|ORIGINAL RESEARCH ARTICLE
|Year : 2016 | Volume
| Issue : 1 | Page : 10-15
Learning professional ethics: Student experiences in a health mentor program
Sylvia Langlois1, Erin Lymer2
1 Department of Occupational Science and Occupational Therapy, Faculty of Medicine, Faculty Lead IPE Curriculum and Scholarship, Centre for Interprofessional Education, University of Toronto, Toronto, Ontario, Canada
2 Centre for Addiction and Mental Health, Toronto, Ontario, Canada
|Date of Web Publication||18-Mar-2016|
Department of Occupational Science and Occupational Therapy, University of Toronto, Rehabilitation Sciences Building, 160-500 University Avenue, Toronto, Ontario, M5G 1V7
Source of Support: None, Conflict of Interest: None
Background: The use of patient centred approaches to healthcare education is evolving, yet the effectiveness of these approaches in relation to professional ethics education is not well understood. The aim of this study was to explore the experiences and learning of health profession students engaged in an ethics module as part of a Health Mentor Program at the University of Toronto. Methods: Students were assigned to interprofessional groups representing seven professional programs and matched with a health mentor. The health mentors, individuals living with chronic health conditions, shared their experiences of the healthcare system through 90 minute semi-structured interviews with the students. Following the interviews, students completed self-reflective papers and engaged in facilitated asynchronous online discussions. Thematic analysis of reflections and discussions was used to uncover pertaining to student experiences and learning regarding professional ethics. Results: Five major themes emerged from the data: (1) Patient autonomy and expertise in care; (2) ethical complexity and its inevitable reality in the clinical practice setting; (3) patient advocacy as an essential component of day-to-day practice; (4) qualities of remarkable clinicians that informed personal ideals for future practice; (5) patients' perspectives on clinician error and how they enabled suggestions for improving future practice. Discussion: The findings of a study in one university context suggest that engagement with the health mentor narratives facilitated students' critical reflection related to their understanding of the principles of healthcare ethics.
Keywords: Consumer involvement, health profession education, personal narratives, professional ethics, student experiences
|How to cite this article:|
Langlois S, Lymer E. Learning professional ethics: Student experiences in a health mentor program. Educ Health 2016;29:10-5
| Background|| |
The teaching of professional ethics and behaviour is a critical element of educational programs for healthcare students, yet it is challenging to identify what students learn and how they understand these essential concepts. The evolving nature of patient-centred approaches to education is reflected in literature, where educators attempt to create authentic experiences to enhance learning. This paper will present findings of a study that explored the experiences and learning of students participating in a professional ethics module as part of a Health Mentor (HM) program. In this context, health mentors are individuals living with chronic health challenges who share their experiences with health science students to contribute to their professional learning.
Instruction in professional ethics and behaviour is considered a fundamental component in the education of health profession students., A variety of strategies for teaching ethics have been reported, including traditional didactic teaching of theoretical perspectives, narratives , clinical vignettes, standardized patients, students playing standardized patient roles, and film. Although the pedagogical strategies vary considerably, the common objective is to encourage students to develop a sense of commitment to patient wellbeing and to become empathetic, reflective practitioners able to address complexity and uncertainty. However, the challenge is for educators to identify an approach that is meaningful for students and produces enduring results that will be translated into future practice.
Typically, ethics courses refer to the four foundational principles of biomedical ethics originally identified in the work of Beauchamp and Childress namely autonomy, non-maleficence, beneficence and justice. Although the value of learning these principles is accepted, students report that the materials presented to them often fail to capture their attention and their instructors suggest that they do not seem to promote the introspection needed to transform behaviour. Educators can provide learners with a toolkit of skills required to respond to a multiplicity of ethical dilemmas they may encounter in practice; however, without the provision of opportunities for deeper learning afforded through the reflective process, integration of ethics principles may be limited.
Deeper learning is enhanced through reflection, a critical competency for health practitioners, that serves to inform the clinical reasoning and decision-making in day-to-day practice as well as in consideration of ethical dilemmas. Sobral suggested that enhanced reflection contributes to a more positive learning experience and to a greater appreciation of the meaningfulness of the encounter. The literature identifies key elements influencing the development of reflective capacity, including a supportive environment, realistic context, mentorship and group discussion. Enhanced ability to engage in critical reflection is essential to the process of transformative learning, where analysis of the meaning of an experience shapes new understanding and serves to guide future behaviours and decision-making.
One method to enhance the authenticity and to provide opportunities for deeper reflection is through the use of narrative., Narratives appear to have significant impact enabling the development of enhanced empathy, professionalism, trustworthiness and reflective practice. Authentic engagement in narrative through cognitive, affective and symbolic applications promotes transformation. Patients provide unique insights that foster student learning, whether through direct or written encounters.
To advance transformative and enduring learning in the area of professional ethics, enriched pedagogical approaches must be considered. This study explores the experiences and learning of health profession students in a professional ethics module as part of the Health Mentor Program where learners engage with individuals, discuss their perceptions in facilitated interprofessional groups and write a reflective paper.
| Methods|| |
This qualitative study involved an analysis of text data from reflective exercises and online discussions of student participants in the Health Mentor (HM) program.
The interprofessional HM Program at the University of Toronto was adapted from a program originally piloted at Thomas Jefferson University, Philadelphia. The HM program enrolled first year students from seven health profession programs and matched them (in interprofessional groups of five students) with health mentors from the community. Health mentors are individuals who have had multiple contact points in the health care system as a result of living with a variety of chronic health challenges. The four program modules included: (1) Chronic Health Challenge in Context; (2) Impact of the Chronic Health Challenge; (3) Ethical and Professionalism Issues; and (4) Patient Safety Issues. Students met with the health mentor as an interprofessional group for approximately 90 minutes on each of four occasions. Each module was guided by semi-structured interview questions developed in consultation with experts in the area. Following each encounter, students submitted a written reflection and participated in facilitated asynchronous online discussions to advance learning pertaining to the interprofessional communication and collaboration competencies, as well as the topic explored in the module.
Only the module on Ethics and Professionalism is described in this paper. Questions for this module were developed in consultation with two bioethicists practicing in hospital and community contexts. Interview questions explored respect, inclusion of the individual in the decision-making process, communication, perceptions of adherence to management plans, and professional and unprofessional behaviours experienced. The program coordinator oriented the health mentors and students to all required materials.
Subjects and study context
First year students participating in the Interprofessional Education (IPE) curriculum at the University of Toronto were invited to participate in the HM program and subsequently in the study. Information letters and consent forms were provided at an orientation session. All students participating in the HM program acknowledged reading the information letters and returned signed consent forms to the principal investigator ( first author). Initially, 118 students registered for the HM program. Over the course of four months, 27 students dropped out of the program, reporting scheduling challenges and workload concerns; none of the remaining students chose to discontinue their involvement in the study. The final sample for analysis of the Ethics and Professionalism module comprised 91 students [Table 1] that were matched with seventeen health mentors [Table 2].
The University of Toronto Research Ethics Board granted approval for this investigation.
Students' one page reflective papers were submitted to Blackboard, the university learning management platform. The research assistant collected these and text from the asynchronous online discussions from the Blackboard discussion board. All students completed a minimum of three posts, as required for program module completion. All identifying information was removed for analysis.
Qualitative data analysis
Braun and Clarke's  inductive thematic analysis approach was used to uncover themes pertaining to student experiences and learning from across the self-reflective papers and online discussions. The second author, who was not involved with the HM program, read the data set multiple times to familiarize herself with the content and to create a list of initial codes. The principal investigator read the data set independently and reviewed, revised and verified the coding schema. Through further close reading and discussion, differences in coding were reconciled. Together, the authors reviewed the coding schema and identified emerging themes. Ideas that reoccurred across the data set were identified as themes. Frequent consultation between the authors facilitated agreement of themes. The data set was re-examined to determine if further relevant information emerged. Following this step, themes were reviewed for internal homogeneity and external heterogeneity. Researcher reflexivity was addressed by monitoring views and values for their influence on the research process through writing of reflexive notes.
Assumptions included the belief that the use of a patient narrative would enable students to relate specific, 'real-world' examples to their understandings of ethics and professionalism and that interaction with a health mentor through the use of narrative would lend students to place a significant emphasis on the importance of patient autonomy in their reflections on ethics and professionalism.
| Results|| |
Five major themes pertaining to student learning and experiences of professional ethics through the health mentor interviews emerged from the data: (1) Patient autonomy and expertise in care; (2) ethical complexity as an inevitable reality of the clinical practice setting; (3) patient advocacy as an essential component of day-to-day practice; (4) qualities of remarkable clinicians informed personal ideals for future practice; (5) patients' perspectives on clinician error enabled suggestions for improving future practice.
Theme 1: Patient autonomy and expertise in care
Students viewed the value of autonomy as foundational to respect for patients' dignity, including concepts of independence and partnership. For example, …incidents such as these emphasize to me the need for healthcare professionals to focus on patient-centered care and to understand that the relationship is a partnership between the patient and the professional, and not one telling the other what to do and the other doing it without question.
Frequently, students referred to the patient as being the “expert” in his/her care. Students upheld the belief that the patient should be consulted and that he/she should be provided with as much information as possible to make informed decisions, which in turn validates their autonomy.
In one incident she advised a resident physician to wait before running X-rays on her daughter following her surgery. He thought she was completely out of line; when in fact she is the expert in her daughter's care and knows how she typically recovers following surgery. The supervising physician took this opportunity to teach the resident how important it is to listen to your patients and understand that they are the experts in their care; they know themselves best.
Theme 2: Ethical complexity as an inevitable reality of the clinical practice setting
Students explored ethical complexity and acknowledged that real life clinical scenarios can present complicated ethical dilemmas. Students discussed whether or not it is important to follow protocols and policies at all times. They concluded that protocols are written for general populations and that at times unique scenarios require a differing approach.
A professional must use discretion when following protocols, because they are designed for general patient populations and may not apply to special patients. When considering an individual patient, it's important to ask oneself how the protocol should be adapted to benefit the patient.
Students also reflected on the difference between persuasion and coercion and respect for patient autonomy.
…How far should the medical professional go in their attempt to influence the patient's decision? While it is important to recommend the best procedures to a patient, it is equally important to respect the patient's wishes, so when do the responsibilities of the medical professional end and the wishes of the patient begin…?
At times, students held opposing viewpoints regarding the ethical implications. The quotations below highlight differing responses:
When she voiced her concerns about the possible risks involved with the surgery, the neurosurgeon was honest and humble in saying that “when you deal with the brain, you never know what will happen. But I will do my best.” The turning point was when her neurosurgeon said to her “I have a wife who is about her age, if she had this brain tumour, I would tell her to have the operation
When (my health mentor) was explaining the situation of how the neurosurgeon told her about her options for surgery that seemed like it could be an ethical issue to me. It seemed like (she) didn't get much information about her condition and that surgery was a viable option. This may be just the way she conveyed it, but it seemed like the doctor almost said that there was only one viable option, and that was to have surgery. She said the way the doctor convinced her of this was not directly, but by saying, “If this were my wife, she would have the surgery.”
Theme 3: Patient advocacy as an essential component of day-to-day practice
Students emphasized the importance of empowering patients to advocate for themselves and the importance of being advocates for individuals when their concerns are not heard or needs not met. Students described the perceived relationship between providing sufficient information to patients and enabling them to advocate for themselves. They highlighted the importance of advocating for patients whose disabilities inhibited self-advocacy.
…I will speak up and advocate for my clients and let other healthcare professionals know that this is a very important concept, and displaying compassion and respect for the person's autonomy is crucial…
More broadly, they discussed the importance of advocacy in the community, advocacy to service providers and program administrators, and advocating for patients to colleagues within the healthcare team.
I would try to find out what kinds of support networks my client has in their community and what gaps there may be. I would try to connect him or her with a social worker or suggest support groups that may help with coping strategies for aspects of their illness.
Theme 4: Qualities of remarkable clinicians informed personal ideals for future practice
In their reflections, students focused on the professional qualities exhibited by health care providers. Students grasped the personal impact of unethical and unprofessional behaviour on the individual. Likewise, they also reflected upon what they had learned about the health care professionals that had made a memorable positive impact on the lives of the health mentors.
I think listening to the tone M.S. used when she described how important it was for her to feel respected by her physician will stay with me throughout my career. It was so crucial to developing a therapeutic relationship and I would not think M.S. would have gone through the whole journey as positively as she did if that relationship was not there. It was very apparent that the professionalism and respect that her healthcare team provided is integral to the healing process.
After having identified what they deemed to be desirable qualities and behaviours of health care professionals, students frequently made commitments to replicate the same attitudes and gestures in their own future practices. For example, after reflecting upon how a physician had validated a health mentor's concerns about an upcoming surgery, one student said:
While there may often be discordance between the patient's and my agenda, I will endeavour to always discuss the patient's hopes and fears and make it clear that although I may not understand where he/she is coming from, it is important to me to understand it to the best of my abilities.
Theme 5: Patients' perspectives on clinician error enabled suggestions for improving future practice
Health mentors were forthcoming with regard to both positive and negative experiences they had encountered, providing a unique opportunity for students to learn from the mistakes of practicing health care professionals. Inspired by the stories of their health mentors' negative experiences, many students made commitments to never make these errors in their own future practices. For example, following a health mentor's report of feeling frustrated with clinicians' impatience with her aphasia-related challenges, one student wrote:
My experience with interviewing …inspires me to be a more active listener …I think it will be important for me to develop a high sensitivity towards non-verbal communication such that I can more effectively work with patients with comprehension and speech disabilities to ensure that I am treating them with the dignity and respect that they deserve.
| Discussion|| |
This study on experiences of students participating in Ethics and Professionalism module with health mentors revealed interesting learning opportunities regarding patient autonomy, ethical complexities, advocacy, professional qualities and suggestions for future practice.
Students valued respect for patient autonomy, recognizing that this involved acknowledgment of the individual's viewpoints, opinions and ideas, even if these differed from those of the healthcare team. In addition, they emphasized the importance of helping clients maintain their autonomy in the face of disability. Students explored issues related to a sense of control, potential choices and the ability to make and have capacity for decision-making. These notions were also identified in a concept analysis of autonomy, where authors described the inter-relationship among the recognition of the person, their capacity to act and ability to take responsibility for actions.
Interestingly, students had emotional reactions to incidents of perceived violations of autonomy, which may contribute to greater “emotional engagement.” Engagement in the personal experiences of individuals has the potential to elicit an emotive dimension, and may serve as a catalyst for critical reflection and moral deliberation. As such, this emotive response may also contribute to a stronger patient-centred ethical approach through recognition of an individual's autonomy.
Ethical concerns in healthcare are becoming increasingly more complex, necessitating enhanced reflective capacity and application of critical thinking skills and decision-making principles. Without the ability to discern issues meaningfully for themselves, future practitioners will not have the ability to reflect on concerns and apply frameworks for more complex analysis. Bertolami  recognized the limitations of teaching values and suggests that educators should provide opportunities for students to develop their own values in the face of multiple viewpoints. In this study, engagement with a health mentor consistently elicited differing perceptions and ethical positions held by students. The importance of the disorienting dilemma, challenge of assumptions, and deeper critical reflection is essential to transformative learning, yet is clearly a limitation of much of traditional teaching of ethical principles. Engagement in health mentor experiences may play a role in enhancing ethical sensitivity and awareness, as well as the potential for the transformative learning.
Advocacy for patients, particularly when they are in vulnerable situations, is a critical foundational value for health practitioners. In their phenomenological case study on patient perceptions of patient-centred care, authors  described key themes of staff attentiveness, involvement and connectedness to individual concerns. Likewise, in this study, students discussed their personal connection to, and growing relationship with, their assigned health mentor. This relationship may have been instrumental in shaping their responses and consequent future desire to be attentive to patients, to promote patient rights, and to provide adequate information and accommodations to enable communication and decision-making.
Students recognized ideal characteristics of health providers through consideration of the impact on recipients. Clearly, role modelling creates a significant impression on professional development of students; however, learner engagement in the narratives of patients may provide an important additional dimension. Not only did these learners begin to describe the ideal characteristics of healthcare providers, they also documented an appreciation of the impact of perceived good and poor interactions on the patient and the provider qualities represented in the corresponding scenarios. While educators and clinicians are typically reticent to share their mistakes with new learners, heath care recipients can often provide fresh insights on impact of their decisions and behaviours to assist in informing future student practice.
Ethics teaching is mandated by most health profession accreditation bodies and educational programs, yet there is evidence in the literature to suggest that traditional pedagogical methods do not necessarily produce enduring results or translation of knowledge to future practice. Opportunities for students to enter into the experiences of patients should be explored further to determine if reported effects are enduring and impact future professional ethics in practice. Additionally, transformative learning, so foundational to changes in values and clinical approaches, is predicated on effective critical reflection; therefore, strategies to enhance reflective capacity at deeper critical levels in conjunction with learner engagement with narratives could be investigated further. As well, further investigations could explore the effects of different interview questions or constructs related to professional ethics. Since, the development of professional ethics among learners is not isolated to any single profession, pedagogical strategies to address interprofessional team approaches could be researched further.
This study had a number of limitations. First, it was conducted in one university and focused on a convenience sample of first year students enrolled in the HM program. Consequently, perceptions reported may not be transferable to other settings. Since only six of the 91 students involved in this study were male, there may be a gender bias in the reflections and online discussions. All data analysis was text-based data and could have been investigated more extensively and produced better interpretations. Subsequent interview data would also have permitted a deeper exploration of themes.
| Conclusion|| |
Despite these limitations, this study revealed that students did develop an appreciation for patient autonomy and considered ethical dilemmas in practice settings. Of particular note is student recognition of their responsibility to advocate for patients within the healthcare team and in the broader community. With enhanced understanding of the impact of good and poor professional behaviours on individuals, students voiced commitments to ensuring that they would practice in a manner where patients would have a voice. These findings could be explored further to investigate potential integration of patient experiences into teaching of professional ethics.
The authors wish to thank members of the Occupational Science and Occupational Therapy Writing Group for their helpful review of a previous draft of this paper.
Financial support and sponsorship
Educational Development Fund, University of Toronto.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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