evaluation of the perceived impact of an interdisciplinary healthcare ethics course on clinical...

© 2004 Blackwell Publishing Ltd.

Learning in Health and Social Care

,

3

, 4, 223–236

Original article

Blackwell Publishing, Ltd.

Evaluation of the perceived impact of an interdisciplinary healthcare ethics course on clinical practice

Christine

Carpenter

PhD MA BA DIp(PT)

,

1

*

Janet

Ericksen

MSc

,

2

Barbara

Purves

PhD(C) S-LP(C)

3

& David S.

Hill

BSc(Pharm) MSc MBA EdD FCSHP

4

1

Senior Lecturer, School of Health and Social Sciences, Coventry University, Priory Street, Coventry CV1 5FB, UK

2

Associate Professor Emerita, School of Nursing, University of British Columbia, 759 E. 22nd Avenue, Vancouver, BC, Canada V5V 1V5

3

Clinical Associate Professor, School of Audiology and Speech Sciences, University of British Columbia, 5804 Fairview Avenue Vancouver, BC, Canada V6T 1Z3

4

Associate Dean, Administration and Clinical Affairs, School of Pharmacy, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, C238, Denver, CO 80262, USA

Abstract

Healthcare professionals and educators perceive that interdisciplinary education

initiatives facilitate improved interdisciplinary team functioning and practice in a

diversity of healthcare settings, but evidence to support this perception has been

lacking. This report presents data from a descriptive study conducted in two phases –

a focus group and the development and administration of a questionnaire – that

sought to evaluate healthcare professionals’ perception of the impact of having taken

an interdisciplinary course in healthcare ethics on the subsequent clinical practice of

healthcare professionals, and to identify implications for future ethics-related,

interdisciplinary course development. The course organization and the course

participants and faculty are briefly described. The findings indicate that respondents

judged the course to be valuable in enhancing their ability to engage in the

interdisciplinary aspects of practice and in addressing ethical issues. They identified

effective components of the education experience and areas in which the course

organization could be improved. Based on these findings, implications for future

curriculum and course planning and evaluation research are discussed.

Keywords

clinical practice,

evaluation, healthcare

ethics, interdisciplinary

education

*Corresponding author. Tel.: +44 024 7688 7075; fax: +44 024 7688 8020;e-mail:[email protected]

Introduction

In this article we present data from a descriptive

study that sought to, first, evaluate healthcare

professionals’ perceptions of the impact of having

participated in an interdisciplinary course in health-

care ethics on their subsequent clinical practice, and,

second, identify implications for future ethics-related,

224 C. Carpenter

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interdisciplinary course development. The course

organization, course participants and faculty will

be briefly described, and the study methods, find-

ings and limitations, and implications for future

curriculum and course planning and evaluation

research will be discussed.

Background

Despite a lack of consensus surrounding the use of

terms such as ‘multidisciplinary’, ‘interdisciplinary’,

‘interprofessional’ and ‘multiprofessional’, the widely

held assumption is that ‘interdisciplinary education’

is a worthwhile goal to pursue. The widespread belief

held by healthcare administrators (Gardiner

et al

.

2002), educators (Drinka & Clark 2000) and students

(Hawk

et al

. 2002) is that (effectively) learning

together is a desirable, necessary and sufficient

precondition for (effectively) working together. It

is generally acknowledged that interdisciplinary

education prepares healthcare profession students

to comprehensively address the needs of individual

clients/patients, while maintaining the discrete

identity of their intended professions, but this

perception has not been rigorously evaluated

(Pirrie, Hamilton & Wilson 1999). Interdiscipli-

nary collaboration and teamwork are considered

fundamental in addressing the complexities of

patient care and are well established, for example, in

the areas of geriatrics (Leipzig, Hyer & Ek 2002),

rehabilitation (Latella 2000) and community care

(Olive, Goodrow & Virgin 1998). Interdisciplinary

care has evolved, in part, because no one person or

discipline can have expertise in all the areas of

specialty knowledge needed for the high-quality

care of clients with complex conditions or disability

(Perkins & Tryssenaar 1994). For these reasons,

an interdisciplinary approach to ethical decision-

making education seems particularly appropriate as

a means of building a foundation for successful

interdisciplinary care in students’ future clinical

practices.

The terms multidisciplinary and interdisciplinary

are often used to characterize approaches to health-

care team functioning (Kumar 2000). The term

‘multidisciplinary’ refers to an often unstructured

group of diverse health professionals practicing in

the same setting. This approach generally involves

team members in sharing their information and

respective goals with each other; however, this dia-

logue does not significantly impact on their respec-

tive approaches to practice. ‘Interdisciplinary’ team

members also share their respective goals for the cli-

ent. However, there is an expectation that all team

members will support the achievement of these

goals throughout the daily interactions with the

client (Capilouto 2000). An example of such co-

operation would be the expectation that once a speech

language pathologist, working with a client follow-

ing a stroke, had determined a safe and effective

method of swallowing, other professionals, such as

nurses and occupational therapists, would reinforce

the same procedure. As Rawson (1994) suggests,

the term ‘

inter

disciplinary’ is associated with the

notion of

inter

dependence, while ‘

multi

discipli-

nary’ implies ‘many and some form of composition

but … does not … suggest any give and take’ (p. 40).

Capilouto (2000) suggests that interdisciplinary

teams differ from multidisciplinary teams in that all

members are considered equal in their contribu-

tions to client care. Miller, Freeman & Ross (2001)

described this type of team, where most members

of the team display a high degree of collaboration,

as ‘integrated’.

While the importance of interdisciplinary teams

in providing patient care has been established

(Drinka & Clark 2000), and the benefits of effective

team functioning have been identified (Miller

et al

.

2001), relatively little attention has been paid as to

how these skills are acquired. Healthcare profession-

als continue to be educated in comparative isolation

from each other (Drinka & Clark 2000), and inter-

disciplinary teamwork is rarely a teaching focus

(Leipzig

et al

. 2002). An understanding of the every-

day practices, values and beliefs of interdisciplinary

colleagues, and recognition of the organizational

constraints shared by all professionals that shape

not only individual clinical practices, but also the

institutional environment, are primarily learned

through serendipitous experiences. The ways in

which attitudes and beliefs about teamwork are

shaped appear to be primarily associated with the

socialization process of becoming a member of a

particular profession (Miller

et al

. 2001; Drinka &

Perceived impact of an interdisciplinary healthcare ethics course on clinical practice 225



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3

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Clark 2000). These different perspectives on team-

work (Miller

et al

. 2001; Leipzig

et al

. 2002), and the

effectiveness of teamwork on patient outcomes

(Burns

et al

. 2000), have only recently begun to be

examined.

The notion of interdisciplinary education in

healthcare is commanding more attention and

represents a realistic curricular objective. However,

while interdisciplinary initiatives (courses, seminars

or clinical fieldwork) involving a diversity of health

disciplines are increasing at many universities, they

are still relatively few compared with the traditional

discipline specific course offerings.

The application of evidence-based decision-

making principles in order to achieve optimal clinical,

economic, and quality of life outcomes in healthcare

has been widely described by the Cochrane Col-

laboration (http://www.cochrane.org/index0.htm)

and others (Evidence-Based Medicine Working

Group. 1992; Sackett

et al

. 2000). Evidence-based

practice in the health services advocates a structured

and systematic approach to evaluating how health-

care is delivered, and a comparable process can be

used when investigating how health professionals

are educated (Greenhalgh

et al

. 2003). Unfortu-

nately, the strength and usefulness of evidence from

educational research required to inform curricular

practices is compromised by similar weaknesses and

limitations to those evident in clinical research.

With an increasing emphasis upon interdisciplinary

and interagency collaboration, ‘a search for stronger

evidence to justify interdisciplinary education in

order to promote collaborative practice is necessary’

(Cooper

et al

. 2000, p. 28). Evaluations of interdisci-

plinary education have been criticized for the lack of

research studies that meet the systematic evidence-

based criteria laid down, for example, by the

Cochrane Collaboration and others (Barr

et al

.

1998; Pirrie

et al.

1999; Greenhalgh

et al

. 2003).

However, some authors (Pirrie

et al

. 1999; Cooper

et al

. 2000; Hammersley 2001) have questioned the

wisdom of uncritically applying evidence-based

criteria in evaluating the complexities of education

research.

The goals of interdisciplinary courses are often

stated in both humanistic and behaviourist terms.

Accordingly, educational questions have a more

complex taxonomy than many questions related to

clinical practice (Greenhalgh

et al

. 2003). Such

questions have ‘a less direct link with particular pre-

ferred study designs, and no universally accepted

criteria for assessing validity’ (Greenhalgh

et al

.

2003, p. 144). Evaluation of education process and

outcomes requires different quality assessment con-

ceptual approaches, involving the review of both

quantitative and qualitative evidence. (Pirrie

et al

.

1999; Cooper

et al

. 2000; Greenhalgh

et al

. 2003).

As faculty members who had been involved in

planning, coordinating and teaching an interdis-

ciplinary healthcare ethics course since its inception

10 years earlier, we recognized the need, not only

to solicit formative feedback from participants at

the end of the course each year, but also to explore

the learning outcomes in terms of former students’

perceptions of the course on their subsequent clin-

ical practices.

Description of the course

This interdisciplinary healthcare ethics course was

introduced as an elective at the University of British

Columbia (UBC) during the 1993–94 academic

year. At that time it was the first course of its kind

in Canada (Kent 1997). Faculty members from

audiology, dentistry, medicine, nursing, pharma-

ceutical sciences, philosophy, rehabilitation sciences,

social work and speech-language pathology

quickly formed a cohesive planning group motivated

by two convictions: an interdisciplinary approach

to healthcare decision-making is best; and every

significant healthcare decision has an ethical com-

ponent (Browne

et al

. 1995). The course remains

a three-credit, upper-level course and has been

offered in both Autumn and Spring terms. In 1993,

70 students registered (we planned for 50) and

90 students registered the following year. Since

then, registration has varied from 30 to 60 students

each term. During this period, the core professional

programmes with students in the course had a total

yearly enrolment of approximately 500 upper

level students who could have been eligible to take the

course. In recent years at the UBC, the importance

of incorporating healthcare ethics content into

individual professional curricula has been recognized,

http://www.cochrane.org/index0.htm

226 C. Carpenter

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and discipline-specific ethics courses and modules

are now being offered by individual academic

programmes, such as medicine and dentistry,

pharmacy and nursing. This has resulted in a decline

in registration in the interdisciplinary course in the

past 3 years; however, the course continues to elicit

considerable interest amongst health professions’

students. Throughout the course’s 10-year history, it

has also attracted individuals who were returning

from clinical practice to obtain higher academic

qualifications. Each year a differing mix of students

from audiology, dentistry, dental hygiene, health

administration, human kinetics, laboratory science,

law, medicine, nursing, nutritional science, occu-

pational therapy, pharmaceutical sciences, physical

therapy, social work and speech-language pathology

are involved in the course. On occasion, quotas

have been established in order to ensure an optimal

interdisciplinary mix.

The course is designed to enable students to:

1

Identify ethical issues in healthcare and reason

competently about them using principles relevant to

healthcare decision-making.

2

Recognize the unique contribution that each dis-

cipline can make in resolving ethical dilemmas in a

diversity of healthcare settings and to understand

the codes of ethics that govern other disciplines.

3

Participate in ethical decision-making discussions

with members of various healthcare disciplines

(Browne

et al

. 1995). This inquiry was designed to

provide some insight to the extent to which inter-

disciplinary ethical decision-making skills in subse-

quent practice may have been influenced by this

course.

The course methods of delivery, content and

readings are reviewed and revised each year in

response to participant formative feedback received

in typical end-of-term course and instructor

evaluations. The coordinating committee use these

evaluations to ensure that the course continued to

reflect current healthcare and clinical practice

issues. A custom course package is developed each

year and includes a comprehensive course guide, an

introduction to healthcare ethics (A. Browne & V.

Sweeney, unpublished), case problems, and a course

reader containing a number of selected readings and

examples of professional codes of ethics.

The course consists of 3-hour sessions held one

evening a week for 13 weeks. These evenings are

divided equally between large group and tutorial

group sessions. The large group sessions are devoted

to lecture or panel presentations on such topics as:

normative ethics, client autonomy and informed

consent, limits to client autonomy, alternative

approaches to ethical decision-making, foregoing

treatment, assisted suicide and active euthanasia,

ethics and research, and resource allocation and the

Canadian healthcare system. These sessions are

intended to give structure and focus to the tutorial

group sessions in which the students discuss specific

cases related to the topics presented in the lecture

presentations. A number of selected cases are pro-

vided for each tutorial evening. In this way, ethical

issues are discussed in the context of the practical

realities of healthcare institutions and complexities

of clinical practice. Each course faculty member acts

as a permanent tutor for a small group, and each

evening the groups are joined by a guest tutor from

a different discipline. Students form interdisciplinary

teams of three or four within the tutorial groups.

Twice during the course each team selects a case

either from those provided or from their experience,

to present to the rest of their group. They are also

expected to develop a one-page handout for their

tutorial group colleagues and the tutors, outlining the

ethical issues arising from the case and to facilitate

a discussion. These case presentations are given a

numerical grade by the other participants of the

tutorial group and the tutors by using pre-established

evaluative criteria. There is a final examination

consisting of short answer questions and an essay

question, which is graded by the course organizers.

Throughout the course we invite informal sum-

mative feedback and at the end of the course we ask

all the students to provide a formative evaluation of

the course using a specifically developed evaluation

form (Appendix I). This form consists of a mix of

closed questions asking the learner to rate the value

of the course and the various components of the

course, and open-ended questions soliciting

individual clarifying comments and suggestions

for improvement. The course has consistently been

rated by a majority of the participants as excellent or

good (see Table 1).




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Global evaluation of the course: 1993–2000

The components of the course include theoretical

ethics lectures, guest presentations, notes in the

course guide, a book of readings, student team

presentations, tutorial group discussions, cases and

problems for discussion by tutorial groups, tuto-

rial group facilitators, and a statement of course

expectations and goals. These components were

consistently rated by a majority of the course

participants as extremely or very useful, with the

exception being the course guide and reader, where

the majority of the rating responses shifted to very

useful and fairly useful. In responding to the open-

ended questions, many of the participant’s most

positive comments referred to the organization and

interdisciplinary approach of the course. Basically,

the same evaluation form has been used since 1993,

and as a result these formative evaluations have

provided consistent and invaluable information

upon which year-to-year course revisions were

based.

In the light of current attention to evidence-based

outcomes in interdisciplinary education, we were

motivated to evaluate course outcomes in terms of

the influence on the clinical practice of those who

had participated in the course. One way to approach

this question was to evaluate former students’ per-

ceptions of the impact of the course on their clinical

practice and on preparing them for complex inter-

disciplinary collaboration and ethical decision-

making. The course has been offered nine times in

10 years, and this history gave us a unique opportu-

nity to follow course participants into their careers

in healthcare and to evaluate the outcomes of

participating in an interdisciplinary health ethics

course. To achieve this, we conducted a non-

experimental, retrospective, descriptive study that

was conducted in two phases: a focus group question-

framing phase; and a questionnaire development

and administration phase.

Study design and implementation

Preliminary focus group

We made the decision to conduct a preliminary

focus group, prior to developing a survey to explore

the feasibility of obtaining relevant information

retrospectively and to identify salient perceptions

and issues related to the perceived impact that

the course participation had on clinical practice.

There is considerable evidence that focus groups

can substantially contribute to the creation of

questionnaires (Barbour 1998; Morgan 1998). The

focus group method involves multiple participants

and, as such, facilitates the collection of a relatively

large amount of data on a topic in a limited period

of time. This was considered a particularly useful

characteristic for this exploratory phase.

Course enrolment lists for 1993–2000 were

obtained from the university registrar records.

Letters were sent to 20 individuals, explaining the

Table 1 Global course evaluation results 1993–2000

Year

(no. enrolled

in course)

No. (%) of

responses

Question 1: What is your global evaluation of this course?

Excellent Good Fair Poor Unacceptable

1993 (n = 70) 52 (74%) 39 13

1994 (n = 90) 50 (56%) 33 16 1

1995 (n = 56) 41 (73%) 15 25 1

1996 Evaluation record missing

1997 (n = 62) 47 (76%) 32 14 1

1998 (n = 64) 55 (86%) 37 18

1999 (n = 58) 46 (79%) 40 5 1

2000 (n = 37) 31 (84%) 16 12 3

228 C. Carpenter

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purpose of the proposed focus group and inviting

them to participate. These individuals were purpo-

sively selected to represent a diversity of professions.

Fourteen individuals agreed to be involved. They

represented 10 professional groups and were cur-

rently in clinical practice. We developed a number of

broad questions related to general recollection of the

course content, and to ethical and healthcare team

issues in practice. These were intended, if necessary,

to encourage and focus the group discussion. To

accommodate the participants’ schedules, the focus

group was held in the evening and was facilitated by

three faculty members. The discussion was audio-

taped and later transcribed. The focus group data

were used to ensure that the questionnaire captured

a range of content areas, rather than relying on

our assumptions about what is relevant, and also

allowed us to incorporate, where appropriate, the

language and vocabulary used by the focus group

participants. By using the focus group findings in

this way, we aimed to enhance the accessibility and

relevance of the questionnaire and to minimize the

differences in how the respondents interpreted the

questions (Morgan 1998).

Questionnaire implementation

The questionnaire items were divided into three

categories: background information to establish a

profile of the respondents; the extent to which

respondents felt that the course contributed to

their current clinical practices in the areas of

interdisciplinary interaction and ethical decision-

making; and a global opinion of the course where we

sought information about the value of the course to

practice and how it might be made more effective

(Appendix II). The latter question was included

because, although we already had data relating to

annual student evaluations of the course, we were

now interested in learning how graduates of the

course, many of whom had gained several years of

clinical experience, would retrospectively evaluate

the course. The questionnaire consisted of a mix

of closed-format items requiring simple ‘yes/no’

answers, or Likert-type items requiring responses

ranging from ‘not at all’ to ‘a great deal’. In addition,

a number of open-format type questions were used,

asking the participant to list priorities or describe

a situation from their practice that exemplified a

phenomenon of interest.

The addresses of these individuals were obtained

from the UBC Alumni Association records. Only

former students for whom mailing addresses could

not be found were excluded. A letter was sent to

these former students informing them about the

study and inviting them to participate by complet-

ing and returning the enclosed questionnaire. Issues

of confidentiality and consent were addressed in the

letter, namely that the questionnaire was anony-

mous and that by completing and returning the

questionnaire, their consent to participate was indi-

cated. As we did not plan to perform a follow-up

mailing, no attempt was made to track the responses

by creating a numbered master list, and the returned

envelopes were discarded. The project received

ethics review board approval in September 2002.

A total of 364 questionnaires were mailed.

Twenty-eight envelopes were returned unopened,

indicating that the person was not known at the

address or that it was an incorrect address. Eighty-

six of the 337 questionnaires delivered were re-

turned for analysis, yielding a response rate of 25.5%.

Because we did not have a numbered master list,

we have no information about non-responders.

Data were entered into a desktop statistical package

and basic descriptive statistics generated.

Study findings

The demographic questions in the survey enabled

us to establish a profile of the respondents in terms

of their discipline, years of clinical practice (if any)

prior to taking the course, primary area of clinical

interest, the interdisciplinary nature of their pra-

ctice, and participation in other similar courses.

All the healthcare disciplines were represented with

the majority of the respondents from nursing

(27%), social work (15%) and medicine (9%)

(Table 2).

The current work settings of respondents

included acute care (41% of respondents), commu-

nity settings (21%) and private practice (14%), with

a small proportion in Kindergarten to Grade 12

school settings, rehabilitation centres, universities




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or in government agencies. Completed question-

naires were received from at least one respondent

from each year that the course had been offered

between 1993 and 2000 (see Table 3).

The number of responses from former students

with clinical practice experience prior to the course

was similar to those with no experience. Forty-one

respondents (48%) reported having an average of

11.5 years of clinical experience (range 1–33 years),

and 45 respondents (52%) reported no prior clinical

experience (beyond that required during their pro-

fessional programme). Respondents were asked to

list the health disciplines, other than their own, with

which they currently worked most closely. Not sur-

prisingly given the practice settings described by the

respondents, the most commonly cited disciplines

were medicine, nursing, physical therapy, social

work, occupational therapy, nutritional sciences

and pharmacy, respectively. Thirty-three (38%) of

respondents had taken at least one other interdisci-

plinary course; 19 (22%) had taken an additional

ethics course.

We were primarily interested in how respondents

evaluated the extent to which the course contributed

to their abilities to collaboratively engage in ethical

decision-making discussions with members of

other healthcare disciplines. For these survey ques-

tions, Likert scale rating means all fell between 3 and

4 on a five-point scale (SD range 1.0–1.2). The cor-

relation coefficient between variables was calculated

using Spearman’s ranked test. Respondents’ ratings

of the overall global value of the course significantly

correlated to their ratings of the extent to which the

course contributed to their ability both to effectively

work as a member of the team (

r =

0.435,

P

< 0.01),

and to identify and address ethical problems in

their practice (

r =

0.644,

P

< 0.01). These findings

suggest that the respondents identified positive

relationships to both their ability to engage in the

interdisciplinary aspects of clinical care and in their

ability to address ethical issues in judging the overall

value of the course.

Several of the respondents had taken other inter-

disciplinary courses and/or ethics courses that may

have influenced subsequent future practice compe-

tencies in ethical decision-making and interdiscipli-

nary teamwork. In order to test for this,

t

-tests were

performed, comparing responses of those who had

taken other interdisciplinary courses to those who

had not for questions relating to interdisciplinary

aspects of clinical practice and to the overall value

of the course. There were no significant differences

between these two subgroups (

P

> 0.1 for all com-

parisons). Similarly,

t

-tests were performed,

comparing responses of those who had taken other

ethics courses (

n

= 19) with those who had not

(

n

= 65). Again, ratings for the overall value of the

course were not significantly different between the

two subgroups (

P

> 0.01). There were also no sig-

nificant differences in the two groups’ ratings of the

Table 2 Respondents’ disciplines (n = 86)

Discipline n

Nursing 24

Social Work 13

Medicine 8

Pharmacy 7

Physical Therapy 6

Health Administration 6

Speech Language Pathology 5

Occupational Therapy 4

Dental hygiene 4

Dentistry 2

Audiology 2

Nutritional sciences 2

Chiropractor 1

Psychology 1

Other 1

Table 3 Year in which the course was taken (n = 86)

Year when the course was offered n

1993 7

1994 7

1995 10

1996 14

1997 13

1998 13

1999 13

2000 9

230 C. Carpenter

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course’s contribution to their ‘awareness’ of ethical

problems or their ‘confidence’ in addressing ethical

problems (

P

> 0.1). However, the groups’ ratings of

the course contribution to their ‘ability to address’

ethical problems in their practices did approach

significance (

P =

0.053). A cautious interpretation

is that respondents who had taken other ethics

courses, on the basis of comparisons with those

courses, identified a particular contribution from

this course.

A further question regarding the influence of

differences among respondents related to whether

they had any clinical experience prior to taking

the course. There were no significant differences

between groups in any of the items relating to

interdisciplinarity. On items relating to ethical

decision-making, a significant difference (

P

> 0.001)

was observed only for the contribution of a frame-

work for ethical decision-making to subsequent

clinical experience, with clinicians who had previous

experience rating this contribution more highly

than other respondents. Differences between the

subgroups in the overall value ratings of the course

to clinical practice approached significance at the

0.05 level (

P =

0.059), in contrast to all other com-

parisons for which

P

-values exceeded 0.3.

These findings were reinforced and expanded

by the qualitative information obtained from the

responses to the open-format questions. These

questions focused on opinions concerning the

applicability of the course content in practice, that

is, the most and least useful aspects of the course and

suggestions for how the course could be improved.

The respondents were encouraged to make more

than one comment in relation to these questions.

The authors analysed these responses by categoriz-

ing them into a number of themes or topics accord-

ing to the degree of repetition and commonality.

Several themes emerged relating to the contribu-

tion made by the course to clinical practice (see

Table 4), and these are described according to the

frequency of similar comments from respondents.

These themes all related to the importance attrib-

uted by the respondents to the learning environ-

ment created by the unique interdisciplinary nature

of the course. The opportunity for interaction with

other students from a diversity of health profes-

sional programmes, the contribution of the multi-

disciplinary faculty and invited speakers, and the

use of complex cases problems that encouraged

team decision-making, were frequently mentioned.

The course content and recommended readings

were generally considered to be accessible, relevant

and applicable to practice.

There was considerable overlap between respond-

ents’ comments about the least useful aspects of the

course and suggestions for improvement. Two main

themes were identified relating to the case problems

and the need to involve medical students in the

course. While the case problems used for analysis in

the tutorial group sessions were appreciated for the

debate and discussion they generated, the respondents

Table 4 Perceived effective aspects of course

Theme Example of respondent quotes

Interdisciplinary focus of course Wonderful opportunity to meet and work with

people from other disciplines – broadened my perspective

Getting to know about other health disciplines – their body of

knowledge, issues, skill sets and perspectives

Case studies discussion in small groups Discussing and analysing ‘real’ complex cases – very enlightening and useful

Applying the decision-making framework to The framework and principles introduced in the course were very

ethical problems in interdisciplinary groups practical; helped to sort through the issues

Guest lectures relevant to clinical practice Speakers based content on relevant examples from

their community/clinical experience

Theoretical material and reading package Ethical principles and theories were made really accessible and applicable

The readings have continued to be a resource for me




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3

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pointed out that they frequently focused on the

‘big ticket’ medically orientated ethical issues rather

than on issues such as discharge placement, in-

formed consent, confidentiality, truth telling and

microallocation of resources more applicable to the

daily practice of the allied health professionals

involved in the course. This was useful feedback,

particularly as the medical student presence in the

course was consistently very low. A number of the

respondents felt that increased involvement of med-

ical students in the course would be advantageous

both for the development of realistic interdiscipli-

nary team relationships and for the quality of the

tutorial group discussions. Other suggestions relat-

ing to the involvement of ethics committees or

members of ethics committees in the course, pro-

viding ‘follow-up’ courses or continuing education

sessions to reinforce the ethical reasoning approach

to ‘real’ clinical situations, and ‘making the course

mandatory for all health profession students’, were

offered.

Discussion

Recent changes in the Canadian healthcare system

and patterns of healthcare delivery have been

characterized by an emphasis on the ‘seamless’

provision of services and are premised on

collaboration and teamwork among health and

social care professionals. There has been a similar

shift of focus in health professional education, from

the specific combination of skills, knowledge and

values that characterize one professional group to

the facilitation of a range of skills, many of which are

complementary or overlapping, in order to build

the foundation for efficient and effective clinical

decision-making in future practice (Pirrie

et al

.

1999; Drinka & Clark 2000). The objectives of this

interdisciplinary health ethics course reflect these

broader goals. However, little evaluation of the long-

term impact of such courses on clinical practice or

effectiveness in preparing practitioners for complex

interdisciplinary practice has been reported in the

literature. This study reports a relationship that

indicates a positive correlation between former

students’ completion of this interdisciplinary ethics

course and their subsequent ability to work in a

team environment and engage in effective ethical

decision-making activities.

There were a number of limitations associated

with this study. The response rate was relatively low

and illustrated the difficulties of contacting former

students when, in many cases, much time had

elapsed since their involvement in the course. Sur-

vey development requires considerable skill and at

least two questions that we included in the question-

naire elicited little useful information. Respondents

who had taken the course more than 5 years prior to

the start of the present investigation stated that they

had difficulty accurately recalling course content

and organization details. The combination of open-

style and closed-style questions made rigorous anal-

ysis and comparison of the findings more difficult.

In addition, in practice it is difficult to infer a

strong relationship between this course and subse-

quent abilities because the questionnaire did not

probe for certain information that might have been

useful in more fully understanding this relationship.

For example, the effectiveness and maturity of inter-

disciplinary teams in healthcare settings may be

more strongly influenced by prevailing institutional

attitudes and expectations. Institutional leaders and

practice managers who have established the condi-

tions for interdisciplinary care, and who support its

place within an organizational structure, send pow-

erful messages to practitioners in all disciplines.

Indeed, while it may be tempting to attribute abili-

ties or skills in future practice to a specific course in

a professional programme, the culture and values of

the practice setting (e.g. to interdisciplinary care)

may exert the most dominant influences. Future

research to investigate the impact of curricular initi-

atives (such as interdisciplinary ethics teaching) on

subsequent practice should gather more informa-

tion about the clinical practice environment of

respondents in order to gain insight to these other

forces. Similarly, apart from some basic demo-

graphic information, the questionnaire did not

gather any information that could be used to assess

the disposition or propensity for respondents to

value interdisciplinary practice in a way that was

independent of the experience from the ethics

course. The administration of the same question-

naire to a control group of practitioners in similar

232 C. Carpenter

et al.



,

3

, 4, 223–236

work settings who had not taken the ethics course

could have provided some insight to addressing this

limitation.

In the future it may also be useful to follow up on

course participants at regular intervals of 2 or

3 years by using either a closed-type item question-

naire or a qualitative research approach, or a combi-

nation of both. Some authors argue that rigorous

qualitative research studies may be best suited to

probing learners’ understanding of the nature and

impact of interdisciplinary education on their

subsequent practice (Pirrie

et al

. 1999; Greenhalgh

et al

. 2003).

This course is currently an elective for the health

professional programmes at the University of

British Columbia. The course faculty recognize that

the demands on students in health-related program-

mes often curtails or limits the elective courses that

they are able to take. In addition, we have struggled,

over the years, to develop the most effective way of

advertising the course. When respondents were

asked how they learned about the course, the over-

whelming response was through their academic

unit calendars, brochures or information provided

by individual faculty members. The literature sug-

gests that the primary barriers to interdisciplinary

education are a lack of rewards for faculty, problems

with scheduling, lack of perceived value by some

disciplines, lack of administrative support and

rigid curricula (Gardiner

et al

. 2002). Clearly, the

respondents’ experiences suggest that interdiscipli-

nary education is valued within individual academic

programmes, but more strategies are needed to

overcome these barriers if a greater number of

health professional students are to have the oppor-

tunity of learning with other disciplines at some

stage in their professional education.

Opinion is divided in the literature on whether

interdisciplinary education is of greater benefit

when introduced earlier or later in the education

process (Perkins & Tryssenar 1994; Drinka & Clark

2000). The students participating in this course dif-

fered in terms of academic maturity and extent of

clinical experiences. However, none of the respond-

ents commented on the differing characteristics of

the students with whom they interacted during the

course, either in terms of the quality of tutorial

group debate or interdisciplinary interactions. Inter-

estingly, the results of this study suggest that res-

pondents taking the course, who had prior clinical

experience, seemed to be able to make more effective

use of the ethical decision-making framework taught

in the course than those without practice experience.

Rigorous formative evaluations of this course

have consistently been conducted and this feedback

has been used to revise the course content, readings

and speakers. As a result, the course has been

responsive to changes in the healthcare system and

the realities of clinical practice in introducing new

topics and maintaining the calibre of the lecturers

and tutor group facilitators. The respondents’

perceptions that the course content and case study

discussions were applicable and relevant to their clin-

ical practice reinforces this course renewal process.

Concluding remarks

This study represents our first attempt to evaluate

the broad objectives of an interdisciplinary health

ethics course in terms of facilitating the inter-

disciplinary ethical decision-making skills of course

participants during subsequent years of ‘real’ clin-

ical practice. The experience has reinforced for us

the difficulty of generating meaningful ‘evidence’

to support interdisciplinary education in healthcare

and, at the same time, the importance of evaluating

the effectiveness of such courses in preparing

students for the complexities of clinical practice.

Acknowledgements

This study was funded by the College of Health Disci-

plines, The University of British Columbia. The

authors would like to acknowledge the contributions

made, between 1993 and 2000, to this course by Alister

Browne PhD, Carson Cooledge MSW, Glenn Drover

MSW, Wayne Wright MSW, David Fielding MSc EdD,

Judith Johnston PhD, Sydney Segal MD, John Silver

BDS Dip(Peridont), and Vincent Sweeney MD.

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234 C. Carpenter et al.


Appendix I

Course evaluation form (used consistently from 1993–2000)

INTERDISCIPLINARY HEALTHCARE ETHICS

Student Course Evaluation

1. What is your global evaluation of the course? (please circle)

excellent good fail poor unacceptable

2. How useful was the following course components (please check):

3. How useful was the course for learning about other healthcare disciplines?

(please circle): extremely very fairly somewhat not

4. How useful was the course for learning about interprofessional teamwork?

(please circle): extremely very fairly somewhat not

Please identify reasons for low ratings, if they are given

5. Approximately what percentage of the readings did you actually read?

(Please indicate any readings that you found particularly helpful/unhelpful)

6. What other aspects of the course were particularly effective, i.e. should be retained or built up?

7. What other aspects of the course, in your opinion, should be changed?

8. How did you learn about this course?

(Please give us your ideas for course recruitment strategies)

Please give us your ideas for educational activities that would enhance interprofessional practice

10. Additional comments:

Extremely Very Fairly Somewhat not

Overall course organization

Coursefaculty

approachable/helpful

Theoretical ethics lectures

Guest presentations

IHHS 401 Course Guide

Health Care ethics:

A Concise Reader

(Browne & Sweeney)

IHHS 401 selected articles

Student case presentations

Small group discussions

Small group facilitators



Appendix II

Questionnaire

Health Care Ethics Course

University of British Columbia

Course Follow-up Evaluation, May 2002

Please respond to the following questions regarding the impact of the interdisciplinary healthcare ethics course on your clinical

practice. The questions below ask about the effect of the course on your interactions with other health professionals, your response

to ethical problems that you now encounter, and your views on the relative value of various aspects of the course.

Background Information

1. Your discipline/profession: ___________________________________________________________________________

2. What is your current work setting (e.g. acute care hospital, community, … ):

________________________________________________________________________________________________

3. Year in which you took this course (check one):

____1993 ____1994 ____1995 ____1996 ____1997 ____1998 ____1999 ____2000

4. Number of years in clinical practice before taking this course: ________________________________________________

5. List three (3) health disciplines, other than your own, with which you now work most closely:

___________________________________________________

___________________________________________________

___________________________________________________

6. Have you taken any other interdisciplinary courses:

________________________________no _______________________________yes (If yes, please specify)

7. Have you taken any other ethics courses:

________________________________no _______________________________yes (If yes, please specify)

Course Outcomes

8. To what extent did this course contribute to your:

(a) Understanding of the role of other health disciplines?

_________________not at all _________________a little _________________somewhat _________________quite a lot

_________________a great deal

(b) Ability to work as a member of a team?

_________________not at all _________________a little _________________somewhat _________________quite a lot

_________________a great deal

(c) Your interest in seeking out professional interactions with members of other disciplines to address patient/client care needs?

_________________not at all _________________a little _________________somewhat

_________________quite a lot _________________a great deal

9. Can you give an example of the way in which the interdisciplinary involvement you experienced in the course directly

influenced your response to a subsequent practice situation involving individuals from other health disciplines:

______________________________no ______________________________yes (If yes, please describe)

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

10. Have you found the ethical decision-making framework (i.e. the four boxes) introduced in the course useful in your practice:



11. To what extent has the course increased your awareness of ethical problems in your practice or in healthcare delivery:



236 C. Carpenter et al.


12. To what extent has the course increased your confidence in addressing ethical problems in your practice:



13. To what extent has the course increased your ability in addressing of ethical problems in your practice:

____not at all ____a little ____somewhat ____quite a lot ____a great deal

14. Which of the following ethical theories have you found most useful in or applicable to your current practice (check one or

more):

______________________________deontology ______________________________utilitarianism

______________________________care ethics ______________________________feminist ethics

______________________________contextual ethics ______________________________virtue ethics

______________________________(other – specify) ______________________________don’t know/none

15. Can you give a specific instance(s) of a situation(s) where knowledge gained in this course has made a difference in how you

approached an ethical problem:

______________________________no ______________________________yes (please describe)

16. In retrospect and in general, how valuable has the course been to your professional practice:



Course Evaluation

17. How did you learn about this ethics course:

__________________________________________________________________________________________

18. Please assist in improving the effectiveness of this course by identifying:

a. The most useful aspects of the course.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

b. The least useful aspects of the course.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

c. Ways in which the course could be improved.

19. Please provide additional comments on any other issues relating to the course.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Thank you

Health Care Ethics Course

University of British Columbia

Course Follow-up Evaluation, May 2002

Appendix II Continued

evaluation of the perceived impact of an interdisciplinary healthcare ethics course on clinical...

Documents