical-Care Nurses Pioneering Spir…