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PubMed1999

Educating for interprofessional collaboration: teaching about values.

Effective interprofessional collaboration depends upon establishing understanding that respects differences in values and beliefs, and thus differences in response to the multiplicity of patient/client/user needs. To facilitate the latter, this article suggests that health and social care students need a formal knowledge of the meaning of values and the varieties of systems within which values are expressed. Students need especially to understand the genesis of their own professional value system and to recognize the gap that inevitably develops between the values of the professional and those of the society within which a professional may function. The conceptual framework that underpins the approach to teaching values to health and social care professionals advocated here is derived from key concepts identified from the literature relating to education for, and participation in, a democratic, multicultural, multifaith society. These are: tolerance, compromise and education for dialogue. Finally, it is suggested that professional educators must take seriously the tasks of educating for professional pluralism.

Cooperative Behavior↗

PubMed2006

Proto-professionalism and the dissecting laboratory.

This essay argues for medical students' dissection of cadavers because this activity offers medical students opportunities to have certain experiences and reflect on them in ways facilitating their development of mature medical professionalism at the time they enter clinical practice. Issues central to professionalism as we envision it are (1) cognitive abilities identified as reflective judgment and principled ethical reasoning as they are exercised in four practice domains and (2) learning to learn in medical settings. We argue further that a key feature of such setting is practitioners' having to deal with ill-structured problems, and so we identify their features and relate their management to the sophisticated cognitive and learning abilities required of medical professionals.

Anatomy↗

PubMed1990

Rewarding medicine: good doctors and good behavior.

Many patients think that there are shortcomings in the ethical dimensions of patient care, and research supports their view. In this issue of Annals, Erde suggests that physicians' incomes should depend on patients' assessments of their ethical behavior in much the same way that waiters' incomes depend on patrons' tips. Although Erde's solution is satiric, the problem is a serious one. The experiences and perspectives of patients regarding their own illness are undervalued by physicians. A truly patient-centered care demands that physicians elicit, understand, and respond to patients' perspectives. Tying physicians' pay to measurements of patient satisfaction is unlikely to dramatically improve the ethical quality of patient care as long as attention to the patient's perspective is seen as peripheral to "good medical care." Rather than relying on a single, easy "fix," we must re-examine all of professional development and practice. We need to choose persons for medical careers who will find patient-centered care rewarding; we need to provide such persons with training and socialization that underscores the value of personalized medicine; and we need to build institutions and systems that facilitate and reinforce patient-centered practice. The best ways to achieve these objectives are as yet unclear, but if we, as physicians, are offended by Erde's "modest proposal," then we must respond by proposing and implementing our own ideas about how patient care can become more humane.

Beneficence↗

PubMedDate not supplied

Professors and professionals: higher education's role in developing ethical dentists.

Both higher education and the dental profession must seek to develop dentists who can combine technical competence with sensitivity to ethical and social concerns. Dental education and the overall higher education experience should seek to produce a practitioner who continues to develop as an ethical professional through ongoing learning, experience, and reflection. In pre-professional education, this goal requires integration of disciplinary content with consideration of contemporary issues that often provide the context for clarifying values and ethical behavior. As the knowledge explosion continues to splinter higher education into specialties and subcategories, attention must be given to integrating the campus as a learning community that promotes an interdisciplinary focus on societal issues. Higher education faculty serve as models for students in demonstrating the responsibility to relate one's area of professional expertise to broader ethical and social concerns.

Cultural Diversity↗

PubMed2001

Clinical trials in developing countries: a review of the moral issues.

Several ethicists have raised criticisms of various placebo-controlled clinical trials conducted in developing countries between 1995 and 1998. This essay reviews and rejects the arguments that these trials violated basic canons of medical ethics, or constituted exploitation by scientists in advanced countries of subjects in developing countries. A uniform international standard for the evaluation of such trials is proposed, replacing the old standard of voluntary and informed consent with a more focused standard of uncoerced and undeceived consent.

Developing Countries↗

PubMed1993

Studying science in the context of ethics.

The authors describe their experiences in developing and introducing a course on responsible conduct at the Graduate School of Biological Sciences at the University of Texas Health Science Center at Houston. The paper covers issues involved with course faculty, course content and format, and evaluation. At least half of the course time focused on general or case-study discussions of the students and faculty about ethical problems raised in course readings or the students' research experiences. An important issue for institutions trying to encourage students to recognize, reason about, and understand ethical concerns is how the institution itself becomes aware of the ethical implications of its own unconsciously or explicitly stated policies. Such reflection among institutional leaders is critical to fostering the public trust necessary for a profession to sustain its right to self-regulation and its claim of authenticity.

Academic Medical Centers↗

PubMed1994

Values influencing neonatal nurses' perceptions and choices.

The purpose of this research was to identify the values influencing the nurses' perception and choice of behavior in a hypothetical clinical situation. The theoretical framework was Rokeach's theory on the nature of human values and value systems. A descriptive study using a mailed survey was conducted on a random sample of 331 members of the National Association of Neonatal Nurses. Data on individual nurse's values, perception of information, and behavioral choices were collected with an investigator-developed questionnaire consisting of a values scale, and an information scale and choice alternatives related to three hypothetical vignettes: a low-birthweight infant, an infant with chromosomal anomalies, and a chronically ill infant. Results of this study indicate that nurses identified a hierarchy of values related to their practice. Information related to infant characteristics was consistently most important; however, in uncertain situations, rules or external protocols had an increased influence on the behavioral choice process. The behavioral choice option with the greatest agreement was different for each situation. A consistently negative correlation between the options within each vignette indicates that nurses have clearly defined choice preferences. Model testing revealed a consistent relationship across the three vignettes between the variable being just and protocol, doing right and infant characteristics, and infant characteristics and the choice options (p < .05).

Adult↗

PubMed2006

Teaching the art of doctoring: an innovative medical student elective.

The authors describe a longitudinal third- and fourth-year elective, 'The Art of Doctoring', introduced in an attempt to counteract perceived frustration and cynicism in medical students at their home institution during the clinical years. The course goals aimed at helping students to develop self-reflective skills; improve awareness of and ability to modify personal attitudes and behaviors that compromise patient care; increase altruism, empathy and compassion toward patients; and sustain commitment to patient care, service and personal well-being. These goals were accomplished through introduction and development of five skill sets: learning from role models and peers; on-site readings of works by medical student- and physician-authors; self- and other-observation; self-reflective techniques; and case-based problem-solving. The course involved regular in-class exercises and homework assignments, as well as a personal project related to improving personal compassion, caring and empathy toward patients. Students also learned to use a coping algorithm to approach problematic clinical and interpersonal situations. Class discussions revealed three issues of recurring importance to students: loss of idealism, non-compliant patients, and indifferent, harsh or otherwise unpleasant attendings and residents. Quantitative and qualitative student evaluations overall indicated a generally favorable response to the course. Problems and barriers included attendance difficulties and variable levels of student engagement. Future directions for this type of educational intervention are considered, as well as its implications for medical education.

Altruism↗

PubMed2004

The professionalism movement: can we pause?

The topic of developing professionalism dominated the content of many academic medicine publications and conference agendas during the past decade. Calls to address the development of professionalism among medical students and residents have come from professional societies, accrediting agencies, and a host of educators in the biomedical sciences. The language of the professionalism movement is now a given among those in academic medicine. We raise serious concerns about the professionalism discourse and how the specialized language of academic medicine disciplines has defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors subsumed under the label of "professionalism." In particular, we argue that the professionalism discourse needs to pay more attention to the academic environment in which students are educated, that it should articulate specific positive behaviors, that the theory of professionalism must be constructed from a dialogue with those we are educating, and that this theoretical and practical discourse must aim at a deeper understanding of social justice and the role of medicine within a just society.

Curriculum↗

PubMed2002

Burnout and nurses' personal and professional values.

The research described in this article was a descriptive study for determining the relationship between the degree of burnout experienced by nurses working in Kocaeli (Turkey), and their personal and professional values. A questionnaire was developed by using information gained from the literature on this subject and from the Maslach Burnout Inventory. The questionnaire was delivered to nurses working in two different hospitals (State Hospital of Izmit and the Gölçük Sea Hospital) in Kocaeli. The sample group was formed from all nurses working in the two hospitals, of whom 160 participated in the study during December 1999 and January 2000. The results showed that nurses' personal and professional values play an important role in the degree of burnout they experience. Equality, altruism and aesthetics were ranked first by those experiencing high levels of emotional exhaustion, and freedom was a priority value for those with a low degree of emotional exhaustion. Freedom, altruism and truth were ranked first by those with prominent feelings of personal accomplishment, and equality and aesthetics were priority values for those with less feeling of personal accomplishment. All nurses, therefore, need to identify and clarify their own personal values, beliefs and assumptions about basic truths.

Adult↗

PubMed1994

Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development.

BACKGROUND: Little is known about the ethical dilemmas that medical students believe they encounter while working in hospitals or how students feel these dilemmas affect them. The authors examine how clinical students perceive their ethical environment, their feelings about their dilemmas, and whether these dilemmas erode students' ethical principles. METHOD: An anonymous mail survey was sent in 1992-93 to the 1,853 third- and fourth-year medical students enrolled at six Pennsylvania medical schools. The survey addressed whether students had encountered situations they felt were ethically problematic, their attitudes toward these situations, and their perceptions of their personal ethical development. Data were analyzed with logistic regression; respondents' comments were analyzed qualitatively. RESULTS: Of the 665 students (36%) who responded, 58% reported having done something they believed was unethical, and 52% reported having misled a patient; 80% reported at least one of these two behaviors. In addition, 98% had heard physicians refer derogatorily to patients; 61% had witnessed what they believed to be unethical behavior by other medical team members, and of these students, 54% felt like accomplices. Many students reported dissatisfaction with their actions and ethical development: 67% had felt bad or guilty about something they had done as clinical clerks; 62% believed that at least some of their ethical principles had been eroded or lost. Controlling for other factors, students who had witnessed an episode of unethical behavior were more likely to have acted improperly themselves for fear of poor evaluation [odds ratio, OR, 1.37 (95% CI, 1.18-1.60)] or to fit in with the team [OR 1.45 (1.25-1.69)]. Moreover, students were twice as likely to report erosion of their ethical principles if they had behaved unethically for fear of poor evaluation [OR 2.25 (1.47-3.45)] or to fit in with the team [OR 1.78 (1.18-2.71)]. CONCLUSION: The ethical dilemmas that medical students perceive as affecting them while serving as clinical clerks are apparently common and often detrimental, and warrant the attention of physicians, educators, and ethicists.

Adult↗

PubMed1997

Development and testing of the ethical reasoning tool (ERT): an instrument to measure the ethical reasoning of nurses.

Ascertaining the thinking of professionals as they are confronted with ethical practice issues is a prerequisite to understanding ethical decision making. Before researchers or educators can examine the effectiveness of various approaches to ethics teaching and learning, there is a need for reliable and valid tools to assess practitioners' cognition. A potential problem with the few measuring instruments currently available is the fact that they ask subjects to rank order existing lists of issues. This says little about an individuals' own thinking about ethical issues and may prompt thinking or responses which would not otherwise have occurred. This paper reports the results of a study to test the psychometric properties of a new instrument, the Ethical Reasoning Tool (ERT) that measures ethical reasoning of nurses. The ERT demonstrates a promising way to reveal unprompted ethical thinking about a practice dilemma, thereby clarifying 'real' versus 'assumed' professional reasoning. The tool allows nurse educators to identify areas of student learning/reasoning deficiency that can be addressed by educational interventions. The ERT also allows nurse educators to evaluate the effectiveness of nursing ethics study units in a trustworthy way.

Adult↗

PubMed2000

An ethical paradox: the effect of unethical conduct on medical students' values.

OBJECTIVE: To report the ethical development of medical students across four years of education at one medical school. DESIGN AND SETTING: A questionnaire was distributed to all four classes at the Wake Forest University School of Medicine during the Spring of 1996. PARTICIPANTS: Three hundred and three students provided demographic information as well as information concerning their ethical development both as current medical students and future interns. MAIN MEASUREMENTS: Results were analyzed using cross-tabulations, correlations, and analysis of variance. RESULTS: Results suggested that the observation of and participation in unethical conduct may have disparaging effects on medical students' codes of ethics with 35% of the total sample (24% of first years rising to 55% of fourth years) stating that derogatory comments made by residents/attendings, either in the patient's presence or absence, were "sometimes" or "often" appropriate. However, approximately 70% of the sample contended that their personal code of ethics had not changed since beginning medical school and would not change as a resident. CONCLUSIONS: Results may represent an internal struggle that detracts from the medical school experience, both as a person and as a doctor. Our goal as educators is to alter the educational environment so that acceptance of such behaviour is not considered part of becoming a physician.

Adult↗

PubMed1992

Measuring the ethical sensitivity of medical students: a study at the University of Toronto.

An instrument to assess 'ethical sensitivity' has been developed. The instrument presents four clinical vignettes and the respondent is asked to list the ethical issues related to each vignette. The responses are classified, post hoc, into the domains of autonomy, beneficence and justice. This instrument was used in 1990 to assess the ethical sensitivity of students in all four medical classes at the University of Toronto. Ethical sensitivity, as measured by this instrument, is not related to age or grade-point average. Sensitivity increases between the 1st and 2nd year and then decreases throughout the rest of undergraduate medical training, such that the 4th-year students identify fewer issues than those entering medical school. Students expressing a career choice of family medicine identify more issues than their peers. Several problems with the use of the instrument and the interpretation of the data were found. Nonetheless, these findings, if reproducible, are important and their meaning needs further discussion.

Beneficence↗

PubMed2005

Pathways of influence in out-of-school time: a community-university partnership to develop ethics.

If we wish to incorporate parents and community members as full partners in building character among youth, then the activities and programs in which youth participate during their out-of-school time are potentially important venues. This chapter describes how numerous agencies in a single community partnered with a university, with the help of the cooperative extension agent, to collect local data on how adolescents used out-of-school time, what they thought about right and wrong, and how well their own behavior comported with their understandings of what was right. Results indicated that surveyed youth characterized themselves as thinking more than acting in ethical ways. For instance, nearly half acknowledged having cheated on a test at least once in the past six months, although the vast majority thought that cheating was wrong. The three pathways the community identified for reaching youth were (1) extracurricular activities at school such as sports, yearbook, and pep club; (2) organized nonschool pursuits such as music, dance, hiking, and biking; and (3) religious activities. They found that nearly 90 percent of high school-aged respondents participated in one or another of these venues.

Adolescent↗

PubMed1993

The ethics objective structured clinical examination.

OBJECTIVE: To develop objective structured clinical examination (OSCE) stations to assess the ability of physicians to address selected clinical-ethical situations, and to evaluate inter-rater agreement in these stations. DESIGN: Two ten-minute OSCE stations were developed using video-taped encounters between attending physicians and standardized patients. One scenario involved a daughter requesting a do-not-resuscitate (DNR) order for her competent mother without the mother's knowledge; the other involved a competent elderly woman requesting not to be re-intubated if her congestive heart failure worsened. The scenarios were evaluated using foreign medical graduates taking an OSCE. Each candidate was scored on his or her interaction with a standardized patient in the two OSCE stations by two independent observers. PARTICIPANTS: Eight attending physicians from the Division of General Internal Medicine at the Toronto Hospital were used to develop the OSCE stations, and 69 foreign medical graduates taking the University of Toronto Pre-Internship Program OSCE were used to evaluate the stations. RESULTS: The inter-rater reliability coefficients for the DNR and intubation scenarios were 0.79 (95% CI 0.69-0.87) and 0.75 (95% CI 0.62-0.84), respectively. For the DNR station, the scores of the two examiners, on a scale of 0 to 10, agreed exactly for 34 candidates (50%), within one mark for 59 candidates (87%), and within two marks for 65 candidates (96%). For the intubation station, the scores of the two examiners agreed exactly for 27 candidates (40%), within one mark for 56 candidates (84%), and within two marks for 63 candidates (94%). CONCLUSIONS: The authors produced ethics OSCE stations with face and content validity and satisfactory inter-rater agreement. Ethics OSCE stations may be suitable for evaluating the ability of medical students and residents to address selected clinical-ethical situations.

Analysis of Variance↗

PubMed2006

Developing and evaluating professionalism.

Professional behaviour, being one of the domains of professionalism, is an area of medical education that has long been of concern to medical educators. At Hacettepe University, our main goal is to have students become conscious of professional identity, values, responsibilities and the physician-patient relationship. We welcome our new students with an opening ceremony on their first day and two months later, the students start the course called "Health-Illness Concepts and Medical Professional Identity". Students are expected to discuss the subjects given to them as scenarios or arguments. The aim of our study is to determine whether the course leads to a positive change in students' attitudes, indicating the attainment of those attributes that reflect professionalism. On the first and the last days of the course, a questionnaire was delivered to the students. Any positive change in preferences between the two questionnaires is identified as an achievement of that attribute. As a result we found that in all of the seven attributes there were positive changes in the students' attitudes. Positive changes varied from 48% to 84% and all were statistically significant. Using more interactive techniques helped the students to make larger percentage changes in their awareness of these professional attributes.

Adult↗

PubMed2005

Toward ethical approaches to the inclusion of peers with disabilities.

What would it mean for program leaders and caregivers to shape the thinking of typically developing youth toward their peers with disabilities in a way that we could regard as ethically sound? The author weaves examples from his research in settings such as Girl Scout troops and Boys and Girls Clubs as well as his own parenting experiences to answer this question. He has found that it is commonplace for program leaders, coaches, and others to avoid direct discussion or acknowledgment of the disabilities of children in their groups, in the mistaken belief that this is the best way to demonstrate that all children are equal and to avoid the perception of discrimination. His interpretation is that this is not a product of thoughtlessness but of caring staff and volunteers who believe they are doing the right thing--the ethical thing--by avoiding acknowledgment of individual differences. Disabilities--even when they are readily apparent--are treated as if they were invisible. Rather than giving disabilities the "silent treatment," the author challenges us to go beyond the prevailing ethos and find ways to build on naturally occurring opportunities to learn more about individual needs and supports.

Adolescent↗