Introduction
The need for education of Healthcare Ethics Committee (HEC) members has been recognized for several decades.Footnote 1 Indeed, as far back as 1994, chaplain and ethicist John Fletcher and health-law scholar, Diane Hoffmann, found that HEC member education was largely informal (self-taught).Footnote 2 Similarly, a 1999–2000 national survey of United States hospitals found that only 5% of individuals conducting clinical ethics consults (CECs) had completed a bioethics-related fellowship or graduate program, while the others either learned from formal onsite training (41%) or independently without formal supervision (45%).Footnote 3 A subsequent 2017–2018 survey portrayed a similar landscape of educational and training attainment while CECs are mostly conducted by health professionals trained in other areas—for example, medicine, nursing, social work, and chaplaincy.Footnote 4 Challenges in providing education for HEC members are manyfold.Footnote 5 Among the most recurrent challenges include geographic accessibility and scheduling accessibility. Healthcare does not take breaks for scheduling convenience, and in recent years, the challenges of COVID-19 have exacerbated the work-life demands of professional health providers worldwide.Footnote 6 Tailoring one’s work schedule around course demands may not be feasible, and taking leave to pursue education may not be possible professionally. Furthermore, in our program’s experience, many of our HEC members have been removed from formal academic settings for many years and find the prospect of reentering the classroom intimidating. In addition to these key elements, we would be remiss to fail to mention the issue of affordability. Most HEC members serve on a volunteer basis to provide ethics services for their institutions. Becoming educated in order to better serve in this (normally volunteer) institutional role of ethics resource should not require they also assume significant personal out-of-pocket expense. While we understand that tuition must be both region and institution specific, we believe it important to remain cognizant of the need for affordability if the field wants to promote greater access to bioethics education for HEC members.
Recognizing these challenges, the Regional Ethics Department (RED) of Kaiser Permanente Northern California (KPNCAL) and Washington State University’s Elson S. Floyd College of Medicine (WSU) partnered to create a clinically oriented Certificate in Medical Ethics (Certificate Program) for healthcare professionals serving on HECs. The Certificate Program is a two-semester postbaccalaureate professional certificate that emphasizes the skills and knowledge needed for HEC members to serve as the “frontline” in addressing ethical issues related to patient care. Although the program does not “certify” individuals to be fully independent ethics consultants, the Certificate Program is meant to enhance basic competencies to identify salient moral issues, their application to common cases, and to apply basic moral concepts and tools of normative reasoning.
For KPNCAL, the Certificate Program reflects RED’s mission to enhance the practice of clinical ethics throughout the region by offering educational content directly related to the work of KPNCAL HEC members. It exists because we need it to exist; our students are the same individuals the department relies on as frontline responders for ethics consultation. For WSU, the Certificate Program exists as part of the University’s Land-Grant Mission, which WSU defines as: “committed to the principles of practical education for all, scholarly inquiry that benefits society, and the sharing of expertise to positively impact the state and communities.”Footnote 7 We believe our model is promising for health systems and educational institutions with similar missions in many regions.
This article will describe our methodology for providing clinical ethics education and training to non-ethicist healthcare professionals. Our target audience is primarily HEC members, but also includes other health professionals for whom ethics is salient to their practice. We also describe adaptations to Certificate Program delivery made in response to the pandemic. Finally, through a discussion of survey results examining feedback received by Certificate Program alumni, we will provide insights into the key elements of educational programs for HECs.
The certificate program
The Certificate in Medical Ethics was conceived and designed to translate the study of medical ethics to the practical demands and limitations of HEC members. Our design emphasizes the following:
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• Specificity of education: As described above, our program emerged from the recognized need to improve the quality of clinical ethics work by HEC members trained in other disciplines. An important aspect of this specificity of education is the Practicum, which is described in much greater detail below.
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• Appreciation for student circumstance: One reoccurring concern from prospective students for our program is the time commitment on top of their already full schedules. The Certificate Program is designed around this concern, and we are able to directly address our students’ availability needs through our balanced asynchronous and synchronous approach to education, coupled with individualized approaches to scheduling. For example, holding synchronous meeting when it matches our students’ best availability rather than when it matches the faculty’s best availability, or adjusting the curriculum itself, such as including a pediatric ethics focus when we have a significant number of pediatricians as students.
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• Affordability: The key to affordability has been to emphasize the program’s contribution to WSU’s land-grant mission, improving the quality of health services through the education of community clinicians and HEC members. To this end, tuition is set to the standard graduate tuition rate for WSU’s Global Campus: for academic year 2023–2024, this is $652.40 per credit hour. Kaiser Permanente employees receive a discount negotiated to reflect the value of KP ethicists teaching the clinical portions (approximately 1/2) of the program. As the 12-credit program is evenly divided between two six-credit semesters falling into different calendar years, the program has been fully reimbursable for most students under their institution’s tuition reimbursement program.
Methodology and pedagogy
The Certificate Program’s students are, first and foremost, healthcare professionals. Our program is specifically designed for their education, recognizing challenges in their availability, their specific interest in clinical ethics (as opposed to more theoretical reflection on bioethics) and their goals for taking their education forward into their daily work.
Two core values underlie our program. First, that the study of ethics is inherently valuable in medical contexts. Healthcare is intrinsically a normative endeavor, seeking to benefit patients, increase quality of life, and mitigate pain and suffering. Healthcare is also intrinsically social, involving at minimum patient and provider. Given these essential features of healthcare, the study of how normative values apply in the social context of medicine—medical ethics— is itself fundamentally valuable in the medical context. Although our students frequently enter the Certificate Program with a very practical desire for us to “teach me to do a consult,” we do not sacrifice the philosophic foundation of clinical ethics, devoting significant class time to theory.
The second core value is the importance of methodology. Ethics analyses and application to “real-life” circumstances have a formal structure. It is incumbent upon faculty that our students competently think through morally complex circumstances and provide well-reasoned recommendations. This requires exposure to scholarship within the field on common consultation themes, such as privacy, confidentiality, and disclosure, but not at the expense of logic, moral reasoning, and analysis.
What we teach
“What should an HEC member know to serve in this role?” One way we answer this question is by referencing the American Society for Bioethics and Humanities (ASBH), Core Competencies for Healthcare Ethics Consultation 2nd ed. Our program builds upon these competencies, as illustrated in example provided in Table 1, with the goal of cultivating a basic level of assessment/analysis, process, and interpersonal skills relevant to the practice of clinical ethics consultation.Footnote 8
Example of competencies met by class1
1 This table is a small subsection of a multi-page document linking competency to class lesson plans, provided here as an example.
The Certificate Program consists of two academic semesters with two 3-credit classes per semester. Throughout the course of each semester (indeed, through the course of the entire academic yearlong program), we move continuously from the theoretical to the practical (from logic to moral theory, to key moral distinctions/concepts/tools, to issues, to cases). The first semester begins with the theoretical foundations of clinical ethics. Topics include introductions to basic logical reasoning and common fallacies, fundamental moral distinctions, consequentialism and deontology, principlism, justice, and harm. We also incorporate coursework on diversity, equity, and inclusion, highlighting the importance of those concepts in the context of clinical ethics.
The second semester transitions into the practice of clinical ethics. Coursework becomes more issue specific with classes on substantive issues such as law and ethics, ethical issues at the end of life, surrogate decision-making, and nonbeneficial treatment. There is also coursework specifically dedicated to the “doing” of an ethics consultation, with classes on analysis and methodology, ethics-note writing and recommendations, cognitive bias and decision-making, and facilitation theory and skills such as negotiation and mediation. The Certificate culminates in the program’s signature feature—the Practicum, which is a realistic simulation exercise, and comprehensive assessment of the students’ yearlong work (see Figure 1 for an overview of the concepts covered throughout the program).
The KP-WSU medical ethics certificate program overview.
How we teach
In response to our students’ needs pertaining to availability and access, the Certificate Program utilizes both a synchronous (live) format, and an asynchronous (on one’s own time) format. These formats allow faculty to provide the integral education that stems from dialogue and discussion while allowing our students to have significant autonomy in managing their schedules.
Asynchronous lessons
The asynchronous lessons are a core feature of the program, meaning students have a limited number of synchronous lessons to incorporate into their schedule.
Asynchronous modules are designed in recognition that different students learn better through different formats. We therefore aim to maximize the types of learning formats used: During each week of the standard 15-week semester, there are assigned readings, a recorded voice-over PowerPoint lecture on a specific topic (such as consequentialism or deontology), written lecture notes, and a student-driven (faculty monitored) online discussion forum where students respond to faculty queries for reflection, and each other’s observations.
Synchronous seminars and workshops
Synchronous “live” seminars are the primary forum for student-faculty interaction provided in the evening over a 2-hour period. The seminars include didactic approaches allowing for students and faculty to engage in a dialogue on a particular topic. Questions raised during the asynchronous lectures are also discussed. During the shift from the first semester to the second semester, synchronous workshops are provided for the purpose of experiential skills-building. These workshops cover the following: methodology-in-practice, inquiry and intake, negotiation, and mediation.Footnote 9
The practicum
The Practicum culminates the Certificate Program and is a feature about which the faculty feel particularly proud. Broadly speaking, the Practicum is a simulated patient experience involving paid professional actors and actual practicing physicians (increasingly alumni of our program) in a role -play scenario involving a family embroiled in a moral dispute. It is meant to be a realistic portrayal of a typical ethics consultation. Trainees in the health professions have long benefited from experiential learning as seen in activities such as standardized patient simulations and problem-based learning.Footnote 10 Even medicine’s “see one, do one, teach one” approach reflects the importance of hands-on training.
The Practicum has three main parts: 1) the intake, 2) the family conference, and 3) the note/recommendation. In all three parts, students are tasked with demonstrating both knowledge and skills-based competencies. During the intake, the student contacts the actors (who are in-role as disputant family members), introduce themselves and the role of ethics, elicit salient values and prepare the person for an upcoming family conference that they will facilitate. They also speak with one of our volunteer physicians who role play the part of attending physician. Once intake is complete, a family conference has the student facilitate discussion among the family members (the physician, unfortunately cannot attend, something that is often true in real consultation circumstances) demonstrating mediative skills, communicating ethical considerations, and option generation. Once the conference ends, the student’s “final essay” is a hybrid chart note and recommendationFootnote 11 that further demonstrates competencies.
These parts occur over the course of several weeks, to allow for all participants (from student-to-faculty) to manage the thorough evaluation process. All interactions with actors and volunteer physicians are self-evaluated and evaluated by faculty. The students record their sessions, and then rewatch it, completing a self-evaluation that asks the students to assess whether they demonstrated an ASBH competency (while not speaking to the quality of the demonstration) (Table 2).Footnote 12
Example of competencies self-assessment form (process skills)1
1 This table is a small subsection of a multi-page self-evaluation form, provided here as an example.
Once they complete their self-evaluation, the student then provides the recording and the self-assessment to a faculty member who watches the session and completes the same assessment, and also provides the student insight into the quality of their demonstration. Once the student and faculty complete the assessment, the faculty member schedules time to give the student one-on-one feedback. This process is slightly different for the family conference, where all faculties attend the conference live, and give feedback after it is complete, and allows the actors to give feedback as well.Footnote 13 The repeated review, assessment, and feedback process is designed for the students’overall improvement, including the quality of their approach and methodology, during the course of the semester.
Pandemic changes and other improvements
The COVID-19 pandemic required us to change much of how our program worked, particularly the synchronous aspects of the Certificate. Although originally daunting, we feel that many of these changes have been for the better of the program overall. During the first 3 years of the Program, the seminars, workshops, and Practicum were all held live and on campus. In order to comply with social distancing needs reflecting pandemic response efforts, the first cohort of the pandemic was completely virtual, with all synchronous activity being hosted on ZOOM Video Communications.Footnote 14
While originally motivated by pandemic social distancing concerns, we found the move to synchronous virtual meetings made our program more easily accessible, and better able to be incorporated into busy schedules. Moreover, the pandemic introduced professionals to virtual platforms such as Zoom and Microsoft Teams, which helped immensely in converting synchronous content to virtual platforms. We found that our student’s familiarity with virtual platforms was helpful, as the transition to online was more acceptable to our students. This transition exponentially increased the feasibility of our program for students in remote locations without sacrificing the content or quality of the program.
COVID-19 also forced us to try changes that we thought might not work; specifically moving the synchronous-heavy simulated Practicum to a completely virtual format. To our delight, the zoom-based family conferences worked very well, and have been extremely helpful in (again) allowing students from any geographic location to fully participate in our Certificate Program, serving the purposes of both KPNCAL and WSU’s Land-Grant Mission.
Outcomes—have we succeeded?
Following the completion of a program’s term, we utilize both informal and formal mechanisms for gauging the success of the program. Particularly for students from KPNCAL’s HECs, the faculty maintain connections with the learners beyond the classroom, forming a collegial relationship with those who remain active HEC members. From the perspective of the KPNCAL faculty, former students show a deep level of introspection and an enhanced ability to communicate complex ethical concepts with both medical and lay audiences. Former students take on clinical ethics case consultations through their committees and sometimes reach back out to their former teachers with questions. In addition, former students show increased fluency with terms used in the field and are better able to support their recommendations with references to clinical ethics scholarship, hospital policies, and legislation.
Course evaluations evidence an appreciation of the content, the flexibility extended to learners, and an increased sense of confidence about their ability to competently execute the steps of informal and formal ethics consultations, for KP and non-KP students alike. Learners aptly identified a tension where they are better prepared for the work of ethics in a hospital setting because they completed the Certificate Program, yet they now recognize that there is far more they have to learn about both the field and practice of clinical ethics consultation. Our longitudinal encounters with former students mirror what they have identified in course evaluations: they recognize the limitations of their knowledge, but they now understand where to look for intellectual support and are empowered to reach out for assistance from their former faculty. We believe this is a good tension, as confidence grounded in naïveté and/or lack of appreciation of limitations can be counterproductive, if not dangerous.
Alumni evaluation
To capture the voice of alumni, we e-mailed a survey to graduates of the Certificate Program. The survey was administered using Research Electronic Data CaptureFootnote 15, Footnote 16 hosted at WSU. The survey inquired about training and experience in clinical ethics before and after the program, in addition to the strengths and weaknesses of various elements of the Certificate Program. Descriptive statistics were calculated using Microsoft Excel.Footnote 17
A total of 24 alumni completed the survey, representing just over half (n = 53%) of the alumni contacted to participate. Physicians constituted a plurality of respondents (n = 10, 42%). Nine respondents (n = 38%) reported receiving no clinical ethics training before completing the Certificate Program; most respondents (n = 16, 67%) did not participate in additional training after completing the Certificate Program. Nearly all respondents (n = 22, 92%) found a good balance between synchronous and asynchronous activities. We refined survey questions developed by Mei Yi Mak, et al. for alumni to evaluate their learning experience conducting the simulated ethics consultation of the Practicum.Footnote 18 Respondents either agreed or strongly agreed that they benefited from this experiential learning (Figure 2).
Impact of the simulated ethics consultation practicum: alumni responsesa,b.
aNo participants selected responses “disagree” or “strongly disagree” when asked to rate their level of agreement with the above statements.
bParticipants without any experience conducting clinical ethics consultations (n = 5, 21%) were not asked to provide responses to statements 2 and 3.
Conclusion
In conclusion, we believe that our Certificate in Medical Ethics offers training and education that enhances the ethical reasoning of practicing healthcare professionals and ensures a level of competency for those individuals serving their hospitals in an ethics-related role, typically, as members of their HEC. Key elements of our program are a specificity of focus on education of HEC members (including, importantly, the “hands-on” simulated ethics consultation experience), attention to scheduling and accessibility, (related) incorporation of video conferencing for live interactive seminars motivated and facilitated (e.g., increased comfort with video conferencing, etc.) by the impact of the COVID-19 pandemic and affordability. We believe these elements can be replicated for education of HEC members across the country.
Disclosure statement
Opinions expressed in this manuscript are solely those of the authors and do not necessarily represent the opinions of Washington State University or Kaiser Permanente.
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