Teaching medical ethics to experienced staff: participants, teachers and method

Clinical ethical practice and associated factors in healthcare facilities in Ethiopia: a cross-sectional study

Background

Clinical ethical practice (CEP) is required for healthcare workers (HCWs) to improve health-care delivery. However, there are gaps between accepted ethical standards and CEP in Ethiopia. There have been limited studies conducted on CEP in the country. Therefore, this study aimed to determine the magnitude and associated factors of CEP among healthcare workers in healthcare facilities in Ethiopia.

Method

From February to April 2021, a mixed-method study was conducted in 24 health facilities, combining quantitative and qualitative methods. Quantitative (survey questionnaire) and qualitative (semi-structured interviews) data were collected. For quantitative and qualitative data analysis, Stata version 14 and Atlas.ti version 7 were utilized. Multiple logistic regression and thematic analysis for quantative and qualitative respectively used.

Results

From a total of 432 study participants, 407 HCWs were involved in the quantitative analysis, 36 participants were involved in five focus group discussions (FGDs), and eleven key informant interviews (KIIs) were involved in the qualitative analysis. The score of good CEP was 32.68%. Similarly, the scores of good knowledge and attitude were 33.50% and 25.31%, respectively. In the multiple logistic regression models, satisfaction with the current profession, availability of functional CECs, compassionate leaders, previously thought clinical ethics in pre-service education and good attitude were significant factors associated with CEP. Among these significant factors, knowledge, compassionate leaders, poor infrastructure, a conducive environment and positive attitudes were also determinants of CEP according to qualitative findings.

Conclusions

The CEP in health care services in Ethiopia is low. Satisfaction with the current profession, functional CECs, positive attitude, compassionate leaders and previously thought clinical ethics were significant factors associated with CEP. The Ministry of Health (MoH) should integrate interventions by considering CECs, compassionate leadership, and positive attitudes and enhance the knowledge of health professionals. Additionally, digitalization, intersectoral collaboration and institutionalization are important for promoting CEP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00800-0.

Changes in ethical attitudes of clinical laboratory professionals after teaching them ethics using three different methods

Background: Ethical attitudes and personal values play a significant role in clinical decision-making; however, they have been given limited attention by professionals in laboratory medicine. Studies suggest that individual attitudes are not static and that professionals learn ethical attitudes through a variety of formal and informal learning methods. This study was conducted to investigate changes in the attitudes of clinical laboratory professionals after teaching them ethics and to compare the results among the 3 groups. Methods: Four topics were selected in the field of medical laboratory ethics as teaching materials. A questionnaire including 22 items was designed and validated. Teaching sessions for the 3 study groups were held. All 65 clinical laboratory participants completed the questionnaire before and after the classes. Paired t test and ANOVA were used to assess differences among groups. Results: Significant differences were found in the mean scores of ethical attitudes before and after the educational intervention among the lecture-based teaching group (p=0.016), problem-based learning group (p=0.001), and all participants (p=0.004). However, no significant difference was found between the mean scores before and after the intervention in role-playing group (p=0.623). Conclusion: Teaching by lecturing and problem-based learning was more effective to change ethical attitude of the laboratory professionals than the role-playing method. Thus, we suggest the implementation of teaching ethics using these methods to improve the ethical attitude of clinical laboratory professionals.

A Meta-analytic Comparison of Face-to-Face and Online Delivery in Ethics Instruction: The Case for a Hybrid Approach

Despite the growing body of literature on training in the responsible conduct of research, few studies have examined the effectiveness of delivery formats used in ethics courses (i.e., face-to-face, online, hybrid). The present effort sought to address this gap in the literature through a meta-analytic review of 66 empirical studies, representing 106 ethics courses and 10,069 participants. The frequency and effectiveness of 67 instructional and process-based content areas were also assessed for each delivery format. Process-based contents were best delivered face-to-face, whereas contents delivered online were most effective when restricted to compliance-based instructional contents. Overall, hybrid courses were found to be most effective, suggesting that ethics courses are best delivered using a blend of formats and content areas. Implications and recommendations for future development of ethics education courses in the sciences are discussed.

Review of Instructional Approaches in Ethics Education

Increased investment in ethics education has prompted a variety of instructional objectives and frameworks. Yet, no systematic procedure to classify these varying instructional approaches has been attempted. In the present study, a quantitative clustering procedure was conducted to derive a typology of instruction in ethics education. In total, 330 ethics training programs were included in the cluster analysis. The training programs were appraised with respect to four instructional categories including instructional content, processes, delivery methods, and activities. Eight instructional approaches were identified through this clustering procedure, and these instructional approaches showed different levels of effectiveness. Instructional effectiveness was assessed based on one of nine commonly used ethics criteria. With respect to specific training types, Professional Decision Processes Training (d = 0.50) and Field-Specific Compliance Training (d = 0.46) appear to be viable approaches to ethics training based on Cohen's d effect size estimates. By contrast, two commonly used approaches, General Discussion Training (d = 0.31) and Norm Adherence Training (d = 0.37), were found to be considerably less effective. The implications for instruction in ethics training are discussed.

Validity of the Italian Code of Ethics for everyday nursing practice

Background:

The research question for this study was as follows: Is the Code of Ethics for Nurses in Italy (Code) a valid or useful decision-making instrument for nurses faced with ethical problems in their daily clinical practice?

Method:

Focus groups were conducted to analyze specific ethical problems through 11 case studies. The analysis was conducted using sections of the Code as well as other relevant documents. Each focus group had a specific theme and nurses participated freely in the discussions according to their respective clinical competencies.

Ethical considerations:

The executive administrative committee of the local nursing licensing council provided approval for conducting this project. Measures were taken to protect the confidentiality of consenting participants.

Findings:

The answer to the research question posed for this investigation was predominantly positive. Many sections of the Code were useful for discussion and identifying possible solutions for the ethical problems presented in the 11 cases.

Conclusion:

We concluded that the Code of Ethics for Nurses in Italy can be a valuable aid in daily practice in most clinical situations that can give rise to ethical problems.

[A pilot study of the professional ethical thinking of Quebec hospital pharmacists and pharmacy students]

OBJECTIVE

The main objective was to assess the position of Quebec pharmaceutical community about pharmaceutical ethics statements. The second objective was to compare the level of agreement of pharmacy students and hospitals pharmacists.

METHOD

Survey conducted one day given in 2012 and 2013 for students in 2013 and from 29/08/2014 to 02/09/2014 for pharmacists. A questionnaire of eight themes and 43 statements was developed: training and education (5 questions), clinical research (7) advertising and marketing (5) evaluation (5) dispensing medication (4), pharmaceutical care (9) economic aspect (6) and code of ethics (2). A Likert scale with four choices was used to measure the level of agreement. The primary outcome was the difference between the level of agreement of pharmacy students and hospital pharmacists. The Chi² test was used.

RESULTS

A total of 347 students and 398 pharmacists responded to the survey. There was a statistically significant difference regarding the level of agreement with 28 statements on 43. The differences focused on eight themes of the questionnaire, or training and education (3/5 significantly different questions), clinical research (2/7), advertising and marketing (2/5), Evaluation (4/5) dispensing medication (4/4), pharmaceutical care (5/9), economic aspect (6/6) and ethics (2/2).

CONCLUSION

This study shows that there is a difference between pharmacists and pharmacy students about pharmaceutical ethics statements.

Ethical violations in the clinical setting: the hidden curriculum learning experience of Pakistani nurses

Background

The importance of the hidden curriculum is recognised as a practical training ground for the absorption of medical ethics by healthcare professionals. Pakistan’s healthcare sector is hampered by the exclusion of ethics from medical and nursing education curricula and the absence of monitoring of ethical violations in the clinical setting. Nurses have significant knowledge of the hidden curriculum taught during clinical practice, due to long working hours in the clinic and front-line interaction with patients and other practitioners.

Methods

The means of inquiry for this study was qualitative, with 20 interviews and four focus group discussions used to identify nurses’ clinical experiences of ethical violations. Content analysis was used to discover sub-categories of ethical violations, as perceived by nurses, within four pre-defined categories of nursing codes of ethics: 1) professional guidelines and integrity, 2) patient informed consent, 3) patient rights, and 4) co-worker coordination for competency, learning and patient safety.

Results

Ten sub-categories of ethical violations were found: nursing students being used as adjunct staff, nurses having to face frequent violence in the hospital setting, patient reluctance to receive treatment from nurses, the near-absence of consent taken from patients for most non-surgical medical procedures, the absence of patient consent taking for receiving treatment from student nurses, the practice of patient discrimination on the basis of a patient’s socio-demographic status, nurses withdrawing treatment out of fear for their safety, a non-learning culture and, finally, blame-shifting and non-reportage of errors.

Conclusion

Immediate and urgent attention is required to reduce ethical violations in the healthcare sector in Pakistan through collaborative efforts by the government, the healthcare sector, and ethics regulatory bodies. Also, changes in socio-cultural values in hospital organisation, public awareness of how to conveniently report ethical violations by practitioners and public perceptions of nurse identity are needed.

Ethics education for clinician-researchers in genetics: The combined approach

Advancements in genomic technology and genetic research have uncovered new and unforeseen ethical and legal issues that must now be faced by clinician-researchers. However, lack of adequate ethical training places clinician-researchers in a position where they might be unable to effectively assess and resolve the issues presented to them. The literature demonstrates that ethics education is relevant and engaging where it is targeted to the level and context of the learners, and it includes real-world based cases approached in innovative ways. In order to test the feasibility of a combined approach to ethics education, a conference was held in 2012 to raise awareness and familiarize participants with the ethical and legal issues surrounding medical technology in genetics and then to have them apply this to reality-based case studies. The conference included participants from a variety of backgrounds and was divided into three sections: (i) informative presentations by experts in the field; (ii) mock REB deliberations; and (iii) a second mock-REB, conducted by a panel of experts. Feedback from participants was positive and indicated that they felt the learning objectives had been met and that the material was presented in a clear and organized fashion. Although only an example of the combined approach in a particular setting, the success of this conference suggests that combining small group learning, practical cases, role-play and interdisciplinary learning provides a positive experience and is an effective approach to ethics education.

Education for values and bioethics

"Education for Values and Bioethics" is a project which aims to help the student to build his/her personal ethics. It was addressed to ninth grade students (mean age 14) who frequented public education in all schools of the City of Porto, Portugal-EU in 2010-2013 (N-1164). This research and action project intended to promote the acquisition of knowledge in the following areas: interpersonal relationships, human rights, responsible sexuality, health, environment and sustainable development, preservation of public property, culture, financial education, social innovation and ethical education for work. The students were asked to answer to a knowledge questionnaire on bioethics. To assess the values it was used Leonard Gordon's Survey of Personal Values and Survey of Interpersonal Values. The results of this study show that the project contributes to an increase of knowledge in the area of bioethics. Also the students enrolled in the program showed a development with regards the acquisition of the basic values of pluralistic societies. It is also suggested that this general knowledge on bioethics could be especially helpful to students that want a career in health sciences.

Ethics in neonatology: a look over Europe

Advances in perinatal medicine have dramatically improved neonatal survival. End-of-life decision making for newborns with adverse prognosis is an ethical challenge, the ethical issues are controversial and little evidence exists on attitudes and values in Europe.

OBJECTIVE

to assess the attitudes of the neonatal departments in perinatal clinical practice in the hospitals of European countries.

METHODS

a questionnaire was send to 55 NICUs from 19 European countries.

RESULTS

Forty five (81.8%) NICUs were Level III. Religion was Christian in 90.7% and we observed that in north countries the religion is more influent on clinical decisions (p = 0.032). Gestational age was considered with no significant difference for clinical investment. North countries consider birth weight (p = 0.011) and birth weight plus gestational age (p = 0.024) important for clinical investment. In north countries ethical questions should not prevail when the decision is made (p = 0.049) and from an ethical point of view, there is no difference between withdraw a treatment and do not initiate the treatment (p = 0.029). More hospitals in south countries administer any analgesia (p = 0.007). When the resuscitation is not successful 96.2% provide comfort care.

CONCLUSION

Our study reveals that cultural and religious differences influenced ethical attitudes in NICUs of the European countries.

A comparison of problem-based learning and conventional teaching in nursing ethics education

The aim of this study was to compare the learning effectiveness of peer tutored problem-based learning and conventional teaching of nursing ethics in Taiwan. The study adopted an experimental design. The peer tutored problem-based learning method was applied to an experimental group and the conventional teaching method to a control group. The study sample consisted of 142 senior nursing students who were randomly assigned to the two groups. All the students were tested for their nursing ethical discrimination ability both before and after the educational intervention. A learning satisfaction survey was also administered to both groups at the end of each course. After the intervention, both groups showed a significant increase in ethical discrimination ability. There was a statistically significant difference between the ethical discrimination scores of the two groups (P < 0.05), with the experimental group on average scoring higher than the control group. There were significant differences in satisfaction with self-motivated learning and critical thinking between the groups. Peer tutored problem-based learning and lecture-type conventional teaching were both effective for nursing ethics education, but problem-based learning was shown to be more effective. Peer tutored problem-based learning has the potential to enhance the efficacy of teaching nursing ethics in situations in which there are personnel and resource constraints.

Ethics education in neonatal-perinatal medicine in the United States

Neonatology is one of the specialties that has immensely benefited from advances in medical technology in the last few decades. These advances have paralleled the rise of the civil rights movements and wider recognition of individual rights. As a result, ethical decision-making has become more complex, involving patients, parents, members of the health care team, and society in general. This has created a need for formal ethics education in neonatal-perinatal medicine fellowship programs. In this article, we briefly explore the current published data on ethics education in pediatric residency and neonatal-perinatal medicine fellowship programs. Then, we discuss the questions an academic educator may face while developing an ethics curriculum in his/her medical institution. Finally, we present the ethics curriculum that we developed in our neonatal-perinatal medicine fellowship program.

Ethics-in-oncology forums

BACKGROUND

We developed an ethics curriculum for hematology/oncology fellows who had already learned medical ethics from medical school and residency programs. The goal of the ethics program was to train fellows in ethics issues specific to hematology/oncology; to raise awareness of ethical issues; and to teach fellows to write, edit, and publish reviews in specific ethical issues.

METHODS

Fellows learned to summarize expert opinions, to understand diversity in cultural concepts relating to ethics, and to crystallize their approaches to ethical dilemmas to selected oncology patients. Fellows were also trained to write ethics discussions in manuscript format, edit the manuscripts, and submit them for publication.

RESULTS

We hypothesized that fellows would learn ethics in oncology by recognizing and choosing an ethical dilemma from among patient population; reviewing the literature for a discussion of relevant ethical issues; presenting the case and facilitating discussion to an ethics-in-oncology committee; hearing faculty and peer input into their cases; and finally writing, editing, and publishing the deliberation. It also increased understanding of health systems management, a new competency required by the Accreditation Council for Graduate Medical Education for board certification.

CONCLUSIONS

Fellows' perceptions about the experience were positive. We recommend that other subspecialty programs consider this format for teaching ethics in their subspecialties.

The ethical education of ophthalmology residents: an experiment

PURPOSE

To demonstrate the effect of ethics education on a resident's ability to answer questions that relate to moral dilemmas and on the clinical evaluations of residents by faculty.

METHODS

The curriculum for the ethics education that was used for this study was designed by the author and consisted of 10 lectures of 1.5 hours each. Five residencies were included in the project. One residency received one lecture, two residencies received three lectures, and two residencies received 10 lectures. To evaluate the moral skills of the residents at the beginning of the course and at the end, the residents were given the Defining Issues Test (DIT-2) developed by James Rest, which involves answering standardized questions about four moral dilemmas. Faculty evaluations were completed before and after the ethics lectures were given. At the beginning of the ethics course, each resident was given a social survey that was designed to assess participation in community, religious, political, and societal activities as well as attitudes about these activities. All residents were also asked demographic information, including their age, gender, and year of residency.

RESULTS

The results of the DIT-2 taken before and after the ethics lectures were compared. No correlations were found in faculty evaluations of clinical performance of the residents before and after the course (P = .052). Associations between DIT-2 scores and questions on community and religion in the social survey were noted.

CONCLUSION

The finding that the effect of an ethics course on residents' ability to answer moral dilemmas did not achieve statistical significance should be accepted with the understanding that this was a first attempt at standardization of many variables, especially the format of the curriculum and materials used. The use of faculty evaluations to assess clinical performance needs to be standardized, and the faculty members need additional training to ensure validity of the results. The social survey was also the first attempt to assess an association between a resident's response to moral dilemmas, attending evaluations, and residents' opinions that relate to community, society, politics, and religion.

Helping medical students to find their moral compasses: ethics teaching for second and third year undergraduates

The paper describes a two week course that has been offered as a special study module to intermediate level (second and third year) undergraduate medical students at Dundee University Medical School for the past five years. The course requires students to research the various aspects of ethical dilemmas that they have identified themselves, and to "teach" these issues to their colleagues in a short PowerPoint presentation as well as to prepare an extended 3000 word essay discussion. The course specifically asks students not to disclose their own ethical positions, as these are probably still in formation and the objective is to promote critical thinking capacity in ethical and moral issues as a prelude to the development of practical skills in dealing with clinical problems. The course is easy to resource for the school and has received universally high evaluations from the students since its inception.

A residência médica em Pneumologia no Brasil

INTRODUÇÃO: A residência médica é um curso de pós-graduação considerado ideal para a formação de especialistas, e é regulamentada no Brasil pela Comissão Nacional de Residência Médica. OBJETIVO: Verificar o número dos programas e de residentes em Pneumologia, a situação dos credenciamentos e sua distribuição em instituições localizadas nas várias regiões do Brasil. MÉTODO: Foi analisada a relação de todos os programas na especialidade de Pneumologia fornecida pela Secretaria Executiva da Comissão Nacional de Residência Médica em abril de 2003, e foram revisados os critérios básicos para o credenciamento na especialidade determinados pela legislação em vigor. RESULTADOS: Observou-se que, dos 58 programas credenciados, 35 eram oferecidos em hospitais da região Sudeste e tinham 133 residentes, enquanto que na região Norte há apenas um programa credenciado, com 3 residentes. CONCLUSÃO: Apesar de todos os 58 programas estarem credenciados, há predomínio na região Sudeste. É necessário um trabalho conjunto entre a Comissão Nacional de Residência Médica e a Sociedade Brasileira de Pneumologia e Tisiologia, no sentido de orientar e disciplinar a criação de novos programas e de estabelecer o número de residentes necessários para as diferentes regiões do país.

[A bioethics curriculum for the pediatric residency program: experience of a university hospital]

BACKGROUND

Pediatric education should be fully committed to being humanistically as well as scientifically responsive to the needs of the times. Although interest in bioethical issues in clinical practice has increased, ethical problem solving is not usually taught in residency training programs.

OBJECTIVE

To describe the implementation of a bioethics training program in our department of pediatrics.

METHODS

We designed a program that took into account the difficulties that such a program might face: time constraints, inadequate training in ethics among medical staff and, sometimes, residents' attitudes towards a formal program.

RESULTS

Throughout the last four years, six to seven ethics sessions per year were scheduled. The contents included traditional topics in medical ethics (i.e. treatment refusal in adolescents or clinical trials involving minors) as well as issues that confront residents during their training (informed consent, confidentiality, etc.). These ethics sessions were based on clinical cases and were integrated into the existing meetings timetable (daily meetings from Monday to Thursday between October and June) and were prepared by the residents themselves.

CONCLUSIONS

The implementation of a bioethics component, using a modified case-based approach, in our pediatric residency program was satisfactory.

Examining ethics in practice: health service professionals' evaluations of in-hospital ethics seminars

This article reviews practitioners' evaluations of in-hospital ethics seminars. A qualitative study included 11 innovative in-hospital ethics seminars, preceded and followed by interviews with most participants. The settings were obstetric, neonatal and haematology units in a teaching hospital and a district general hospital in England. Fifty-six health service staff in obstetric, neonatal, haematology, and related community and management services participated; 12 attended two seminars, giving a total of 68 attendances and 59 follow-up evaluation interviews. The 11 seminars facilitated by an ethicist addressed the key local concerns of staff about the social and ethical consequences of advances in genetics and their impact on professional policies and practice. Seminar agendas were drawn from prior interviews with 70 staff members. During evaluation interviews, participants commented on general aspects that they had enjoyed, how the sessions could be improved, timing, the mix of participants, the quality of the facilitation, whether sessions should be more challenging, after-effects of sessions, and interest in attending seminars and contacting the ethicist in future. Participants valued the increased interprofessional understanding and coherent discussion of many pressing issues that addressed important though seldom discussed ethical questions. The seminars worked well in the different hospitals and specialties.