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Phua GLG, Owyong JLJ, Leong ITY, Goh S, Somasundaram N, Poon EYL, Chowdhury AR, Ong SYK, Lim C, Murugam V, Ong EK, Mason S, Hill R, Krishna LKR. A systematic scoping review of group reflection in medical education. BMC MEDICAL EDUCATION 2024; 24:398. [PMID: 38600515 PMCID: PMC11007913 DOI: 10.1186/s12909-024-05203-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Reviewing experiences and recognizing the impact of personal and professional views and emotions upon conduct shapes a physician's professional and personal development, molding their professional identity formation (PIF). Poor appreciation on the role of reflection, shortages in trained tutors and inadequate 'protected time' for reflections in packed medical curricula has hindered its integration into medical education. Group reflection could be a viable alternative to individual reflections; however, this nascent practice requires further study. METHODS A Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure a review of group reflections in medical education. Independent searches of articles published between 1st January 2000 and 30th June 2022 in bibliographic and grey literature databases were carried out. Included articles were analysed separately using thematic and content analysis, and combined into categories and themes. The themes/categories created were compared with the tabulated summaries of included articles to create domains that framed the synthesis of the discussion. RESULTS 1141 abstracts were reviewed, 193 full-text articles were appraised and 66 articles were included and the domains identified were theories; indications; types; structure; and benefits and challenges of group reflections. CONCLUSIONS Scaffolded by current approaches to individual reflections and theories and inculcated with nuanced adaptations from other medical practices, this SSR in SEBA suggests that structured group reflections may fill current gaps in training. However, design and assessment of the evidence-based structuring of group reflections proposed here must be the focus of future study.
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Affiliation(s)
- Gillian Li Gek Phua
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Lien Centre for Palliative Care, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Jasmine Lerk Juan Owyong
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- School of Humanities and Behavioural Sciences, Singapore University of Social Sciences, 463 Clementi Road, Singapore, Singapore
| | - Ian Tze Yong Leong
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Suzanne Goh
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- KK Women's and Children Hospital, 100 Bukit Timah Rd, Singapore, 169854, Singapore
| | - Nagavalli Somasundaram
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Eileen Yi Ling Poon
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | | | - Simon Yew Kuang Ong
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Crystal Lim
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Medical Social Services, Singapore General Hospital, 16 College Road, Block 3 Level 1, Singapore, 169854, Singapore
| | - Vengadasalam Murugam
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Eng Koon Ong
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Assisi Hospice, 832 Thomson Rd, Singapore, Singapore
- Office of Medical Humanities, SingHealth Medicine Academic Clinical Programme, 31 Third Hospital Ave, Singapore, 168753, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA, UK
| | - Ruaridh Hill
- Health Data Science, University of Liverpool, Whelan Building, The Quadrangle, Brownlow Hill, Liverpool, UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, Singapore, Singapore.
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore.
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA, UK.
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, Singapore, Singapore.
- Centre for Biomedical Ethics, National University of Singapore, Singapore, Singapore.
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Chew QH, Lee TS, Sim K. Moral injury and associated context, contributors and consequences within mental healthcare professionals: a scoping review. Postgrad Med 2023; 135:646-668. [PMID: 37776227 DOI: 10.1080/00325481.2023.2266007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/28/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVES We sought to examine the contributory factors as well as consequences of moral injury amongst healthcare workers within mental healthcare settings. METHODS Several databases were searched for relevant studies from database inception until May 2023. Keywords and concepts included moral injury and distress in mental healthcare and psychiatry. We identified 961 studies, of which 48 were assessed for eligibility. Eventually, 35 studies were included in the review. Papers were selected for inclusion if 1) they included mental healthcare professionals (MHP) regardless of practice setting, 2) moral injury as experienced by MHP was one of their main variables of interest, 3) were written in English. Year of publication, location of study, participant characteristics, study design, settings in which injury occur (context), factors contributing to moral injury (contributors), and its effects on MHP (consequences) were extracted from the studies. RESULTS The majority of studies were conducted in the West (n = 26, 74.3%). Contributors to moral injury were found at the individual (e.g. poor competence), practice setting (e.g. lack of resources), and organizational levels (e.g. inconsistent policies). Moral injury had negative repercussions for the individual (e.g. psychological and physical symptoms), healthcare teams (e.g. lack of trust and empathy), and healthcare system (e.g. staff attrition). CONCLUSIONS Seen through the moral habitability framework, interventions must include an acknowledgment of the influence of various factors on the ability of MHP to enact their moral agency, and seek to establish safe moral communities within a supportive moral climate.
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Affiliation(s)
- Qian Hui Chew
- Research Division, Institute of Mental Health, Singapore, Singapore
| | - Tih-Shih Lee
- Neuroscience and Behavioral Disorders Program, Duke-NUS Medical School, Singapore, Singapore
| | - Kang Sim
- West Region, Institute of Mental Health, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Milling L, Nielsen DS, Kjær J, Binderup LG, de Muckadell CS, Christensen HC, Christensen EF, Lassen AT, Mikkelsen S. Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study. PLoS One 2023; 18:e0284826. [PMID: 37494384 PMCID: PMC10370897 DOI: 10.1371/journal.pone.0284826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/07/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA. METHODS We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis. RESULTS All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values. CONCLUSION This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.
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Affiliation(s)
- Louise Milling
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dorthe Susanne Nielsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jeannett Kjær
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lars Grassmé Binderup
- Department for the Study of Culture, Philosophy, University of Southern Denmark, Odense, Denmark
| | | | | | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Aalborg University Hospital and Aalborg University, Aalborg, Denmark
- Emergency Medical Services, Region North Denmark, Aalborg, Denmark
| | | | - Søren Mikkelsen
- Department of Anaesthesiology and Intensive Care, Prehospital Research Unit, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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From "What" to "How": Experiential Learning in a Graduate Medicine for Ethicists Course. Camb Q Healthc Ethics 2022; 31:131-140. [PMID: 35049451 DOI: 10.1017/s0963180121000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Teaching healthcare ethics at the doctoral level presents a particular challenge. Ethics is often taught to medical students, but rarely is medicine taught to graduate students in health care ethics. In this paper, Medicine for Ethicists [MfE] - a course taught both didactically and experientially - is described. Eight former MfE students were independently interviewed in a semi-structured, open-ended format regarding their experience in the experiential component of the course. Themes included concrete elements about the course, elements related to the broader PhD student learning experience, and themes related to the students' past and future career experiences. Findings are related to the educational philosophy of John Dewey and David Kolb's experiential learning theory. Broader implications of this work are explored.
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Nowak A, Schildmann J, Nadolny S, Heirich N, Linoh KP, Rosenau H, Dutzmann J, Sedding D, Noutsias M. Clinical ethics case consultation in a university department of cardiology and intensive care: a descriptive evaluation of consultation protocols. BMC Med Ethics 2021; 22:99. [PMID: 34301238 PMCID: PMC8305900 DOI: 10.1186/s12910-021-00668-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital. METHODS Semi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. All documents were analysed by two researchers independently. RESULTS Twenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43-96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1-65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases. CONCLUSIONS To the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes.
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Affiliation(s)
- Andre Nowak
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.
| | - Stephan Nadolny
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.,Nursing Science Staff Unit, Franziskus-Hospital Harderberg, Niels-Stensen-Klinken, Alte Rothenfelder Str. 23, 49124, Georgsmarienhütte, Germany
| | - Nicolas Heirich
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty , Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Kim P Linoh
- Chair of Criminal Law, Criminal Procedure and Medical Law, Law School, Faculty of Law and Economics, Martin Luther University Halle-Wittenberg, Universitätsplatz 6, 06108, Halle (Saale), Germany
| | - Henning Rosenau
- Chair of Criminal Law, Criminal Procedure and Medical Law, Law School, Faculty of Law and Economics, Martin Luther University Halle-Wittenberg, Universitätsplatz 6, 06108, Halle (Saale), Germany
| | - Jochen Dutzmann
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Daniel Sedding
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.,Department of Internal Medicine A, Division of Cardiology, Angiology, Nephrology and Intensive Medical Care , Ruppiner Kliniken, Medical School of Brandenburg Theodor Fontane (MHB) , Fehrbelliner Strasse 38 , 16816 , Neuruppin , Germany
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Molyneux S, Sukhtankar P, Thitiri J, Njeru R, Muraya K, Sanga G, Walson JL, Berkley J, Kelley M, Marsh V. Model for developing context-sensitive responses to vulnerability in research: managing ethical dilemmas faced by frontline research staff in Kenya. BMJ Glob Health 2021; 6:e004937. [PMID: 34244204 PMCID: PMC8268889 DOI: 10.1136/bmjgh-2021-004937] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/20/2021] [Indexed: 01/02/2023] Open
Abstract
Health research in low-resource settings often involves individuals and populations defined as 'vulnerable'. There is growing attention in the literature to the ethical dilemmas that frontline research staff face while conducting such research. However, there is little documented as to how research staff might support one another in identifying and handling these dilemmas in different contexts. Over the course of conducting empirical ethics research embedded in the Childhood Acute Illness & Nutrition Network, we developed an approach to examine and respond to the ethical issues and dilemmas faced by the study teams, particularly frontline staff. In this paper we describe the specific tools and approach we developed, which centred on regular cross-team ethics reflection sessions, and share lessons learnt. We suggest that all studies involving potentially vulnerable participants should incorporate activities and processes to support frontline staff in identifying, reflecting on and responding to ethical dilemmas, throughout studies. We outline the resources needed to do this and share piloted tools for further adaptation and evaluation. Such initiatives should complement and feed into-and certainly not in any way replace or substitute for-strong institutional ethics review, safeguarding and health and safety policies and processes, as well broader staff training and career support initiatives.
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Affiliation(s)
- Sassy Molyneux
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Priya Sukhtankar
- Department of Child Health, Gloucester Hospitals NHS Foundation Trust, Gloucester, UK
| | - Johnstone Thitiri
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Rita Njeru
- Ethox Centre and Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kui Muraya
- Kemri-Wellcome Trust, Centre for Geographic Medicine Research Coast, Nairobi, Kenya
| | - Gladys Sanga
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - James Berkley
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Maureen Kelley
- Ethox Centre and Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Vicki Marsh
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research Coast, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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