ETHOS: a modular ethics-informed online mindfulness program for emotional well-being, moral resilience and burnout prevention in hospital practitioners — protocol for a mixed-methods single-arm proof-of-concept study

ETHOS: a modular ethics-informed online mindfulness program for emotional well-being, moral resilience and burnout prevention in hospital practitioners — protocol for a mixed-methods single-arm proof-of-concept study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol ETHOS: a modular ethics-informed online mindfulness program for emotional well-being, moral resilience and burnout prevention in hospital practitioners — protocol for a mixed-methods single-arm proof-of-concept study Pierrick Laulan, Matthieu L.G. Fernandez This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9097265/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Burnout and emotional exhaustion among hospital practitioners are common and are frequently intensified by sustained workload and morally challenging clinical situations. Mindfulness-based interventions can improve stress and well-being, yet uptake in hospital settings is often constrained by long session formats, shift work and limited protected time. We developed ETHOS (Ethics-informed Training for Hospital practitioners: Online Skills for mindful practice), a brief, modular mindfulness program that integrates micro-skills for responding to moral adversity and value conflict. Methods This mixed-methods, single-arm proof-of-concept study will recruit approximately 30 hospital practitioners from a French hospital. ETHOS comprises six weekly online modules delivered via a secure platform. Each week includes a formal session split into two 30-minute parts (≈ 60 minutes/week core dose): mindfulness training plus ethics-informed moral-resilience application that can be completed on separate days. Participants will also access guided audio practices offered in two brief formats (5 and 10 minutes) and 60–90-second ‘micro-practices’ designed for clinical workflow. A booster online module will be delivered four weeks after the program. Assessments will be completed at baseline (T0), post-intervention (T1, week 6), pre-booster (T2, week 10; brief assessment), and follow-up (T3, week 18). Primary outcomes are feasibility and acceptability (recruitment, retention, module completion, home practice adherence, participant-reported acceptability and burden). Secondary outcomes include emotional exhaustion and other burnout dimensions, psychological well-being, stress, mindfulness, self-compassion, and ethics-related outcomes (moral distress and moral resilience). A purposive subsample will be invited to participate in semi-structured interviews to explore mechanisms of change, usability and engagement with the online format, contextual facilitators and barriers, and perceived ethical relevance. After completion of the T3 follow-up (end of the parent study), participants will be offered an optional advanced extension course (Phase 2) evaluated under a separate protocol; extension outcomes will be reported separately. Discussion This protocol addresses an implementation-critical question: can a short, modular mindfulness program with an ethics-informed component be feasible and acceptable for hospital practitioners while showing a signal of change in well-being and burnout-related outcomes? Findings will inform refinement of the intervention and the design of a subsequent randomized trial. Trial registration : The study will be registered prior to enrolment of the first participant. At the time of protocol submission, registration had not yet been completed because recruitment had not started and the protocol was still being finalized. Mindfulness hospital practitioners burnout emotional exhaustion moral distress moral resilience ethic of care mixed methods. Figures Figure 1 Background Burnout, emotional well-being and moral adversity in hospital practice Hospital practitioners routinely operate under high job demands (time pressure, high-stakes decision making, complex coordination, and frequent emotional exposure) that contribute to chronic stress and burnout. [ 1 ] Burnout, classically characterized by emotional exhaustion, depersonalization/cynicism, and reduced professional accomplishment [ 2 ], has been linked to poorer well-being, reduced work engagement, and adverse organizational outcomes (including higher turnover intentions and poorer quality/safety of care). [ 3 – 4 ] In parallel with workload-related strain, clinicians are frequently exposed to morally challenging situations (e.g., perceived non-beneficial care, resource constraints, and conflicts between patient wishes, family requests, and institutional policies). [ 5 – 6 ] Moral distress, often described as the psychological distress that arises when one recognizes the ethically appropriate action but feels constrained from acting accordingly, has been the focus of conceptual refinement in recent years. [ 6 – 7 ] A growing literature links moral distress to emotional exhaustion; a recent systematic review and meta-analysis reported a moderate positive association between moral distress and emotional exhaustion in healthcare professionals (pooled r ≈ 0.33). [ 8 ] Together, workload-related strain and recurrent moral adversity highlight the need for pragmatic and scalable preventive interventions for hospital practitioners. In this perspective, psychological symptoms such as emotional exhaustion may be understood not only as individual stress reactions but also as signals of underlying ethical strain. We use the term “ethical canaries” as a pedagogical metaphor for such early-warning cues. The broader “ethical canary” metaphor has been articulated by Somerville [ 10 ], and related discussions in healthcare ethics and clinician burnout underscore how early warning signals can reveal deeper ethical or organizational dysfunction before it becomes institutionally visible [ 11 – 12 ]. Mindfulness-based interventions for healthcare professionals In the present study, mindfulness is conceptualized within a psychological and secular framework, focusing on attentional regulation, meta-awareness, and emotion regulation processes rather than on its Buddhist soteriological foundations [ 13 ]. Mindfulness-based interventions (MBIs), are structured interventions derived from Mindfulness-Based Stress Reduction (MBSR) and related curricula that integrate formal mindfulness practices, experiential inquiry, and between-session practice while allowing context-sensitive adaptations. [ 14 ] MBIs have accumulated evidence for improving stress and well-being in healthcare professionals. A systematic review focused on mindfulness-based stress reduction (MBSR) in healthcare professionals concluded that MBSR is effective for reducing anxiety, depression and stress and for increasing mindfulness and self-compassion; it also highlighted that abbreviated MBSR formats can be comparable to standard 8-week programs for several psychological outcomes. [ 15 ] Meta-analytic evidence in primary healthcare professionals suggests that MBIs can reduce key burnout dimensions (including emotional exhaustion) and increase personal accomplishment, although study quality is heterogeneous. [ 16 ] During periods of extreme occupational demand (e.g., the COVID-19 pandemic), systematic reviews similarly suggest improvements in stress and mental well-being following MBIs, while effects on burnout can be less consistent. [ 17 ] Mechanistically, mindfulness training is theorized to reduce stress reactivity through improvements in attention regulation, body awareness, and emotion regulation, as well as a shift in perspective on thoughts and self (decentering). [ 18 ] Mediation evidence further implicates changes in cognitive and emotional reactivity and reductions in repetitive negative thinking as candidate pathways. [ 19 ] Despite these promising findings, many hospital-based MBIs face a recurring feasibility constraint: the traditional MBSR schedule (long weekly sessions plus a day-long retreat and substantial daily practice) is difficult to align with clinical shifts and limited protected time. [ 20 – 21 ] Consequently, several worksite-adapted programs have been developed. Mindfulness in Motion (MIM), for instance, was designed for chronically high-stress work environments and delivered onsite with shorter contact time (typically ~ 1-hour weekly group sessions combining brief didactics, guided mindfulness practice and gentle yoga-based movement, supported by optional between-session audio/video materials). [ 22 ] In parallel, online and app-supported mindfulness programs have shown benefits for stress and well-being in adult populations and may help overcome scheduling barriers for clinicians. [ 23 ] Rationale for a brief, modular and progressive program Shortening mindfulness programs must balance feasibility with intervention integrity. A review of MBSR studies examining whether in-class contact hours are related to psychological distress outcomes found no significant association between class hours and effect sizes, suggesting that carefully designed adaptations with reduced class time may be worthwhile when time commitment is a major barrier. [ 24 ] At the same time, mindfulness training is typically progressive: practices and themes are sequenced to support skill acquisition (attention stabilization, interoceptive awareness, emotional awareness, decentering from thoughts, compassion/values, and integration/relapse prevention). [ 20 ] For hospital practitioners, who face variable schedules and acute stress peaks, modularity can be operationalized by splitting weekly content into shorter, self-paced parts (e.g., two 30-minute modules) while preserving a coherent progression, complemented by brief daily practice options and on-shift micro-practices. Why integrate an ethics-informed (moral-resilience) component Mindfulness originates from contemplative traditions in which attentional training is typically embedded within an explicit ethical orientation (e.g., intentions of non-harming, compassion, and integrity), rather than being a value-neutral attentional technique. [ 13 , 25 – 28 ] In contemporary clinical and organizational mindfulness-based interventions (MBIs), ethical dimensions are often conveyed implicitly (through teacher embodiment, inquiry, and an emphasis on kindness and non-judgment), yet the assumption that mindfulness can be delivered as a morally neutral “technology” has been increasingly questioned. [ 13 , 25 – 26 , 28 ] For an intervention intended to support practitioners facing moral adversity, it is therefore important to specify what is meant by “ethics” and how ethical reflection is operationalized. In the present work, “ethics-informed” refers to a pragmatic, non-prescriptive lens for clarifying values, agency and feasible next steps under real-world constraints; it is not intended as moral instruction, performance enhancement, or a way of individualizing structural problems. To clarify what we mean by “ethics” in the present work, we draw on the ethics of care (care ethics). Originally articulated in moral psychology (e.g., Gilligan [ 32 ]) and later developed within bioethics, care ethics emerged partly in response to the decontextualized rationalism of principlism (i.e., the four-principles approach emphasizing autonomy, beneficence, non-maleficence, and justice). [ 29 ] It foregrounds relationality, dependence, and vulnerability (e.g., patient fragility, family distress, and team interdependence under uncertainty) and emphasizes situated judgment and responsiveness to concrete needs (e.g., tailoring communication, prioritization, and feasible “next steps” under constraints), rather than the application of abstract principles alone. [ 30 – 35 ] This relational and context-sensitive approach resonates with Ricoeur’s account of practical wisdom, understood as the capacity to deliberate within concrete situations by holding together solicitude, justice, and self-esteem in the pursuit of “the good life with and for others in just institutions” [ 36 ]. Tronto’s practice-oriented account describes care as unfolding through four phases (recognition of need, willingness to respond, direct care-giving action, and the care receiver’s response) linked to the ethical elements of attentiveness, responsibility, competence and responsiveness. [ 30 – 31 ] This process-oriented view lends itself to brief, on-shift skills: noticing a morally salient need, taking responsibility at one’s level, selecting a feasible and competent action, and checking and adjusting in light of the receiver’s response. Care ethics is best treated as a complementary lens rather than a replacement for principle-based ethics: basic rights and principles remain indispensable, while care ethics supports practical wisdom in adapting responses to singular persons and contexts and highlights the need for boundaries to prevent over-involvement and burnout. [ 30 ] Related relational-ethics frameworks and dialogical approaches to clinical ethics consultation similarly emphasize mutual respect, engagement and context. [ 35 , 37 ] Contemplative science also differentiates between attentional (‘concentration’) practices, constructive/ethics-based practices (e.g., compassion and loving-kindness), and perspective- or wisdom-based practices (e.g., self-transcendence and interdependence), which may have distinct implications for prosocial and moral outcomes. [ 38 ] Empirically, evidence that mindfulness training reliably translates into prosocial or ethically aligned behavior is mixed and context-dependent. Meta-analyses generally report small-to-moderate associations between mindfulness and prosociality, with substantial heterogeneity and indications of publication bias. [ 39 – 41 ] Experimental and organizational studies suggest plausible pathways via reduced cognitive-affective reactivity and moral disengagement but also highlight that effects may depend on individual moral identity and contextual framing. For example, in a randomized controlled study using computational modeling of moral decisions (money-for-harm trade-offs), mindfulness training prevented a time-related decline in moral preferences by attenuating the increasing weight placed on monetary gain. [ 42 – 44 ]. This suggests that attentional training alone may be insufficient to support ethically attuned action without explicit cultivation of ethical reflexivity and relational attunement, i.e. capacities that enable practitioners to recognize value conflicts, maintain moral agency, and respond with wise intention rather than reactive compliance or disengagement. Importantly, moral adversity in healthcare is shaped not only by individual coping but also by organizational conditions, often discussed in terms of ethical climate (shared perceptions of how ethical issues are handled in a workplace). [ 9 ] Integrating an ethics-informed (moral-resilience) component may therefore increase clinical relevance by explicitly linking mindfulness skills to professional values, agency and “wise action” under constraints. Moral resilience has been defined as the capacity to preserve or restore one’s integrity in response to moral complexity, distress, and adversity in clinical practice, and its measurement science has advanced with the development and psychometric evaluation of the Rushton Moral Resilience Scale (including a revised 16-item version). [ 45 ] Related constructs such as moral injury have been increasingly discussed in healthcare to describe more persistent symptom patterns following repeated moral adversity, although boundaries between constructs remain debated. [ 46 – 47 ] Rather than aiming to strengthen mere endurance, the present approach seeks to cultivate lucid and responsible responsiveness to moral tension, i.e. an inner ethical vigilance that signals when practice drifts from one’s professional commitments [ 25 , 48 – 49 ]. Strengthening professionals’ capacity to tolerate moral adversity without addressing its ethical significance risks fostering desensitization or normalization of problematic practices. At the level of program delivery, the mindfulness field has also articulated ethical principles and standards (e.g., do no harm, competence, integrity, respect for rights and dignity, and attention to power dynamics in teacher-participant relationships), intended to complement existing professional codes of ethics. [ 48 – 49 ] Logic model Box 1 summarizes the hypothesized logic model linking ETHOS (Ethics-informed Training for Hospital practitioners: Online Skills for mindful practice) components to proximal mechanisms and downstream outcomes, with ethical climate treated as a key contextual factor that may shape feasibility and response. Box 1. ETHOS logic model (hypothesized pathways) Contextual inputs high job demands and emotional load; recurrent moral adversity/value conflict; organizational constraints and ethical climate. Intervention components modular mindfulness training (attention anchoring, interoceptive awareness, decentering/open monitoring, compassion-oriented practices) + brief ethics-informed application using a recurring 4-step tool and workflow-compatible micro-practices (lucid ethical-oriented responsiveness). Proximal mechanisms reduced stress reactivity and cognitive-emotional narrowing; improved attention and emotion regulation; increased self-compassion and balanced self-relating under pressure; ethical awareness; clearer values/agency appraisal and selection of feasible “next steps”. Ethics-related processes reduced moral reactivity in the moment; cultivation of lucid, responsible responsiveness to moral tension (ethical vigilance) through repeated rehearsal of aligned micro-actions, recognition of value conflicts and appropriate escalation or support seeking when needed. Downstream outcomes reduced emotional exhaustion (key burnout signal) and perceived stress; improved psychological well-being and ethically aligned action; sustained use of brief practices in clinical workflow. Contextual moderator ethical climate and perceived organizational support for addressing ethical issues may shape engagement with the ethics-informed component and the feasibility of applying micro-actions in practice, and the salience of ethical signals (‘ethical canaries’) in daily work. A schematic representation is provided in Fig. 2. Study objectives The primary objective of this proof-of-concept study is to evaluate the feasibility and acceptability of ETHOS in hospital practitioners (recruitment, retention, module completion, adherence to home practice, and participant-reported acceptability/burden). Secondary objectives are to estimate the magnitude and variability of pre-post changes in burnout-related outcomes (with a focus on emotional exhaustion), emotional well-being and stress, and to explore changes in candidate mechanisms (mindfulness, self-compassion, moral distress, and moral resilience). A qualitative component will explore perceived mechanisms, contextual facilitators/barriers, usability of the online modular format, and ethical relevance, and will inform refinement of the intervention and the design of a future randomized controlled trial. Methods/Design Study design This is a prospective, mixed-methods, single-arm proof-of-concept study with repeated measures. Quantitative outcomes will be assessed at four timepoints: baseline (T0), post-intervention (T1, week 6), pre-booster (T2, week 10; brief assessment), and follow-up (T3, week 18). A qualitative component (semi-structured interviews) will be conducted after T1 (and, where feasible, after T3) in a purposive subsample. After completion of the T3 follow-up assessment, participants will be offered enrollment in an optional post-study extension course (Phase 2) evaluated under a separate protocol with separate consent; the parent study endpoints and analyses reported in this protocol are restricted to T0–T3. Reporting and transparency The protocol is written to align with SPIRIT guidance for clinical trial protocols and the CONSORT extension for pilot and feasibility studies, adapted to a single-arm design. [ 50 – 51 ] Additional reporting guidance for protocols of pilot and feasibility studies was also considered. [ 52 ] Intervention reporting follows the Template for Intervention Description and Replication (TIDieR) principles. [ 53 ] A SPIRIT schedule table is also provided, in line with journal expectations for protocol reporting. [ 50 ] Setting The study will be conducted at a French hospital (France). The ETHOS program will be delivered fully online via a secure, hospital-approved platform that allows asynchronous access (e.g., from home or during protected learning time), with automated reminders to support engagement. Study status At the time of protocol submission, recruitment has not started and no participants have been enrolled. The study protocol is being finalized following scientific feedback. The ethics application will be submitted to the appropriate ethics committee once the protocol has been stabilized, and the study will not begin before written ethics approval has been obtained. Participants Eligible participants will be hospital practitioners (e.g., physicians, residents, nurses, and allied health professionals) currently employed at the hospital and involved in patient care. Participants must be aged ≥ 18 years, able to provide informed consent, and able to access the online platform (internet-enabled computer or smartphone). Because the intervention is self-paced, eligibility requires willingness and practical ability to complete at least four of the six weekly modules within the delivery window (allowing for on-call duties and leave). The delivery window corresponds to the 6-week intervention period (weeks 1–6), during which weekly modules are unlocked sequentially and can be completed asynchronously. Exclusion criteria are kept minimal for pragmatic feasibility and include: (i) current severe psychiatric episode requiring acute treatment (e.g., active psychosis, severe major depression with high suicide risk), (ii) current substance dependence, or (iii) any condition that would make participation in mindfulness practice unsafe or impractical (as judged by the participant and, if needed, their treating clinician). Previous mindfulness experience is not an exclusion criterion; it will be measured at baseline and considered in exploratory analyses. Baseline characterization will also capture key demographic and professional/contextual variables (e.g., age, gender, profession/role, years of experience, clinical unit, shift pattern/night work, and typical weekly working hours) to describe the sample and to explore heterogeneity in feasibility and outcomes. If the optional patient feedback sub-study is implemented, patients will receive a brief information sheet and provide separate informed consent before completing an anonymous survey; refusal or non-participation will not affect the care they receive. Recruitment and informed consent Recruitment will use a multi-channel strategy adapted to hospital constraints: email invitations via institutional mailing lists, brief presentations at departmental meetings, posters in staff areas, and information relayed by occupational health / quality-of-work-life (QVT) channels when available. Recruitment materials will frame ETHOS as a brief, flexible, online skills program for practitioners experiencing work-related stress, emotional overload, or moral tension, and for those wishing to strengthen well-being and sustain practice. To limit selection pressure and stigma, messages will emphasize voluntary participation, confidentiality, and that supervisors will not know who participates. Interested staff will receive an information sheet describing study aims, time commitment (approximately 60 minutes/week delivered as two ~ 30-minute modules, plus optional 5–10-minute guided practice and brief 60–90-second micro-practices during shifts), confidentiality, and the right to withdraw. Informed consent will be obtained electronically (or in writing) prior to baseline assessment. Sample size justification The target sample is approximately 30 participants. This sample size is not intended to provide definitive tests of effectiveness; rather, it is appropriate for estimating feasibility parameters (e.g., retention, adherence) and for obtaining preliminary estimates of outcome variability and standardized change. Contemporary guidance for pilot and feasibility studies emphasizes parameter estimation over hypothesis testing and cautions against treating small pilots as efficacy studies. [ 54 – 55 ] A commonly cited rule-of-thumb is 12 participants per group in pilot work. [ 56 ] We selected a larger single-arm sample to better characterize feasibility in a heterogeneous practitioner population and to support exploratory moderation and mechanism analyses, with appropriate caution regarding statistical power. Exploratory moderation and mechanism analyses will be limited to a small, theory-driven set to reduce overfitting and will be interpreted cautiously. Intervention: ETHOS program Overview and theoretical rationale ETHOS is a brief, online mindfulness program designed for hospital practitioners with limited protected time. It adapts core mindfulness-based program elements (guided practice, experiential learning, inquiry/reflection, and between-session practice) while explicitly integrating ethics-informed moral-resilience micro-skills relevant to value conflict and ethical constraints in clinical work. Adaptation decisions were guided by the principle of maintaining core mindfulness “ingredients” while modifying format and delivery to fit context. [ 57 ] Intervention development and support. The ETHOS modules were developed by the two authors. The first author has formal training in mindfulness-based approaches and has conducted prior academic work on mindfulness [ 58 – 59 ]. The second author is a clinical neuropsychologist who integrates mindfulness-based practices in clinical work. Although ETHOS is delivered asynchronously through pre-recorded modules, participants will have access to a study contact for questions or difficulties. Any report of sustained distress or adverse reactions potentially related to mindfulness practice will be reviewed promptly by the research team, and participants will be advised to pause/modify practice and to seek appropriate support (e.g., occupational health service, psychologist, or physician/mental health clinician) when indicated (see “Harms and adverse events”). Format ETHOS will be delivered over six weeks via a secure online platform. Each week, participants will complete a formal session split into two modular parts of approximately 30 minutes each: • Part A (≈ 30 min): mindfulness training (short didactic, a guided practice, and a brief reflective / intention-setting prompt). • Part B (≈ 30 min): ethics-informed application and moral-resilience skill (case-anchored reflection and rehearsal of a brief tool for responding to moral pressure). Part B will integrate Tronto’s care ethics and the recurring 4-step tool to cultivate lucid and responsible responsiveness to moral tension. The two parts can be completed on separate days to accommodate clinical schedules while preserving a coherent weekly progression. The core prescribed dose is approximately 60 minutes/week (two ~ 30-minute modules). Between modules, participants will be invited to complete brief guided practices in either a 5-minute or 10-minute format (choice-based home-practice dose), plus optional 60–90-second micro-practices designed for clinical workflow (e.g., before entering a patient room, after a difficult conversation, after an adverse event, or following moral conflict). A booster online module will be delivered four weeks after week 6 to refresh practice, address barriers, and rehearse application to current clinical stressors. After completion of the T3 follow-up assessment, participants will be offered an optional post-study advanced extension course (Phase 2) under a separate protocol. Sequential release and catch-up window. To preserve the progressive structure of the curriculum, weekly content will be released sequentially (one module per week). Each week’s module (Part A and Part B) will be unlocked at the start of the corresponding week and will remain accessible for the remainder of the 6-week intervention period, allowing participants to catch up if a given week is missed due to on-call duties, leave, or workload peaks. For feasibility metrics, module completion will be defined as completion of each Part (A and/or B) within the 6-week delivery window (i.e., up to the end of week 6, prior to the post-intervention assessment). Core components The ETHOS core component draws on established mindfulness-based program (MBP) practice families, including (i) mindful breathing and attention training, (ii) body scan and interoceptive awareness, (iii) mindful movement (gentle stretching suitable for work clothes), (iv) open monitoring of thoughts and emotions (decentering), and (v) compassion-oriented practices (kindness toward self/others; supportive inner dialogue). This selection reflects core practices taught across first-generation MBPs (e.g., MBSR/MBCT) and aligns with definitional work specifying essential MBP components and permissible contextual adaptations while maintaining program integrity. [ 14 , 20 ] In healthcare professionals, MBSR-based protocols typically include formal practices (e.g., body scan, sitting meditation, mindful walking, gentle yoga) and informal practices, supporting the rationale for the present practice families and the emphasis on brief “on-shift” application. [ 15 ] Compassion-oriented elements (e.g., self-kindness and supportive inner dialogue) are included to foster a balanced, non-judgmental stance toward distress and to support self-relating under pressure. [ 60 ] Booster session (4 weeks post-program) To support maintenance of skills and real-world transfer under clinical constraints, the program includes a brief booster module scheduled 4 weeks after completion of the core curriculum. Booster/maintenance contacts are commonly used in behavior change and psychological interventions to reinforce skill use and support maintenance, although incremental benefits vary across contexts and implementation choices. [ 61 ] In clinician- and workplace-adapted mindfulness programs, maintenance phases and ongoing “touchpoints” (e.g., optional booster sessions and brief reminder materials) have been used to consolidate practice and address implementation barriers (e.g., limited time, interruptions). [ 62 – 63 ] The ETHOS booster (≈ 45–60 min, online) comprises (i) a short guided practice (10–15 min) revisiting the most frequently used “on-shift” skills (brief grounding + decentering), (ii) structured troubleshooting of barriers and facilitators encountered during clinical implementation, and (iii) tailored planning of micro-practices for participants’ recurrent stressors (case vignettes; if–then implementation intentions). Booster fidelity is documented via attendance and a brief checklist of covered elements. Ethics-informed moral-resilience module The ethics-informed component translates moral adversity into a brief, psychologically actionable practice rather than normative instruction. It is designed to help participants clarify what matters, what is within their agency, and what a feasible next step is under real-world constraints, while explicitly avoiding moralization and over-responsibilization. Across the six weeks, it introduces and repeatedly rehearses a recurring 4-step tool (≈ 2–4 minutes) aligned with Tronto’s care-ethics elements (attentiveness, responsibility, competence, and responsiveness) [ 30 – 31 ] and closes each Part B with a brief ‘three-lens check’ (≈ 30 seconds) to support transfer and to protect against over-responsibilization. The tool is summarized in Box 2 and is woven into Part B of every weekly module. This approach is inspired by ethics-informed resilience programs in healthcare (e.g., MEPRA) that combine mindfulness with skills for confronting ethical challenges. [ 64 – 65 ] Box 2. ETHOS recurring 4-step tool and three-lens check 1. Notice : Attentively identify the moral pressure/need (“What feels ethically difficult or value-incongruent right now?”). This step builds on awareness of a triggering signal (the “ethical canary”) and corresponds to caring about in the care ethics framework described by Joan Tronto. 2. Regulate : 30–60 seconds of mindful grounding to reduce reactive narrowing. This step draws on mindfulness-based attentional regulation. 3. Clarify : Clarify values and agency (“What matters most here?” “What is within my control or influence in the next hour/day?”) and choose a feasible micro-action. This step corresponds to taking care of in Tronto’s care ethics framework. 4. Act & check : Take the micro-action and briefly check responsiveness (“What changed for the patient/others and for me?” “What is the next wise step—communication, consultation/escalation, documentation, or recovery/self-care?”). This step corresponds to taking care of in Tronto’s care ethics framework. Three-lens check (≈ 30 seconds) : patient and practitioner well-being; relational responsiveness (how care is received); institutional constraints and available support/escalation options. This reflective framing is conceptually informed by the ethical perspective articulated by Paul Ricoeur, emphasizing self-esteem, solicitude, and justice in practical wisdom. Session-by-session content Table 1 summarizes the weekly module themes and practice structure. Module recordings, audio files and worksheets will be standardized and version-controlled to support delivery integrity. Table 1 ETHOS intervention content and practice structure (TIDieR-informed summary). Week Part A: Mindfulness training (≈ 30 min) Main guided practice(s) Part B: Ethics-informed application (≈ 30 min) Between-week practice (choose 5 or 10 min) + micro-practices Week 1 Orientation; stress, burnout and attention. Introducing intention-setting, the ‘mindful pause’ and basic attentional anchoring (breath). Short mindful breathing (5–10 min) + brief body scan (8–10 min). Attentiveness (caring about): moral adversity in clinical work and values awareness. Introduce a care-ethics lens and the recurring 4-step tool as a first exercise in noticing ethical tension, framing moral pressure as an “ethical canary”; rehearse with a low-stakes example; clarify ‘what matters’ at work. Daily 5 or 10 min breathing/body scan audio. Micro-practice: 60–90-sec pause before/after a patient encounter; note one value-aligned intention. Week 2 Interoception and emotion cues. Expanding attention to body sensations and early stress signals. Body scan (10–15 min) + grounding. Responsibility (taking care of): moral emotions (e.g., guilt, frustration) and ‘just responsibility’ (responsibility vs over-responsibility). Use grounding and self-compassion and apply the 4-step tool when moral pressure triggers strong affect. Daily 5 or 10 min body scan audio. Micro-practice: ‘ground-breathe-label’ (30–60 sec) + a brief self-compassion phrase. Week 3 Thoughts, rumination and cognitive narrowing. Decentering and open monitoring. Open monitoring (10–15 min) with labeling of thoughts/emotions. Competence (care giving): selecting feasible micro-actions under team/system constraints. Use the 4-step tool to clarify values/agency and rehearse a brief communication micro-step (seeking clarification/support). Highlight that responsiveness to moral cues can guide feasible action without moral overload. Daily 5 or 10 min open-monitoring audio. Micro-practice: ‘name it + choose’ (30–60 sec) before responding in a difficult interaction. Week 4 Mindful movement and compassion. Working with fatigue and compassion strain. Gentle mindful movement (≈ 10 min) and/or loving-kindness (5–10 min). Responsiveness (care receiving): checking impact and adjusting in real time. Apply the 4-step tool to after-event moral residue; integrate boundaries, recovery, and seeking support when needed. Frame the check as monitoring moral tension: is it signaling unresolved ethical strain? Daily 5 or 10 min movement or kindness audio. Micro-practice: hand-on-heart grounding; brief recovery ritual after a hard conversation. Week 5 Mindfulness in interpersonal stress. Bringing attention to difficult conversations and uncertainty. Practice with a recent interpersonal stressor (guided imagery) + mindful breathing. Integration and agency: rehearse the full care cycle and identify what is within control/influence. Plan value-aligned micro-actions for recurrent interpersonal stressors (e.g., consult, document, escalate appropriately). Daily 5 or 10 min practice of choice. Micro-practice: ‘values check’ + one small action in the next hour/day. Week 6 Integration and maintenance. Review of skills; relapse prevention; building a personal practice plan. Choice practice (breath/body/open monitoring) + brief reflection. Institutional constraints and maintenance: consolidate the 4-step tool; anticipate high-risk situations; plan escalation/support options and a realistic maintenance plan; prepare for booster. Participants are invited to reflect on how early ethical cues can guide sustained ethical attention and action within organizational constraints. Daily practice of choice (5 or 10 min). Maintain micro-practices; prepare for booster. Booster (Week 10) Refresh core practices; troubleshoot barriers; re-establish routine. Guided practice of choice (≈ 10 min) + problem-solving reflection. Apply the 4-step tool to a current morally challenging situation; update maintenance plan for the next month; reinforce noticing early ethical cues and using proportionate action and support-seeking. Maintenance micro-practices; optional reminder prompts; prepare for follow-up assessment. Optional post-study extension (Phase 2): ETHOS-Advanced After participants complete the T3 follow-up assessment (week 18), they will be offered the opportunity to enroll in an optional post-study advanced extension course (“ETHOS-Advanced”). The purpose of ETHOS-Advanced is to provide a higher-dose continuation pathway for motivated participants, supporting longer-term maintenance of mindfulness skills and deeper integration of ethics-informed moral-resilience micro-skills anchored in Ricoeurian practical wisdom and Tronto’s care ethic. Phase 2 is not part of the parent proof-of-concept study described in this protocol. It will be implemented under a separate protocol and consent procedure (and registered as appropriate prior to enrollment), and its outcomes will be reported in a separate manuscript. This separation preserves the interpretability of the parent study’s feasibility endpoints and effect size estimates through T3 and avoids mixing core-trial exposure with optional, self-selected additional training. The design is informed by evidence that follow-on (“graduate” or advanced) mindfulness curricula can yield additional gains in well-being and mental health beyond introductory courses. For example, Mindfulness-Based Cognitive Therapy—Taking it Further (MBCT-TiF), an adapted program for graduates of MBCT/MBSR, showed clinically meaningful improvements in mental well-being compared with ongoing mindfulness practice in a randomized controlled trial. [ 66 ] ETHOS-Advanced will consist of four weekly online modules delivered asynchronously on the same secure platform. Each module is approximately 60 minutes (two 30-minute parts) and includes (i) a longer guided mindfulness practice (≈ 15–20 min) plus brief inquiry/reflection focused on working with difficult affect and moral residue, and (ii) an advanced ethics-informed module integrating Tronto’s care ethic with Ricoeurian practical wisdom, emphasizing reflective deliberation, moral discernment, and situational ethical adjustment. This phase builds on the Phase 1 foundation (mindfulness + care ethics) and progressively introduces the Ricoeurian ethical horizon (“a good life, with and for others, in just institutions”) as a guiding framework for ethical discernment. Participants are invited to use a reflective journal structured around three columns corresponding to the Ricoeurian poles (good life / solicitude / just institutions), fostering daily ethical attention. Between modules, participants are invited to engage in a 10-minute daily guided practice and to continue on-shift micro-practices and use of the 4-step tool. • A1 (Deepening practice): stabilizing practice under pressure; working with avoidance and fatigue; sustaining intention. • A2 (Moral residue and repair): identifying moral residue, guilt and self-blame; self-compassion and realistic responsibility; recovery micro-practices. • A3 (Relational practice in teams): mindful communication in value conflict; perspective-taking; brief debriefing scripts; receiving feedback on care. • A4 (Sustaining change in institutions): mapping spheres of control/influence; identifying escalation/support resources; maintenance plan for practice and ethical action. • B1: Introducing the Ricoeurian ethical horizon in daily care; journaling using the three poles; anchoring ethical intention with meditation. • B2: Reflective attention to moral tensions in practice; deliberation exercises on competing values; practicing micro-adjustments to preserve integrity. • B3: Integrating relational care (Tronto) with practical wisdom (Ricoeur) in team interactions; communication, escalation, and supportive feedback. • B4: Institutional awareness and ethical action; anticipating constraints; mapping escalation pathways; sustaining a reflective, morally attuned practice. In Phase 2, the ethics-informed module (B) is based on a secular framework. It explicitly integrates self-esteem, solicitude, and justice within Tronto’s relational care framework, supporting reflective deliberation under real-world constraints. Rather than merely increasing endurance, ETHOS promotes lucid and responsible responsiveness to moral pressure, preserving integrity while avoiding desensitization or over-responsibilization. Planned dissemination will reflect this two-phase structure: (i) the parent proof-of-concept study (Phase 1) will be reported as the primary feasibility article (Article 1; outcomes through T3), and (ii) the optional extension evaluation will be reported separately as an extension article (Article 2), using T3 as the baseline for Phase 2 and focusing on uptake, retention and exploratory changes through post-extension and follow-up. Outcomes and measures All outcomes and assessment timepoints described below pertain to the parent ETHOS proof-of-concept study (Phase 1) through T3. The optional Phase 2 extension will be evaluated under a separate protocol; planned Phase 2 outcomes are summarized briefly for transparency. Primary outcomes: feasibility and acceptability Feasibility outcomes will be operationalized as: (i) recruitment rate (number enrolled / number expressing interest; and time required to reach target sample), (ii) retention (completion of T1 and T3 assessments), (iii) module completion (number of weekly Part A/Part B modules completed), (iv) adherence to between-session practice and on-shift transfer (self-reported practice frequency and duration, micro-practice use, and application of the 4-step tool), captured through brief weekly practice logs (≤ 1 minute) and complemented by optional platform analytics when available, and (v) delivery integrity indicators (e.g., confirmation that the intended module content was available and accessed as scheduled; version control of materials). Acceptability will be assessed through a brief post-intervention questionnaire capturing perceived usefulness, burden, fit with clinical workflow, and likelihood of continued practice. Acceptability items will be informed by the Theoretical Framework of Acceptability (TFA) domains (affective attitude, burden, perceived effectiveness, ethicality, self-efficacy, and opportunity costs). [ 67 ] To capture the ethics-informed aspect of ETHOS with minimal additional burden, we will include a short set of ETHOS-specific items focusing on perceived ethical relevance, clarity of agency boundaries (self/team vs institutional constraints), perceived non-moralizing framing, and perceived risk of individualizing structural problems. At T1, participants will also complete the Client Satisfaction Questionnaire-8 (CSQ-8) and provide open-ended feedback. [ 68 ] A brief follow-up acceptability check (continued usefulness, burden, and likelihood of continued practice) will also be collected at T3. A brief checklist of potential unwanted effects (e.g., increased guilt/self-blame, rumination, or sustained distress triggered by morally challenging material) will be completed post-intervention (T1) and at follow-up (T3), with an open-ended option to describe context. Progression criteria Progression criteria will be pre-specified using a traffic-light approach to guide decisions about moving to a larger trial. Proposed criteria are summarized in Table 2 and will be refined with stakeholders and interpreted in context (e.g., seasonal peaks). Table 2 Pre-specified progression criteria (traffic-light approach). Domain Green (proceed) Amber (revise) Red (re-design / stop) Recruitment speed ≥ 30 enrolled within ≤ 12 weeks 20–29 within 12 weeks < 20 within 12 weeks Retention ≥ 80% at T1 and ≥ 70% at T3 60–79% at T1 or 50–69% at T3 below amber thresholds Engagement (module completion) ≥ 70% complete ≥ 8/12 module parts ( ≈ ≥ 4/6 weeks with both parts completed) 50–69% complete ≥ 8 parts or substantial completion of Part A but low Part B completion < 50% complete ≥ 8 parts or consistently low Part B completion Acceptability Mean satisfaction ≥ 20/32 on CSQ-8 and predominantly positive qualitative feedback Mixed satisfaction/feedback Low satisfaction and/or negative qualitative feedback Secondary outcomes: psychological and work-related variables Secondary outcomes are selected to (i) capture domains relevant to practitioner well-being and burnout, (ii) reflect plausible mechanisms of mindfulness-based change, and (iii) address the ethics-informed component. For core outcomes (burnout/emotional exhaustion, well-being, perceived stress, mindfulness, self-compassion), validated French versions will be used. For burnout/exhaustion, the MBI-HSS will be complemented by the Copenhagen Burnout Inventory (CBI) as an exploratory measure at T0, T1, and T3; the CBI is omitted at T2 to keep the brief assessment short. For ethics-specific constructs (moral distress, moral resilience, moral injury symptoms, and perceived ethical climate), we will use existing French versions when available. If a validated French measure covering the same construct is available, we will prioritize it; otherwise, we will translate/adapt measures following established cross-cultural procedures (forward–back translation and pretesting) and treat results as exploratory. [ 69 ] Ethical climate will be assessed using the Hospital Ethical Climate Survey (HECS) [ 70 ], and moral injury symptoms will be assessed using the Moral Injury Symptom Scale - Health Professional (MISS-HP) [ 47 ] as exploratory measures. Measures and timepoints are summarized in Table 3 . Optional salivary cortisol measure (exploratory) To complement self-report stress and burnout outcomes with an objective index of hypothalamic–pituitary–adrenal (HPA) axis activity, participants will be offered an optional salivary cortisol assessment at baseline (T0) and post-intervention (T1). Salivary cortisol is a non-invasive marker of free cortisol concentrations and is widely used in field stress research. [ 71 – 72 ] In burnout, cortisol indices have shown heterogeneous alterations across studies; including cortisol here is intended primarily to assess feasibility and to triangulate subjective stress and exhaustion signals for a future randomized trial. [ 73 ] Participants who opt in will receive a home collection kit (e.g., Salivette or passive drool tubes) with written instructions and pre-labeled sample codes. On two typical days within each assessment window (preferably non-night-shift days), they will collect saliva (i) immediately upon awakening, (ii) 30 minutes after awakening (cortisol awakening response; CAR), and (iii) at bedtime. Sampling time, wake time, sleep duration, and relevant confounders (e.g., shift pattern, acute illness, medication including glucocorticoids, nicotine/caffeine intake) will be recorded. Participants will be asked to refrain from eating, drinking (except water), brushing teeth, or smoking for at least 30 minutes before each sample and to store samples refrigerated/frozen until return to the research team. Samples will be stored at -20°C and analyzed in batch using a high-sensitivity enzyme immunoassay. Field sampling and CAR assessment procedures will follow established recommendations. [ 72 , 74 ] Exploratory patient-reported experience measures To complement practitioner-reported outcomes and to assess whether ETHOS skills translate into patients’ experience of care, we will pilot a brief, anonymous patient feedback module in a subset of participating clinicians who have direct patient contact. Subject to ethics approval (or amendment), each participating clinician will invite a small convenience sample of patients (e.g., 3–5 per timepoint) to complete a short survey immediately after a routine encounter at two timepoints: pre-intervention (baseline window) and post-intervention (within 2 weeks after week 6). Where feasible, we will also explore feasibility of an additional follow-up sample at T3. The survey will include the 6-item Brief Health Care Climate Questionnaire (HCCQ; French version), assessing patients’ perceptions of autonomy-supportive care, plus a single global item on perceived communication quality (e.g., feeling listened to). [ 75 ] Patient surveys will be anonymous, will not include health identifiers, and will not be shared with clinicians in an individually identifiable manner. Feasibility metrics will include the proportion of clinicians able to recruit patients, patient response rate, and missing data. Table 3 Secondary and exploratory outcome measures and assessment timepoints. Construct / domain Instrument Timepoints Notes Burnout (key secondary outcome: emotional exhaustion) Maslach Burnout Inventory – Human Services Survey (MBI-HSS (MP), French validated version) [ 2 , 76 ] T0, T1, T2 (brief), T3 Primary burnout signal outcome retained for comparability with prior healthcare literature; French validation available [ 76 ]. Burnout / exhaustion profile (CBI, exploratory) Copenhagen Burnout Inventory (CBI) [ 77 – 78 ] T0, T1, T3 Complementary exploratory measure of personal, work-related, and client-related exhaustion; added alongside the MBI-HSS to broaden interpretability and omitted at T2 to limit burden. Psychological well-being WHO-5 Well-Being Index (French version) [ 79 ] T0, T1, T2 (brief), T3 Brief and widely used well-being measure; French psychometric data available [ 79 ]. Perceived stress Perceived Stress Scale (PSS-10), French version [ 80 ] T0, T1, T3 Global perceived stress; factorial validation in French working population [ 80 ]. Mindfulness skills Mindful Attention Awareness Scale (MAAS), French version [ 81 – 82 ] T0, T1, T3 Mechanism candidate; brief attention/awareness measure with French psychometrics [ 81 ]. Self-compassion Self-Compassion Scale—Short Form (SCS-SF), French version [ 83 – 84 ] T0, T1, T3 Mechanism candidate; French version psychometric data available [ 83 ]. Moral distress Measure of Moral Distress for Healthcare Professionals (MMD-HP) [ 85 ] T0, T1, T3 Ethics-related outcome. If a validated French version is unavailable, translation/adaptation will follow published cross-cultural guidelines [ 69 ] and results will be treated as exploratory. Moral resilience Revised Rushton Moral Resilience Scale (RMRS-16) [ 45 ] T0, T1, T3 Ethics-related mechanism/outcome. If a validated French version is unavailable, translation/adaptation will follow published cross-cultural guidelines [ 69 ] and results will be treated as exploratory. Ethical climate (contextual factor) Hospital Ethical Climate Survey (HECS) [ 70 ] T0, T3 Contextual covariate capturing perceived support and norms for addressing ethical issues; included to inform feasibility and exploratory moderation. If a validated French version is unavailable, translation/adaptation will follow published cross-cultural guidelines [ 69 ]. Moral injury symptoms (exploratory) Moral Injury Symptom Scale – Health Professional (MISS-HP) [ 47 ] T0, T1, T3 Exploratory ethics-related outcome capturing more persistent moral adversity symptoms (e.g., guilt, shame, betrayal, loss of meaning). Included to test measurement feasibility and inform future refinement. If a validated French version is unavailable, translation/adaptation will follow published cross-cultural guidelines [ 69 ] and results will be treated as exploratory. Physiological stress biomarker (optional) Salivary cortisol (home sampling; CAR + diurnal decline) [ 71 – 72 , 74 ] T0, T1 Optional exploratory biomarker to complement self-report stress and burnout outcomes; feasibility indicators include uptake and sampling adherence. Interpretation will be cautious given known heterogeneity in burnout-related cortisol findings. [ 73 ] Patient-reported experience (optional sub-study) Brief Health Care Climate Questionnaire (HCCQ-6; French version) + 1 global communication item Baseline (pre-intervention window) and post-intervention (T1); optional follow-up (T3) Optional, brief, anonymous patient feedback collected after routine encounters in a subset of patient-facing clinicians. Data will be analyzed descriptively (e.g., clinician-level means) to inform feasibility and signal of relational impact. Qualitative outcomes Semi-structured interviews (≈ 30–45 minutes) will be conducted with an estimated 10–12 participants purposively sampled to reflect variation in baseline burnout and moral adversity (moral distress and moral injury symptoms), module completion, and practice adherence. Interviews will explore: perceived changes and mechanisms; concrete moments of on-shift application (guided practices, micro-practices, and the recurring 4-step tool), including situations in which the tool felt difficult to use or insufficient; usability and engagement with the online modular format (two-part sessions, reminders, and workflow fit); perceived ethical relevance and perceived non-moralizing framing (including whether the program clarified agency boundaries between the individual/team and institutional constraints); experiences of responsibility and support-seeking/escalation in constrained contexts; perceived unintended effects (e.g., increases in guilt/self-blame or rumination) and strategies used for grounding and recovery; and contextual facilitators/barriers at individual, team and organizational levels, with recommendations for refinement (content, dose, sequencing, and implementation). Where feasible, we will also invite participants to provide one concrete example of applying the 4-step tool to a recent morally challenging situation (de-identified). Qualitative reporting will follow COREQ guidance. [ 86 ] Optional Phase 2 extension outcomes (separate protocol) For participants who provide separate consent to Phase 2, assessment will be conducted at Phase 2 baseline (T3, serving as the post-parent-study timepoint), post-extension (T4; approximately week 22), and follow-up (T5; approximately week 30). Phase 2 primary outcomes will be feasibility and acceptability (uptake among eligible completers, retention, module completion, and perceived burden/usefulness). Exploratory outcomes will include within-person change from T3 to T4/T5 in a reduced battery selected to minimize burden (emotional exhaustion, psychological well-being, perceived stress, mindfulness, self-compassion, and ethics-related outcomes such as moral distress and moral resilience). Analyses will be descriptive and hypothesis-generating. Schedule of enrollment, interventions, and assessments The timing of study procedures is summarized in Table 4 (SPIRIT schedule). The optional Phase 2 extension occurs after T3 under a separate protocol and is therefore not included in the SPIRIT schedule. An optional patient-reported experience sub-study (HCCQ-6) is shown as exploratory and is contingent on ethics approval. Table 4 SPIRIT schedule of enrollment, intervention, and assessments. Study period Enrollment Baseline (T0) Intervention (Weeks 1–6) Post-intervention (T1, week 6) Pre-booster (T2, week 10) Follow-up (T3, week 18) Eligibility screen X Informed consent X Sociodemographics & work context X Primary feasibility metrics (module completion, practice logs) X X X X Acceptability / satisfaction (T1; brief T3 follow-up) and unwanted effects Reporting as needed X (incl. CSQ-8; unwanted effects) X (brief; incl. unwanted effects) Burnout / emotional exhaustion (MBI) X X X (brief) X Burnout / exhaustion profile (CBI) X X X Well-being (WHO-5) X X X (brief) X Perceived stress (PSS-10) X X X Mindfulness (MAAS) X X X Self-compassion (SCS-SF) X X X Moral distress (MMD-HP) X X X Moral resilience (RMRS-16) X X X Ethical climate (HECS) X X Moral injury symptoms (MISS-HP) X X X Qualitative interview (subsample) X Optional Salivary cortisol (optional) X X Patient-reported experience (HCCQ-6; optional) X X X Data management, confidentiality and quality assurance Participants will be assigned a unique study identifier. Questionnaire data will be collected via a secure electronic platform compliant with institutional requirements and the General Data Protection Regulation (GDPR). Identifying information (consent forms, contact details) will be stored separately from survey data. Only the research team will have access to the re-identification key. Audio recordings of interviews (when applicable) will be stored on encrypted institutional servers and transcribed with removal of identifying information. Because ETHOS is delivered through pre-specified online modules, delivery integrity is primarily ensured through version control of the content (locked recordings and worksheets) and platform checks confirming availability. Engagement will be monitored through self-report practice logs and, where feasible, platform analytics (e.g., module access/completion timestamps). Optional patient surveys (if implemented) will be anonymous, will not include clinical identifiers, and will not be linkable to medical records; results will be analyzed and reported in aggregated form. Analysis plan Quantitative analysis Analyses will primarily be descriptive and estimation-focused, consistent with a single-arm proof-of-concept design. Feasibility outcomes (recruitment rate/speed, retention at T1 and T3, module completion, and practice adherence) will be summarized using proportions and 95% confidence intervals (exact binomial intervals where appropriate), as well as means/medians and dispersion (SD/IQR) for continuous feasibility indicators. Progression criteria will be evaluated descriptively against the pre-specified traffic-light thresholds (Table 2 ). Definition of exposure (“dose received”). Weekly modules are released sequentially (one per week) and can be completed asynchronously; each unlocked module remains accessible throughout the 6-week delivery window (weeks 1–6), allowing catch-up within that period. For feasibility metrics, module completion will be defined as completion of each weekly Part (A and/or B) within the 6-week delivery window (i.e., up to the end of week 6, prior to the post-intervention assessment). Completion will be summarized separately for Part A and Part B and as a combined threshold (e.g., ≥ 8/12 completed parts). Practice log indicators (guided practice days, duration category when available, micro-practice use, and 4-step tool use) will be summarized descriptively over time. Secondary continuous outcomes (signal of change). For continuous secondary outcomes, within-person change from baseline (T0) to each follow-up timepoint will be estimated using both (i) standardized mean change effect sizes and (ii) mixed-effects models. Standardized mean change will be expressed as Hedges’ \({g}_{av}\) (small-sample corrected). Effect sizes will be reported with 95% confidence intervals, with emphasis on magnitude and uncertainty rather than dichotomous significance testing. Mixed-effects models will be used to estimate time effects while accounting for within-person correlation. For each outcome, we will fit a model with time as a categorical fixed effect and participant as a random intercept (e.g., outcome ~ time + (1|participant)). Model-based estimated marginal means will be used to obtain pre-specified contrasts, prioritizing: T0→T1 (post-intervention signal), T0→T3 (maintenance), and T1→T3 (trajectory after program completion). Where model convergence and sample size allow, we will explore adding random slopes for time; otherwise, the random-intercept specification will be retained. Given the proof-of-concept design and limited power, p-values will be interpreted cautiously; inference will focus on point estimates and uncertainty intervals. Missing data. Patterns and extent of missingness will be summarized by timepoint and by key baseline characteristics. Mixed-effects models will be estimated using maximum likelihood, which accommodates incomplete repeated-measures data under a missing-at-random assumption. For standardized mean change estimates, pairwise available data will be used for each contrast (e.g., T0–T1), and the number of complete pairs contributing to each estimate will be reported. As a sensitivity check, we will compare main estimates to complete-case results for key outcomes when feasible. Exploratory associations with engagement. Associations between engagement indicators (module completion, practice log metrics) and outcome change will be explored descriptively (e.g., correlations and regression models adjusting for baseline outcome levels), acknowledging potential confounding and self-selection. These analyses are hypothesis-generating and intended to inform refinement of the intervention and the design of a subsequent trial. Exploratory moderation. A small, theory-driven set of baseline variables specified a priori (e.g., baseline emotional exhaustion, baseline moral distress, perceived ethical climate, and prior mindfulness experience) will be examined as potential moderators of change using time × moderator interactions in mixed-effects models. Given limited power and multiple comparisons, moderation results will be treated as exploratory and interpreted cautiously. Exploratory mechanism analyses. Formal mediation analyses are likely underpowered. As a pragmatic alternative, we will examine whether changes in candidate mechanisms (mindfulness and self-compassion; T0→T1) are associated with changes in key outcomes (emotional exhaustion and well-being; T0→T1 and T0→T3) using correlations and regression models (e.g., outcome change regressed on mechanism change, with baseline adjustment). These analyses are hypothesis-generating and will inform endpoint selection and mechanistic measurement for a future randomized trial. Patient feedback sub-study. Patient-reported measures (HCCQ-6 and the global communication item) will be analyzed descriptively to assess feasibility (patient response rate, missing data) and to obtain preliminary signal estimates. Given clustering by clinician and small numbers per clinician, results will primarily be summarized using clinician-level means (pre vs post) and overall descriptive statistics, with cautious interpretation. Optional salivary cortisol sub-study. Cortisol concentrations will be inspected for outliers and values may be log-transformed to reduce skew. For each day, we will derive standard indices including the cortisol awakening response (CAR; e.g., AUCi from awakening and + 30 min samples) and a diurnal decline estimate (e.g., slope across sampling times). Analyses will be primarily descriptive; pre-post change (T0→T1) in cortisol indices will be summarized with standardized mean change and exploratory mixed-effects models when feasible, adjusting for sampling time deviations, wake time, day type (work vs non-work), and key confounders (e.g., glucocorticoid medication, shift pattern). Sampling adherence and missingness will be reported explicitly, following recommendations for field cortisol assessment. [ 72 , 74 ] Analyses of the optional Phase 2 extension (post-T3) will be conducted and reported separately under its dedicated protocol; T3 will serve as the extension baseline, and effect estimates will be treated as exploratory. Qualitative analysis Interview transcripts will be analyzed using reflexive thematic analysis, following Braun and Clarke’s approach. [ 87 ] Initial coding will be inductive, with the TFA domains used as a sensitizing framework to ensure coverage of acceptability constructs. [ 67 ] Two researchers will code a subset of transcripts to develop a shared coding approach, then proceed with iterative refinement of themes. Team discussions will be used to support reflexivity and to examine alternative interpretations. Reporting will follow COREQ. [ 86 ] Mixed-methods integration Quantitative and qualitative findings will be integrated using a convergent mixed-methods logic. A joint display will map feasibility metrics and outcome change patterns to qualitative themes about fit, mechanisms, and contextual barriers/facilitators. Integration will be used to prioritize protocol refinements and to derive implementation hypotheses for a future trial. Harms and adverse events Mindfulness practices are generally low risk, but transient increases in distress can occur, particularly when attention is directed toward difficult internal experiences. Because ETHOS explicitly addresses morally challenging clinical situations, some participants may experience increased moral emotions (e.g., guilt, frustration) or reactivation of distressing memories related to constrained care. Participants will be informed that they may pause, modify, or skip any practice and may discontinue at any time; the goal is not to intensify self-blame but to clarify agency and support wise, feasible action under constraints. Session 1 will include guidance on grounding, titration, and recognizing when to seek additional support. Potential unwanted effects (e.g., sustained distress, increased guilt/self-blame, rumination, or sleep disturbance) will be assessed using a brief checklist at T1 and T3 and via an open-ended item. Participants will also be reminded that they may contact the study team at any time during the study if distress, moral burden, or other concerns arise. Reported adverse events will be reviewed by the principal investigator (or a delegated clinician on the team) within 72 hours; if clinically indicated, participants will be advised to pause the program and will be referred to appropriate support options such as the occupational health service, a psychologist, or a physician/mental health clinician, as appropriate. Serious adverse events judged related to participation will be documented and reported to the ethics committee according to local requirements. Given the low-risk, single-site, non-pharmacological nature of the intervention, no independent data monitoring committee is planned. This protocol describes a proof-of-concept evaluation of ETHOS, a brief, modular mindfulness program designed for hospital practitioners and explicitly aligned with the ethical and moral dimensions of clinical work. The program is designed to address common implementation barriers (time, shift work) by combining shorter sessions with flexible home-practice formats, while preserving progressive skill acquisition. By embedding a moral-resilience micro-tool and case-anchored reflection, the intervention aims to increase clinical relevance and to directly target distress linked to value conflict and constrained agency. The study’s primary contribution will be feasibility evidence (who enrolls, what dose is achievable, which components are valued, and what organizational constraints arise), complemented by preliminary effect size estimates and mechanism signals. Limitations include the single-arm design, which precludes causal inference, and limited power for complex mediation/moderation. Nevertheless, the mixed-methods approach will provide actionable information to refine content, optimize delivery and select primary outcomes for a future randomized trial. The staged (two-phase) structure also supports implementation planning. The 6-week ETHOS curriculum is designed as a low-threshold entry point compatible with time-constrained clinical schedules, whereas the optional post-study Phase 2 extension provides a higher-dose pathway for participants who wish to deepen practice once feasibility and acceptability have been demonstrated. Follow-on mindfulness curricula for course graduates have been explicitly developed to sustain and deepen practice after initial MBCT/MBSR courses, with randomized evidence supporting added benefit for well-being. [ 66 ] Similarly, clinician- and workplace-adapted mindfulness programs have incorporated maintenance phases and ongoing booster touchpoints to support longer-term sustainability of gains. [ 62 – 63 ] To ensure clarity and transparency, results will be disseminated in two complementary manuscripts: Article 1 will report the parent proof-of-concept outcomes through T3 (feasibility, acceptability, and preliminary effect size estimates), whereas Article 2 will report the post-study extension evaluation (Phase 2), including uptake, retention and exploratory changes from T3 to post-extension and follow-up among extension participants. Declarations Ethics approval and consent to participate At the time of submission, no human participants have been enrolled and no study procedures have started. The protocol is being finalized prior to ethics submission. The full study protocol will be submitted to the appropriate ethics committee before the study begins, and all study procedures will start only after written ethics approval has been obtained. All participants will provide informed consent electronically before participation. Consent for publication Not applicable (no individual person’s data will be published in identifiable form). Availability of data and materials De-identified quantitative datasets and analysis code will be made available on an open repository (e.g., OSF [Open Science Framework]) after publication, subject to institutional and legal constraints. Qualitative transcripts will not be publicly shared due to the risk of re-identification in a small workplace setting; access may be considered upon reasonable request and ethics approval. Competing interests The authors declare that they have no competing interests. Funding No funding. Authors' contributions Pierrick Laulan and Matthieu L.G. Fernandez jointly developed the ETHOS intervention and the study protocol. Pierrick Laulan drafted the manuscript. Matthieu L.G. Fernandez critically revised the manuscript for important intellectual content. Both authors read and approved the final manuscript. 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Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17:88. doi: 10.1186/s12913-017-2031-8 . Larsen DL, Attkisson CC, Hargreaves WA, Nguyen TD. Assessment of client/patient satisfaction: development of a general scale. Eval Program Plann. 1979;2(3):197–207. doi: 10.1016/0149-7189(79)90094-6 . Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186–3191. doi: 10.1097/00007632-200012150-00014 . Olson LL. Hospital nurses' perceptions of the ethical climate of their work setting. J Nurs Scholarsh. 1998;30(4):345–349. doi: 10.1111/j.1547-5069.1998.tb01331.x . Hellhammer DH, Wüst S, Kudielka BM. Salivary cortisol as a biomarker in stress research. Psychoneuroendocrinology. 2009;34(2):163–171. doi: 10.1016/j.psyneuen.2008.10.026 . Adam EK, Kumari M. Assessing salivary cortisol in large-scale, epidemiological research. Psychoneuroendocrinology. 2009;34(10):1423–1436. doi: 10.1016/j.psyneuen.2009.06.011 . Danhof-Pont MB, van Veen T, Zitman FG. Biomarkers in burnout: a systematic review. J Psychosom Res. 2011;70(6):505–524. doi: 10.1016/j.jpsychores.2010.10.012 . Stalder T, Kirschbaum C, Kudielka BM, et al. Assessment of the cortisol awakening response: expert consensus guidelines. Psychoneuroendocrinology. 2016;63:414–432. doi: 10.1016/j.psyneuen.2015.10.010 . Czajkowska Z, Wang H, Hall NC, Sewitch M, Körner A. Validation of the English and French versions of the Brief Health Care Climate Questionnaire. Health Psychology Open. 2017;4(2):2055102917730675. doi: 10.1177/2055102917730675 . Lheureux F, Truchot D, Borteyrou X, Rascle N. Maslach Burnout Inventory—Human Services Survey (MBI-HSS): structure factorielle et qualités psychométriques de la version française. Le Travail Humain. 2017. Kristensen TS, Borritz M, Villadsen E, Christensen KB. The Copenhagen Burnout Inventory: a new tool for the assessment of burnout. Work Stress. 2005;19(3):192–207. doi: 10.1080/02678370500297720 . Romo L, Zerhouni O, Nann S, Rebuffe E, Tessier S, Touzé C, Cruchet L, Duret C. Assessment of Burnout in the General Population of France: Comparing the Maslach Burnout Inventory and the Copenhagen Burnout Inventory. Ment Health Sci. 2025;3(2):e97. doi: 10.1002/mhs2.97 . Hochberg G, Pucheu S, Kleinebreil L, Halimi S, Fructuoso-Voisin C. WHO-5, a tool focusing on psychological needs in patients with diabetes: the French contribution to the DAWN study. Diabetes Metab. 2012;38(6):515–522. doi: 10.1016/j.diabet.2012.06.002 . Bellinghausen L, Collange J, Botella M, Emery JL, Albert E. Factorial validation of the French version of the Perceived Stress Scale in a working population. Sante Publique. 2009;21(4):365–373. doi: 10.3917/spub.094.0365 . Jermann F, Billieux J, Laroi F, d’Argembeau A, Bondolfi G, Zermatten A, Van der Linden M. Mindful Attention Awareness Scale (MAAS): psychometric properties of the French translation and exploration of its relations with emotion regulation strategies. Psychol Assess. 2009. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84(4):822–848. Le Barbenchon E, Genin M. Development and factor structure of the French version of the Self-Compassion Scale Short Form (SCS-SF-FV). Journal of Behavioral and Cognitive Therapy. 2024;34(1):100484. doi: 10.1016/j.jbct.2023.100484 . Raes F, Pommier E, Neff KD, Van Gucht D. Construction and factorial validation of a short form of the Self-Compassion Scale. Clin Psychol Psychother. 2011;18(3):250–255. Epstein EG, Whitehead PB, Prompahakul C, Thacker LR, Hamric AB. Enhancing understanding of moral distress: the Measure of Moral Distress for Health Care Professionals (MMD-HP). AJOB Empir Bioeth. 2019;10(2):113–124. doi: 10.1080/23294515.2019.1586008 . Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–357. doi: 10.1093/intqhc/mzm042 . Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9097265","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":617066310,"identity":"edcfd23a-76c0-48fe-a828-69c168741947","order_by":0,"name":"Pierrick Laulan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYBAC+2YQaQCE7ED6AQODHIh/4AEeLQaHYVqYgXQCA4MxWEsCPi0HoDRMS2IDA4SBW8tx5mOfKwrsjBmYmZ9JJNTcSZ8fdvgh0BY7Od0GXH5hS555xiDZjIGZzUwi4diz3I230wyAWpKNzQ7gsIWZx5ixweCADdBhQC1sh3M3zk4AaTmQuA2nFv7PUC3s3yQS/h1ON5yd/oGAFh5mkBagw3jMJBLbDifIS+cQsoUN5LBkYzZmnmKLxL7DhhukcwoOJBjg8Qv/4ceMDX/sDPvZ2zfe+PDtsLz87PTNHz5U2Mnh0gIHbHBDwCoNCChHAfINpKgeBaNgFIyCkQAAKKJYqnbj0OoAAAAASUVORK5CYII=","orcid":"","institution":"University of Lausanne","correspondingAuthor":true,"prefix":"","firstName":"Pierrick","middleName":"","lastName":"Laulan","suffix":""},{"id":617066311,"identity":"3c3d3f27-d7ed-43b3-a3fd-289bc0ec704d","order_by":1,"name":"Matthieu L.G. Fernandez","email":"","orcid":"","institution":"Centre Hospitalier Intercommunale de Mont-de- Marsan et du Pays des Sources","correspondingAuthor":false,"prefix":"","firstName":"Matthieu","middleName":"L.G.","lastName":"Fernandez","suffix":""}],"badges":[],"createdAt":"2026-03-11 18:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9097265/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9097265/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106300564,"identity":"4fbe8b89-9f74-459d-8a39-0a91aa4f9862","added_by":"auto","created_at":"2026-04-07 09:14:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50164,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eETHOS hypothesized logic model linking intervention components, proximal mechanisms, and outcomes.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9097265/v1/aa11b65208f6fed8c7e7730f.png"},{"id":106300590,"identity":"e96b653a-93ef-407b-9abf-dd7a7bd80eb4","added_by":"auto","created_at":"2026-04-07 09:14:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2050132,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9097265/v1/0cce16b3-3927-49f1-90b1-9912cee56f4e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"ETHOS: a modular ethics-informed online mindfulness program for emotional well-being, moral resilience and burnout prevention in hospital practitioners — protocol for a mixed-methods single-arm proof-of-concept study","fulltext":[{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eBurnout, emotional well-being and moral adversity in hospital practice\u003c/h2\u003e \u003cp\u003eHospital practitioners routinely operate under high job demands (time pressure, high-stakes decision making, complex coordination, and frequent emotional exposure) that contribute to chronic stress and burnout. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Burnout, classically characterized by emotional exhaustion, depersonalization/cynicism, and reduced professional accomplishment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], has been linked to poorer well-being, reduced work engagement, and adverse organizational outcomes (including higher turnover intentions and poorer quality/safety of care). [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn parallel with workload-related strain, clinicians are frequently exposed to morally challenging situations (e.g., perceived non-beneficial care, resource constraints, and conflicts between patient wishes, family requests, and institutional policies). [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Moral distress, often described as the psychological distress that arises when one recognizes the ethically appropriate action but feels constrained from acting accordingly, has been the focus of conceptual refinement in recent years. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] A growing literature links moral distress to emotional exhaustion; a recent systematic review and meta-analysis reported a moderate positive association between moral distress and emotional exhaustion in healthcare professionals (pooled r\u0026thinsp;\u0026asymp;\u0026thinsp;0.33). [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Together, workload-related strain and recurrent moral adversity highlight the need for pragmatic and scalable preventive interventions for hospital practitioners. In this perspective, psychological symptoms such as emotional exhaustion may be understood not only as individual stress reactions but also as signals of underlying ethical strain. We use the term \u0026ldquo;ethical canaries\u0026rdquo; as a pedagogical metaphor for such early-warning cues. The broader \u0026ldquo;ethical canary\u0026rdquo; metaphor has been articulated by Somerville [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and related discussions in healthcare ethics and clinician burnout underscore how early warning signals can reveal deeper ethical or organizational dysfunction before it becomes institutionally visible [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMindfulness-based interventions for healthcare professionals\u003c/h2\u003e \u003cp\u003eIn the present study, mindfulness is conceptualized within a psychological and secular framework, focusing on attentional regulation, meta-awareness, and emotion regulation processes rather than on its Buddhist soteriological foundations [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Mindfulness-based interventions (MBIs), are structured interventions derived from Mindfulness-Based Stress Reduction (MBSR) and related curricula that integrate formal mindfulness practices, experiential inquiry, and between-session practice while allowing context-sensitive adaptations. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] MBIs have accumulated evidence for improving stress and well-being in healthcare professionals. A systematic review focused on mindfulness-based stress reduction (MBSR) in healthcare professionals concluded that MBSR is effective for reducing anxiety, depression and stress and for increasing mindfulness and self-compassion; it also highlighted that abbreviated MBSR formats can be comparable to standard 8-week programs for several psychological outcomes. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Meta-analytic evidence in primary healthcare professionals suggests that MBIs can reduce key burnout dimensions (including emotional exhaustion) and increase personal accomplishment, although study quality is heterogeneous. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] During periods of extreme occupational demand (e.g., the COVID-19 pandemic), systematic reviews similarly suggest improvements in stress and mental well-being following MBIs, while effects on burnout can be less consistent. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Mechanistically, mindfulness training is theorized to reduce stress reactivity through improvements in attention regulation, body awareness, and emotion regulation, as well as a shift in perspective on thoughts and self (decentering). [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Mediation evidence further implicates changes in cognitive and emotional reactivity and reductions in repetitive negative thinking as candidate pathways. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite these promising findings, many hospital-based MBIs face a recurring feasibility constraint: the traditional MBSR schedule (long weekly sessions plus a day-long retreat and substantial daily practice) is difficult to align with clinical shifts and limited protected time. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Consequently, several worksite-adapted programs have been developed. Mindfulness in Motion (MIM), for instance, was designed for chronically high-stress work environments and delivered onsite with shorter contact time (typically\u0026thinsp;~\u0026thinsp;1-hour weekly group sessions combining brief didactics, guided mindfulness practice and gentle yoga-based movement, supported by optional between-session audio/video materials). [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] In parallel, online and app-supported mindfulness programs have shown benefits for stress and well-being in adult populations and may help overcome scheduling barriers for clinicians. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRationale for a brief, modular and progressive program\u003c/h3\u003e\n\u003cp\u003eShortening mindfulness programs must balance feasibility with intervention integrity. A review of MBSR studies examining whether in-class contact hours are related to psychological distress outcomes found no significant association between class hours and effect sizes, suggesting that carefully designed adaptations with reduced class time may be worthwhile when time commitment is a major barrier. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] At the same time, mindfulness training is typically progressive: practices and themes are sequenced to support skill acquisition (attention stabilization, interoceptive awareness, emotional awareness, decentering from thoughts, compassion/values, and integration/relapse prevention). [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] For hospital practitioners, who face variable schedules and acute stress peaks, modularity can be operationalized by splitting weekly content into shorter, self-paced parts (e.g., two 30-minute modules) while preserving a coherent progression, complemented by brief daily practice options and on-shift micro-practices.\u003c/p\u003e\n\u003ch3\u003eWhy integrate an ethics-informed (moral-resilience) component\u003c/h3\u003e\n\u003cp\u003eMindfulness originates from contemplative traditions in which attentional training is typically embedded within an explicit ethical orientation (e.g., intentions of non-harming, compassion, and integrity), rather than being a value-neutral attentional technique. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] In contemporary clinical and organizational mindfulness-based interventions (MBIs), ethical dimensions are often conveyed implicitly (through teacher embodiment, inquiry, and an emphasis on kindness and non-judgment), yet the assumption that mindfulness can be delivered as a morally neutral \u0026ldquo;technology\u0026rdquo; has been increasingly questioned. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] For an intervention intended to support practitioners facing moral adversity, it is therefore important to specify what is meant by \u0026ldquo;ethics\u0026rdquo; and how ethical reflection is operationalized. In the present work, \u0026ldquo;ethics-informed\u0026rdquo; refers to a pragmatic, non-prescriptive lens for clarifying values, agency and feasible next steps under real-world constraints; it is not intended as moral instruction, performance enhancement, or a way of individualizing structural problems.\u003c/p\u003e \u003cp\u003eTo clarify what we mean by \u0026ldquo;ethics\u0026rdquo; in the present work, we draw on the ethics of care (care ethics). Originally articulated in moral psychology (e.g., Gilligan [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]) and later developed within bioethics, care ethics emerged partly in response to the decontextualized rationalism of principlism (i.e., the four-principles approach emphasizing autonomy, beneficence, non-maleficence, and justice). [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] It foregrounds relationality, dependence, and vulnerability (e.g., patient fragility, family distress, and team interdependence under uncertainty) and emphasizes situated judgment and responsiveness to concrete needs (e.g., tailoring communication, prioritization, and feasible \u0026ldquo;next steps\u0026rdquo; under constraints), rather than the application of abstract principles alone. [\u003cspan additionalcitationids=\"CR31 CR32 CR33 CR34\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] This relational and context-sensitive approach resonates with Ricoeur\u0026rsquo;s account of practical wisdom, understood as the capacity to deliberate within concrete situations by holding together solicitude, justice, and self-esteem in the pursuit of \u0026ldquo;the good life with and for others in just institutions\u0026rdquo; [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTronto\u0026rsquo;s practice-oriented account describes care as unfolding through four phases (recognition of need, willingness to respond, direct care-giving action, and the care receiver\u0026rsquo;s response) linked to the ethical elements of attentiveness, responsibility, competence and responsiveness. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] This process-oriented view lends itself to brief, on-shift skills: noticing a morally salient need, taking responsibility at one\u0026rsquo;s level, selecting a feasible and competent action, and checking and adjusting in light of the receiver\u0026rsquo;s response. Care ethics is best treated as a complementary lens rather than a replacement for principle-based ethics: basic rights and principles remain indispensable, while care ethics supports practical wisdom in adapting responses to singular persons and contexts and highlights the need for boundaries to prevent over-involvement and burnout. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Related relational-ethics frameworks and dialogical approaches to clinical ethics consultation similarly emphasize mutual respect, engagement and context. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eContemplative science also differentiates between attentional (\u0026lsquo;concentration\u0026rsquo;) practices, constructive/ethics-based practices (e.g., compassion and loving-kindness), and perspective- or wisdom-based practices (e.g., self-transcendence and interdependence), which may have distinct implications for prosocial and moral outcomes. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Empirically, evidence that mindfulness training reliably translates into prosocial or ethically aligned behavior is mixed and context-dependent. Meta-analyses generally report small-to-moderate associations between mindfulness and prosociality, with substantial heterogeneity and indications of publication bias. [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] Experimental and organizational studies suggest plausible pathways via reduced cognitive-affective reactivity and moral disengagement but also highlight that effects may depend on individual moral identity and contextual framing. For example, in a randomized controlled study using computational modeling of moral decisions (money-for-harm trade-offs), mindfulness training prevented a time-related decline in moral preferences by attenuating the increasing weight placed on monetary gain. [\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This suggests that attentional training alone may be insufficient to support ethically attuned action without explicit cultivation of ethical reflexivity and relational attunement, i.e. capacities that enable practitioners to recognize value conflicts, maintain moral agency, and respond with wise intention rather than reactive compliance or disengagement.\u003c/p\u003e \u003cp\u003eImportantly, moral adversity in healthcare is shaped not only by individual coping but also by organizational conditions, often discussed in terms of ethical climate (shared perceptions of how ethical issues are handled in a workplace). [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Integrating an ethics-informed (moral-resilience) component may therefore increase clinical relevance by explicitly linking mindfulness skills to professional values, agency and \u0026ldquo;wise action\u0026rdquo; under constraints. Moral resilience has been defined as the capacity to preserve or restore one\u0026rsquo;s integrity in response to moral complexity, distress, and adversity in clinical practice, and its measurement science has advanced with the development and psychometric evaluation of the Rushton Moral Resilience Scale (including a revised 16-item version). [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] Related constructs such as moral injury have been increasingly discussed in healthcare to describe more persistent symptom patterns following repeated moral adversity, although boundaries between constructs remain debated. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] Rather than aiming to strengthen mere endurance, the present approach seeks to cultivate lucid and responsible responsiveness to moral tension, i.e. an inner ethical vigilance that signals when practice drifts from one\u0026rsquo;s professional commitments [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Strengthening professionals\u0026rsquo; capacity to tolerate moral adversity without addressing its ethical significance risks fostering desensitization or normalization of problematic practices.\u003c/p\u003e \u003cp\u003e At the level of program delivery, the mindfulness field has also articulated ethical principles and standards (e.g., do no harm, competence, integrity, respect for rights and dignity, and attention to power dynamics in teacher-participant relationships), intended to complement existing professional codes of ethics. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/p\u003e\n\u003ch3\u003eLogic model\u003c/h3\u003e\n\u003cp\u003eBox 1 summarizes the hypothesized logic model linking ETHOS (Ethics-informed Training for Hospital practitioners: Online Skills for mindful practice) components to proximal mechanisms and downstream outcomes, with ethical climate treated as a key contextual factor that may shape feasibility and response.\u003c/p\u003e\n\u003ch3\u003eBox 1. ETHOS logic model (hypothesized pathways)\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eContextual inputs\u003c/strong\u003e \u003cp\u003ehigh job demands and emotional load; recurrent moral adversity/value conflict; organizational constraints and ethical climate.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIntervention components\u003c/strong\u003e \u003cp\u003emodular mindfulness training (attention anchoring, interoceptive awareness, decentering/open monitoring, compassion-oriented practices) + brief ethics-informed application using a recurring 4-step tool and workflow-compatible micro-practices (lucid ethical-oriented responsiveness).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eProximal mechanisms\u003c/strong\u003e \u003cp\u003ereduced stress reactivity and cognitive-emotional narrowing; improved attention and emotion regulation; increased self-compassion and balanced self-relating under pressure; ethical awareness; clearer values/agency appraisal and selection of feasible \u0026ldquo;next steps\u0026rdquo;.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics-related processes\u003c/strong\u003e \u003cp\u003ereduced moral reactivity in the moment; cultivation of lucid, responsible responsiveness to moral tension (ethical vigilance) through repeated rehearsal of aligned micro-actions, recognition of value conflicts and appropriate escalation or support seeking when needed.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDownstream outcomes\u003c/strong\u003e \u003cp\u003ereduced emotional exhaustion (key burnout signal) and perceived stress; improved psychological well-being and ethically aligned action; sustained use of brief practices in clinical workflow.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eContextual moderator\u003c/strong\u003e \u003cp\u003eethical climate and perceived organizational support for addressing ethical issues may shape engagement with the ethics-informed component and the feasibility of applying micro-actions in practice, and the salience of ethical signals (\u0026lsquo;ethical canaries\u0026rsquo;) in daily work. A schematic representation is provided in Fig.\u0026nbsp;2.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy objectives\u003c/h2\u003e \u003cp\u003eThe primary objective of this proof-of-concept study is to evaluate the feasibility and acceptability of ETHOS in hospital practitioners (recruitment, retention, module completion, adherence to home practice, and participant-reported acceptability/burden). Secondary objectives are to estimate the magnitude and variability of pre-post changes in burnout-related outcomes (with a focus on emotional exhaustion), emotional well-being and stress, and to explore changes in candidate mechanisms (mindfulness, self-compassion, moral distress, and moral resilience). A qualitative component will explore perceived mechanisms, contextual facilitators/barriers, usability of the online modular format, and ethical relevance, and will inform refinement of the intervention and the design of a future randomized controlled trial.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods/Design","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis is a prospective, mixed-methods, single-arm proof-of-concept study with repeated measures. Quantitative outcomes will be assessed at four timepoints: baseline (T0), post-intervention (T1, week 6), pre-booster (T2, week 10; brief assessment), and follow-up (T3, week 18). A qualitative component (semi-structured interviews) will be conducted after T1 (and, where feasible, after T3) in a purposive subsample. After completion of the T3 follow-up assessment, participants will be offered enrollment in an optional post-study extension course (Phase 2) evaluated under a separate protocol with separate consent; the parent study endpoints and analyses reported in this protocol are restricted to T0\u0026ndash;T3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eReporting and transparency\u003c/h2\u003e \u003cp\u003eThe protocol is written to align with SPIRIT guidance for clinical trial protocols and the CONSORT extension for pilot and feasibility studies, adapted to a single-arm design. [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] Additional reporting guidance for protocols of pilot and feasibility studies was also considered. [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] Intervention reporting follows the Template for Intervention Description and Replication (TIDieR) principles. [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] A SPIRIT schedule table is also provided, in line with journal expectations for protocol reporting. [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThe study will be conducted at a French hospital (France). The ETHOS program will be delivered fully online via a secure, hospital-approved platform that allows asynchronous access (e.g., from home or during protected learning time), with automated reminders to support engagement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStudy status\u003c/h2\u003e \u003cp\u003eAt the time of protocol submission, recruitment has not started and no participants have been enrolled. The study protocol is being finalized following scientific feedback. The ethics application will be submitted to the appropriate ethics committee once the protocol has been stabilized, and the study will not begin before written ethics approval has been obtained.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eEligible participants will be hospital practitioners (e.g., physicians, residents, nurses, and allied health professionals) currently employed at the hospital and involved in patient care. Participants must be aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years, able to provide informed consent, and able to access the online platform (internet-enabled computer or smartphone). Because the intervention is self-paced, eligibility requires willingness and practical ability to complete at least four of the six weekly modules within the delivery window (allowing for on-call duties and leave). The delivery window corresponds to the 6-week intervention period (weeks 1\u0026ndash;6), during which weekly modules are unlocked sequentially and can be completed asynchronously.\u003c/p\u003e \u003cp\u003eExclusion criteria are kept minimal for pragmatic feasibility and include: (i) current severe psychiatric episode requiring acute treatment (e.g., active psychosis, severe major depression with high suicide risk), (ii) current substance dependence, or (iii) any condition that would make participation in mindfulness practice unsafe or impractical (as judged by the participant and, if needed, their treating clinician). Previous mindfulness experience is not an exclusion criterion; it will be measured at baseline and considered in exploratory analyses. Baseline characterization will also capture key demographic and professional/contextual variables (e.g., age, gender, profession/role, years of experience, clinical unit, shift pattern/night work, and typical weekly working hours) to describe the sample and to explore heterogeneity in feasibility and outcomes. If the optional patient feedback sub-study is implemented, patients will receive a brief information sheet and provide separate informed consent before completing an anonymous survey; refusal or non-participation will not affect the care they receive.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment and informed consent\u003c/h2\u003e \u003cp\u003eRecruitment will use a multi-channel strategy adapted to hospital constraints: email invitations via institutional mailing lists, brief presentations at departmental meetings, posters in staff areas, and information relayed by occupational health / quality-of-work-life (QVT) channels when available. Recruitment materials will frame ETHOS as a brief, flexible, online skills program for practitioners experiencing work-related stress, emotional overload, or moral tension, and for those wishing to strengthen well-being and sustain practice. To limit selection pressure and stigma, messages will emphasize voluntary participation, confidentiality, and that supervisors will not know who participates. Interested staff will receive an information sheet describing study aims, time commitment (approximately 60 minutes/week delivered as two\u0026thinsp;~\u0026thinsp;30-minute modules, plus optional 5\u0026ndash;10-minute guided practice and brief 60\u0026ndash;90-second micro-practices during shifts), confidentiality, and the right to withdraw. Informed consent will be obtained electronically (or in writing) prior to baseline assessment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSample size justification\u003c/h2\u003e \u003cp\u003eThe target sample is approximately 30 participants. This sample size is not intended to provide definitive tests of effectiveness; rather, it is appropriate for estimating feasibility parameters (e.g., retention, adherence) and for obtaining preliminary estimates of outcome variability and standardized change. Contemporary guidance for pilot and feasibility studies emphasizes parameter estimation over hypothesis testing and cautions against treating small pilots as efficacy studies. [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] A commonly cited rule-of-thumb is 12 participants per group in pilot work. [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] We selected a larger single-arm sample to better characterize feasibility in a heterogeneous practitioner population and to support exploratory moderation and mechanism analyses, with appropriate caution regarding statistical power. Exploratory moderation and mechanism analyses will be limited to a small, theory-driven set to reduce overfitting and will be interpreted cautiously.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eIntervention: ETHOS program\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eOverview and theoretical rationale\u003c/h2\u003e \u003cp\u003eETHOS is a brief, online mindfulness program designed for hospital practitioners with limited protected time. It adapts core mindfulness-based program elements (guided practice, experiential learning, inquiry/reflection, and between-session practice) while explicitly integrating ethics-informed moral-resilience micro-skills relevant to value conflict and ethical constraints in clinical work. Adaptation decisions were guided by the principle of maintaining core mindfulness \u0026ldquo;ingredients\u0026rdquo; while modifying format and delivery to fit context. [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cb\u003eIntervention development and support.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe ETHOS modules were developed by the two authors. The first author has formal training in mindfulness-based approaches and has conducted prior academic work on mindfulness [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. The second author is a clinical neuropsychologist who integrates mindfulness-based practices in clinical work. Although ETHOS is delivered asynchronously through pre-recorded modules, participants will have access to a study contact for questions or difficulties. Any report of sustained distress or adverse reactions potentially related to mindfulness practice will be reviewed promptly by the research team, and participants will be advised to pause/modify practice and to seek appropriate support (e.g., occupational health service, psychologist, or physician/mental health clinician) when indicated (see \u0026ldquo;Harms and adverse events\u0026rdquo;).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eFormat\u003c/h2\u003e \u003cp\u003eETHOS will be delivered over six weeks via a secure online platform. Each week, participants will complete a formal session split into two modular parts of approximately 30 minutes each:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Part A (\u0026asymp;\u0026thinsp;30 min): mindfulness training (short didactic, a guided practice, and a brief reflective / intention-setting prompt).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Part B (\u0026asymp;\u0026thinsp;30 min): ethics-informed application and moral-resilience skill (case-anchored reflection and rehearsal of a brief tool for responding to moral pressure).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003ePart B will integrate Tronto\u0026rsquo;s care ethics and the recurring 4-step tool to cultivate lucid and responsible responsiveness to moral tension. The two parts can be completed on separate days to accommodate clinical schedules while preserving a coherent weekly progression. The core prescribed dose is approximately 60 minutes/week (two\u0026thinsp;~\u0026thinsp;30-minute modules). Between modules, participants will be invited to complete brief guided practices in either a 5-minute or 10-minute format (choice-based home-practice dose), plus optional 60\u0026ndash;90-second micro-practices designed for clinical workflow (e.g., before entering a patient room, after a difficult conversation, after an adverse event, or following moral conflict). A booster online module will be delivered four weeks after week 6 to refresh practice, address barriers, and rehearse application to current clinical stressors. After completion of the T3 follow-up assessment, participants will be offered an optional post-study advanced extension course (Phase 2) under a separate protocol.\u003c/p\u003e \u003cp\u003eSequential release and catch-up window.\u003c/p\u003e \u003cp\u003eTo preserve the progressive structure of the curriculum, weekly content will be released sequentially (one module per week). Each week\u0026rsquo;s module (Part A and Part B) will be unlocked at the start of the corresponding week and will remain accessible for the remainder of the 6-week intervention period, allowing participants to catch up if a given week is missed due to on-call duties, leave, or workload peaks. For feasibility metrics, module completion will be defined as completion of each Part (A and/or B) within the 6-week delivery window (i.e., up to the end of week 6, prior to the post-intervention assessment).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eCore components\u003c/h2\u003e \u003cp\u003eThe ETHOS core component draws on established mindfulness-based program (MBP) practice families, including (i) mindful breathing and attention training, (ii) body scan and interoceptive awareness, (iii) mindful movement (gentle stretching suitable for work clothes), (iv) open monitoring of thoughts and emotions (decentering), and (v) compassion-oriented practices (kindness toward self/others; supportive inner dialogue). This selection reflects core practices taught across first-generation MBPs (e.g., MBSR/MBCT) and aligns with definitional work specifying essential MBP components and permissible contextual adaptations while maintaining program integrity. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] In healthcare professionals, MBSR-based protocols typically include formal practices (e.g., body scan, sitting meditation, mindful walking, gentle yoga) and informal practices, supporting the rationale for the present practice families and the emphasis on brief \u0026ldquo;on-shift\u0026rdquo; application. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Compassion-oriented elements (e.g., self-kindness and supportive inner dialogue) are included to foster a balanced, non-judgmental stance toward distress and to support self-relating under pressure. [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eBooster session (4 weeks post-program)\u003c/h2\u003e \u003cp\u003eTo support maintenance of skills and real-world transfer under clinical constraints, the program includes a brief booster module scheduled 4 weeks after completion of the core curriculum. Booster/maintenance contacts are commonly used in behavior change and psychological interventions to reinforce skill use and support maintenance, although incremental benefits vary across contexts and implementation choices. [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] In clinician- and workplace-adapted mindfulness programs, maintenance phases and ongoing \u0026ldquo;touchpoints\u0026rdquo; (e.g., optional booster sessions and brief reminder materials) have been used to consolidate practice and address implementation barriers (e.g., limited time, interruptions). [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] The ETHOS booster (\u0026asymp;\u0026thinsp;45\u0026ndash;60 min, online) comprises (i) a short guided practice (10\u0026ndash;15 min) revisiting the most frequently used \u0026ldquo;on-shift\u0026rdquo; skills (brief grounding\u0026thinsp;+\u0026thinsp;decentering), (ii) structured troubleshooting of barriers and facilitators encountered during clinical implementation, and (iii) tailored planning of micro-practices for participants\u0026rsquo; recurrent stressors (case vignettes; if\u0026ndash;then implementation intentions). Booster fidelity is documented via attendance and a brief checklist of covered elements.\u003c/p\u003e \u003cp\u003eEthics-informed moral-resilience module\u003c/p\u003e \u003cp\u003eThe ethics-informed component translates moral adversity into a brief, psychologically actionable practice rather than normative instruction. It is designed to help participants clarify what matters, what is within their agency, and what a feasible next step is under real-world constraints, while explicitly avoiding moralization and over-responsibilization. Across the six weeks, it introduces and repeatedly rehearses a recurring 4-step tool (\u0026asymp;\u0026thinsp;2\u0026ndash;4 minutes) aligned with Tronto\u0026rsquo;s care-ethics elements (attentiveness, responsibility, competence, and responsiveness) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and closes each Part B with a brief \u0026lsquo;three-lens check\u0026rsquo; (\u0026asymp;\u0026thinsp;30 seconds) to support transfer and to protect against over-responsibilization. The tool is summarized in Box 2 and is woven into Part B of every weekly module. This approach is inspired by ethics-informed resilience programs in healthcare (e.g., MEPRA) that combine mindfulness with skills for confronting ethical challenges. [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBox 2. ETHOS recurring 4-step tool and three-lens check\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e1. Notice\u003c/b\u003e: Attentively identify the moral pressure/need (\u0026ldquo;What feels ethically difficult or value-incongruent right now?\u0026rdquo;). This step builds on awareness of a triggering signal (the \u0026ldquo;ethical canary\u0026rdquo;) and corresponds to caring about in the care ethics framework described by Joan Tronto.\u003c/p\u003e \u003cp\u003e\u003cb\u003e2. Regulate\u003c/b\u003e: 30\u0026ndash;60 seconds of mindful grounding to reduce reactive narrowing. This step draws on mindfulness-based attentional regulation.\u003c/p\u003e \u003cp\u003e\u003cb\u003e3. Clarify\u003c/b\u003e: Clarify values and agency (\u0026ldquo;What matters most here?\u0026rdquo; \u0026ldquo;What is within my control or influence in the next hour/day?\u0026rdquo;) and choose a feasible micro-action. This step corresponds to taking care of in Tronto\u0026rsquo;s care ethics framework.\u003c/p\u003e \u003cp\u003e\u003cb\u003e4. Act \u0026amp; check\u003c/b\u003e: Take the micro-action and briefly check responsiveness (\u0026ldquo;What changed for the patient/others and for me?\u0026rdquo; \u0026ldquo;What is the next wise step\u0026mdash;communication, consultation/escalation, documentation, or recovery/self-care?\u0026rdquo;). This step corresponds to taking care of in Tronto\u0026rsquo;s care ethics framework.\u003c/p\u003e \u003cp\u003e\u003cb\u003eThree-lens check (\u0026asymp;\u0026thinsp;30 seconds)\u003c/b\u003e: patient and practitioner well-being; relational responsiveness (how care is received); institutional constraints and available support/escalation options. This reflective framing is conceptually informed by the ethical perspective articulated by Paul Ricoeur, emphasizing self-esteem, solicitude, and justice in practical wisdom.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eSession-by-session content\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the weekly module themes and practice structure. Module recordings, audio files and worksheets will be standardized and version-controlled to support delivery integrity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eETHOS intervention content and practice structure (TIDieR-informed summary).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePart A: Mindfulness training (\u0026asymp;\u0026thinsp;30 min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMain guided practice(s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePart B: Ethics-informed application (\u0026asymp;\u0026thinsp;30 min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetween-week practice (choose 5 or 10 min) + micro-practices\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrientation; stress, burnout and attention. Introducing intention-setting, the \u0026lsquo;mindful pause\u0026rsquo; and basic attentional anchoring (breath).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eShort mindful breathing (5\u0026ndash;10 min) + brief body scan (8\u0026ndash;10 min).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAttentiveness (caring about): moral adversity in clinical work and values awareness. Introduce a care-ethics lens and the recurring 4-step tool as a first exercise in noticing ethical tension, framing moral pressure as an \u0026ldquo;ethical canary\u0026rdquo;; rehearse with a low-stakes example; clarify \u0026lsquo;what matters\u0026rsquo; at work.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDaily 5 or 10 min breathing/body scan audio. Micro-practice: 60\u0026ndash;90-sec pause before/after a patient encounter; note one value-aligned intention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInteroception and emotion cues. Expanding attention to body sensations and early stress signals.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBody scan (10\u0026ndash;15 min) + grounding.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResponsibility (taking care of): moral emotions (e.g., guilt, frustration) and \u0026lsquo;just responsibility\u0026rsquo; (responsibility vs over-responsibility). Use grounding and self-compassion and apply the 4-step tool when moral pressure triggers strong affect.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDaily 5 or 10 min body scan audio. Micro-practice: \u0026lsquo;ground-breathe-label\u0026rsquo; (30\u0026ndash;60 sec)\u0026thinsp;+\u0026thinsp;a brief self-compassion phrase.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThoughts, rumination and cognitive narrowing. Decentering and open monitoring.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpen monitoring (10\u0026ndash;15 min) with labeling of thoughts/emotions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCompetence (care giving): selecting feasible micro-actions under team/system constraints. Use the 4-step tool to clarify values/agency and rehearse a brief communication micro-step (seeking clarification/support). Highlight that responsiveness to moral cues can guide feasible action without moral overload.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDaily 5 or 10 min open-monitoring audio. Micro-practice: \u0026lsquo;name it +\u0026thinsp;choose\u0026rsquo; (30\u0026ndash;60 sec) before responding in a difficult interaction.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMindful movement and compassion. Working with fatigue and compassion strain.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGentle mindful movement (\u0026asymp;\u0026thinsp;10 min) and/or loving-kindness (5\u0026ndash;10 min).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResponsiveness (care receiving): checking impact and adjusting in real time. Apply the 4-step tool to after-event moral residue; integrate boundaries, recovery, and seeking support when needed. Frame the check as monitoring moral tension: is it signaling unresolved ethical strain?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDaily 5 or 10 min movement or kindness audio. Micro-practice: hand-on-heart grounding; brief recovery ritual after a hard conversation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMindfulness in interpersonal stress. Bringing attention to difficult conversations and uncertainty.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePractice with a recent interpersonal stressor (guided imagery) + mindful breathing.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntegration and agency: rehearse the full care cycle and identify what is within control/influence. Plan value-aligned micro-actions for recurrent interpersonal stressors (e.g., consult, document, escalate appropriately).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDaily 5 or 10 min practice of choice. Micro-practice: \u0026lsquo;values check\u0026rsquo; + one small action in the next hour/day.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeek 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntegration and maintenance. Review of skills; relapse prevention; building a personal practice plan.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChoice practice (breath/body/open monitoring) + brief reflection.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInstitutional constraints and maintenance: consolidate the 4-step tool; anticipate high-risk situations; plan escalation/support options and a realistic maintenance plan; prepare for booster. Participants are invited to reflect on how early ethical cues can guide sustained ethical attention and action within organizational constraints.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDaily practice of choice (5 or 10 min). Maintain micro-practices; prepare for booster.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBooster (Week 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefresh core practices; troubleshoot barriers; re-establish routine.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGuided practice of choice (\u0026asymp;\u0026thinsp;10 min) + problem-solving reflection.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eApply the 4-step tool to a current morally challenging situation; update maintenance plan for the next month; reinforce noticing early ethical cues and using proportionate action and support-seeking.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaintenance micro-practices; optional reminder prompts; prepare for follow-up assessment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eOptional post-study extension (Phase 2): ETHOS-Advanced\u003c/h2\u003e \u003cp\u003eAfter participants complete the T3 follow-up assessment (week 18), they will be offered the opportunity to enroll in an optional post-study advanced extension course (\u0026ldquo;ETHOS-Advanced\u0026rdquo;). The purpose of ETHOS-Advanced is to provide a higher-dose continuation pathway for motivated participants, supporting longer-term maintenance of mindfulness skills and deeper integration of ethics-informed moral-resilience micro-skills anchored in Ricoeurian practical wisdom and Tronto\u0026rsquo;s care ethic.\u003c/p\u003e \u003cp\u003ePhase 2 is not part of the parent proof-of-concept study described in this protocol. It will be implemented under a separate protocol and consent procedure (and registered as appropriate prior to enrollment), and its outcomes will be reported in a separate manuscript. This separation preserves the interpretability of the parent study\u0026rsquo;s feasibility endpoints and effect size estimates through T3 and avoids mixing core-trial exposure with optional, self-selected additional training.\u003c/p\u003e \u003cp\u003eThe design is informed by evidence that follow-on (\u0026ldquo;graduate\u0026rdquo; or advanced) mindfulness curricula can yield additional gains in well-being and mental health beyond introductory courses. For example, Mindfulness-Based Cognitive Therapy\u0026mdash;Taking it Further (MBCT-TiF), an adapted program for graduates of MBCT/MBSR, showed clinically meaningful improvements in mental well-being compared with ongoing mindfulness practice in a randomized controlled trial. [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eETHOS-Advanced will consist of four weekly online modules delivered asynchronously on the same secure platform. Each module is approximately 60 minutes (two 30-minute parts) and includes (i) a longer guided mindfulness practice (\u0026asymp;\u0026thinsp;15\u0026ndash;20 min) plus brief inquiry/reflection focused on working with difficult affect and moral residue, and (ii) an advanced ethics-informed module integrating Tronto\u0026rsquo;s care ethic with Ricoeurian practical wisdom, emphasizing reflective deliberation, moral discernment, and situational ethical adjustment.\u003c/p\u003e \u003cp\u003e This phase builds on the Phase 1 foundation (mindfulness\u0026thinsp;+\u0026thinsp;care ethics) and progressively introduces the Ricoeurian ethical horizon (\u0026ldquo;a good life, with and for others, in just institutions\u0026rdquo;) as a guiding framework for ethical discernment. Participants are invited to use a reflective journal structured around three columns corresponding to the Ricoeurian poles (good life / solicitude / just institutions), fostering daily ethical attention. Between modules, participants are invited to engage in a 10-minute daily guided practice and to continue on-shift micro-practices and use of the 4-step tool.\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u0026bull; A1 (Deepening practice): stabilizing practice under pressure; working with avoidance and fatigue; sustaining intention.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; A2 (Moral residue and repair): identifying moral residue, guilt and self-blame; self-compassion and realistic responsibility; recovery micro-practices.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e \u0026bull; A3 (Relational practice in teams): mindful communication in value conflict; perspective-taking; brief debriefing scripts; receiving feedback on care.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; A4 (Sustaining change in institutions): mapping spheres of control/influence; identifying escalation/support resources; maintenance plan for practice and ethical action.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e \u0026bull; B1: Introducing the Ricoeurian ethical horizon in daily care; journaling using the three poles; anchoring ethical intention with meditation.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; B2: Reflective attention to moral tensions in practice; deliberation exercises on competing values; practicing micro-adjustments to preserve integrity.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; B3: Integrating relational care (Tronto) with practical wisdom (Ricoeur) in team interactions; communication, escalation, and supportive feedback.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; B4: Institutional awareness and ethical action; anticipating constraints; mapping escalation pathways; sustaining a reflective, morally attuned practice.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003eIn Phase 2, the ethics-informed module (B) is based on a secular framework. It explicitly integrates self-esteem, solicitude, and justice within Tronto\u0026rsquo;s relational care framework, supporting reflective deliberation under real-world constraints. Rather than merely increasing endurance, ETHOS promotes lucid and responsible responsiveness to moral pressure, preserving integrity while avoiding desensitization or over-responsibilization.\u003c/p\u003e \u003cp\u003ePlanned dissemination will reflect this two-phase structure: (i) the parent proof-of-concept study (Phase 1) will be reported as the primary feasibility article (Article 1; outcomes through T3), and (ii) the optional extension evaluation will be reported separately as an extension article (Article 2), using T3 as the baseline for Phase 2 and focusing on uptake, retention and exploratory changes through post-extension and follow-up.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Outcomes and measures","content":" \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003cp\u003eAll outcomes and assessment timepoints described below pertain to the parent ETHOS proof-of-concept study (Phase 1) through T3. The optional Phase 2 extension will be evaluated under a separate protocol; planned Phase 2 outcomes are summarized briefly for transparency.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003ePrimary outcomes: feasibility and acceptability\u003c/h2\u003e \u003cp\u003eFeasibility outcomes will be operationalized as: (i) recruitment rate (number enrolled / number expressing interest; and time required to reach target sample), (ii) retention (completion of T1 and T3 assessments), (iii) module completion (number of weekly Part A/Part B modules completed), (iv) adherence to between-session practice and on-shift transfer (self-reported practice frequency and duration, micro-practice use, and application of the 4-step tool), captured through brief weekly practice logs (\u0026le;\u0026thinsp;1 minute) and complemented by optional platform analytics when available, and (v) delivery integrity indicators (e.g., confirmation that the intended module content was available and accessed as scheduled; version control of materials).\u003c/p\u003e \u003cp\u003eAcceptability will be assessed through a brief post-intervention questionnaire capturing perceived usefulness, burden, fit with clinical workflow, and likelihood of continued practice. Acceptability items will be informed by the Theoretical Framework of Acceptability (TFA) domains (affective attitude, burden, perceived effectiveness, ethicality, self-efficacy, and opportunity costs). [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] To capture the ethics-informed aspect of ETHOS with minimal additional burden, we will include a short set of ETHOS-specific items focusing on perceived ethical relevance, clarity of agency boundaries (self/team vs institutional constraints), perceived non-moralizing framing, and perceived risk of individualizing structural problems. At T1, participants will also complete the Client Satisfaction Questionnaire-8 (CSQ-8) and provide open-ended feedback. [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] A brief follow-up acceptability check (continued usefulness, burden, and likelihood of continued practice) will also be collected at T3. A brief checklist of potential unwanted effects (e.g., increased guilt/self-blame, rumination, or sustained distress triggered by morally challenging material) will be completed post-intervention (T1) and at follow-up (T3), with an open-ended option to describe context.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eProgression criteria\u003c/h2\u003e \u003cp\u003eProgression criteria will be pre-specified using a traffic-light approach to guide decisions about moving to a larger trial. Proposed criteria are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and will be refined with stakeholders and interpreted in context (e.g., seasonal peaks).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePre-specified progression criteria (traffic-light approach).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreen (proceed)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmber (revise)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRed (re-design / stop)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecruitment speed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30 enrolled within \u0026le;\u0026thinsp;12 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u0026ndash;29 within 12 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20 within 12 weeks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;80% at T1 and \u0026ge;\u0026thinsp;70% at T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u0026ndash;79% at T1 or 50\u0026ndash;69% at T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ebelow amber thresholds\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEngagement (module completion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;70% complete\u0026thinsp;\u0026ge;\u0026thinsp;8/12 module parts (\u0026thinsp;\u0026asymp;\u0026thinsp;\u0026ge;\u0026thinsp;4/6 weeks with both parts completed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u0026ndash;69% complete\u0026thinsp;\u0026ge;\u0026thinsp;8 parts or substantial completion of Part A but low Part B completion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50% complete\u0026thinsp;\u0026ge;\u0026thinsp;8 parts or consistently low Part B completion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean satisfaction\u0026thinsp;\u0026ge;\u0026thinsp;20/32 on CSQ-8 and predominantly positive qualitative feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMixed satisfaction/feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow satisfaction and/or negative qualitative feedback\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eSecondary outcomes: psychological and work-related variables\u003c/h2\u003e \u003cp\u003eSecondary outcomes are selected to (i) capture domains relevant to practitioner well-being and burnout, (ii) reflect plausible mechanisms of mindfulness-based change, and (iii) address the ethics-informed component. For core outcomes (burnout/emotional exhaustion, well-being, perceived stress, mindfulness, self-compassion), validated French versions will be used. For burnout/exhaustion, the MBI-HSS will be complemented by the Copenhagen Burnout Inventory (CBI) as an exploratory measure at T0, T1, and T3; the CBI is omitted at T2 to keep the brief assessment short. For ethics-specific constructs (moral distress, moral resilience, moral injury symptoms, and perceived ethical climate), we will use existing French versions when available. If a validated French measure covering the same construct is available, we will prioritize it; otherwise, we will translate/adapt measures following established cross-cultural procedures (forward\u0026ndash;back translation and pretesting) and treat results as exploratory. [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] Ethical climate will be assessed using the Hospital Ethical Climate Survey (HECS) [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], and moral injury symptoms will be assessed using the Moral Injury Symptom Scale - Health Professional (MISS-HP) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] as exploratory measures. Measures and timepoints are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eOptional salivary cortisol measure (exploratory)\u003c/h2\u003e \u003cp\u003eTo complement self-report stress and burnout outcomes with an objective index of hypothalamic\u0026ndash;pituitary\u0026ndash;adrenal (HPA) axis activity, participants will be offered an optional salivary cortisol assessment at baseline (T0) and post-intervention (T1). Salivary cortisol is a non-invasive marker of free cortisol concentrations and is widely used in field stress research. [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e] In burnout, cortisol indices have shown heterogeneous alterations across studies; including cortisol here is intended primarily to assess feasibility and to triangulate subjective stress and exhaustion signals for a future randomized trial. [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eParticipants who opt in will receive a home collection kit (e.g., Salivette or passive drool tubes) with written instructions and pre-labeled sample codes. On two typical days within each assessment window (preferably non-night-shift days), they will collect saliva (i) immediately upon awakening, (ii) 30 minutes after awakening (cortisol awakening response; CAR), and (iii) at bedtime. Sampling time, wake time, sleep duration, and relevant confounders (e.g., shift pattern, acute illness, medication including glucocorticoids, nicotine/caffeine intake) will be recorded. Participants will be asked to refrain from eating, drinking (except water), brushing teeth, or smoking for at least 30 minutes before each sample and to store samples refrigerated/frozen until return to the research team. Samples will be stored at -20\u0026deg;C and analyzed in batch using a high-sensitivity enzyme immunoassay. Field sampling and CAR assessment procedures will follow established recommendations. [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eExploratory patient-reported experience measures\u003c/h2\u003e \u003cp\u003eTo complement practitioner-reported outcomes and to assess whether ETHOS skills translate into patients\u0026rsquo; experience of care, we will pilot a brief, anonymous patient feedback module in a subset of participating clinicians who have direct patient contact. Subject to ethics approval (or amendment), each participating clinician will invite a small convenience sample of patients (e.g., 3\u0026ndash;5 per timepoint) to complete a short survey immediately after a routine encounter at two timepoints: pre-intervention (baseline window) and post-intervention (within 2 weeks after week 6). Where feasible, we will also explore feasibility of an additional follow-up sample at T3. The survey will include the 6-item Brief Health Care Climate Questionnaire (HCCQ; French version), assessing patients\u0026rsquo; perceptions of autonomy-supportive care, plus a single global item on perceived communication quality (e.g., feeling listened to). [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] Patient surveys will be anonymous, will not include health identifiers, and will not be shared with clinicians in an individually identifiable manner. Feasibility metrics will include the proportion of clinicians able to recruit patients, patient response rate, and missing data.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSecondary and exploratory outcome measures and assessment timepoints.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstruct / domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInstrument\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTimepoints\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurnout (key secondary outcome: emotional exhaustion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaslach Burnout Inventory \u0026ndash; Human Services Survey (MBI-HSS (MP), French validated version) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T2 (brief), T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary burnout signal outcome retained for comparability with prior healthcare literature; French validation available [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurnout / exhaustion profile (CBI, exploratory)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCopenhagen Burnout Inventory (CBI) [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComplementary exploratory measure of personal, work-related, and client-related exhaustion; added alongside the MBI-HSS to broaden interpretability and omitted at T2 to limit burden.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological well-being\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWHO-5 Well-Being Index (French version) [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T2 (brief), T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBrief and widely used well-being measure; French psychometric data available [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived Stress Scale (PSS-10), French version [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGlobal perceived stress; factorial validation in French working population [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMindfulness skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMindful Attention Awareness Scale (MAAS), French version [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMechanism candidate; brief attention/awareness measure with French psychometrics [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-compassion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-Compassion Scale\u0026mdash;Short Form (SCS-SF), French version [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMechanism candidate; French version psychometric data available [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoral distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeasure of Moral Distress for Healthcare Professionals (MMD-HP) [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthics-related outcome. If a validated French version is unavailable, translation/adaptation will follow published cross-cultural guidelines [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] and results will be treated as exploratory.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoral resilience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRevised Rushton Moral Resilience Scale (RMRS-16) [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthics-related mechanism/outcome. If a validated French version is unavailable, translation/adaptation will follow published cross-cultural guidelines [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] and results will be treated as exploratory.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthical climate (contextual factor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospital Ethical Climate Survey (HECS) [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContextual covariate capturing perceived support and norms for addressing ethical issues; included to inform feasibility and exploratory moderation. If a validated French version is unavailable, translation/adaptation will follow published cross-cultural guidelines [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e].\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoral injury symptoms (exploratory)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMoral Injury Symptom Scale \u0026ndash; Health Professional (MISS-HP) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1, T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExploratory ethics-related outcome capturing more persistent moral adversity symptoms (e.g., guilt, shame, betrayal, loss of meaning). Included to test measurement feasibility and inform future refinement. If a validated French version is unavailable, translation/adaptation will follow published cross-cultural guidelines [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] and results will be treated as exploratory.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysiological stress biomarker (optional)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSalivary cortisol (home sampling; CAR\u0026thinsp;+\u0026thinsp;diurnal decline) [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT0, T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptional exploratory biomarker to complement self-report stress and burnout outcomes; feasibility indicators include uptake and sampling adherence. Interpretation will be cautious given known heterogeneity in burnout-related cortisol findings. [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient-reported experience (optional sub-study)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrief Health Care Climate Questionnaire (HCCQ-6; French version)\u0026thinsp;+\u0026thinsp;1 global communication item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline (pre-intervention window) and post-intervention (T1); optional follow-up (T3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptional, brief, anonymous patient feedback collected after routine encounters in a subset of patient-facing clinicians. Data will be analyzed descriptively (e.g., clinician-level means) to inform feasibility and signal of relational impact.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative outcomes\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews (\u0026asymp;\u0026thinsp;30\u0026ndash;45 minutes) will be conducted with an estimated 10\u0026ndash;12 participants purposively sampled to reflect variation in baseline burnout and moral adversity (moral distress and moral injury symptoms), module completion, and practice adherence. Interviews will explore: perceived changes and mechanisms; concrete moments of on-shift application (guided practices, micro-practices, and the recurring 4-step tool), including situations in which the tool felt difficult to use or insufficient; usability and engagement with the online modular format (two-part sessions, reminders, and workflow fit); perceived ethical relevance and perceived non-moralizing framing (including whether the program clarified agency boundaries between the individual/team and institutional constraints); experiences of responsibility and support-seeking/escalation in constrained contexts; perceived unintended effects (e.g., increases in guilt/self-blame or rumination) and strategies used for grounding and recovery; and contextual facilitators/barriers at individual, team and organizational levels, with recommendations for refinement (content, dose, sequencing, and implementation). Where feasible, we will also invite participants to provide one concrete example of applying the 4-step tool to a recent morally challenging situation (de-identified). Qualitative reporting will follow COREQ guidance. [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eOptional Phase 2 extension outcomes (separate protocol)\u003c/h2\u003e \u003cp\u003eFor participants who provide separate consent to Phase 2, assessment will be conducted at Phase 2 baseline (T3, serving as the post-parent-study timepoint), post-extension (T4; approximately week 22), and follow-up (T5; approximately week 30). Phase 2 primary outcomes will be feasibility and acceptability (uptake among eligible completers, retention, module completion, and perceived burden/usefulness). Exploratory outcomes will include within-person change from T3 to T4/T5 in a reduced battery selected to minimize burden (emotional exhaustion, psychological well-being, perceived stress, mindfulness, self-compassion, and ethics-related outcomes such as moral distress and moral resilience). Analyses will be descriptive and hypothesis-generating.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eSchedule of enrollment, interventions, and assessments\u003c/h2\u003e \u003cp\u003eThe timing of study procedures is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e (SPIRIT schedule). The optional Phase 2 extension occurs after T3 under a separate protocol and is therefore not included in the SPIRIT schedule. An optional patient-reported experience sub-study (HCCQ-6) is shown as exploratory and is contingent on ethics approval.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSPIRIT schedule of enrollment, intervention, and assessments.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnrollment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e(T0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003e(Weeks 1\u0026ndash;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePost-intervention\u003c/p\u003e \u003cp\u003e(T1, week 6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePre-booster\u003c/p\u003e \u003cp\u003e(T2, week 10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003e(T3, week 18)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEligibility screen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformed consent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographics \u0026amp; work context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary feasibility metrics (module completion, practice logs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptability / satisfaction (T1; brief T3 follow-up) and unwanted effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReporting as needed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX (incl. CSQ-8; unwanted effects)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX (brief; incl. unwanted effects)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurnout / emotional exhaustion (MBI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX (brief)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurnout / exhaustion profile (CBI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell-being (WHO-5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX (brief)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived stress (PSS-10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMindfulness (MAAS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-compassion (SCS-SF)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoral distress (MMD-HP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoral resilience (RMRS-16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthical climate (HECS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoral injury symptoms (MISS-HP)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQualitative interview (subsample)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOptional\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSalivary cortisol (optional)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient-reported experience (HCCQ-6; optional)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eX\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eData management, confidentiality and quality assurance\u003c/h2\u003e \u003cp\u003eParticipants will be assigned a unique study identifier. Questionnaire data will be collected via a secure electronic platform compliant with institutional requirements and the General Data Protection Regulation (GDPR). Identifying information (consent forms, contact details) will be stored separately from survey data. Only the research team will have access to the re-identification key. Audio recordings of interviews (when applicable) will be stored on encrypted institutional servers and transcribed with removal of identifying information. Because ETHOS is delivered through pre-specified online modules, delivery integrity is primarily ensured through version control of the content (locked recordings and worksheets) and platform checks confirming availability. Engagement will be monitored through self-report practice logs and, where feasible, platform analytics (e.g., module access/completion timestamps). Optional patient surveys (if implemented) will be anonymous, will not include clinical identifiers, and will not be linkable to medical records; results will be analyzed and reported in aggregated form.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eAnalysis plan\u003c/h2\u003e \u003cdiv id=\"Sec35\" class=\"Section4\"\u003e \u003ch2\u003eQuantitative analysis\u003c/h2\u003e \u003cp\u003eAnalyses will primarily be descriptive and estimation-focused, consistent with a single-arm proof-of-concept design. Feasibility outcomes (recruitment rate/speed, retention at T1 and T3, module completion, and practice adherence) will be summarized using proportions and 95% confidence intervals (exact binomial intervals where appropriate), as well as means/medians and dispersion (SD/IQR) for continuous feasibility indicators. Progression criteria will be evaluated descriptively against the pre-specified traffic-light thresholds (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eDefinition of exposure (\u0026ldquo;dose received\u0026rdquo;).\u003c/b\u003e Weekly modules are released sequentially (one per week) and can be completed asynchronously; each unlocked module remains accessible throughout the 6-week delivery window (weeks 1\u0026ndash;6), allowing catch-up within that period. For feasibility metrics, module completion will be defined as completion of each weekly Part (A and/or B) within the 6-week delivery window (i.e., up to the end of week 6, prior to the post-intervention assessment). Completion will be summarized separately for Part A and Part B and as a combined threshold (e.g., \u0026ge;\u0026thinsp;8/12 completed parts). Practice log indicators (guided practice days, duration category when available, micro-practice use, and 4-step tool use) will be summarized descriptively over time.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSecondary continuous outcomes (signal of change).\u003c/b\u003e For continuous secondary outcomes, within-person change from baseline (T0) to each follow-up timepoint will be estimated using both (i) standardized mean change effect sizes and (ii) mixed-effects models. Standardized mean change will be expressed as Hedges\u0026rsquo; \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({g}_{av}\\)\u003c/span\u003e\u003c/span\u003e(small-sample corrected). Effect sizes will be reported with 95% confidence intervals, with emphasis on magnitude and uncertainty rather than dichotomous significance testing.\u003c/p\u003e \u003cp\u003eMixed-effects models will be used to estimate time effects while accounting for within-person correlation. For each outcome, we will fit a model with time as a categorical fixed effect and participant as a random intercept (e.g., outcome\u0026thinsp;~\u0026thinsp;time + (1|participant)). Model-based estimated marginal means will be used to obtain pre-specified contrasts, prioritizing: T0\u0026rarr;T1 (post-intervention signal), T0\u0026rarr;T3 (maintenance), and T1\u0026rarr;T3 (trajectory after program completion). Where model convergence and sample size allow, we will explore adding random slopes for time; otherwise, the random-intercept specification will be retained. Given the proof-of-concept design and limited power, p-values will be interpreted cautiously; inference will focus on point estimates and uncertainty intervals.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMissing data.\u003c/b\u003e Patterns and extent of missingness will be summarized by timepoint and by key baseline characteristics. Mixed-effects models will be estimated using maximum likelihood, which accommodates incomplete repeated-measures data under a missing-at-random assumption. For standardized mean change estimates, pairwise available data will be used for each contrast (e.g., T0\u0026ndash;T1), and the number of complete pairs contributing to each estimate will be reported. As a sensitivity check, we will compare main estimates to complete-case results for key outcomes when feasible.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExploratory associations with engagement.\u003c/b\u003e Associations between engagement indicators (module completion, practice log metrics) and outcome change will be explored descriptively (e.g., correlations and regression models adjusting for baseline outcome levels), acknowledging potential confounding and self-selection. These analyses are hypothesis-generating and intended to inform refinement of the intervention and the design of a subsequent trial.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExploratory moderation.\u003c/b\u003e A small, theory-driven set of baseline variables specified a priori (e.g., baseline emotional exhaustion, baseline moral distress, perceived ethical climate, and prior mindfulness experience) will be examined as potential moderators of change using time \u0026times; moderator interactions in mixed-effects models. Given limited power and multiple comparisons, moderation results will be treated as exploratory and interpreted cautiously.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExploratory mechanism analyses.\u003c/b\u003e Formal mediation analyses are likely underpowered. As a pragmatic alternative, we will examine whether changes in candidate mechanisms (mindfulness and self-compassion; T0\u0026rarr;T1) are associated with changes in key outcomes (emotional exhaustion and well-being; T0\u0026rarr;T1 and T0\u0026rarr;T3) using correlations and regression models (e.g., outcome change regressed on mechanism change, with baseline adjustment). These analyses are hypothesis-generating and will inform endpoint selection and mechanistic measurement for a future randomized trial.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatient feedback sub-study.\u003c/b\u003e Patient-reported measures (HCCQ-6 and the global communication item) will be analyzed descriptively to assess feasibility (patient response rate, missing data) and to obtain preliminary signal estimates. Given clustering by clinician and small numbers per clinician, results will primarily be summarized using clinician-level means (pre vs post) and overall descriptive statistics, with cautious interpretation.\u003c/p\u003e \u003cp\u003eOptional salivary cortisol sub-study. Cortisol concentrations will be inspected for outliers and values may be log-transformed to reduce skew. For each day, we will derive standard indices including the cortisol awakening response (CAR; e.g., AUCi from awakening and +\u0026thinsp;30 min samples) and a diurnal decline estimate (e.g., slope across sampling times). Analyses will be primarily descriptive; pre-post change (T0\u0026rarr;T1) in cortisol indices will be summarized with standardized mean change and exploratory mixed-effects models when feasible, adjusting for sampling time deviations, wake time, day type (work vs non-work), and key confounders (e.g., glucocorticoid medication, shift pattern). Sampling adherence and missingness will be reported explicitly, following recommendations for field cortisol assessment. [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAnalyses of the optional Phase 2 extension (post-T3) will be conducted and reported separately under its dedicated protocol; T3 will serve as the extension baseline, and effect estimates will be treated as exploratory.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative analysis\u003c/h3\u003e\n\u003cp\u003eInterview transcripts will be analyzed using reflexive thematic analysis, following Braun and Clarke\u0026rsquo;s approach. [\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e] Initial coding will be inductive, with the TFA domains used as a sensitizing framework to ensure coverage of acceptability constructs. [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] Two researchers will code a subset of transcripts to develop a shared coding approach, then proceed with iterative refinement of themes. Team discussions will be used to support reflexivity and to examine alternative interpretations. Reporting will follow COREQ. [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eMixed-methods integration\u003c/h2\u003e \u003cp\u003eQuantitative and qualitative findings will be integrated using a convergent mixed-methods logic. A joint display will map feasibility metrics and outcome change patterns to qualitative themes about fit, mechanisms, and contextual barriers/facilitators. Integration will be used to prioritize protocol refinements and to derive implementation hypotheses for a future trial.\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eHarms and adverse events\u003c/h2\u003e \u003cp\u003eMindfulness practices are generally low risk, but transient increases in distress can occur, particularly when attention is directed toward difficult internal experiences. Because ETHOS explicitly addresses morally challenging clinical situations, some participants may experience increased moral emotions (e.g., guilt, frustration) or reactivation of distressing memories related to constrained care. Participants will be informed that they may pause, modify, or skip any practice and may discontinue at any time; the goal is not to intensify self-blame but to clarify agency and support wise, feasible action under constraints. Session 1 will include guidance on grounding, titration, and recognizing when to seek additional support.\u003c/p\u003e \u003cp\u003ePotential unwanted effects (e.g., sustained distress, increased guilt/self-blame, rumination, or sleep disturbance) will be assessed using a brief checklist at T1 and T3 and via an open-ended item. Participants will also be reminded that they may contact the study team at any time during the study if distress, moral burden, or other concerns arise. Reported adverse events will be reviewed by the principal investigator (or a delegated clinician on the team) within 72 hours; if clinically indicated, participants will be advised to pause the program and will be referred to appropriate support options such as the occupational health service, a psychologist, or a physician/mental health clinician, as appropriate. Serious adverse events judged related to participation will be documented and reported to the ethics committee according to local requirements. Given the low-risk, single-site, non-pharmacological nature of the intervention, no independent data monitoring committee is planned.\u003c/p\u003e \u003cp\u003eThis protocol describes a proof-of-concept evaluation of ETHOS, a brief, modular mindfulness program designed for hospital practitioners and explicitly aligned with the ethical and moral dimensions of clinical work. The program is designed to address common implementation barriers (time, shift work) by combining shorter sessions with flexible home-practice formats, while preserving progressive skill acquisition. By embedding a moral-resilience micro-tool and case-anchored reflection, the intervention aims to increase clinical relevance and to directly target distress linked to value conflict and constrained agency. The study\u0026rsquo;s primary contribution will be feasibility evidence (who enrolls, what dose is achievable, which components are valued, and what organizational constraints arise), complemented by preliminary effect size estimates and mechanism signals. Limitations include the single-arm design, which precludes causal inference, and limited power for complex mediation/moderation. Nevertheless, the mixed-methods approach will provide actionable information to refine content, optimize delivery and select primary outcomes for a future randomized trial.\u003c/p\u003e \u003cp\u003eThe staged (two-phase) structure also supports implementation planning. The 6-week ETHOS curriculum is designed as a low-threshold entry point compatible with time-constrained clinical schedules, whereas the optional post-study Phase 2 extension provides a higher-dose pathway for participants who wish to deepen practice once feasibility and acceptability have been demonstrated. Follow-on mindfulness curricula for course graduates have been explicitly developed to sustain and deepen practice after initial MBCT/MBSR courses, with randomized evidence supporting added benefit for well-being. [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e] Similarly, clinician- and workplace-adapted mindfulness programs have incorporated maintenance phases and ongoing booster touchpoints to support longer-term sustainability of gains. [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTo ensure clarity and transparency, results will be disseminated in two complementary manuscripts: Article 1 will report the parent proof-of-concept outcomes through T3 (feasibility, acceptability, and preliminary effect size estimates), whereas Article 2 will report the post-study extension evaluation (Phase 2), including uptake, retention and exploratory changes from T3 to post-extension and follow-up among extension participants.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the time of submission, no human participants have been enrolled and no study procedures have started. The protocol is being finalized prior to ethics submission. The full study protocol will be submitted to the appropriate ethics committee before the study begins, and all study procedures will start only after written ethics approval has been obtained. All participants will provide informed consent electronically before participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable (no individual person’s data will be published in identifiable form).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDe-identified quantitative datasets and analysis code will be made available on an open repository (e.g., OSF [Open Science Framework]) after publication, subject to institutional and legal constraints. Qualitative transcripts will not be publicly shared due to the risk of re-identification in a small workplace setting; access may be considered upon reasonable request and ethics approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePierrick Laulan and Matthieu L.G. Fernandez jointly developed the ETHOS intervention and the study protocol. Pierrick Laulan drafted the manuscript. Matthieu L.G. Fernandez critically revised the manuscript for important intellectual content. Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Marion Thorignac for her help with ethical guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor information is provided on the title page.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDemerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):499\u0026ndash;512. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/0021-9010.86.3.499\u003c/span\u003e\u003cspan address=\"10.1037/0021-9010.86.3.499\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaslach C, Jackson SE. 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Qual Res Psychol. 2006;3(2):77\u0026ndash;101. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1191/1478088706qp063oa\u003c/span\u003e\u003cspan address=\"10.1191/1478088706qp063oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pilot-and-feasibility-studies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pafs","sideBox":"Learn more about [Pilot and Feasibility Studies](http://pilotfeasibilitystudies.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/PAFS/default.aspx","title":"Pilot and Feasibility Studies","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mindfulness, hospital practitioners, burnout, emotional exhaustion, moral distress, moral resilience, ethic of care, mixed methods.","lastPublishedDoi":"10.21203/rs.3.rs-9097265/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9097265/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBurnout and emotional exhaustion among hospital practitioners are common and are frequently intensified by sustained workload and morally challenging clinical situations. Mindfulness-based interventions can improve stress and well-being, yet uptake in hospital settings is often constrained by long session formats, shift work and limited protected time. We developed ETHOS (Ethics-informed Training for Hospital practitioners: Online Skills for mindful practice), a brief, modular mindfulness program that integrates micro-skills for responding to moral adversity and value conflict.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis mixed-methods, single-arm proof-of-concept study will recruit approximately 30 hospital practitioners from a French hospital. ETHOS comprises six weekly online modules delivered via a secure platform. Each week includes a formal session split into two 30-minute parts (\u0026asymp;\u0026thinsp;60 minutes/week core dose): mindfulness training plus ethics-informed moral-resilience application that can be completed on separate days. Participants will also access guided audio practices offered in two brief formats (5 and 10 minutes) and 60\u0026ndash;90-second \u0026lsquo;micro-practices\u0026rsquo; designed for clinical workflow. A booster online module will be delivered four weeks after the program. Assessments will be completed at baseline (T0), post-intervention (T1, week 6), pre-booster (T2, week 10; brief assessment), and follow-up (T3, week 18). Primary outcomes are feasibility and acceptability (recruitment, retention, module completion, home practice adherence, participant-reported acceptability and burden). Secondary outcomes include emotional exhaustion and other burnout dimensions, psychological well-being, stress, mindfulness, self-compassion, and ethics-related outcomes (moral distress and moral resilience). A purposive subsample will be invited to participate in semi-structured interviews to explore mechanisms of change, usability and engagement with the online format, contextual facilitators and barriers, and perceived ethical relevance. After completion of the T3 follow-up (end of the parent study), participants will be offered an optional advanced extension course (Phase 2) evaluated under a separate protocol; extension outcomes will be reported separately.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eThis protocol addresses an implementation-critical question: can a short, modular mindfulness program with an ethics-informed component be feasible and acceptable for hospital practitioners while showing a signal of change in well-being and burnout-related outcomes? Findings will inform refinement of the intervention and the design of a subsequent randomized trial.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003e: The study will be registered prior to enrolment of the first participant. 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