Teaching and assessing ethics in the newborn ICU

Knowledge assessment tool for pediatric parenteral nutrition: A validation study

BACKGROUND

Parenteral nutrition (PN) is a high-risk medication, and its prescription and administration requires extensive training. Difficulties inherent with bedside teaching have made teaching these concepts challenging. Currently, no knowledge assessment tools with validity evidence exist to test the effectiveness of new PN teaching interventions. We sought to develop and provide validity evidence for a pediatric PN knowledge test to measure the effectiveness of future teaching interventions.

METHODS

We created a multiple-choice question knowledge assessment tool that underwent content validation by PN experts and was emailed to potential participants. We evaluated the knowledge assessment tool for factorial validity, internal consistency reliability, and discriminant validity.

RESULTS

We enrolled 103 medical students (40%), residents and fellow trainees (55%), and attending physicians (5%) into the study between October 2021 and October 2022. Five of the 30 questions performed poorly based on their nonsignificant contribution to the primary aim of assessing pediatric PN knowledge. Following the exclusion of those questions, the knowledge assessment tool demonstrated an acceptable model fit, and the root mean squared error of approximation was <5%. The omega coefficient was 0.829, indicating acceptable levels of reliability, and using an analysis of variance test (ANOVA) demonstrated significant differences between groups, showing good discrimination between levels of experience (F[2, 80] = 39.002; P < 0.001).

CONCLUSION

We have developed and provided validity evidence for a multiple-choice question knowledge test that may be used by educators and programs to evaluate knowledge of pediatric PN in physicians and trainees.

Uninformed Origins: Should We Be Advising Parents on the Source of Medicines and Therapies?

Respecting patient autonomy through the process of soliciting informed consent is a cornerstone of clinical ethics. In pediatrics, until a child becomes an adult or legally emancipated, that ethical tenet takes the form of respect for parental decision-making authority. In instances of respecting religious beliefs, doing so is not always apparent and sometimes the challenge lies not only in the healthcare provider's familiarity of religious restrictions but also their knowledge of medical interventions themselves which might conflict with those restrictions. We examine a case of a newborn receiving animal-derived surfactant, a common scenario in neonatology, and present considerations for providers to weigh when confronting when such an intervention might conflict with parent's religious beliefs. We end with strategizing ways to address this issue as a medical community.

Ethik-Fortbildungen als Element der Klinischen Ethikarbeit: Ein Überblick über Formate und weitere strukturierende Elemente

Ausgehend von den Erfahrungswerten sechs Klinischer Ethiker*innen an Universitätsklinika in Deutschland wurde eine strukturierte Auseinandersetzung mit dem Arbeitsfeld der Fortbildungen im Rahmen der Klinischen Ethikarbeit vorgenommen. Die Zusammenarbeit wurde von der Fragestellung geleitet, was bei der Konzeption einer Ethik-Fortbildung innerhalb einer Einrichtung zu berücksichtigen ist. Der methodische Zugang zur Beantwortung der explorativen Fragestellung bestand in einem mehrstufigen, deskriptiven Verfahren, das alternierend in gemeinsamen Arbeitssitzungen und individueller Arbeit zwischen den Sitzungen umgesetzt wurde.

Als Resultat zeigt der Aufsatz eine Übersicht über die Bandbreite möglicher Fortbildungsformate auf, die denjenigen Hilfestellung bieten kann, die in ihrer Einrichtung Fortbildungen zu ethischen Themen konzipieren und durchführen wollen. Darüber hinaus bietet er einen Überblick über die bei der Umsetzung jeweils zu berücksichtigenden direkt strukturierenden sowie indirekt strukturierenden Merkmale. Es wird an Beispielen aufgezeigt, welche Formatvarianten sich in Kombination mit welchen direkt strukturierenden Merkmalen in den ausgewählten Universitätsklinika bewährt haben.

Der Beitrag liefert eine Diskussionsgrundlage, um die strukturierte Auseinandersetzung mit konzeptionellen Fragen ethischer Fortbildung in der Klinik zu befördern.

Developing a digitally innovative ethics and professionalism curriculum for neonatal-perinatal medicine fellows: a 3-year multicenter pilot study

OBJECTIVES

The purpose of this study was to develop and regionally pilot a digitally innovative curriculum in ethics and professionalism in neonatology and study the effects on trainee knowledge and confidence.

STUDY DESIGN

We developed 13 modules in ethics for neonatology fellows and piloted them at three academic institutions utilizing a flipped-classroom approach. Baseline surveys in ethics knowledge and confidence in approaching ethical dilemmas were compared with repeat surveys after curriculum completion. Pre- and post-tests were also administered for all 13 modules.

RESULTS

Forty-four of 49 eligible fellows participated (90% response rate). Pre/post comparisons demonstrated significant improvements in overall knowledge and in 8/13 modules, as well as improvement in overall confidence and individually when navigating 16/22 ethical dilemmas.

CONCLUSIONS

After completing this curriculum, participants' knowledge scores and reported confidence in approaching ethical challenges significantly improved. Future steps include assessing the effects of this innovative curriculum via an ongoing international pilot.

Decision making at extreme prematurity: Innovation in clinician education

Decision-making at extreme prematurity remains ethically and practically challenging and can result in parental and clinician distress. It is vital that clinicians learn the necessary skills integral to counseling and decision-making with families in these situations. A pedagogical approach to teaching counseling should incorporate adult learning theory, emphasize multidisciplinary team in-situ simulation that links to counseling clinicians' daily practice, and includes critical reflection, debriefing, and program assessment. Multiple educational strategies that train clinicians in advanced communication and decision-making offer promising results to optimize antenatal counseling and shared decision-making for families facing possible delivery at extreme prematurity. Continued process evaluation and innovation in these educational domains are needed while also assessing the effect on patient-centered outcomes.

Postgraduate ethics training programs: a systematic scoping review

BACKGROUND

Molding competent clinicians capable of applying ethics principles in their practice is a challenging task, compounded by wide variations in the teaching and assessment of ethics in the postgraduate setting. Despite these differences, ethics training programs should recognise that the transition from medical students to healthcare professionals entails a longitudinal process where ethics knowledge, skills and identity continue to build and deepen over time with clinical exposure. A systematic scoping review is proposed to analyse current postgraduate medical ethics training and assessment programs in peer-reviewed literature to guide the development of a local physician training curriculum.

METHODS

With a constructivist perspective and relativist lens, this systematic scoping review on postgraduate medical ethics training and assessment will adopt the Systematic Evidence Based Approach (SEBA) to create a transparent and reproducible review.

RESULTS

The first search involving the teaching of ethics yielded 7669 abstracts with 573 full text articles evaluated and 66 articles included. The second search involving the assessment of ethics identified 9919 abstracts with 333 full text articles reviewed and 29 articles included. The themes identified from the two searches were the goals and objectives, content, pedagogy, enabling and limiting factors of teaching ethics and assessment modalities used. Despite inherent disparities in ethics training programs, they provide a platform for learners to apply knowledge, translating it to skill and eventually becoming part of the identity of the learner. Illustrating the longitudinal nature of ethics training, the spiral curriculum seamlessly integrates and fortifies prevailing ethical knowledge acquired in medical school with the layering of new specialty, clinical and research specific content in professional practice. Various assessment methods are employed with special mention of portfolios as a longitudinal assessment modality that showcase the impact of ethics training on the development of professional identity formation (PIF).

CONCLUSIONS

Our systematic scoping review has elicited key learning points in the teaching and assessment of ethics in the postgraduate setting. However, more research needs to be done on establishing Entrustable Professional Activities (EPA)s in ethics, with further exploration of the use of portfolios and key factors influencing its design, implementation and assessment of PIF and micro-credentialling in ethics practice.

Testing a Communication Assessment Tool for Ethically Sensitive Scenarios: Protocol of a Validation Study

Background

Although well-designed instruments to assess communication during medical interviews and complex encounters exist, assessment tools that differentiate between communication, empathy, decision-making, and moral judgment are needed to assess different aspects of communication during situations defined by ethical conflict. To address this need, we developed an assessment tool that differentiates competencies associated with practice in ethically challenging situations. The competencies are grouped into three distinct categories: communication skills, civility and respectful behavior, clinical and ethical judgment and decision-making.

Objective

The overall objective of this project is to develop an assessment tool for ethically sensitive scenarios that measures the degree of respect for the attitudes and beliefs of patients and family members, the demands of clinical decision-making, and the success in dealing with ethical conflicts in the clinical context. In this article, we describe the research method we will use during the pilot-test study using the neonatal context to provide validity evidence to support the features of the Assessment Communication Tool for Ethics (ACT4Ethics) instrument.

Methods

This study is part of a multiphase project designed according to modern validity principles including content, response process, internal structure, relation to other variables, and social consequences. The design considers threats to validity such as construct underrepresentation and factors exerting nonrandom influence on scores. This study consists of two primary steps: (1) train the raters in the use of the new tool and (2) pilot-test a simulation using an Objective Structured Clinical Examination. We aim to obtain a total of 90 independent assessments based on the performance of 30 trainees rated by 15 trained raters for analysis. A comparison of raters’ responses will allow us to compute a measure of interrater reliability. We will additionally compare the results of ACT4Ethics with another existing instrument.

Results

This study will take approximately 18 months to complete and the results should be available by September 2019.

Conclusions

ACT4Ethics should allow clinician-teachers to assess and monitor the development of competency of trainees’ judgments and communication skills when facing ethically sensitive clinical situations. The instrument will also guide the provision of meaningful feedback to ensure that trainees develop specific communication, empathy, decision-making, and ethical competencies.

International Registered Report Identifier (IRRID)

PRR1-10.2196/12039

Needs assessment of ethics and communication teaching for neonatal perinatal medicine programs in Canada

Objective

To explore ethics education needs in Canadian Neonatal Perinatal Medicine (NPM) training programs.

Methods

A retrospective review of NPM trainees' performance at the National NPM Objective Structured Clinical Examination (OSCE) was undertaken for 2012 to 2017 and two distinct cross-sectional online surveys were carried out. One survey targeted recently graduated neonatologists (RGNs) who completed 2 years' training in a Canadian NPM program between 2010 and 2015; the other survey was sent to Canadian NPM training program directors (PDs). The domains of interest were: perception of education, ethics and communication topics, educational strategies, assessment of trainees' competencies, and barriers to neonatal ethics education.

Results

NPM trainees generally performed less well in stations involving ethics and communication relative to other domains on the National OSCE. Forty-seven RGNs (44.3%) and 12 PDs (92.3%) completed the survey. Over 90% of PDs and RGNs agreed on the importance of training in ethics and communication. Both groups highly valued training on topics related to communication. Preferred teaching strategies were experiential: observation and feedback. PDs mentioned the importance of using validated tools to regularly and formally assess trainees. They recognized challenges in regard to financial resources, physical space, and faculty training in patient-physician communication.

Conclusions

National OSCE results indicate the need to improve neonatal ethics and communication training in Canadian NPM programs. RGNs and PDs identified important topics, as well as teaching and evaluation strategies. These results can be used to develop a training program for ethics and communication in NPM.

Assessing Ethics Knowledge: Development of a Test of Ethics Knowledge in Neonatology

OBJECTIVE

To develop and validate the Test of Ethics Knowledge in Neonatology (TEK-Neo) with good internal consistency reliability, item performance, and construct validity that reliably assesses interprofessional staff and trainee knowledge of neonatal ethics.

STUDY DESIGN

We adapted a published test of ethics knowledge for use in neonatology. The novel instrument had 46 true/false questions distributed among 7 domains of neonatal ethics: ethical principles, professionalism, genetic testing, beginning of life/viability, end of life, informed permission/decision making, and research ethics. Content and correct answers were derived from published statements and guidelines. We administered the voluntary, anonymous test via e-mailed link to 103 participants, including medical students, neonatology fellows, neonatologists, neonatology nurses, and pediatric ethicists. After item reduction, we examined psychometric properties of the resulting 36-item test and assessed overall sample performance.

RESULTS

The overall response rate was 27% (103 of 380). The test demonstrated good internal reliability (Cronbach α = 0.66), with a mean score of 28.5 ± 3.4 out of the maximum 36. Participants with formal ethics training performed better than those without (30.3 ± 2.9 vs 28.1 ± 3.5; P = .01). Performance improved significantly with higher levels of medical/ethical training among the 5 groups: medical students, 25.9 ± 3.7; neonatal nurses/practitioners, 27.7 ± 2.7; neonatologists, 28.8 ± 3.7; neonatology fellows, 29.8 ± 2.9; and clinical ethicists, 33.0 ± 1.9 (P < .0001).

CONCLUSIONS

The TEK-Neo reliably assesses knowledge of neonatal ethics among interprofessional staff and trainees in neonatology. This novel tool discriminates between learners with different levels of expertise and can be used interprofessionally to assess individual and group performance, track milestone progression, and address curricular gaps in neonatal ethics.