The impact of an ethics training programme on the success of clinical ethics services

Abstract

The interdisciplinary Hannover Qualification Programme on ethics consultation has trained hospital staff to operate clinical ethics services in their respective hospitals since 2003. To evaluate Hannover Qualification Programme, all former participants were contacted using an online questionnaire including four domains: status quo before attending Hannover Qualification Programme, present status, impact of Hannover Qualification Programme, future challenges. Research objectives were the long-term satisfaction with Hannover Qualification Programme and its impact on clinical ethics services. The response rate was 45% (167/369). Hannover Qualification Programme was evaluated as helpful and the responders were capable of applying their acquired skills. Most participants could contribute to the implementation of clinical ethics services. They were satisfied with Hannover Qualification Programme and with the degree of changes in their hospitals. In conclusion, clinical ethics education had long-term effects on trainees and on their respective hospitals. Problems were mentioned rather in the field of utilisation than with implementation or quality of clinical ethics services.

Keywords

Clinical ethics services ethics consultation ethics education ethics committee empirical study

Introduction

Over the past decade, clinical ethics services (CES) have been increasingly implemented in hospitals, using different types of ethics case consultation and organisational structures.^1–6 Several national and regional clinical ethics networks with varying services and goals were set up.^7–11 On a European level, the European Clinical Ethics Network (ECEN) for exchange, research and clinical ethics education was founded. In Germany, certification requirements for hospitals include some sort of clinical ethics support. Both standards and a curriculum for CES have been established.⁷ The Central Ethics Commission at the German Medical Association launched a recommendation in favour of CES.¹²

The introduction of CES has been accompanied by various training programmes to increase the competency building for committee members and/or to improve practical application of ethics knowledge for clinical staff in general.^3,13–19 However, a national US survey in children’s hospitals reported that on-the-job training for clinical ethicists was the most frequent form, and that only about a third endorsed a more formal training such as an intensive bioethics minicourse, mentoring by an experienced ethicist, or a relevant master degree.⁴ A major aspect observed in recent times has been the lack of financial and administrative support for CES (including education) in hospitals.^3–5,20 Some authors argue that for sustainable changes in clinical settings, apart from the pre-conditions for CES in the hospitals’ accreditation guidelines, a formal certification of clinical ethics consultants seems inevitable.^20,21

In Germany, the Hannover Qualification Programme (HQP) ‘Ethics Consultation in Hospitals’, an interdisciplinary programme for all professions working in health care, has been established in 2003. Details about this nationwide non-academic programme, which consists of basic and advanced modules, have been published recently.¹⁵ Its goal is to qualify health care professionals (primarily physicians, nurses, chaplains) by means of an academically profound and practice-orientated schedule as precursors to implement and run CES in their respective hospitals. It contains CES’ main tasks such as ethics case consultation (various techniques), institutional policies, and ethics training for hospital staff. The basic module provides knowledge and skills in clinical ethics, organisational ethics and ethics deliberation. It enables participants to develop individual strategies for implementing ethics consultation services in their institutions. Several advanced modules cover methodological trainings on basic knowledge and skills in facilitating a moral deliberation on the ward and thematic modules to intensify knowledge and skills about relevant ethical issues in hospital. Such topics include decision-making at the end of life, living wills and ethical issues at the beginning of life.¹⁵ Thirteen basic modules and 17 advanced modules took place until April 2011. There was a total of 430 attendants, some with repeated participations (n = 702).

In literature, empirical reports exist about the characteristics of CES in respect of the composition of CES’ members, tasks, mode of self-evaluation, financing and training frequency.^3,5,8,22,23 Some follow-up and empirical studies concerning ethics training for CES are reported, especially in psychiatric clinics.²⁴ However, to our knowledge there is no in-depth exploration of the impact a formal clinical ethics training programme has on the performance of CES in a hospital as such.

HQP was continuously evaluated after each module, formally by questionnaires and informally by oral feedback. The outcome showed very good results concerning participants’ satisfaction, didactics and organisation of the courses.¹⁵ Suggestions for improvement were continuously implemented in the following modules, and the programme was adapted accordingly. To evaluate the long-term impact of HQP on participants and to further develop the HQP itself, we asked all former participants (October 2003 until April 2011) to take part in an online survey. The follow-up of participants and their long-term experience with HQP as well as the schedule itself were the main focus of our research. Besides, our survey provided results on topics such as structures of CES, CES’ tasks, implementation problems, institutional aspects, evaluation methods, financing, and supplementary training sessions.

Methods

The online questionnaire comprised 27 questions, 12 of which were multiple-choice questions; all questions could be answered independently (Table 1). Respondents without a CES were guided to skip nine questions concerning present tasks, problems and the impact of their CES. We developed four content domains: (1) status quo concerning the implementation of CES before attending HQP, (2) present status after attending the programme, (3) general impact of HQP, and (4) future challenges. The survey was completed by socio-demographic data (professional background, size of hospital, ownership of hospital, holding regulations). The questionnaire was pretested by eight ethics committee members from different professional backgrounds who had not taken part in HQP so far, and was slightly revised accordingly.

Table 1

Structure and content of the online questionnaire.

Questionnaire	No.	Questions	Single/multiple answers
I. Status quo before attending HQP	(1)	Type of CES	Multiple
(2)	Who initiated participation in HQP?	Multiple
(3)	Reimbursement of fee	Single
(4)	Role of hospital accreditation for implementation of CES	Single (5-point LS)
II. Present status of CES	(5)	Type of CES	Multiple
(6)	Membership in CES	Single
(7)	Number of ethics consultations during preceding year	Single
(8)	Institutional policies developed during preceding year	Single
(9)	Ethics trainings during preceding year	Single
(10)	Ethics consultant position available	Single
(11)	Satisfaction with work of CES	Single (5-point LS)
(12)	Problems of CES	Multiple
(13)	Modes of evaluation of CES	Multiple
(14)	Change of communication in hospital	Single (5-point LS)
III. Impact of HQP	(15)	Attendance in module(s) of the programme	Multiple
(16)	Additional in-house training	Single
(17)	Degree of support by HQP	Single (5-point LS)
(18)	Manner of support by HQP	Multiple
(19)	Transfer into practice	Multiple
(20)	Changes in CES since participation	Multiple
(21)	Ethics resources used	Multiple
(22)	Confidence/competence of participants in … moderation of case consultations	Single (5-point LS)
… active participation in CES	Single (5-point LS)
… organising ethics trainings	Single (5-point LS)
… chairing a CES	Single (5-point LS)
IV. Future challenges	(23)	Options for networking among CES	Multiple
V. Socio-demographic data	(24)	Professional background	Single
(25)	Size of hospital (no. of beds)	Single
(26)	Ownership of hospital	Single
(27)	Regulations of holding	Single
VI. Free text box

HQP, Hannover Qualification Programme; CES, clinical ethics services; LS, Likert Scale.

Former participants of HQP were contacted via e-mail in April 2011. Twenty participants only had an institutional, not a personalised e-mail address. After three weeks, a reminder was sent out. Of the total 430 attendants of the programme (2003–2004/2011), 369 could successfully be contacted via e-mail. The response rate was 45% (n = 167).

The online survey was conducted in cooperation with Uniparkprogramme Software Package by Globalpark AG, Cologne, who safeguarded protection of anonymity and provided descriptive statistical analysis. We performed a two-tailed logistic regression analysis for multivariate testing by SPSS according to Pearson. We tested for correlations concerning the availability of an employed ethics consultant, participants’ satisfaction with CES’ work, professional backgrounds, number of hospital beds and ownership of hospital as independent variables. Significant results were depicted in cross tables and absolute numbers. Single or systematic missing items were excluded previously to avoid conglomerations. To improve the description, several items were dichotomised or categorized. The item “undecided” was excluded. The significance level was fixed as p < .05.

Results

Sample characteristics

Of the respondents, 78% had attended the basic module of the HQP, 53% one or more advanced modules, and 18% the network meeting (n = 165). Forty-eight per cent (26% once, 22% several times) had invited one of the instructors of the programme for an additional in-house training, 6% planned to do so; 46% made no use of this offer (n = 164).

The professional background of the respondents was: physicians 32%, chaplains 28%, nurses 25%, and others 19%, which was representative of total participation in HQP (Table 2). The respondents worked in hospitals of different ownership.

Table 2

Respondents’ professional background and size of hospital.

n	%
Studied cases	Professional background		166	100
		Physicians	53	32
		Chaplains	47	28
		Nurses	35	21
		Others	31	19
Number of hospital beds		164	100
		<1000	32	20
		501–1000	54	32
		351–500	35	21
		200–350	34	21
		<200	9	6

Status before attending the programme

Seventy-three per cent attended the programme on their own initiative, 19% were sent by their hospital managements, 13% by an already existing ethics committee (n = 166). The fee was fully or partly reimbursed by the institution in 84% (n = 166). Certification activities of the hospital were important for the implementation of an ethics service in 43% (19% “strongly agree”; 25% “agree”) (n = 166).

Present status

After participation in HQP, 135 respondents reported on a clinical ethics committee (CEC) compared to 88 before participation (n = 167) (Figure 1). The indicated number of available ethics consultants increased from 6 to 37, and the number of ethics forums/round tables from 18 to 27; the answers indicating the absence of any kind of CES decreased from 25 to 4, the number of currently planned CES's decreased from 47 to 9.

Figure 1

Types of clinical ethics services before and after participation in the qualification programme (n = 167).

Ninety-two per cent of the respondents were members of a CES (148/160). Eighty-four per cent of respondents had carried out ethics case consultations during the past year (n = 157) (Table 3). Eighty-two per cent of respondents had organised ethics education sessions (n = 156). Institutional policies were developed during the past year in 41%, 20% were planning to do so, 39% had none (n = 155). Furthermore, among the 84% of the respondents working within a holding structure, 21% reported holding ethics policies (e.g. for advance directives or education sessions) (n = 164).

Table 3

Tasks of CES in the course of the preceding year: number of ethics case consultations, completion of an institutional policy, organisation of an ethics training.

Ethics consultation	0	1–5	6–10	11–25	>25	Total^a
Number	25	86	27	11	8	157
Percentage	16	55	17	7	5	100
Ethics trainings	0	1–2	3–5	>5
Number	28	85	31	12	156
Percentage	18	54	20	8	100
Institutional policies	Yes	No	Present working state
Number	64	60	31	155
Percentage	41	39	20	100

Seven additional respondents skipped questions as no CES was available yet.

Employed ethicist

Twenty-six per cent of CES had installed some sort of formal position for an ethics consultant (n = 157) (Table 4).

Table 4

Position in charge of CEC administration (n = 157^a).

Position	n	%
Full-time position	5	3
50% position	11	7
Less than 50% position	14	9
Others	11	7
No position	116	74
Total	157	100

Seven additional respondents skipped questions as no CES was available yet.

There was a significant correlation between the existence of any form of position and the number of ethics case consultations (r = .414; p < .001); a significant correlation between such a specific position and the number of ethics trainings organised (r = .261; p < .05), but no correlation between the position and the drafting of institutional policies. Larger hospitals were more likely to set up some kind of position (r = .305; p < .001).

Impact of HQP

Curriculum of HQP

Eighty-nine per cent evaluated HQP as helpful (46% “very helpful”; 43% “helpful”), 9% were undecided, and 2% found it to be “less helpful” (n = 162). Concerning didactics, the respondents judged as “very helpful” the training of ethics case consultations in small groups (76%), the interdisciplinary team of instructors (71%), the exchange with other participants (67%), the plenum papers (58%), small group sessions (16%), and other items (3%) (n = 164). The group of chaplains correlates significantly with the positive acknowledgment of small-group works (r = .212; p < .05).

Practical consequences

Concerning the organisation of CES, 84% could fully or partly put their own ideas and considerations into practice. Twenty-two per cent judged that they could fully do so, 42% reported a practice transfer to some extent after a sound discussion process (n = 163). Twenty-four per cent could only partly transfer their ideas into practice as they were rejected. The respondents reported significant changes in their hospitals after attending the qualification programme, particularly an increase of ethics training sessions (38%), a reflection process on CES’s work and strategy (34%), more frequent CEC meetings (33%), increase of ethics case consultations (29%), the elaboration of CES statutes (29%), a change in the CES’s composition (19%) and others (start of evaluation, annual working plan, regular meetings with the hospital managers, inclusion of quality management, budget for CES) (n = 153).

Further training

HQP supported a continuous learning process in clinical ethics: 58% started to read books and papers on clinical ethics, 55% attended ethics conferences, 46% used the German internet platform (www.ethikkomitee.de), 46% used the internet for information about clinical ethics, 33% searched literature on the relevant ethics databases, 27% exchanged with other CES, 13% mentioned other topics (n = 164).

Effects on ethics case consultations

Another long-term effect of HQP was that former participants felt competent to moderate ethics case consultations (Figure 2). Active participation in CES, the organisation of training sessions and chairing CES, was deemed rather high (n = 167). There was no correlation between the self-assessed competence and the professional background. Physicians, nurses and chaplains felt equally well prepared for these tasks after participating in HQP.

Figure 2

After participation in the qualification programme: “I feel competent for …” (n = 167).

Participants’ assessment of own CES

Fify-nine per cent were satisfied (51% “content”, 8% “very content”) with the work of their CES, 21% were not satisfied (18% “not content”, 3% “very discontent”), 20% were undecided (n = 154).

There were significant positive correlations between satisfaction with the CES’ work, the number of ethics case consultations (r = .334; p < .001), and the number of ethics trainings organised (r = 359; p < .001) respectively, but no correlation between satisfaction and the drafting of institutional policies. Satisfaction with CES’ work did not correlate with the professional background of the participants. Thus, physicians, nurses and hospital chaplains similarly benefited from HQP.

Fourteen per cent had no major problems with their CES (n = 155). Problems specified included: too little publicity in hospital (55%), too few ethics case consultations (55%), lack of time (45%), reluctance of hospital staff members (25%), lack of support by hospital management (18%), too few education sessions (9%), and other reasons (12%).

Evaluation was performed by means of an annual report (53%), within the hospital’s annual quality management report (26%), and by other means (15%); 26% had no evaluation procedure (n = 155). Fifty-five per cent of the respondents reported that the mode of communication had improved (11% “strongly agree”, 44% “agree”), 19% did not notice any change; 26% were undecided (n = 153).

Networking

The survey revealed a strong need for networking among respondents. For future networking, the German internet platform (www.ethikkomitee.de) was considered to be important (64%); this also applied to online-counselling possibilities (50%) and network meetings both in Hannover (49%) and locally (47%) (n = 166).

Discussion

Effects of the HQP

A large majority of participants (89%) evaluated HQP’s different methods and interdisciplinarity as helpful. They felt competent for participation in CES, for its organisation, the moderation of case consultations and even, to a lesser degree, for chairing a CES. We found that during the proceeding year a high proportion had actually performed the main three CES tasks taught in HQP: ethics case consultation (84%), ethics training (82%), institutional policies (61%). In a UK national survey among 51 CES chairs, similar numbers for ethics case consultation and institutional policies were reported.⁵ In a Norwegian study, 30 of 31 CES had arranged hospital seminars with altogether 4400 participations, 26/31 were involved in ethics case consultation as well as in the drafting of guidelines.³ Even if some bias can be assumed because possibly the more motivated and successful participants were more likely to answer our questionnaire, we can draw the conclusion that – apart from other local supporting circumstances – the programme fulfilled its goal of enabling and motivating hospital staff to implement CES and offer case consultations. We have no information on how often and whether at all the respondents themselves used ethics case consultation.^25,26

It has been a major goal of the HQP from its very beginning to encourage and enable participants to find specific ways of CES implementation in their respective institutions. A large majority reported that they succeeded to do so. Ten to 38% of the respondents noticed changes in their hospitals after attending the programme in the sense of intensifying and optimising CES’ tasks and reflecting their work. More than half of the respondents noticed a change in the mode of communication about ethical issues due to the CES’ work. But we also found an apparent neglect of the institutional challenges which can often only be solved by institutional measures (e.g. guidelines, policies, management strategies). While ethics case consultations seem to have an apparently positive immediate effect for CES members, we have to stress in HQP that still in the long run it will frequently be the drafting of institutional policies or other institutional issues which can support changes in hospitals.^2,27

One focus of HQP has been to point out the importance of evaluating CES’ work. Seventy-four per cent of the respondents in our study had some form of CES evaluation (written or oral feedback) in their hospital. Slowther et al.⁵ reported 59% in the UK. However, though the necessity of quality control is widely recognized, and also taught in the HQP, we have to notice that the way it should be done properly is still much disputed in the literature.^16,23,28,29

As the HPQ stresses its interdisciplinary focus, it is noteworthy that there was almost no difference between the main three professional groups concerning the training methods. To some extent, hospital chaplains preferred small group work more than other professional groups, which indicated that interdisciplinary ethics training programmes should offer different teaching methods. However, we found no difference between the professional groups concerning the self-assessment of their competence after having taken part in the training. This confirms that the multiprofessional education programme contributes to all professional groups equally in becoming competent to provide ethics consultation in an active and self-assured manner.

Part of the HQP schedule is an introduction to the use of the internet for CES. As a high proportion of the respondents used the internet and a particular German internet platform for CES (www.ethikkomitee.de) to gain information about clinical ethics, future efforts could be focused on updated supply of helpful information and training for an efficient and reliable use. Some respondents even demanded online counselling opportunities. Examples from the US show that in exceptional cases ethics consultation by video conferences could be used successfully in rural settings.³⁰ Louhiala et al.⁹ promoted a Finnish web-based ethics consultation service which could supplement local CES work.

Follow-up of participants

In our study about the impact of formal ethics education on the subsequent development of CES, we found a high level of satisfaction of the respondents with their CES’s work. According to the results, participants’ satisfaction with their work increased significantly with the number of ethics case consultations performed and more education sessions organised during the preceding year. However, satisfaction did not significantly depend on the implementation of institutional policies. Dissatisfaction was mentioned rarely and referred to the CES’s present working methods or because the CES was not used enough in everyday clinical practice.

Financial matters

For the future, if profound changes in hospitals are sought to ameliorate moral distress of staff and patients, an even larger part of hospital staff needs to be trained and sensitised to ethical dilemmas and their possible solutions, though with varying intensity,³¹ all the more as during the last years another rather widespread dilemma has emerged in hospitals: the allocation of scarce resources, of course also affecting the CES budgets. It is noteworthy that nearly half of our respondents considered hospital certification guidelines as important for the implementation of their CES, and that in 84% of the respondents the fee for HQP was reimbursed by the respective institution. Slowther et al.⁵ reported that about 60% of CES in the UK receive trust financial support for external training. In a US study in paediatric hospitals, in 33% salary support and in almost 50% administrative support was available.⁴ Difficulties with a lack of formal training and the question of funding an ethics education programme are reported by various authors and are partly ascribed to a lack of regulatory requirements.^{3–5,16,21,32}

Nearly all respondents were members of a CES and at least a small proportion of 19% of the respondents reported some kind of formal position for CES in their institution. It could be shown that the existence of a position significantly raised the number of ethics case consultations and the organisation of ethics education (in-house and external). One might draw the conclusion that sustainable and satisfactory CES work can be supported considerably by installing some kind of formal position. Other studies confirm the substantial workload of CES and the subsequent need for financial and staff support to cope with the tasks decently.³

Contrary to other studies, we found that it was rather the larger hospitals which had an especially appointed position.⁴ The size of the hospital also had an influence on the number of case consultations and educational sessions organised. It is subject to discussion whether emphasising this aspect in HQP could intensify a regional networking between smaller hospitals, thus improving the quality of CES.

Limits of HQP

The format of HQP has certain limits: It can only qualify single persons among the hospital staff, and even if this is accompanied by in-house training, only a small proportion of the staff can be reached. HQP certainly has to be complemented and further supported by hospital management, including financial, educational and administrative resources.²⁰ It might also be worthwhile to reflect proposals to direct in-house ethics education to specific, morally significant areas, such as ICU or obstetric wards.⁶

Limits of the study

This study has certain limits: First, only participants with known e-mail addresses could be reached (369/430), including 20 with a non-personal e-mail address. Secondly, the respondents had varying time periods of CES experience since having taken part in HQP (ranging from 3 to 91 months). Thirdly, it can be assumed that there is a bias of respondents towards the more committed and successful participants. This could result in disproportionately high reporting of formal inhouse training, more positive reports about changes observed, and higher satisfaction with CES’ performance. Fourthly, HQP has to be judged as only one milestone among other ethics trainings and strategies. Fifthly, self-assessed competence needs to be judged carefully as it tends to be overestimated.³³

Conclusion

To conclude, HQP has long-term effects on former participants as far as the main topics of the programme are concerned. Beyond immediate approval for course content and didactics, most participants were able to apply the acquired knowledge and skills to their clinical practice. They felt well prepared and were able to contribute to the implementation of CES at their respective hospitals. In retrospect, a vast majority was satisfied with HQP itself, and with their skills and capabilities of applying the contents of HQP to case consultations and ethics education in the hospital. Practical problems were rather mentioned in the field of practical application (too little publicity, too few ethics case consultations, lack of time, too few education sessions) than in the field of implementation and self-assessed quality of the CES. These challenges are indicators of how to improve the qualification programme in the upcoming courses.

Footnotes

Acknowledgements

The Hannover Qualification Programme (HQP) is a cooperation between the four authors. The authors would like to thank Sabrina Johann for statistical support, Marie Danelski and Elin Scheel for proof-reading and Irene Leonhardt-Kurz for secretarial support.

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