Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review

This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics support approaches are available, how they are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a “bottom-up” perspective might give healthcare personnel opportunities to think and reflect more than a “top-down” perspective. A “bottom-up” approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a “top-down” approach risks removing such moral responsibility.     

Trainee to trained: helping senior psychiatric trainees make the transition to consultant

PURPOSE: To describe the contents and results of a series of annual fora for senior psychiatric trainees in New Zealand. These fora were designed to address a perceived gap in the training of psychiatrists in non-clinical skills. PROCEDURES: The contents of the fora are described, and qualitative and quantitative feedback from participants is reported, These data were gathered from participants for the purposes of quality improvement, using questionnaires designed for this setting. Issues addressed included participants' self-ratings of gains in knowledge, as well as their ratings of tutor effectiveness, the forum overall and the extent to which their needs were met. Qualitative feedback included suggestions for improvements and identification of key learning gains. MAIN FINDINGS: There was an increase in understanding in all topic areas as assessed by the participants. In addition, participants made unanticipated gains in confidence and their sense of empowerment. The opportunity to meet with peers and the increased sense of collegiality were valued. Suggestions for improvements were incorporated into fora held in successive years. PRINCIPAL CONCLUSIONS: Non-clinical skills can be taught successfully to senior trainees in a forum setting, which can also facilitate development of peer support and empowerment. More time for practice and discussion of how the teachers coped with challenging situations would improve the forum. It is recommended that such non-clinical skills also be incorporated into the teaching of senior trainees in the workplace.     

Educational assessment of general practice experience for psychiatric trainees

Eighteen psychiatric trainees spent 6 months each as general practice trainees. The educational impact of the experience was assessed by a self-assessment questionnaire, a semi-structured interview and a videotaped interview with a psychiatric patient. Each assessment was conducted at baseline and after 12 months. A control group of 14 trainees was recruited from the same rotation. On the self-assessment questionnaire, the study registrars rated their abilities to solve general medical problems significantly improved compared to controls. They had also acquired greater understanding of the limitations of their knowledge and their legal responsibilities towards their patients. The semi-structured interview failed to distinguish between the two groups. Videotapes for rating at baseline and follow-up were available for only 17 of the trainees. Assessment of the tapes used the Maguire Scale and the Interview Behaviour Scale. Neither scale demonstrated any intervention effect. The interviews were all characterized by a preponderance of 'closed psychological' and 'checking-out' questions. It appears that psychiatric trainees' interviewing styles had not been influenced by the experience. This study suggests that psychiatric trainees gain greater confidence in their role as a doctor and greater understanding of the scope and nature of general practice by such an attachment. It is unclear whether or not supplementary interviewing skills had been acquired which were not utilized in the taped interview, which conforms very much to traditional psychiatric examination behaviour. Trainees were reassured that they had increased their knowledge without losing any of their specific professional skills.     

'It's a cultural expectation…' The pressure on medical trainees to work independently in clinical practice

Context Medical trainees demonstrate a reluctance to ask for help unless they believe it is absolutely necessary, a situation which could impact on the safety of patients. This study aimed to develop a theoretical exploration of the pressure on medical trainees to be independent and to generate theory‐based approaches to the implications for patient safety of this pressure towards independent working. Methods In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase 2, 36 in‐depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. Results Participants conceived that the pressure towards independence in clinical work originated in trainees’ desire to lay claim to the identity of a doctor (as a member of a group of autonomous high achievers), and in organisational issues such as heavy workloads and constant evaluations. Discussion The identity and organisational issues related to the pressure towards independence were explored through the lenses of established theories from education and psychology. Consideration of Lave and Wenger’s situated learning theory suggests that giving attention to the ‘independent doctor’ ideal, through measures such as involving trainees when their supervisors ask for help, could impact the safety of teaching team practice. Amalberti et al.’s migration model explains how pressures to maximise productivity and individual gain may cause teaching teams to migrate beyond the boundaries of safe practice and suggests that managing triggers (such as workload and high‐stakes evaluations) for violations of safe practice might improve safety. Implementation and evaluation of these theory‐based approaches to the safety of teaching team practice would contribute to a better understanding of the links between trainee independence and patient safety.     

The impact of evidence-based education on a perinatal capacity-building initiative in Macedonia

CONTEXT: The perinatal mortality rate (PMR) in Macedonia is among the highest in Europe. The World Bank supported a consultant (HEJ) to collaborate with a Macedonian team to develop a national perinatal strategy with the goal of reducing the PMR. Education was given priority in the form of a hospital-based initiative to develop the capacity of health professionals to introduce evidence-based perinatal practice into 16 participating hospitals. A "train the teachers" approach was used, with trainees introduced to modern education and clinical practice in Sydney and subsequently supported to train their colleagues in Skopje. OBJECTIVES: To describe the development, implementation and evaluation of the educational intervention. METHODS: A curriculum, based on specific Macedonian needs, was developed in order to integrate teaching in the knowledge, skills and attitudinal domains of learning, using small group, interactive techniques. Twenty-five Macedonian doctors and nurses participated in 4-month (phase 1a) and 6-month (phase 1b) teaching programmes at a tertiary perinatal unit in Sydney. Australian staff conducted 4 2-week modules for 36 trainees in Macedonia (phase 2). The phase 1 trainees conducted 8 modules for 57 colleagues in Skopje (phase 3). The intervention was evaluated by trainee questionnaires, assessments of competence, changes in hospital practice and pre- (1997-99) and post-intervention (2000-01) comparisons of PMR. RESULTS: A total of 115 doctors and nurses graduated from the programme. Positive responses to the education programme exceeded 80%. Evidence-based practice in 16 participating hospitals (covering 91% of all Macedonian births) was verified in 6 key areas of neonatology. The PMR fell significantly from 27.4 to 21.5 per 1000 births (RR 0.79, 95% CI 0.73, 0.85). The early neonatal death rate in babies weighing over 1000 g fell by 36%. CONCLUSIONS: The intervention has increased the capacity of Macedonians to practise best-evidence perinatal medicine and improve outcomes. Sustainability is predicted by the "train the teachers" approach, with concurrent strengthening of the infrastructure and organisational framework.     

Management of somatic presentations of psychiatric illness in general medical settings: evaluation of a new training course for general practitioners

An improved teaching package is described which aims to help general practice trainees manage somatized presentations of psychological distress. The package comprises a training videotape in which a reattribution model is demonstrated, with material for role-play of new skills and small-group video feedback of consultations. Eighteen general practice trainees attending an 8-week course in psychiatry participated fully in the somatization management teaching programme. The teaching package was evaluated by blind rating of general interview skills and model specific skills demonstrated by trainees during 10 to 15-minute clinical interviews with professional role-players. Ratings were made on pre-training and post-training videotaped interviews. A significant improvement was demonstrated in general interview skills. Improvements were also noted in specific reattribution skills post-training. The evaluation revealed that skills in the model can be effectively learned, and that improvements in the package have resulted in its improved efficacy.     

Paradigm shift, metamorphosis of medical ethics, and the rise of bioethics

Both the increasing incorporation of medical technology and new social demands (including those for health care) beginning in the 1960s have brought about significant changes in medical practice. This situation has in turn sparked a growth in the philosophical debate over problems pertaining to ethical practice. These issues no longer find answers in the Hippocratic ethical model. The authors believe that the crisis in Hippocratic ethics could be described as a period of paradigm shift in which a new set of values appears to be emerging. Beginning with the bioethics movement, the authors expound on the different ethical theories applied to medical practice and conclude that principlism is the most appropriate approach for solving the new moral dilemma imposed on clinical practice.     

Developing an outcome-focused core curriculum

BACKGROUND: Many UK medical schools have modified their curricula to meet the requirements of the General Medical Council and other external agencies. In particular, efforts have been focused on increasing integration and reducing factual overload through the definition of a core curriculum. Various approaches to curriculum change have been adopted in an attempt to meet such demands. PURPOSE: This paper describes a curriculum development process, which commences with a clear vision, adopts an outcome-based approach and identifies clear statements of learning outcomes. The process led to the development of an outcome-focused core curriculum structured around clinical problems, which is available to all students and staff. CONCLUSION: A model of curriculum development has evolved which is relatively simple in concept, and appears to be easy to comprehend by students, teaching staff and visitors from other institutions. It provides a practical framework for managing the difficult problems of integration and factual overload. It should be of general interest and applicability to other schools with health professional programmes looking for a realistic and acceptable way of defining a core curriculum.     

Trialling a new way to learn clinical skills: systematic clinical appraisal and learning

AIM: To describe and evaluate the effectiveness of a new method of teaching clinical skills designed to increase students' active and self-directed learning as well as tutor feedback. METHODS: A total of 22 consenting Year 4 medical students undertaking general practice and general surgery clinical experience were involved in a pre- and post-test research design. In the initial period of the study, students were taught clinical skills in a traditional manner. In the second phase a clinical teaching strategy called systematic clinical appraisal and learning (SCAL) was utilised. This learning strategy involved active and self-directed learning, holistic care and immediate feedback. Students independently saw a patient and were asked to make judgements about the patient's potential diagnosis, tests required, management, psychosocial needs, preventive health requirements, and any ethical problems. These judgements were then compared with those of the clinical supervisor, who saw the same patient independently. Students recorded details for each consultation. Comparisons were made of the two study periods to examine whether the use of SCAL increased the number of students' independent judgements, perceived student learning, tutor feedback and self-directed learning. RESULTS: During the SCAL learning period, students reported making a greater number of statistically significant independent judgements, and receiving significantly increased tutor feedback in both general practice and general surgery. The number of learning goals set by students was not found to differ between the two periods in surgery but significantly increased in general practice in the SCAL period. Students' perceptions of their learning significantly increased in the SCAL period in surgery but not in general practice. During the traditional learning period in both settings, there was limited student decision-making about most aspects of care, but particularly those relating to prevention, psychosocial issues and ethics. CONCLUSIONS: The SCAL approach appears to offer some advantages over traditional clinical skills teaching. It appears to encourage active and independent decision-making, and to increase tutor feedback. Further exploration of the approach appears warranted.     

Ethics in the clinic: a comparison of two Dutch teaching programmes

This paper compares ethics programmes in clinical education in two medical schools in the Netherlands. Ethics education in the University of Maastricht is case oriented, whereas the emphasis in ethics teaching in the Catholic University of Nijmegen is focused on the methods of ethics and moral reasoning. The general objectives, format and evaluation are discussed. Both programmes assume that in clinical decision-making normative and technical issues are intertwined; if a normative dimension is intrinsic to medical practice itself, students should learn during clinical training how to explicate and evaluate the moral quandaries of their profession. The positive characteristics of the Maastricht programme (student-centred approach, relevant cases, team-teaching of ethicist and clinician), if combined with those of the Nijmegen programme (a coherent theoretical framework and method for case analysis and interpretation), would create a new, powerful model for clinical ethics teaching. In a recent report such a model is advocated for all Dutch medical schools.     

C.A.R.E.: an approach for teaching ethics in medicine

Various societal factors have contributed to an increase in the ethical dilemmas faced by physicians, yet limited formal training in ethical decision-making is provided for those practitioners during their medical education. The pluralistic nature of contemporary medicine seems amenable to the development of common clinical and educational approaches to ethical dilemmas. The authors propose one such framework--a four question approach called C.A.R.E.--that encourages physicians at all levels of training to acknowledge individual and collective factors that enter into ethical decision-making. These questions are clearly described, and examples for use of the model in teaching settings are also provided. The authors believe that this approach can have significant utility in medical education and clinical settings, and advocate for its use and evaluation.     

Vaccines--but not as we know them: an ethical evaluation of HPV vaccination policy in Australia

Objective: To show how systematic ethical evaluation of public health policy may reveal issues of moral significance for critical examination. Method: Using Australia's human papillomavirus (HPV) vaccination program as an exemplar and adopting an approach outlined elsewhere, we determine whether conditions of effectiveness, proportionality, necessity and least infringement, and public justification, are met such that any breach of autonomy or justice principles associated with this intervention can be defended. Conclusions: While the HPV vaccine itself may be efficacious, some aspects of the program lack sufficient moral justification and raise concerns around procedural and social justice and gender equity. Implications: Public health interventions deploying new technologies against new targets – such as vaccines against cancer and chronic illness – require approaches crafted to their specific risk‐benefit profiles that have carefully considered the ethical issues involved. Systematic ethical reflection is a useful tool for this.     

Improving the psychiatric skills of the general practice trainee: an evaluation of a group training course

Fourteen general practice trainees took part in a course specifically designed to improve their psychiatric interviewing skills. The trainees were instructed in the problem-based model and were taught in a group setting with the use of videotape feedback. A significant improvement was demonstrated in the trainees' ability to identify psychiatric illness accurately, and there were significant changes in their interview behaviours after training. Those who were below average before training showed the greatest improvement. The implications of these findings are discussed. Group video feedback training is as effective as one-to-one video feedback training in improving the psychiatric interviewing skills of GP trainees, and could be more widely employed in general practice vocational training.     

Teaching interviewing with simulated patients

The use of social-work students as simulated patients for teaching interviewing to general practice trainees, is described. The results of analysing the video-tape feedback for one such patient, with a small group of trainees, are given to illustrate the method used.     

Educational impact of in-training assessment (ITA) in postgraduate medical education: a qualitative study of an ITA programme in actual practice

Objectives To investigate the experiences and opinions of programme directors, clinical supervisors and trainees on an in‐training assessment (ITA) programme on a broad spectrum of competence for first year training in anaesthesiology. How does the programme work in practice and what are the benefits and barriers? What are the users' experiences and thoughts about its effect on training, teaching and learning? What are their attitudes towards this concept of assessment? Methods Semistructured interviews were conducted with programme directors, supervisors and trainees from 3 departments. Interviews were audiotaped and transcribed. The content of the interviews was analysed in a consensus process among the authors. Results The programme was of benefit in making goals and objectives clear, in structuring training, teaching and learning, and in monitoring progress and managing problem trainees. There was a generally positive attitude towards assessment. Trainees especially appreciated the coupling of theory with practice and, in general, the programme inspired an academic dialogue. Issues of uncertainty regarding standards of performance and conflict with service declined over time and experience with the programme, and departments tended to resolve practical problems through structured planning. Discussion Three interrelated factors appeared to influence the perceived value of assessment in postgraduate education: (1) the link between patient safety and individual practice when assessment is used as a licence to practise without supervision rather than as an end‐of‐training examination; (2) its benefits to educators and learners as an educational process rather than as merely a method of documenting competence, and (3) the attitude and rigour of assessment practice.     

Toward a procedure for integrating moral issues in health technology assessment

OBJECTIVES: Although ethics has been on the agenda in health technology assessment (HTA) since its inception, the integration of moral issues is still not standard and is performed in a vast variety of ways. Therefore, there is a need for a procedure for integrating moral issues in HTA. METHODS: Literature review of existing approaches together with application of various theories in moral philosophy and axiology. RESULTS: The article develops a set of questions that addresses a wide range of moral issues related to the assessment and implementation of health technology. The issues include general moral issues and moral issues related to stakeholders, methodology, characteristics of technology, and to the HTA process itself. The questions form a kind of checklist for use in HTAs. CONCLUSIONS: The presented approach for integrating moral issues in HTA has a broad theoretical foundation and has shown to be useful in practice. Integrating ethical issues in HTAs can be of great importance with respect to the dissemination of HTA results and in efficient health policy making.     

Improving the psychiatric skills of established general practitioners: evaluation of group teaching

Ten established general practitioners, eight of whom were also trainers, took part in a course designed to improve their psychiatric interviewing skills. Participants were instructed in the problem-based model with audiotape and videotape feedback of real consultations in a group setting. Although those attending were experienced practitioners with a particular interest in the management of psychological problems, evaluation demonstrated a significant improvement in their skills after training. It is suggested that trainers could be trained to provide a similar teaching experience for their own trainees.     

A pragmatist approach to clinical ethics support: overcoming the perils of ethical pluralism

In today’s pluralistic society, clinical ethics consultation cannot count on a pre-given set of rules and principles to be applied to a specific situation, because such an approach would deny the existence of different and divergent backgrounds by imposing a dogmatic and transcultural morality. Clinical ethics support (CES) needs to overcome this lack of foundations and conjugate the respect for the difference at stake with the necessity to find shared and workable solutions for ethical issues encountered in clinical practice. We argue that a pragmatist approach to CES, based on the philosophical theories of William James, John Dewey, and Charles Sanders Peirce, can help to achieve the goal of reaching practical solutions for moral problems in the context of today’s clinical environment, characterized by ethical pluralism. In this article, we outline a pragmatist theoretical framework for CES. Furthermore, we will show that moral case deliberation, making use of the dilemma method, can be regarded an example of a pragmatist approach to CES.

     

Acquisition of communication skills in postgraduate training for general practice

PURPOSE: The evidence suggests that a longitudinal training of communication skills embedded in a rich clinical context is most effective. In this study we evaluated the acquisition of communication skills under such conditions. METHODS: In a longitudinal design the communication skills of a randomly selected sample of 25 trainees of a three-year postgraduate training programme for general practice were assessed at the start and at the end of training. Eight videotaped real life consultations were rated per measurement and per trainee, using the MAAS-Global scoring list. The results were compared with each other and with those of a reference group of 94 experienced GPs. RESULTS: The mean score of the MAAS-Global was slightly increased at the end of training (2.4) compared with the start (2.2). No significant difference was found between the final results of the trainees and the reference group. According to the criteria of the rating scale the performance of both trainees and GPs was unsatisfactory. CONCLUSION: The results of this study indicate that communication skills do not improve in a three-year postgraduate training comprising both a rich clinical context and a longitudinal training of communication skills, and that an unsatisfactory level still exists at the end of training. Moreover, GPs do not acquire communication skills during independent practice as they perform comparably to the trainees. Further research into the measurement of communication skills, the teaching procedures, the role of the GP-trainer as a model and the influence of rotations through hospitals and the like, is required.     

Audit and summative assessment: two years' pilot experience

An audit project has been submitted by all trainees in the West of Scotland since 1992 as part of a pilot process for summative assessment. The impact of 2 consecutive years of audit was assessed on 117 trainees in May 1994. A response rate of 89% was achieved. For 82 trainees (79%) this was their first practical experience of audit and as a result of it 85% felt more confident in introducing change to their next practice. Protected time was still a problem for the majority (53%) and one-third wanted more help from their trainer. Thirty trainees (29%) had attended four or fewer formal practice meetings in their 10 months of training, with 10% never having attended one. The previous trainee's audit project was rarely or never discussed with 70 trainees (87%) and only 12 trainees were evaluating changes recommended. An audit project as part of summative assessment may be encouraging trainees to think about change after they leave their training practices. Few, however, are evaluating change and protected time and support are still required. The marking of the summative assessment audit project may need to address this.