Ethics education to support ethical competence learning in healthcare: an integrative systematic review - BMC Medical Ethics - BMC Medical Ethics
Forty articles were included for review to explore the available literature regarding ethics education for healthcare professionals and students in clinical practice. The results showed a widespread international distribution of studies. Most of the studies were conducted in the United States (n = 5) and Taiwan (n = 5). When dividing the articles into continents, 17 were from Asia, 14 from Europe, six from North America, and three from Australia. Table 3 shows the key themes and sub-themes identified through the thematic analysis.
Making ethical competence learning possible
Making ethical competence learning possible for managing ethical problems in clinical practice requires support. However, this support entails those certain conditions be met for learning in the organisation in which ethics education is conducted, including opportunities to plan the education. The design and content of education are governed by external structures and the way in which the learning objectives have been specified. To support learning, it is also important that education is designed to facilitate opportunities to receive and create meaning with respect to the information received, change one's own values and attitudes, and determine the consequences of one's own actions. Interaction with others is important since it can constitute a valuable source of knowledge, especially with respect to determining whether the individual healthcare professional or student has understood or done something correctly. Simultaneously, ethics education is influenced by both the healthcare professionals and the students who have different qualifications, expectations, and strategies for their learning.
The factors influencing the planning and organization of ethical education were discussed in 32 articles. Three sub-themes were identified: (1) creating conditions for learning, (2) designing strategies for learning, and (3) interacting with others.
Creating conditions for learning
A starting point for making ethical competence learning possible is to identify and shed light on the kinds of ethical problems that healthcare professionals and students in clinical practice are expected to be able to manage and to create conditions for this learning. Therefore, it is important that ethics education reflect the relevant conditions for ethical competence learning by using real work situations [36]. One way to create such conditions is to construct appropriate learning objectives that clearly describe what should be achieved in terms of knowledge, skills, approaches, and values to effectively manage ethical problems [37, 38]. However, the perception of what is relevant is influenced by healthcare professionals' and students' previous experiences of ethical problems in their everyday healthcare work. Limited experience entails a risk that the education will not be perceived as relevant, and that the educational content may be difficult to absorb [39].
Another condition that influences ethics education is the time available. Developing an ethical identity and creating meaning in discussions about ethical problems in everyday healthcare work takes time [37, 40]. Simultaneously, it might be difficult to predict how long, for example, group discussions may take to shed light on the various aspects of ethical problems [39]. There is thus a risk that the time will be too short and insufficient to finish the discussion, or that there may be too much time, thus causing the discussions to be perceived as less engaged [37]. Therefore, it is important that the time aspect be considered in the design of education.
Finally, it is essential to create conditions for psychological safety and confidence in ethics education, or, in other words, to enable opportunities to express opinions or make blunders without this leading to consequences for the participants [41]. Instead, trust between the participants should be emphasised and acknowledged in discussions about ethical problems in clinical practice [40, 42, 43]. Simultaneously, there is a risk that high staff turnover and frequent changes in management may limit opportunities for building trust through conversation [44]. Passive or absent healthcare professionals and students might also limit opportunities for establishing such trust, for example, in group discussions [45].
Design strategies for learning
Different design strategies make ethical competence learning possible, through which the healthcare professionals and students can be brought to ask questions, make comments, and talk about their previous knowledge or own experiences. Knowledge of, for example, ethical values can be gained through theoretical lectures and the reading of appropriate literature [46,47,48]. Simultaneously, it is valuable to design ethics education so that theoretical learning activities are integrated with practical ones and thereby provide an experience of real-life situations [46]. Skills can be practiced through workshops [49], case studies and problem-solving sessions [37, 43, 47, 48, 50,51,52,53]. Understanding one's own values and attitudes can be facilitated through, for example, role-play or simulation activities [54,55,56], narratives [40, 57, 58], storytelling [42] and discussions in small groups [38, 43,44,45, 47, 59,60,61,62]. Small group discussions are appropriate when healthcare professionals or students are unwilling to stand out by asking questions or giving individual opinions in learning situations in which many people participate [63].
There are also different educational technologies to consider in the design of strategies for ethical competence learning. For example, the internet makes it easier to deliver lectures and carry out exercises [64], as well as to discuss issues in groups with digital aids [59]. This means that ethics education can take place in the form of internet-based education where video conferencing technique is used. This technique is valuable when using external educators in a rural setting for example in rural-based hospitals [59]. This technique is also useful to stimulate discussions with other healthcare professionals or students who are outside their regular workplaces [59]. However, a prerequisite for internet-based education is that the workplace has the required learning resources such as reliable internet connection and video equipment [64].
Ethics education needs to be built on strategies that optimise the ability to achieve the desired learning objectives [48]. To achieve these objectives, it may be necessary to choose different design strategies [36]. However, the strategy that best supports the development of a "professional self" is difficult to determine, for example, in terms of its ability to influence healthcare professionals' and students' capabilities for moral sensitivity [47, 65, 66] and critical thinking [47]. Nevertheless, support and learning activities do not necessarily promote ethical competence learning. Instead, these activities can also lead to stagnation in the development of ethical competence [67, 68].
Interacting with others
An open atmosphere and interaction between participants are important in ethics education when sensitive issues are discussed [69]. Sometimes, it is difficult to express one's critical thoughts about ethical problems in everyday healthcare work, since relationships with others and cohesion between individuals can be affected and compromised [45, 57]. Simultaneously, there is a need for healthcare professionals and students to formulate their thoughts, feelings, and intentions about the ethical problems that they have observed themselves or heard about through colleagues [37, 38, 41, 43, 45]. Making ethical competence learning possible based on problem solving, interaction, and discussion of ethical problems in clinical practice can therefore be a support mechanism for healthcare professionals and students [37]. Learning together about issues that are perceived as ethically problematic can strengthen both the individual and their relationships with their colleagues [44, 52].
Simulation is a way of highlighting ethical problems that exist in interactions with other individuals, such as patients or family members [54]. Narrative groupwork is another way of highlighting and processing ethical problems [57]. Through a narrative, different perspectives can be made visible and lead to in-depth learning about ethically challenging work situations [58]. With group discussions, ethical problems can be viewed in different ways [59], which in turn can lead to improvements in dealing with such problems [44]. However, if group discussions are to lead to improvements, it is necessary that there be a willingness to discuss what is perceived as ethically problematic in everyday healthcare work [38, 45], as well as an interest in learning new approaches [37]. There is also a need for a welcoming climate in which the contradictions between different perceptions and attitudes can be balanced in a constructive way [43, 51].
Having awareness of one's own thoughts and perceptions
Ethical competence learning can help healthcare professionals and students in clinical practice direct their attention to ethical problems that they were not previously aware of. Such learning can involve unconscious attitudes, approaches, or emotions. These aspects influence how healthcare professionals and students react to ethical problems in everyday healthcare work.
The aspects that influence awareness of one's own thoughts and perceptions were discussed in 22 articles in terms of both educational design and the content of ethics education. Two sub-themes were identified: (1) visualising attitudes and approaches, and (2) experiencing emotional conditions.
Visualising attitudes and approaches
Being aware of one's own thoughts and perceptions in one's attitudes and approaches to circumstances such as a certain illness, patient, or event influence what is perceived as an ethical problem in clinical practice [41, 70]. One way of designing ethics education that facilitates the visualisation of ethical problems is to use a narrative approach [40, 57, 58]. Using narrative writing, one's own or others' attitudes and approaches to everyday healthcare work situations where ethical problems occur can be made visible [57]. Examples of such ethical problems are when honesty and respect for the patient are not demonstrated, or when the establishment of trust in the care encounter is lacking [57].
Another way to visualise one's own or others' attitudes and approaches when designing ethics education is to use learning activities based on problems or scenarios [48, 51, 52, 54,55,56, 64]. This ethical competence learning focuses on challenging and realistic situations, such as conflicts regarding informed consent or cases where tensions arise between the patient's wishes and needs in relation to professional norms [36]. Problem- or scenario-based learning stimulates healthcare professionals and students to learn and develop new understandings that allow them to manage ethical problems in their clinical practice [36]. Such learning could also create a means of engagement to discuss how ethical problems should be managed [64]. The visibility can also emerge by reserving time for ethical reflection and, in systematic forms, discussing ethical problems in everyday healthcare work [38, 43,44,45, 59, 70]. Attitudes towards a particular illness or patient, for example, govern our way of justifying the approaches used [70]. By highlighting how healthcare professionals and students think about and analyse their attitudes and approaches when designing ethics education, previous habits can be made visible and critically examined [44]. The visibility of attitudes and approaches promotes a process of change in one's own thoughts and perceptions [43, 45]. However, it is essential to consider that attitudes and approaches are complex, developed over time, and strongly influenced by the perceptions of individuals who are close to the healthcare professionals and students undergoing training in healthcare professions [36, 48]. Accordingly, ethics education to support ethical competence learning does not always lead to a change in how ethical problems are managed in everyday clinical practice [71].
Experiencing emotional conditions
Awareness of one's own or others' emotions influences what is perceived as an ethical problem in everyday healthcare work. Healthcare professionals and students in clinical practice encounter a variety of ethical problems in which they are either actors or observers. Depending on the prevailing circumstances on site and at a given time, ethical problems, and their significance, as well as their relevance, can be experienced differently. When designing ethics education, real experiences, such as incidents that are ethically challenging and witnessed by healthcare professionals or students, can be used in ethical competence learning [58]. Group discussions make it possible for all participants to hear different interpretations and reflections on the same situation [38, 45]. Furthermore, such discussions can draw attention to situations where care and treatment have been experienced as unethical, such as when the patients' concerns are not heard, or their needs are not met [61].
By imitating a realistic situation through simulation, healthcare professionals and students are given the opportunity to learn about real-life situations, apply ethical content in the situation, and experience different emotional states [56]. Educational content that highlights emotions, such as feelings of dependence, vulnerability, fear of abandonment, and a lack of control, gives healthcare professionals and students an opportunity to change their perspectives on factors such as caregiving and care-recipients [55]. Simulation can also be a way to raise awareness of other people's ways of feeling and experiencing specific work situations, regardless of whether they play the role of professional, patient, or family member [56].
Doing right by the patient's best interests
Healthcare professionals and students in clinical practice are constantly faced with ethical problems related to patients, their significant others, colleagues, and the work organization. Dealing with such problems primarily involves reasoning about what is right and good to make decisions about what needs to be done in a specific situation. However, doing right based on the patient's best interests can sometimes jeopardize the management of ethical problems since it could conflict with other patients' interest, which may not be ethically acceptable or legally permitted.
Those aspects influencing healthcare professionals' and students' capabilities to do right by the patient's best interests were discussed in 19 articles. Two sub-themes were identified: (1) managing emotions and tensions, and (2) managing different perspectives in the situation.
Managing emotions and tensions
Ethical problems can provoke strong emotions, such as anger, disapproval, and frustration [40]. These emotions, in turn, generate tensions, such as those between ethical values and legal principles in relation to how healthcare professionals and students in clinical practice perceive a particular situation [40, 51]. Therefore, it is essential that ethics education be designed to provide time and space for reflection. By reflecting together with others, thoughts and perceptions about these emotions and tensions can be verbalised [43, 72]. Ethics education should provide the opportunity to learn how to deal with emotions [40] and foster understanding of what is ethically 'right' or 'wrong' for the patient [45], which in turn influences the decisions made by healthcare professionals and students in clinical practice [51, 70]. Group discussion, for example in ethics seminar, is a way to reduce unethical behaviour [73]. There is, however, a difference between learning how to manage ethical problems in everyday healthcare work and how these problems are actually managed, since one's own inabilities or limitations may influence the outcome [62].
Managing different perspectives on the situation
In everyday healthcare work, healthcare professionals and students face several challenges in determining how to 'do the right thing' in situations that arise in their contact with patients and their significant others. Ethical problems can arise when two perspectives, such as an ethical and a legal perspective, collide, as would be the case when there is conflict between what is perceived to be best for the patient and the patient's right to self-determination [37]. There may also be a feeling of inadequacy in managing ethical problems in care situations [38] since there is rarely only one way to cope with the situation [51]. Therefore, ethics education needs to be designed in such a way that the content includes both medical and ethical reasoning when the care situation is to be resolved [70, 74].
The design of such training could consist of lectures that are combined with watching movies, playing games, and performing case analyses and group discussions [37, 47, 60, 65]. Through such training, an increased understanding of ethical problems can be gained [54, 72], for example, regarding the ways in which certain patients, events, and situations are to be viewed [37, 57, 65]. Ethical competence learning with a focus on 'thinking ethics' and problematising one's own capabilities to judge and act can be an eye-opener for healthcare professionals and students [72, 75]. This can strengthen the capability to identify certain situations and provide examples of instances where ethical values and norms have been violated [66].
Even if the design and content of ethics education focus on thinking about critical ethics, this does not necessarily mean that the degree of critical ethics thinking is influenced [47]. Prerequisites for ethical competence learning of how to manage different perspectives and do right by the patient's best interests are, among other things, that there is time for discussion, and that the educational content is perceived as useful [37]. It is also crucial that such learning be based on consideration and respect for different beliefs, so that ethical problems can be managed effectively in everyday healthcare work [43,44,45, 54].
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