From Moral Distress to Moral Resilience: How Reflective Writing-Based Ethics Education Supports Professional Identity Formation and Prevents Moral Injury Among First-Year Pharmacy Students.

OBJECTIVE: This study aimed to characterize potentially morally injurious events (PMIEs) experienced by first-year pharmacy students and to examine how structured reflective writing facilitates recognition, processing, and meaning-making related to these events and supports moral resilience development. METHODS: A qualitative study was conducted with 39 first-year pharmacy students enrolled in a required ethics course at a military medical university in Taiwan. Students completed a structured four-prompt reflective writing exercise addressing ethical dilemmas, emotional responses, behavioral choices, and lessons learned. Narratives were analyzed using qualitative content analysis with investigator triangulation and peer debriefing to enhance trustworthiness. RESULTS: Five categories of PMIEs were identified: academic integrity dilemmas, complicity through silence, professional role conflicts, organizational justice dilemmas, and interpersonal boundary dilemmas. Moral distress arose primarily from the gap between moral knowledge and moral action created by systemic constraints rather than ethical confusion. Reflective writing facilitated externalization of distress, emotional processing, perspective-taking, and meaning-making. Five mechanisms of moral resilience development emerged-reframing through mentorship, creative problem-solving, reduction of inappropriate self-blame, transformation of distress into agency, and professional identity strengthening. CONCLUSIONS: PMIEs are prevalent among first-year pharmacy students before clinical rotations. Structured reflective writing supports professional identity formation and moral resilience; however, effective prevention requires multi-level strategies combining individual reflection, mentorship, faculty development, and institutional reform.