[Implementing the Objective Structured Clinical Examination (OSCE) in postgraduate education in nursing science-a pilot project to assess ethical competences in nursing practice and research]. / Implementierung des Objective Structured Clinical Examination (OSCE) im Masterstudiengang Pflegewissenschaft ­ Pilotprojekt zur Prüfung der ethischen Kompetenz in Pflegepraxis und -forschung.

Background: Teaching ethical competencies is an essential component of professional and postgraduate curricula. Developing practical-ethical problem-solving competencies as well as appraising program-specific studies and related research ethics are topics typically addressed. However, assessment of these ethical competencies poses a challenge. Written or oral assessment formats addressing relevant learning objectives is mainly limited to knowledge testing alone, often not capturing relevant skills or attitudes pertinent to those competencies. Aim: During the reaccreditation of the masters of science (MSc) program in Nursing Science at Witten/Herdecke University, this challenge was addressed by implementation of an innovative examination format for postgraduate education. Procedure: For the module "Ethics in nursing practice and research" a format based on the Objective Structured Clinical Examination (OSCE) format was developed. This assessment method incorporates evaluation of acquired skills and attitudes of nursing students. Conclusion: The article demonstrates development and adaption of the OSCE format for this purpose.

Nurses' decision-making in ethically relevant clinical situations using the example of breathlessness: study protocol of a reflexive grounded theory integrating Goffman's framework analysis.

INTRODUCTION: Decision-making (DM) in healthcare can be understood as an interactive process addressing decision makers' reasoning as well as their visible behaviour after the decision is made. Other key elements of DM are ethical aspects and the role as well as the treatment options of the examined professions. Nurses' DM to choose interventions in situations of severe breathlessness is such interactions. They are also ethically relevant regarding the vulnerability of affected patients and possible restrictions or treatment options. The study aims to explore which factors influence nurses' DM to use nursing interventions in situations where patients suffer from severe breathlessness. METHODS AND ANALYSIS: Qualitative study including nurses in German hospital wards and hospices. A triangulation of different methods of data collection-participant observation and qualitative expert interviews-and analysis merge in a reflexive grounded theory approach which integrates Goffman's framework analysis. It allows an analysis of nurses' self-statements about DM, their behaviour in relevant clinical situations and its influences. Data collection and analysis will be examined simultaneously. ETHICS AND DISSEMINATION: Informed consent will be gained from all participants and the institutional stakeholders. Ongoing consent has to be ensured since observations will take place in healthcare institutions and many patients will be highly vulnerable. The study has been evaluated and approved by the Witten/Herdecke University Ethics Committee, Witten, Germany. Results of the study will be published at congresses and in journal papers.

Medical Students' Development of Ethical Judgment - Exploring the Learners' Perspectives using a mixed methods approach.

Objective: Contemporary healthcare requires physicians to have well developed ethical judgment skills in addition to excellent clinical skills. However, no consensus has been reached on how to best teach ethical judgment skills during medical training. Previous studies revealed inconclusive results and applied varying theoretical frameworks. To date, the students' perspectives on their development in ethical judgment has received less attention. Better insights in the learners' experiences can help to improve educational interventions in medical ethics. Methods: A vignette featuring a challenging case with opposing views between a patient's parents and a physician followed by a questionnaire was presented to a cohort of medical students at a German medical school at three points in time during their medical training (Year 1, 2 and 5). The questionnaire included closed and open-ended questions addressing the participant's preferred, hypothetical actions, their reasoning as well as the resources informing their reasoning. Content analysis was used for qualitative data; frequencies and percentages were used to describe quantitative findings. Results: The response rate remained stable (28%) over the study period. Participants' responses changed overtime. Accepting parents' autonomy in the decision-making process was the majority standpoint of students in year 1 and 2 and became less often cited in year 5 (Year 1/2/5: 68/67/48%). On the contrary, not readily following the parents' decision for medical reasons was a minority standpoint in year 1 and became more prevalent over time (year 1/2/5: 12/17/42%). Judgments were only partly based on ethics training. Instead, participants drew on experiences from their clinical clerkships and their personal lives. Throughout the study, participants did not feel well-prepared to make a judgment in the case (Average 2.7 on a Likert-Scale; 1=very well prepared, 4=very poor). Conclusions: Over the course of their medical training, the participants seemed to increasingly frame the presented vignette as a medical problem. To optimize the development of ethical judgment teaching of ethics should be more integrated in clinical teaching. In addition to the analysis of rare and extreme cases, teaching ethics should also expand on challenges students and junior doctors commonly encounter themselves to promote ethical sensitivity and confidence in students.

Evaluating an evidence-based curriculum in undergraduate palliative care education: piloting a phase II exploratory trial for a complex intervention.

BACKGROUND: By 2013 Palliative Care will become a mandatory examination subject in the medical curriculum in Germany. There is a pressing need for effective and well-designed curricula and assessment methods. Debates are on going as how Undergraduate Palliative Care Education (UPCE) should be taught and how knowledge and skills should be assessed. It is evident by this time that the development process of early curricula in the US and UK has led to a plethora of diverse curricula which seem to be partly ineffective in improving the care for the seriously ill and dying offered by newly qualified doctors, as is demonstrated in controlled evaluations. The goals of this study were to demonstrate an evidence-based approach towards developing UPCE curricula and investigate the change in medical students' self-perceived readiness to deal with palliative care patients and their families. METHODS: To evaluate the effects of the UPCE curriculum we chose a prospective, controlled, quasi-experimental, pre, retrospective-pre, post study design. A total of n = 37 3rd and 4th -year medical students were assigned to the intervention group (n = 15; 4th -year) and to the control group (n = 22; 3rd-year). Resting on the self-efficacy concept of Bandura the measurement was conducted by a refined test-battery based on two independent measurements (the revised Collet-Lester-Fear-of-Death-Scale and the instrument of the "Program in Palliative Care Education and Practice" at Harvard Medical School) including 68 items altogether in a five-point Likert-scale. These items were designed to test elementary skills in caring for the dying and their relatives as perceived by medical undergraduates. Datasets from both groups were analysed by paired and independent two-sample t-test. The TREND statement for reporting non-randomized evaluations was applied for reporting on this quasi-experimental study. RESULTS: Three constructs showed statistically significant differences comparing the intervention group before and after. Willingness to accompany a dying patient increased from 21.40 to 37.30 (p < .001). Self-estimation of competence in communication with dying patients and their relatives increased from 12.00 to 23.60 (p = .001). Finally, self-estimation of knowledge and skills in Palliative Care increased from 8.30 to 13.20 (p = .001). CONCLUSIONS: This study is a small but systematic step towards rigorous curricular development in palliative care. Our manualised curriculum is available for scrutiny and scientific feedback to support an open and constructive process of best-practice comparison in palliative care.

[Nurses end-of-life decision making. Professional nurses about the application of complementary care for patients with breathlessness]. / Pflegerische Entscheidungen am Lebensende. Professionell Pflegende zum Einsatz komplementärpflegerischer Massnahmen bei Patienten mit Atemnot.

Aim of this study was to explore the nursing professionals' experiences and handling of decisions to provide complementary care for patients with breathlessness at the end of life. Therefore, it presents one of the first studies in the German speaking area addressing genuine nursing decisions belonging to their responsibility. Based on Grounded Theory Methodology the data were collected and analysed synchronously. Results show a high professional and emphatic decision making process always focussing on the patient. "To consider the patient" emanates from their general attitude and is influenced by the possibility to be human themselves and by reflecting ones limitations. At the same time participants described a repertoire of complementary care procedures which they use in their daily nursing routine. This study illustrates the decision making process and outlines the general attitude influencing all decisions and actions of nurses to relieve breathlessness. Furthermore, it shows for the first time a range of currently used complementary care procedures to treat patients with breathlessness at the end of life.

Palliative care for the elderly--developing a curriculum for nursing and medical students.

BACKGROUND: Delivering palliative care to elderly, dying patients is a present and future challenge. In Germany, this has been underlined by a 2009 legislation implementing palliative care as compulsory in the medical curriculum. While the number of elderly patients is increasing in many western countries multimorbidity, dementia and frailty complicate care. Teaching palliative care of the elderly to an interprofessional group of medical and nursing students can help to provide better care as acknowledged by the ministry of health and its expert panels. In this study we researched and created an interdisciplinary curriculum focussing on the palliative care needs of the elderly which will be presented in this paper. METHODS: In order to identify relevant learning goals and objectives for the curriculum, we proceeded in four subsequent stages. We searched international literature for existing undergraduate palliative care curricula focussing on the palliative care situation of elderly patients; we searched international literature for palliative care needs of the elderly. The searches were sensitive and limited in nature. Mesh terms were used where applicable. We then presented the results to a group of geriatrics and palliative care experts for critical appraisal. Finally, the findings were transformed into a curriculum, focussing on learning goals, using the literature found. RESULTS: The literature searches and expert feedback produced a primary body of results. The following deduction domains emerged: Geriatrics, Palliative Care, Communication & Patient Autonomy and Organisation & Social Networks. Based on these domains we developed our curriculum. CONCLUSIONS: The curriculum was successfully implemented following the Kern approach for medical curricula. The process is documented in this paper. The information given may support curriculum developers in their search for learning goals and objectives.

[Cura sui--selfcare and its relationship to nursing]. / CURA SUI - Die Selbstsorge und ihre Beziehung zur Pflege.

Self care is an answer to the response of finiteness, which is given through the fact of the human body. The article demonstrates in reference to the Selfcaredeficit-Theory (Orem, 2006) how self care in everyday life, ancient roman called it cura sui, is related to nursing practice, specially to acutecare. Self care turns out as an category of ambivalence between ethics and power.

[Dealing with sensitive interview topics--insights into the research project "Everyday life of people with urinary incontinence"]. / Umgang mit sensiblen Themen in Interviews--Einblicke in das Forschungsprojekt "Harninkontinenz im Alltag der Betroffenen".

This article has been written as part of a research project investigating the experiences of people with urinary incontinence. In this article a systematic literature analysis combined with excerpts from the study was used to describe and reflect on the best way to conduct interviews on sensitive topics. Ethical aspects are emphasised. These include informed and process consent, different types, places, and phases of such an interview, and reasons for people to participate in such interviews. It is shown that grappling with sensitive and shameful topics can promote recruitment of potential candidates and add depth to qualitative research. As such, sensitive interview topics constitute important quality indicators for qualitative research.

[Relevance and modification of autonomy and care at the end of life. Results of a survey by means of a vignette-study]. / Zur Bedeutung und Gestaltung von Autonomie und Fürsorge am Lebensende. Ergebnisse einer Befragung im Rahmen einer Vignettenstudie.

For several years the public and the associations of nurses and physicians have discussed ways and possibilities for a good and professional end-of-life attendance of patients. In this connection a descriptive vignette-study (n = 152) investigates the relevancy of nurses' and physicians' capability to ensure the patient's autonomy (expressed by a living will) and care for the patient. In their vignette-stories' assessments and answers to additional questions nurses and physicians judge that both values, autonomy and care, are essential. But it remains unclear, what autonomy and care mean to them and how both values be joined together and modified in a practicable way. If this ambiguousness is an expression of the matter itself, if it therefore never becomes quite clear what autonomy and care mean in end-of-life attendance, legislation and professional curricula should take this into consideration.

[Quality criteria that are important to residents of elders' homes and their relatives--a literature analysis]. / Qualitätskriterien, die Altenpflegeheim- bewohnern und Angehörigen wichtig sind--Eine Literaturanalyse.

This literature analysis attempts to identify quality criteria which are important for residents of nursing homes and their relatives. To this end, 13 research articles published in international scientific journals were analysed. For the residents themselves, the ability to manage their daily lives autonomously as well as their ability to structure social contacts and relationships appears to be of special importance. In contrast, relatives emphasise criteria that refer to the quality of the care provided and the structure quality of the institutional setting. For them it is of specific importance to know that residents feel at home in the facility.