Teaching and learning in interprofessional ethics education: Tutors’ perspectives

Abstract

Background

Ethical dilemmas that arise in the clinical setting often require the collaboration of multiple disciplines to be resolved. However, medical and nursing curricula do not prioritize communication among disciplines regarding this issue. A common teaching strategy, problem-based learning, could be used to enhance communication among disciplines. Therefore, a university in southern Taiwan developed an interprofessional ethics education program based on problem-based learning strategies. This study described tutors’ experience teaching in this program.

Aim

To explore the phenomenon of teaching and learning in interprofessional ethics education for medical and nursing students from the perspectives of tutors.

Design

Phenomenological qualitative research.

Methods

Medical and nursing students completed a 6-week interprofessional ethics education program moderated by either physician or nurse tutors. At the conclusion of the ethics education program, all 14 tutors were invited to participate in focus group interviews. Among them, six tutors (three nursing tutors and three physician tutors) participated in additional individual interviews. All of the contents from the focus group interviews and individual interviews were recorded and transcribed. Using the phenomenological approach, the phenomenon of teaching and learning in interprofessional ethics education were generated.

Ethical consideration

The study was approved by the Institutional Review Board.

Findings

Three themes emerged from the tutors' teaching perspectives, including the instructor’s motivation to teach, the use of narrative case scenarios, and the emphasis on improving interprofessional ethics communication.

Discussion

Problem-based learning creates an interprofessional communication platform in interprofessional ethics education. The phenomenon of value convergence between tutors and students, between different students’ professions, and between different students’ professional maturities is observed.

Conclusion

Problem-based learning is an effective teaching strategy for creating a communication platform for interprofessional ethics education. Ethic curriculum should emphasize motivating instructor, use narrative case scenarios, and focus on interprofessional communication.

Keywords

Ethics education interprofessional education narrative problem-based learning instructor’s perspective

Introduction

Managing ethical dilemmas in clinical practice requires effective communication among multiple disciplines. Current nursing ethics education is focused on improving students’ moral decision-making and moral reasoning skills.^1–3 According to the National Academies of Practice (NAP), the role of the nurse in interprofessional health care is to communicate, coordinate, make decisions, and cooperate with different hospital professionals.⁴ Therefore, the goal of nursing ethics education should focus on interprofessional communication.

The World Health Organization (WHO, 2010) defines interprofessional education as “students from two or more professions learning about, from and with each other to enable effective collaboration and improve health outcomes.”⁵ In terms of educational goals, interprofessional education intends to equip students of different professions to understand each other’s professional scope, roles, responsibilities, and to promote communication and teamwork to protect patients’ health and safety.^6–13 Interprofessional communication practice is one of the core competencies for interprofessional education.⁵ In this study, interprofessional ethical education combines ethics education and interprofessional communication to create opportunities for interprofessional dialogue on ethical issues.

Problem-based learning is an interactive learning process that enables students from different disciplines to explore knowledge while promoting communication and discussion to achieve an educational goal.^6,11,14–16 It is routinely used to promote interprofessional communication.^8,10,14 When rich narrative case scenarios are added to problem-based learning, this further enhances students’ experience by simulating a complex real-world problem. Rich narrative case scenarios indicate the characters, time, situation, and important plot points in ethical situations through storytelling, which in turn recreates an authentic human experience and enhances students’ ethical reasoning skills.^14,17–19

Problem-based learning is a learner-centered approach moderated by professional healthcare tutors. Tutors play important roles as participatory observers, thinkers, and learners in the teaching process of problem-based learning by observing students from different educational viewpoints.^20–23,26 Competent tutors can create an environment suitable for learning by using language, mannerism, and expression to convey teaching information to meet curriculum objectives.^23–25 The teaching perspectives offered by different tutors can improve the curriculum design of interprofessional ethics and contribute to the effectiveness of interprofessional ethics education. The purpose of this study, therefore, is to explore the phenomenon of teaching and learning in interprofessional ethics education from the perspective of tutors.

Methods

Study Design

The phenomenological research method was used to describe, analyze, and explain the phenomenon of teaching and learning in interprofessional ethics education from the perspective of tutors. Based on phenomenology, the tutors’ teaching experience were described, analyzed, and summarized in the study. Researchers applied eidetic intuition—insight into the essence of the collected data—to describe the reality of student ethics communications as recounted by tutors.

Interprofessional ethics education curriculum design

An interprofessional ethics curriculum was designed by a team of instructors from nursing, medical, and philosophy at a university in southern Taiwan. This curriculum included interprofessional ethics curriculum objectives, narrative case scenarios, and problem-based learning methodologies. Narrative case scenarios were the original development of the curriculum and research team to facilitate interprofessional ethical communication between medical and nursing students. The resulting course lasted for 6 weeks with 2 hours per week. Narrative case scenarios were discussed during weekly session. There were two case scenarios. The first case was a patient being treated with Extra-Corporeal Membrane Oxygenation (ECMO) in the intensive care unit. Although the patient was critically ill and vital signs could hardly be maintained, the family insisted on saving the patient’s life, creating an ethical dilemma. The second case involved communication issues related to differing views of physicians and nurses on the method of dressing change and antibiotic use. These scenarios were created to ensure that physicians and nurses have different viewpoints, but not “opposite”, “against”, or “criticism”, to provide interprofessional learning. The teaching materials focused on professional values and decision-making directions on ethical issues to create a platform for discussion. Prior to the start of the course, tutors were required to participate in a workshop to learn the importance, educational purpose, and curriculum plans of this interprofessional ethics education course in order to achieve a teaching consensus.

Students enrolled in the course included 71 fifth year medical students who were enrolled in a 6-year medical education program and 90 nursing students who were in the final year of their program. All students (n = 161) were divided into 14 groups with equal representation of each discipline across groups. They did not pre-read case scenarios before class. A tutor was assigned to each group to moderate the group discussions of case scenarios.

Participants

A total of 14 tutors participated in this course, and all tutors (6 medical tutors and 8 nursing tutors) participated in focus group interview, so the focus group interview covered all tutors. There were ten female and four male tutors, all with more than 10 years of clinical and classroom teaching experiences. After the focus group interview, the researchers purposeful sampled the “good narrators” in the focus group interview. Purposeful sampling of good narrators is a commonly used sampling method in qualitative research. The main purpose is to provide richer research data. Six “good narrator” tutors (three nursing tutors and three medical tutors with only one being male) participated in additionally individual interviews. The focus group interview and the individual interviews lasted about 2 h.

The focus group and the individual interview guide

Interview guide included questions that encouraged tutors to share their observations on the communication and dialogue between medical students and nursing students participating in the course:

1. Please share your teaching experience in tutoring medical and nursing students in problem-based learning.

2. Please share what you have observed about the communication and dialogue between medical and nursing students.

3. Please share how you facilitate interactions between medical and nursing students.

Data collection and analysis

A member of the curriculum development and research team conducted the focus group interview and the individual interviews. The focus group interview and the individual interviews were recorded and then transcribed. The research team members first read each verbatim transcription in detail, coded meaningful words or phrases, and then categorized the codes to summarize common themes.^27–30 Finally, applied phenomenology to explain the phenomenon of teaching and learning in interprofessional ethics education for medical and nursing students from the perspective of tutors.

Rigor

The interviewer described the research purpose, research design, and protection of confidential information to participants before data collection, building trust with participants to obtain honest data, thereby establishing research credibility and dependability. Investigator triangulation was applied for data analysis to ensure that the findings reflected participants’ perspectives in order to achieve the confirmability. The credibility of the interviews, dependability of data collection, and the confirmability and coherence of data analysis promoted the rigor of the study.³¹

Ethical consideration

The study was approved by the University Hospital’s Institutional Review Board (IRB) before data collection to ensure research ethics such as informed consent, privacy, and respect (KMUH-IRB-20110089). During the informed consent process, it was ensured that participants were given sufficient information and voluntarily participated in the study without coercion or manipulation, in order to achieve the ethical consideration on respect. At the same time, maintaining the privacy of research participants was achieved by assuring research participants that their personal private information would not appear in public documents to avoid identification.

Findings

Three themes emerged from the verbatim transcriptions: instructor’s motivation, the use of narrative ethics case scenarios, and the emphasis on improving interprofessional ethics communication.

Theme 1. Instructor’s motivation: recognizing the importance of interprofessional ethics communication

Tutors were willing to participate in interprofessional ethics education courses and to guide the discussions of cases scenarios because they recognized the importance of interprofessional teamwork when approaching ethical dilemmas in the clinical settings. Tutors emphasized the importance of incorporating interprofessional ethics communication into students’ education programs, as illustrated in the following:

“Moral conflicts often occur between different professionals. Students learn from the case scenario discussions regarding potential situations of ethical conflicts they may encounter when working with different professionals. In this course, I can guide students in terms of how to communicate with other disciplinary, so that students learn to respect other’s perspectives and manage ethical conflicts. This provides opportunities for better collaboration between different professionals.” (3)

“When working in a hospital, effective communication between physicians and nurses is important. To do so, both physicians and nurses must have professional judgment and communication skills to share the information collected from patients. So the team members can work together to provide comprehensive care to their patients, which all starts with education.” (2)

“Without interprofessional training in students’ education programs, they may lack the ability to be effective team members upon graduation. Interprofessional ethics education provides students with the opportunity to learn the perspectives of other professionals so that they can practice as effective teamwork in the future. During this course, I could share my experience in handling ethical conflicts in the clinical settings with students.” (4)

Although the interprofessional ethics curriculum only spanned over 6 weeks, the impact on one student was evident by a tutor observing changes in a medical student’s behaviors during a clinical rotation. This provided an incentive for an instructor to modify her teaching strategies:

“Students can learn humanistic care from the interprofessional ethics course. After having completed teaching this course and observing the impacts on students, I am now considering that asking students to observe my communication with patients about difficult ethical decisions is a requirement of clinical teaching. I am so glad that a medical student who enrolled in this course demonstrated respect for patients' wishes and provided more humanistic care than those who did not take the course during their clerkships in the clinical.” (5)

Theme 2. The use of narrative ethics case scenarios

Tutors mentioned that the design of the ethics case scenarios should be conformed to students’ knowledge level and background. The first narrative case scenario regarding a patient undergoing ECMO in the intensive care unit proved to be a challenge for novice nursing and medical students. None of the disciplines had the opportunity to care for ECMO patients before the interprofessional ethics course. Although the discussion of the first ethical case focused on the ethical consideration of the meaning of life, tutors observed that students’ understanding of the intensive care unit and ECMO limited the discussion contents of their ethical thinking and ethical decision-making:

“The case scenario about ECMO is too difficult for students. Scenarios that students are more likely to encounter in the hospital should be used, and students’ abilities should be considered. This makes it easier for students to engage with their work and express their ideas.” (2)

However, some tutors mentioned that students could learn from the ECMO case scenario. Their view was that the problem-based learning teaching strategy was to establish autonomous learning. When students encountered unfamiliar ECMO issues, they would be encouraged to search for relevant information for self-learning:

“As students were not familiar with ECMO, they spent some time learning ECMO knowledge at first.” (5)

“As students had never seen or learned about ECMO, they were stimulated their interest in the discussions of ECMO.” (4)

Tutors specifically proposed that there should be no right or wrong answers in the design of narrative case scenarios. The second scenario involved an error in which a resident physician did not strictly follow aseptic technique when changing the dressing for the patient, which was corrected by a nurse. Tutors illustrated the need for no right or wrong answer:

“If there is right or wrong answer in the scenario, it leaves little platform for ethical discussions. The setting of ethical scenario issues should be based on moral conflicts in decision-making caused by different values between the two sides. Such conflicts are where communication is needed.” (2)

Theme 3. The emphasis on improving interprofessional ethics communication

Category 3.1. Equivalence in students’ educational background

Through interprofessional ethics education, students of different professions engage in ethical communication and learning; therefore, selecting learners with similar professional development is suggested to encourage dialogue. In this study, medical students entered the hospital for the first year of their clerkship compared to nursing students who had practiced in the hospital for 1 year. Therefore, in the first two classes of interprofessional ethics education, medical students could not effectively communicate with nursing students as they did not experience ethical dilemmas in the clinical setting:

“Nursing students with one year of clinical experience can share their views on nursing in the interprofessional ethics class. However, medical students are just starting their internships in the hospital. They cannot effectively communicate with nursing students in the first two classes.” (2)

“In the first two classes, the ability of nursing students to find information or explore the ethical situation of the case scenario is significantly better than that of medical students in professional preparation.” (4)

Dialogue improved over time as medical students began interning in the hospital. After the third interprofessional ethics class, medical students became more familiar with the clinical situation, and the two disciplines began to communicate and share their views on narrative ethics scenarios smoothly:

“Nursing students pay more attention to humanistic care in case discussions because they have practiced in the hospital. Medical students gain more clinical experience after two classes and can share their professional opinions. Then, the two sides can communicate effectively.” (5)

Category 3.2. Use of tutors’ group interaction skills

Medical students and nursing students did not know each other before the interprofessional ethics course. Especially in the first 2 weeks of the course, tutors needed to adopt group interaction skills to assist medical and nursing students in communication and learning due to the different dialogue backgrounds of the two disciplines. Tutors shared several skills used to promote group interaction:

• Praise and encouragement: “At the beginning, the students did not know each other, so I felt leading student discussions were also a challenge for a tutor. Therefore, no matter what questions the students raised, I would first praise them. Based on the student’s question, I then asked other students if anyone had considered this idea. Tutors need to have the skills to lead discussions.” (1)

• Do not criticize or show partiality to either side: “I would invite students to share their views. During the discussion, I would remind myself not to criticize students' thoughts.” (3) “I am a nursing instructor and I am only familiar with nursing students. I need to remind myself not to show partiality to either side during student discussions.” (1)

• Encourage discussion: “I had the narrative case scenario in my hand. The student read one sentence, then I read one sentence, but I read it in a more excited tone. Only when students feel different would they be interested in the discussion.” (G)

• Role play: “I asked students to engage in role-play conversation. Some played the role of medical personnel, and some played family members. Ethical decisions might be different after role swaps. When discussing the second scenario, there was a conflict of values due to the sterile dressing change technique. I let the students play the role of the patient. Students also did not want their health and safety to be jeopardized because doctors or nurses did not strictly adhere to sterile technique.” (4)

• Experience sharing: “I would share my clinical experience of similar ethical case scenarios to provide a reference for students and spark discussions between the two sides.” (3)

• Prepare before teaching and create the desire to understand another discipline’s perspective: “I (physician instructor) borrowed some nursing textbooks from the library before the interprofessional ethics class. Trying to understand what nursing education is now focusing on can help me improve the ethical communication between students' professions. I found that I never knew how my nurse partners were trained. I would create a desirable feeling for students to want to understand other professions during the discussion.” (G)

Discussion

Problem-based learning creates an interprofessional communication platform in interprofessional ethics education. Ethical values emphasize openness and respect for differing values. Unlike professional knowledge, which has consistent right and wrong standards, the diversity of ethical values often interferes with interprofessional communication in patients’ care. Diversity of ethical values refers to the phenomenon that different professions may have the similar or different ethical views on events in the work of the health care team. Respect for diversity of ethical values is important for interprofessional collaboration, as it avoids one-sided decisions that cause harm to patients or other team members.^10,14 Professionals should first maintain an open attitude towards multiple values, then share their views, and finally, produce a convergence of values. The purpose of the convergence of values is not to convince others, but to state one’s views in the process of communication and discussion, and then to respect different views so as to achieve broader understanding. Although this study has no prior knowledge of the values of teachers and students, through the interprofessional ethics education via problem-based learning strategy, the phenomenon of value convergence is observed.

1. The act of teaching promotes the convergence of values between tutors and students in different professions

Instructors’ attitudes affect students’ learning.^9,22,32 Although instructors understand the importance of interprofessional communication in the workplace, they seldom teach students from different disciplines. Through the interprofessional ethics education program, instructors realize their identity as interprofessional tutors, reflect on their values, practice their ideas through teaching, and then generate enthusiasm to learn together with students. Through the problem-based learning-teaching process, tutors achieve convergence of values with students in different professions through sharing their clinical experience of respect, communication, and collaboration. Tutors have their own professional backgrounds, but they are not often familiar with the background of students in other professions before interprofessional ethics education. Based on the results of this study, during the interprofessional ethics education program, a tutor began reviewing the other disciplines’ textbooks before class to understand the possible thoughts of the students with other professional background, demonstrating the possibility of value convergence.

Interprofessional ethics education creates a learning and growth platform shared by instructors and students in the process of teaching and learning.³³ The research findings suggest that after interprofessional ethics education, a tutor can reflect on teaching the students in the hospital and obtain positive feedback from humanistic care attitudes displayed by students, demonstrating the convergence of values between tutors and students. Moreover, since tutors are either physician tutors or nursing tutors when facing both medical students and nursing students, they will remind themselves not to show partiality to either side and respect students of different professions. Tutors’ enthusiasm and humanistic care attitudes are transmitted in the interprofessional ethics teaching process, which has a subtle influence on students and creates a friendly environment with empathy, care, and support for students.^22,32

2. Rich narrative ethics case scenarios promote the convergence of professional knowledge and ethical values between students in different professions

Rich narrative ethics case scenarios emphasize multiple viewpoints so each discipline can reach a better patient care consensus through communication and coordination.¹⁴ Medical and nursing students can gain an understanding of professional knowledge after reading relevant information within the rich narrative case scenarios. Following discussion, emphasis is placed in the context to achieve a convergence of professional knowledge and ethical care values.

The story in the first narrative case scenario takes place in an intensive care unit. The patient is undergoing ECMO. Neither medical students nor nursing students have clinical experience caring for ECMO patients in the intensive care unit. Although some tutors said that this teaching material did not conform to the educational level of the students, some tutors also observed that students could acquire professional knowledge through learning. Through the learning process of problem-based learning, students may learn about unfamiliar topics by themselves and engage in discussions from different professional angles to explore different ethics values in the ECMO scenario. Through this discovery, they can carry out the convergence of professional knowledge and ethical values.

The second narrative case scenario involves aseptic technique during a dressing change. Without following aseptic technique, students are faced with “right” or “wrong” questions. Some tutors mentioned ethical teaching material should try not to involve right and wrong issues in order to leave a platform for ethical discussions. However, as an instructor observed student discussions, nursing students explained in detail the importance of the aseptic technique to medical students and mentioned the training process of the nursing profession, thus winning the respect of the medical students. At the end of the course, medical students also took the initiative to share that they would respect and listen to nurses more when working in the hospital. From the results of the study, it could be seen that, regardless of whether students are familiar with the scenario setting, regardless of whether the scenario implies right or wrong correct answers, through the problem-based learning, the rich narrative ethics case scenarios promote the convergence of interprofessional knowledge and ethics values between medical students and nursing students.

3. Group interaction skills promote the convergence of values between students of different professional maturities

Similar professional maturity of students is a consideration for interprofessional ethics education because it is conducive to interprofessional ethical discussions. Although tutors believe that the gap in students’ professional maturity affects interprofessional dialogue, especially during the first two classes of this study, the findings of this study show that tutors’ group interaction skills may assist students at different maturities of professional development in dialogue. As the course time progresses, the values between students of different professional maturities will converge.

However, to promote more effective communication and discussions among students from different professions, it is suggested that the professional maturity of students participating in the curriculum should be considered.³⁴ The interprofessional ethics curriculum should be designed to avoid the gap of professional knowledge and to avoid impairing the original purposes of interprofessional respect, communication, collaboration, and learning. Therefore, it is recommended to add an ethical theory course into interprofessional ethics education to provide a basis for students’ ethical analysis and decision-making, it may help to narrow the gap in the degree of ethical knowledge between different professions and encourage interprofessional communication.³⁵

The interprofessional ethics education tutors used various group interaction skills such as praise, encouragement, and non-criticism, which can promote the interaction of students of different professional maturity levels, and at the same time convey positive and caring messages to students.³² Role-playing allows students to focus on the interactive process which promotes professional discussions. When students try to conform to the roles they play, their inner emotions will be wakened. The expression of real emotions allows students to recognize the viewpoints of different roles and leads to interprofessional dialogue. This is one of the ways to train empathy. Although the role-playing interaction skill can trigger discussion, tutors still should be careful not to let students’ emotions dominate the discussion process, and play an assisting role in a timely manner to guide students to focus on ethical analysis and decision-making to truly assist students in their learning.³⁶

Conclusion

Based on the research findings of the tutors’ reflections, and through students’ interprofessional communication, the phenomenon of value convergence between tutors and students, between different students’ professions, and between different students’ professional maturities is found. Although different professions have their own professional connotations and values, the unanimous purpose of a team is the holistic care of patients. If students can reduce misunderstandings and improve professional cooperation through interprofessional discussions and communications, they can go beyond a single professional perspective and create a sense of team identity. The result would be team members able to learn and grow together, avoid possible omissions in care, and provide complete patient-centered care.

This study also finds that an instructor who agrees with interprofessional ethics education goals, has enthusiasm, and has the skills to promote group interaction is an element of interprofessional ethics education. If interprofessional teaching materials can be closer to the education level of students or have no objective right and wrong answers, it can not only provide a platform for students to discuss with each other but also promote students’ interprofessional ethics communication and learning. As for the education level of the students, if maturities are similar, this can promote learning. Therefore, it is recommended that students involved in interprofessional education should consider gaps in professional maturity, for example, all students have already experienced hospital internships. However, this study shows that tutors’ group interaction skills can help narrow differences in educational maturities.

Although tutors are the facilitators of student learning, through the problem-based learning teaching method, students and tutors can draw closer to each other’s values on ethical issues through the process of instructor-student discussion. Both instructors and students play an important role in interprofessional ethics learning. Students are the main target of learning, while instructors are the catalyst for students’ learning in this process. Thus, instructors need to prepare for the interprofessional ethics class. An effective method for instructor preparation could be a teaching workshop. In the workshop, tutors can learn other views from different professionals, discuss interprofessional ethics teaching plans and the professional background of students participating in the course, develop instructor guides, and reach consensus regarding teaching methods.

Limitations

Some tutors believed that the 6-week interprofessional ethics course was not long enough to promote the growth of students’ humanistic care. The learning process for interprofessional ethics is such that it takes time for the skills be become established. With this in mind, this course provides an educational opportunity for interprofessional communication, and it is hoped that students will be able to respect and cooperate in future clinical work after 6 weeks of interprofessional ethics education learning.

Footnotes

Acknowledgements

Special thanks to the tutors who participated in interprofessional ethics education courses and accepted interviews.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Taiwan Ministry of Science and Technology (grant number NSC 101-2511-S-037-001-).

ORCID iD

Hsun-Kuei Ko

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