Syed Hashmi

Background Morally challenging situations arise frequently in contemporary pediatric practice. Despite this, few pediatric studies have examined how to support residents navigating these experiences or measure growth in this domain. To address this gap, we developed and piloted a longitudinal, multimodal curriculum designed to prepare residents to recognize and respond to moral challenges. Methods Curriculum development followed Kern's six-step model and was informed by a previously published needs assessment and review of existing literature. A mixed-methods design evaluated the intervention across Kirkpatrick's levels of evaluation. We designed two complementary tools: (a) an Objective Structured Clinical Examination (OSCE) emphasizing applied ethical reasoning and professional accountability, and (b) the Cognitive Affective Reflection on Ethical Experiences: Moral Encounters Tool (CARE-MET), which provided preliminary validity evidence for assessing residents' perceived self-efficacy in navigating moral events. Thematic and content analyses were conducted on qualitative data. Paired analyses of matched participants at timepoint 1 (T1) and timepoint 2 (T2) were conducted using Wilcoxon Rank Sum test and Cohen's d effect sizes. Results Of 81 eligible residents, 65 completed the CARE-MET at T1 and 52 of 57 eligible residents completed it at T2. Most participants (64/65, 97%) rated the curriculum as valuable. Residents identified value in the use of real clinical cases, diverse perspectives, and protected space for emotional processing. Paired analyses revealed significant improvements across five of six CARE-MET domains with large Cohens d (> 0.7). Experiencing moral distress was unchanged pre- and post-curriculum. Two separate cohorts of PGY-3 residents completed the OSCE at T1 (n = 12) and T2 (n = 14). Residents in both cohorts scored similarly high in empathic practice. Communicating the possibility of death without treatment was one significant difference between cohorts. This shift occurred more frequently at T2 than T1 (36% vs 0%, p = 0.024). Conclusions This curriculum offers a promising framework for preparing pediatric residents to navigate care that might be morally distressing yet ethically permissible. Gaps persisted in applied decision-making, legal understanding, and professional accountability. These findings support the need for longitudinal instruction in the moral, ethical, and legal dimensions of pediatric practice and highlight the value of developing tools capable of measuring growth in these domains.