Critical dialogue method of ethics consultation: making clinical ethics facilitation visible and accessible.

In clinical ethics consultations, clinical ethicists bring moral reasoning to bear on concrete and complex clinical ethical problems by undertaking ethical deliberation in collaboration with others. The reasoning process involves identifying and clarifying ethical values which are at stake or contested, and guiding clinicians, and sometimes patients and families, to think through ethically justifiable and available courses of action in clinical situations. There is, however, ongoing discussion about the various methods ethicists use to do this ethical deliberation work. In this paper, we make visible and accessible seven steps of facilitation used in the critical dialogue method of ethics consultation.We describe how the facilitation techniques serve two overall purposes. First, to identify ethically justified responses to ethical questions. Second, to assist participants to gain greater moral clarity, understanding and confidence to respond to ethical challenges as independent moral agents.By describing in detail facilitation steps for clinical ethics consultation, we aim to advance the scholarship of 'clinical ethics facilitation methods' and to demystify the ethical deliberation work undertaken by clinical ethicists.

Exploring Collaboration and Social Dynamics in the Paediatric Morbidity and Mortality Meeting, A Qualitative Case Study.

AIM: To explore collaboration and social dynamics within paediatric Morbidity and Mortality meetings. DESIGN: Qualitative Exploratory Case Study Methodology incorporating semi-structured interviews and qualitative observations. METHODS: Data were collected in a large quaternary paediatric hospital in Melbourne, Australia. Semi-structured interviews with meeting attendees were conducted after observing and documenting meeting conduct. Reflexive thematic analysis was used to interpret data and generate a thematic map of findings. RESULTS: Forty-four interviews and 32 meeting observations were conducted between July 2019 and January 2020. Participants valued collaboration between attendees in Morbidity and Mortality meetings, however there were barriers to this. They included differing views about roles and negative impacts of hierarchies and authority. Senior doctors dominated discussion, and participants described this occasionally signalling reverence and respect, but sometimes signified intimidation and feeling unsure about how to contribute. Because of this complexity, successfully achieving positive social dynamics in a meeting required active promotion and management. CONCLUSION: Morbidity and Mortality meetings mirror the complexity and richness of the clinical environment. Descriptions of how meeting conduct can shape positive workplace culture and address hierarchical obstructions to safe clinical care highlight their far-reaching potential. Effective collaboration is an intrinsic part of realising this value. IMPACT: This paper addresses a paucity in the literature in understanding how social dynamics and collaboration in Morbidity and Mortality meetings are interpreted and experienced. These findings illuminate challenges and obstacles to achieving a productive and equitable social dynamic in meetings. They also illustrate positive discrimination strategies that may improve participation and widespread engagement of nurses, junior doctors, and allied health professionals. Importantly, fostering constructive social dynamics in the Morbidity and Mortality meeting could positively impact patient safety culture and therefore patient care. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Goals of the Morbidity and Mortality meeting in acute care: A scoping review.

OBJECTIVE: The objective of this study was to describe what is known about understandings of the goals of the Morbidity and Mortality meeting. REVIEW METHODS USED: The study utilised scoping review methodology. DATA SOURCES: Papers in English presenting empirical data published in academic journals with Morbidity and Mortality meetings as the central concept of study. Included papers presented data about the perception of stakeholders about goals of the Morbidity and Mortality meeting. Medline, Embase, and CINAHL databases were search conducted from earliest record - October 20th 2021. A manual search of the reference lists of all included papers identified further eligible papers. REVIEW METHODS: Data about the location, participant type, and methods/ methodology were extracted and entered onto a database. Content analysis of the results and discussion sections of qualitative papers yielded broad categories of meeting goal. This provided a framework for the organisation of the quantitative findings, which were subsequently extracted and charted under these categories. RESULTS: Twenty-five papers were included in the review, and six main categories were identified in the qualitative synthesis of findings. These included meeting goals related to quality and safety, education, legal and reputational risk management, professional culture, family/caregivers, and peer support. CONCLUSIONS: There are heterogeneous understandings of key terminologies used to describe Morbidity and Mortality meeting goals, particularly evident within understandings of educational and quality and safety meeting goals. This paper defines and unravels this complexity in a way that researchers and clinicians can define, compare and evaluate their own department's meeting goals.

Visitor restrictions in hospitals during infectious disease outbreaks: An ethical approach to policy development and requests for exemptions.

In this paper, we explore the ethics of restricting visitation to hospitals during an infectious disease outbreak. We aim to answer three questions: What are the features of an ethically justified hospital visitor restriction policy? Should policies include scope for case-by-case exemptions? How should decisions about exemptions be made? Based on a critical interpretive review of the existing ethical literature on visitor restrictions, we argue that an ethically justified hospital visitor restriction policy has the following features: proportionality, comprehensiveness, harm mitigation, exemptions for specific patient populations, visitation decisions made separately from a patient's treating clinicians, transparency, and consistency in application. We also argue that an ethical policy ought to include scope for case-by-case exemptions for individual patients. We propose a process for ethical decision-making that provides a shared language and structure to decrease the risks and burdens of decision-making when clinicians or managers are considering requests for exemptions.

Preparedness for dental practice in Australia: a qualitative study on the experiences of final-year students and new graduates.

BACKGROUND: Limited data exists regarding the perspectives of newly graduated dental practitioners (NGDPs) and final-year students (FYS) about their preparedness for dental practice. This information is crucial to inform developments in ongoing professional development for newly qualified dental practitioners and future reviews and development of accreditation standards, policies, and the professional competencies of newly qualified dental practitioners. Thus, the primary goal of this paper was to describe the perceptions of preparedness for dental practice of NGDPs and FYSs. METHODS: Individual semi-structured interviews were conducted between March and July 2020. All interviews were audiotaped, transcribed, and analysed using a thematic analysis. RESULTS: Eighteen NGDPs and four FYS from across Australia participated in the qualitative interviews. A strong theme from the data was that respondents believed they were well prepared for common challenges in dental practice and patient care. A second prominent theme was participants' awareness of specific areas of limitation in their knowledge and specific skills including (list them). This data highlights a high level of self-awareness and potential for self-directed learning of NGDPs. It also provides specific content areas for future curriculum developers. CONCLUSIONS: Newly graduated dental practitioner and final-year student participants were satisfied with the theoretical and evidence-based information in their formal learning and teaching activities to begin practicing as dental practitioners. In some areas, NGDPs felt underprepared, mostly attributed to limited clinical treatment exposure, and other contextual elements of clinical practice, and thought transitional support may be required. The research reinforces the value of seeking and learning from students' and NGDPs' perspectives.

COVID-19 recovery: implications for cancer care clinicians.

The wellbeing of clinicians delivering cancer care needs to be considered and included in recovery roadmaps from the COVID-19 pandemic. In this paper, we refer to a report undertaken by Cancer Australia to review and reflect on the impact of COVID-19 in the delivery of cancer care. The report focused on post COVID-19 recovery and asked 3 questions: What changed? What has been the impact of that change? And how can high-value changes be embedded or enhanced? We suggest the same three questions should also be asked of cancer care clinicians. Using the three Cancer Australia questions, we draw from clinicians' insights collected through the Victorian COVID-19 Cancer Network (VCCN) and from the wider health professional literature. We summarise key features of the COVID-19 experience for cancer care clinicians, highlighting moral distress, fatigue and disrupted practice. We then discuss how pandemic-related ethical values might guide health leaders and administrators to balance support for clinician wellbeing with ongoing delivery of cancer care for patients.

Mixed-method analysis of screening for Strongyloides stercoralis prior to immunosuppression: a problem of limited bandwidth?

BACKGROUND: Guidelines recommend screening for strongyloidiasis prior to immunosuppression in those at epidemiological risk, as hyperinfection following immunosuppression is often fatal. The uptake of this recommendation is unknown and we aimed to explore this in our setting. AIMS: To determine the proportion of adult patients at epidemiological risk for strongyloidiasis who were screened prior to immunosuppression at the Royal Melbourne Hospital, and to explore the factors that influenced clinicians' decision to screen for strongyloidiasis prior to immunosuppression. METHODS: This study used a mixed-methods approach. First, a 12-month (1 January 2018 to 1 January 2019) retrospective observational study was used to quantify the proportion of those at epidemiological risk who were screened prior to immunosuppression, while also identifying variables that were positively or negatively associated with screening. Second, clinicians from relevant specialties were recruited for focus group sessions to explore factors that influenced their decision to screen according to an interpretivist framework. RESULTS: A total of 230 newly immunosuppressed patients at epidemiological risk of strongyloidiasis were identified, of whom 87 (37.8%) were screened prior to immunosuppression. In multivariate analysis, older patients, outpatients and people from non-English-speaking backgrounds were significantly less likely to be screened. In focus groups, several barriers and enablers to screening were identified. Notably, clinicians reported that a major barrier was the cognitive load required to clinically reason about this uncommon disease, in addition to other priorities. CONCLUSIONS: We identified many missed opportunities to screen patients at risk of hyperinfection, particularly those most vulnerable. To improve screening, this study highlights the importance of reducing cognitive load by using decision-support tools, which may facilitate screening in vulnerable patients and in time-constrained settings.

Telling the truth to seriously ill children: Considering children's interests when parents veto telling the truth.

How should clinicians respond when parents will not allow their child to know the truth about their medical condition and treatment? There is wide consensus amongst clinicians and ethicists that children should be given "honest" information delivered in a developmentally appropriate manner. However, the basis in ethical theory is not clear, especially for pre-adolescents. These children are old enough to understand some information, but are not yet "mature minors" capable of making their own health care decisions. We take the position that thinking in terms of a child's "right to know" is not the most helpful in dealing with the ethical complexity of these situations. We propose that questions of truth-telling are best addressed in terms of how a child's interests are promoted or set back by being told the truth. Our first step is to give an account of the concept of children's interests in general. Then we relate that account specifically to truth-telling. In doing so, we use a relatively straightforward hypothetical but realistic case, in order to illustrate how ethical deliberation using interests would proceed. The case is not intended to be particularly contentious or difficult, so that the focus is on the nature of the ethical reasoning, rather than any complexities of the case.

Preparedness for practice of newly qualified dental practitioners in the Australian context: an exploratory study.

BACKGROUND: The current study explored the perspectives of preparedness for dental practice from a range of relevant stakeholders (i.e., educators, employers, final-year students, graduates, practitioners, and professional associations) using an anonymous online survey in which participants described either their preparedness for practice, or the preparedness of graduates they have encountered, across six domains. RESULTS: A total of 120 participants completed the survey. Participants were from several Australian states and territories; regional, rural, and urban locations; and working in the public and private sector. Students and new graduates generally felt prepared for activities in all the identified domains. Stakeholders reported consistently that the knowledge of dental profession graduates was at the required level to enter practice in Australia in a safe way. Activities involving the knowledge of clinical entrepreneurship and financial solvency were the dimensions where students and graduates felt least prepared (e.g., explaining fees, negotiating finances). In the domains involving clinical and technical competencies, students and new graduates self-assessed as less prepared around managing dental trauma and medical emergencies. On the other hand, activities around social and community orientation, and to a lesser extent professional attitudes and ethical judgements, were the dimensions where students and graduates felt the most prepared. CONCLUSIONS: Present findings indicate that there appear to be good standards of preparedness for practice for graduate dental professionals. This exploratory study provides insights into the nature of preparedness for Australian dental professionals and provides a basis for targeting education and professional development to address areas of need.

Preparedness for practice of newly qualified dental professionals in Australia - educator, employer, and consumer perspectives.

BACKGROUND: Limited data regarding the perspectives of other observers (i.e. those who educate, employ or receive care from) of new graduates' preparedness to practice is available. The present study aimed to explore perceptions of different observers regarding the preparedness to practice and work readiness of newly qualified dental professionals. This broader range of perspectives is crucial to inform the development of educational programs, including continuing professional development, for newly qualified dental professionals, by clarifying the skills, knowledge and behaviours expected by the dental profession and wider public. RESULTS: Nineteen individual qualitative interviews were undertaken. Interview participants included clinical demonstrators (n = 9; 2 Oral Health Therapists; 5 Dentists; and 2 Prosthetists), dental course convenors (n = 4), representatives of large employers (n = 2), and consumers (n = 4). According to this diverse group of respondents, dental students receive adequate theoretical and evidence-based information in their formal learning and teaching activities, which prepares them for practice as dental professionals. There were no specific clinical areas or procedures where preparedness was highlighted as a major concern. Notwithstanding this, specific graduate skills which would benefit from further training and consolidation were identified, including areas where higher levels of experience would be beneficial. Nonetheless, respondents indicated that new graduates were aware of their limitations and had developed self-discipline and ethics that would allow them to identify conditions/situations where they would not have the experience or expertise to provide care safely. CONCLUSIONS: From an observer perspective, dental students appeared to have gained adequate theoretical and evidence-based information in their formal learning and teaching activities to prepared them to commence practicing safely as dental professionals. Areas were identified in which new graduates were underprepared and when transitional support may be required.

Supporting cancer care clinicians to 'hold' their patients during and beyond the COVID-19 pandemic: a role for reflective ethics discussions.

The COVID-19 pandemic has placed an overwhelming burden on healthcare delivery globally. This paper examines how COVID-19 has affected cancer care clinicians' capacity to deliver cancer care in the Australian context. We use the lens of 'holding patients' (drawing from attachment theory, psychology and from Australian Indigenous knowledge) to conceptualise cancer clinicians' processes of care and therapeutic relationships with patients. These notions of 'holding' resonate with the deep responsibility cancer care clinicians feel towards their patients. They enrich ethical language beyond duties to benefit, avoid harm, respect patients' autonomy and provide just treatment. We consider the disruptive effects of COVID-19 on care delivery and on clinicians themselves. We then show how models of clinical ethics and other similar reflective discussion approaches are a relevant support mechanism to assist clinicians to process and make sense of COVID-19's disruptions to their professional ethical role of holding patients during and beyond the pandemic.

Should clinicians make chest surgery available to transgender male adolescents?

Bioethicists are increasingly engaged in considering the ethical issues associated with the care of transgender people. One such issue facing paediatric clinicians is requests for chest surgery from transgender male adolescents. For transgender young people who identify as male but have already progressed through the mid to late stages of puberty, hormone treatment will not reverse breast development. Some of these young people are distressed by their chest, and request surgery to remove this tissue. Demand for this surgery during adolescence is increasing. However, few paediatric hospitals make this intervention available to adolescents. This paper focuses on the following ethical question: Should clinicians make chest surgery available to transgender male adolescents? We argue that making chest surgery available to transgender male adolescents under some circumstances is ethically justifiable for three reasons, based on the concepts of beneficence, privacy, and non-discrimination. Firstly, the limited evidence to date suggests that chest surgery is beneficial to transgender male adolescents who seek this intervention. Secondly, chest surgery protects transgender adolescents' privacy by enabling them to better control disclosure of their transgender identity. Thirdly, chest surgery is already performed on other adolescent males for psychosocial reasons, such as in the case of gynaecomastia; non-discrimination thus provides a further reason for making chest surgery available to transgender male adolescents whose male gender identity is consistent. We suggest that the ethical justifiability of chest surgery in any specific transgender adolescent's case will depend on the individual patient's circumstances.

Balancing health worker well-being and duty to care: an ethical approach to staff safety in COVID-19 and beyond.

The COVID-19 pandemic has highlighted the risks that can be involved in healthcare work. In this paper, we explore the issue of staff safety in clinical work using the example of personal protective equipment (PPE) in the COVID-19 crisis. We articulate some of the specific ethical challenges around PPE currently being faced by front-line clinicians, and develop an approach to staff safety that involves balancing duty to care and personal well-being. We describe each of these values, and present a decision-making framework that integrates the two. The aim of the framework is to guide the process of balancing these two values when staff safety is at stake, by facilitating ethical reflection and/or decision-making that is systematic, specific and transparent. It provides a structure for individual reflection, collaborative staff discussion, and decision-making by those responsible for teams, departments and other groups of healthcare staff. Overall the framework guides the decision maker to characterise the degree of risk to staff, articulate feasible options for staff protection in that specific setting and identify the option that ensures any decrease in patient care is proportionate to the increase in staff well-being. It applies specifically to issues of PPE in COVID-19, and also has potential to assist decision makers in other situations involving protection of healthcare staff.

"Starting from a higher place": linking Habermas to teaching and learning clinical reasoning in the emergency medicine context.

Teaching clinical reasoning in emergency medicine requires educators to foster diagnostic accuracy and judicious decision-making amidst chaotic ambient factors including clinician fatigue, high cognitive load, and diverse patient expectations. The current study applies the early work of Jurgen Habermas and his knowledge-constitutive interests as a lens to explore an educational approach where physician-educators were asked to make their expert reasoning visible to emergency medicine trainees, to more deliberately make visible and accessible the context-specific thinking that emergency physicians routinely use. An action research methodology was used. The 'making thinking visible' teaching approach was introduced to five emergency medicine educators working in large public hospital emergency departments. Participants were asked to trial this teaching method and document its impact on student learning over two reporting cycles. Based on written reports of trialing the teaching approach, participants identified a need to change from: (1) introducing thinking structures to cultivating enquiry; and, (2) providing explanations based on cognitive thinking routines towards encouraging the learner to see the relevance of the clinical context. Educators described how they developed a more diagnostic and reflexive approach to learners, recognized the need to cultivate independent thinking, and valued the opportunity to reflect on their usual teaching. Teaching clinical reasoning using the 'making thinking visible' approach prompted educators to decrease the emphasis on providing technical information to assisting learners to understand the purposes and meanings behind clinical reasoning in emergency medicine. The knowledge-constitutive interests work of Jurgen Habermas was found to provide a robust framework supporting this emancipatory teaching approach.

Pilot Study: Thinking Outside the Square in Cultivating "Soft Skills"-Going beyond the Standard Optometric Curriculum.

SIGNIFICANCE: No research in optometric education that uses Moore's concept of creativity and object-based learning to cultivate "soft skills" exists. The design and outcomes of this study will contribute to the body of optometric education, and future research will assess the applicability of these findings to other allied health disciplines. PURPOSE: Optometrists, like all health care professionals, need to be proficient in soft skills such as effective communication and interpersonal skills. Rather than assuming these soft skills can be developed "on the job," we implemented a teaching intervention for students to develop their communication, interpersonal, and teamwork skills. METHODS: Students from optometry, arts management, and animation attended an autobiographical museum in interdisciplinary groups and examined an artifact relating to aspects of professionalism mentioned previously. We evaluated whether and how students experienced this activity as enhancing their creativity and other soft skills via survey results and thematic analysis of their reflective essays. RESULTS: Our findings showed that this group work has augmented their professional development, with approximately 90% of the students reporting that it had helped in critical self-reflection and future improvement of communication and interpersonal skills. Eighty percent of the students stated that this group work was beneficial and enjoyable and recommended object-based and interdisciplinary learning to be embedded in future group work. Themes generated from the essays were the following: (a) perceptions of object-based learning in a museum and (b) insights into group work experiences. CONCLUSIONS: This is the first pilot study that investigates group work across optometry and nonclinical disciplines in a post-graduate curriculum using museum objects. Our findings, based on students' perceptions, imply that students emerged from the program with the intent to transfer their learning to their future practice. We propose that this purposefully designed-based and creative group work may support the development of professional attributes essential for optometric students.

Paediatric clinicians' experiences of parental online health information seeking: A qualitative study.

AIM: The aim of this research was to explore clinicians' experiences of parents' online health information seeking (OHIS) behaviour about selective dorsal rhizotomy for the management of cerebral palsy. METHODS: Using qualitative methodology, clinicians likely to have had experience with parents requesting selective dorsal rhizotomy were invited to participate in semi-structured interviews. Interviews with 13 clinicians were recorded, transcribed and inductive content analysis was used to identify, code and organise the data into themes. RESULTS: Participants highlighted how parental OHIS was changing clinical communication. Negative effects included a shift in clinicians' attention from giving advice and guidance to spending time discussing online findings, justifying how this information applies to a particular child and managing parents' judgments about clinical views. Positive effects included more collaboration and sharing of ideas. These results are presented in three main themes: (i) the informed parent; (ii) the clinicians' role; and (iii) a new clinical dynamic. CONCLUSION: This research reinforces the notion that OHIS is changing the communication dynamic and clinicians' and parents' roles within the clinical encounter. Of significance was the number of challenges clinicians are facing as a result of online information, including managing parental understanding of non-evidenced information and responding to negative feedback about their practice. This research suggests a need for educational support and ongoing professional development for clinicians to assist them to adjust to new goals and expectations of clinical interactions with 'informed' parents.

Ripple effect of a clinical teaching fellow programme in an Australian paediatric hospital.

AIM: Bedside teaching performed by experienced clinicians is an expected component of medical student training. As clinicians often have high clinical demands and a lack of formal training in teaching methods, clinical teaching fellowships have been established. In clinical teaching fellowships, clinicians with an interest and expertise in medical education provide medical students with standardised teaching. Studies about the impact of clinical teaching fellowships have demonstrated benefits for both clinical teaching fellows (CTFs) and medical students. However, studies have not evaluated the impact of these fellowships on other clinicians or learning relationships within the institution. In this study, we aimed to address this gap by gathering data on the perspectives of CTFs, medical students and hospital consultants. METHOD: A mixed-method design was used, utilising a combination of surveys for CTFs, medical students and hospital consultants and semi-structured telephone interviews for CTFs. Quantitative and qualitative data were obtained. RESULTS: The combination of data from CTFs, medical students and consultants enabled a more comprehensive understanding of the impact of the CTF programme within the institution. Although benefits were identified for CTFs and medical students, the consultant group noted that they were less involved in teaching medical students and that the CTFs were not well integrated into the ward team. CONCLUSION: This research highlights the importance of considering not only direct outcomes of teaching and learning but broader influences on more implicit teaching opportunities and relationships within hospital teams.

"I Had No Idea That Other People in the World Thought Differently to Me": Ethical Challenges in Small Animal Veterinary Practice and Implications for Ethics Support and Education.

Although veterinarians encounter ethical challenges in their everyday practice, few studies have examined how they make sense of and respond to them. This research used semi-structured interviews and a qualitative methodology (phenomenological and constructivist/interpretivist approaches) to explore ethical challenges experienced by seven small animal city veterinarians and their ethical decision-making strategies. Thematic analysis of the interview transcripts identified four broad ethical issues: The first concerned disagreements about the best interests of the animal; the second centered on clinical uncertainty about the most appropriate treatment for the animal; the third involved factors influencing ethical reasoning and decision making; and the fourth concerned how ethics education might prepare veterinary students for future ethical decision making. An overarching theme identified in the analysis was one of enormous personal distress. Furthermore, a sense of veterinarians being interested in how others might think and feel about ethical challenges came through in the data. The results give insight into how veterinarians experience and respond to ethical challenges. The research also provides empirical information about everyday practice to inform future education in ethics and ethical decision making for veterinary students.

Pediatric Ethics Consultation: Practical Considerations for the Clinical Ethics Consultant.

Clinical ethics consultants face a wide range of ethical dilemmas that require broad knowledge and skills. Although there is considerable overlap with the approach to adult consultation, ethics consultants must be aware of differences when they work with infant, pediatric, and adolescent cases. This article addresses unique considerations in the pediatric setting, reviews foundational theories on parental authority, suggests practical approaches to pediatric consultation, and outlines current available resources for clinical ethics consultants who wish to deepen their skills in this area.

Ethics of fertility preservation for prepubertal children: should clinicians offer procedures where efficacy is largely unproven?

Young children with cancer are treated with interventions that can have a high risk of compromising their reproductive potential. 'Fertility preservation' for children who have not yet reached puberty involves surgically removing and cryopreserving reproductive tissue prior to treatment in the expectation that strategies for the use of this tissue will be developed in the future. Fertility preservation for prepubertal children is ethically complex because the techniques largely lack proven efficacy for this age group. There is professional difference of opinion about whether it is ethical to offer such 'experimental' procedures. The question addressed in this paper is: when, if ever, is it ethically justifiable to offer fertility preservation surgery to prepubertal children? We present the ethical concerns about prepubertal fertility preservation, drawing both on existing literature and our experience discussing this issue with clinicians in clinical ethics case consultations. We argue that offering the procedure is ethically justifiable in certain circumstances. For many children, the balance of benefits and burdens is such that the procedure is ethically permissible but not ethically required; when the procedure is medically safe, it is the parents' decision to make, with appropriate information and guidance from the treating clinicians. We suggest that clinical ethics support processes are necessary to assist clinicians to engage with the ethical complexity of prepubertal fertility preservation and describe the framework that has been integrated into the pathway of care for patients and families attending the Royal Children's Hospital in Melbourne, Australia.