This article combines foundational and empirical aspects of healthcare education and develops a framework for teaching ethical theories inspired by pragmatist learning theory and recent work on the concept of moral resilience. It describes an exemplary implementation and presents data from student evaluation.
Objectives:
After a pilot implementation in a regular ethics module, the feasibility and acceptance of the novel framework by students were evaluated.
Research design:
In addition to the regular online module evaluation, specific questions referring to the teaching of ethical theories were added using simple (yes/no) and Likert rating answer formats.
Participants and research context:
At the Bern University of Applied Sciences, a total of 93 students from 2 parallel sub-cohorts of the bachelor’s program in nursing science were sent the online survey link after having been exposed to the same modular contents. A total of 62% of all students participated in the survey.
Ethical considerations:
The survey was voluntary and anonymous. Students were free to write their name and additional comments.
Findings:
Students consider ethical theories—as taught within the proposed framework—as practically applicable, useful, and transferable into practice.
Discussion:
Teaching ethical theories within the proposed framework overcomes the shortcomings described by current research. Students do not consider the mutually exclusive character of ethical theories as an insurmountable problem.
Conclusion:
The proposed framework is likely to promote the effectiveness of healthcare ethics education. Inspired by pragmatist learning theory, it enables students to consider ethical theories as educative playgrounds that help them to “frame” and “name” the ethical issues they encounter in daily practice, which is seen as an expression of moral resilience. Since it does not advocate a single ethical theory, but is open to the diversity of traditions that shape ethical thinking, it promotes a culturally sensitive, ethically reflected healthcare practice.
VeloskiJJFieldsSKBoexJR. Measuring professionalism: a review of studies with instruments reported in the literature between 1982 and 2002. Acad Med2005; 80: 366–370.
5.
MattickK. Teaching and assessing medical ethics: where are we now?J Med Ethics2006; 32: 181–185.
6.
DuckettLLRydenMB. Education for ethical nursing practice. In: RestJRNarváezD (eds) Moral development in the professions: psychology and applied ethics. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994, pp. 51–69.
7.
RestJRNarvaezDThomaSJ. A neo-Kohlbergian approach to morality research. J Moral Educ2000; 29: 381–395.
8.
SlováckováBSlovácekL. Moral judgement competence and moral attitudes of medical students. Nurs Ethics2007; 14: 320–328.
9.
VanlaereLGastmansC. Ethics in nursing education: learning to reflect on care practices. Nurs Ethics2007; 14: 758–766.
10.
NarvaezD. Integrative ethical education. In: KillenMSmetanaJG (eds) Handbook of moral development. Mahwah, NJ: Lawrence Erlbaum Associates, 2006, pp. 703–732.
11.
SilvermanHJDagenaisJGordon-LipkinE. Perceived comfort level of medical students and residents in handling clinical ethics issues. J Med Ethics2012; 39: 55–58.
12.
SchulzSWoestmannBHuengesB. How important is medical ethics and history of medicine teaching in the medical curriculum? An empirical approach towards students' views. GMS Zeitschrift für Medizinische Ausbildung2012; 29: 10–18.
13.
BuyxAMMaxwellBSchöne-SeifertB. Challenges of educating for medical professionalism: who should step up to the line?Med Educ2008; 42(8): 758–764.
14.
CampbellAVChinJVooT. How can we know that ethics education produces ethical doctors?Med Teach2007; 29: 431–436.
15.
HaffertyF. Measuring medical professionalism: a commentary. In: SternDT (ed.) Measuring medical professionalism. New York: Oxford University Press, 2006, pp. 281–306.
16.
KushnerTKThomasmaDC (eds). Ward ethics: dilemmas for medical students and doctors in training. 3rd ed. Cambridge/New York: Cambridge University Press, 2008.
17.
BanduraA. Social cognitive theory of moral thought and action. In: KurtinesWMGewirtzJL (eds) Handbook of moral behavior and development: volume 1: theory. Hillsdale, NJ: Lawrence Erlbaum Associates, 1991, pp. 45–103.
18.
Karnieli-MillerOVuTRHoltmanMC. Medical students’ professionalism narratives: a window on the informal and hidden curriculum. Acad Med2010; 85: 124–133.
19.
HicksLK. Understanding the clinical dilemmas that shape medical students’ ethical development: questionnaire survey and focus group study. BMJ2001; 322: 709–710.
20.
GaufbergEHBataldenMSandsR. The hidden curriculum: what can we learn from third-year medical student narrative reflections?Acad Med2010; 85: 1709–1716.
KalaitzidisESchmitzK. A study of an ethics education topic for undergraduate nursing students. Nurse Educ Today2012; 32: 111–115.
25.
EcklesREMeslinEMGaffneyM. Medical ethics education: where are we? Where should we be going? A review. Acad Med2005; 80: 1143–1152.
26.
JosephSJuwahC. Using constructive alignment theory to develop nursing skills curricula. Nurse Educ Pract2012; 12: 52–59.
27.
MossopLDennickRHammondR. Analysing the hidden curriculum: use of a cultural web. Med Educ2013; 47: 134–143.
28.
BuelowJRMahanPLGarrityAW. Ethical dilemmas as perceived by healthcare students with teaching implications. J Coll Teach Learn2010; 7(2): 85–92.
29.
JohnstonCHaughtonP. Medical students’ perceptions of their ethics teaching. J Med Ethics2007; 33: 418–422.
30.
DyrbyeLNThomasMRShanafeltTD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med2006; 81: 354–373.
31.
DyrbyeLN. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA2010; 304: 1173–1180.
32.
ZwackJSchweitzerJ. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med2013; 88: 382–389.
33.
EpsteinEGHamricAB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics2009; 20: 330–342.
34.
BanduraA. Selective activation and disengagement of moral control. J Soc Issues1990; 46: 27–46.
35.
BennettAEagan ChamberlinSM. Resisting moral residue. Pastoral Psychol2012; 62(2): 151–162.
36.
BeauchampTLChildressJF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press, 2013.
AveyardHEdwardsSWestS.Core topics of health care ethics. The identification of core topics for interprofessional education. J Interprof Care2005; 19: 63–69.
39.
McCarthyJ. A pluralist view of nursing ethics. Nurs Philos2006; 7: 157–164.
40.
ShiveSEMarksR. The influence of ethical theories in the practice of health education. Health Promot Pract2006; 7: 287–288.
41.
LawlorR. Moral theories in teaching applied ethics. J Med Ethics2007; 33: 370–372.
42.
LawlorR. Against moral theories: reply to Benatar. J Med Ethics2008; 34: 826–828.
43.
PaasFGogTSwellerJ. Cognitive load theory: new conceptualizations, specifications, and integrated research perspectives. Educ Psychol Rev2010; 22: 115–121.
44.
KottowMH. Theoretical aids in teaching medical ethics. Med Health Care Philos1999; 2: 225–229.
45.
HopeT. Medical ethics: a very short introduction. Oxford/New York: Oxford University Press, 2004.
46.
BenatarD. Moral theories may have some role in teaching applied ethics. J Med Ethics2007; 33: 671–672.
47.
MiyasakaMYamanouchiHDewaK. Narrative approach to ethics education for students without clinical experience. Forensic Sci Int2000; 113: 515–518.
48.
LegetC. Avoiding evasion: medical ethics education and emotion theory. J Med Ethics2004; 30: 490–493.
49.
BouvilleM. On using ethical theories to teach engineering ethics. Sci Eng Ethics2008; 14: 111–120.
50.
BenatarD. Teaching moral theories is an option: reply to Rob Lawlor. J Med Ethics2009; 35: 395–396.
51.
SaundersB. How to teach moral theories in applied ethics. J Med Ethics2010; 36: 635–638.
52.
MattickKBlighJ. Undergraduate ethics teaching: revisiting the Consensus Statement. Med Educ2006; 40: 329–332.
53.
Lekalakala-MokgeleE. Facilitation in problem-based learning: experiencing the locus of control. Nurse Educ Today2010; 30: 638–642.
54.
PaasFRenklASwellerJ. Cognitive load theory: instructional implications of the interaction between information structures and cognitive architecture. Instr Sci2004; 32: 1–8.
55.
PaasFSwellerJ. An evolutionary upgrade of cognitive load theory: using the human motor system and collaboration to support the learning of complex cognitive tasks. Educ Psychol Rev2012; 24: 27–45.
56.
SwellerJAyresPKalyugaS. Cognitive load theory. New York: Springer, 2011.
57.
JongT. Cognitive load theory, educational research, and instructional design: some food for thought. Instr Sci2010; 38: 105–134.
58.
KjeldstadliKTyssenRFinsetA. Life satisfaction and resilience in medical school—a six-year longitudinal, nationwide and comparative study. BMC Med Educ2006; 6: 48.
59.
McAllisterMMcKinnonJ. The importance of teaching and learning resilience in the health disciplines: a critical review of the literature. Nurse Educ Today2009; 29: 371–379.
60.
TempskiPMartinsMAParoHB. Teaching and learning resilience: a new agenda in medical education. Med Educ2012; 46: 345–346.
61.
HoweASmajdorAStöcklA. Towards an understanding of resilience and its relevance to medical training. Med Educ2012; 46: 349–356.
62.
DunnLBIglewiczAMoutierC. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry2008; 32: 44–53.
63.
HoodR. A critical realist model of complexity for interprofessional working. J Interprof Care2012; 26: 6–12.
64.
GallagherA. Moral distress and moral courage in everyday nursing practice. Online J Issues Nurs2011; 16: 8.
ScottPA. Emotion, moral perception, and nursing practice. Nurs Philos2000; 1: 123–133.
67.
FesmireS. John Dewey and moral imagination: pragmatism in ethics. Bloomington, IN: Indiana University Press, 2003.
68.
JacksonDFirtkoAEdenboroughM. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. J Adv Nurs2007; 60: 1–9.
69.
RautioASunnariVNuutinenM. Mistreatment of university students most common during medical studies. BMC Med Educ2005; 5: 36.
70.
WeberET. Rawls, Dewey, and constructivism: on the epistemology of justice. London: Continuum Publishing Corp, 2012.
71.
ElkjaerB. Pragmatism: a learning theory for the future. In: IllerisK (ed.) Contemporary theories of learning: learning theorists, in their own words. London: Routledge, 2009, pp. 74–89.
72.
ElkjaerBSimpsonB. Pragmatism: a lived and living philosophy. What can it offer to contemporary organization theory? In: TsoukasHChiaR (eds) Philosophy and organization theory. Bingley: Emerald Group, 2011, pp. 55–84.
73.
DeweyJ. How we think. Memphis, TN: General Books, 2010 [1910].
74.
DeweyJ. Human nature and conduct: an introduction to social psychology. Amherst, NY: Prometheus Books, 2002.
75.
LiaschenkoJOguzNYBrunnquellD. Critique of the tragic “case” method in ethics education. J Med Ethics2006; 32: 672–677.
