Mapping the Competencies and Entrustable Professional Activities of Medical Ethics for Faculty Members

doi:10.21203/rs.3.rs-2122782/v1

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Mapping the Competencies and Entrustable Professional Activities of Medical Ethics for Faculty Members

https://doi.org/10.21203/rs.3.rs-2122782/v1

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published 05 Jun, 2023

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Introduction

The present study aimed to develop core competencies and Entrustable Professional Activities (EPAs) for faculty members through participating in faculty development courses in the field of medical ethics.

Methods

This study included five stages. First, based on the literature review and interviews with 14 experts and through inductive content analysis, categories and subcategories were extracted. Second, content validity of the core competency list was assessed by 16 experts using qualitative and quantitative approaches. Third, based on previous phase, a framework for EPAs was developed by research taskforce in two sessions through consensus. Fourth, content validity of the list of EPAs compiled based on three-point Likert was evaluated by 11 medical ethics experts from necessity and relevance perspective. Fifth, EPAs were mapped by 10 experts to the developed core competencies.

Results

After literature review and interviews, 295 codes were extracted, which were further classified into six categories and 18 subcategories. Based on the validation results, five core competencies and 23 EPAs were developed that were required for faculty members in the field of medical ethics. Identified core competencies included teaching, research and scholarship in the field of medical ethics, communication skills, moral reasoning, and decision-making, policy-making and ethical leadership.

Conclusion

Medical teachers can be strongly effective in moralizing healthcare system, and present findings showed that faculty members should acquire extensive core competencies and EPAs for proficiently integrating medical ethics in curricula. Faculty development programs can be designed in the field of medical ethics for faculty members to help them acquire core competencies and EPAs.

Medical Ethics

Entrustable Professional Activities

Competencies

Faculty Members

Medical ethics is a core competency in medical education (1), and faculty members can be significantly effective in conveying moral values to students (2). Faculty members tackle medical ethics challenges in clinical service delivery, education, and research (3). Thus, successfully providing clinical services to patients depends not only on medical knowledge and skills, but also appropriate and ethical relationship with patients, respect for patient confidentiality and privacy, honesty with patients, as well as maintaining patients’ trust (4), that also lead to reducing medical errors (5). Moreover, majority of medical knowledge comes from scientific research, and hence, appropriate teaching of ethics in research is a major duty of faculty members in addition to presenting knowledge regarding code of conducts and guidelines in healthcare practice (6, 7). Moreover, observance of ethical principles in providing clinical services and research by faculty members, as role models, affects students as it informally conveys them moral values through hidden curriculum (8, 9). Observing professional behaviors through such role modeling, which can later have positive effects on improving patient care delivery (10), is often considered stronger than that the direct teaching in formal curriculum (11). Through role modeling, medical teachers affect medical students’ attitudes, norms, and beliefs, as well as help them develop professional values (12). However, direct teaching of medical ethics to students is required (13), and without it, students may not achieve moral growth and decision-making capacity to resolve ethical dilemmas (14).

Sometimes, faculty members consider themselves incapable of teaching and conveying moral values and professional behaviors to students because they have not received formal education in medical ethics (15). Eckles et al. showed that faculty members could not play their role in improving medical ethics competency of students, and it needs that medical faculty members should learn about their role in the field of medical ethics through participation in relevant faculty development programs (16). Evidence shows that medical ethics education for them has been neglected (17) or inadequate (18). Hence, to design an effective medical ethics program for faculty members, core competencies in medical ethics should be highlighted, since, currently, competency-based education is considered a fundamental strategy for training and evaluation (19). Unlike for competencies defined in medical education, for ethical competencies, research work has been limited, and no definition was uniformly agreed upon (20). In addition to, faculty member’s typical duties and professional plans in various training situations, for each training program, they need to adapt themselves to have related, required and expected competencies. This study aimed at defining core competencies and Entrustable Professional Activities (EPAs) for faculty members that need to be accommodated in the faculty development courses.

This study was conducted at Tehran University of Medical Sciences (TUMS) in Iran in 2018-2020 in 5 stag.

A - Stage 1: Literature review

A1: Narrative review of the literature was conducted using the following keywords: "fellowship", "faculty development", "curriculum", "medical ethics", "bioethics" in PubMed, Web of Science, and Scopus databases on English articles. By critically reviewing the articles’ title and abstract, those related to undergraduate medical education and other professions’ trainings were excluded. However, articles about faculty members were included, and abstracts presented at conferences or other meetings were disregarded. Then, the remaining articles were thematically reviewed and analyzed.

A2: A rapid review of gray literature was done on Google to identify medical ethics fellowship and faculty development programs, and the gathered data was excluded regarding registration-type information of curricula, irrelative to medical ethics curricula, or no access to full-detail programs. The data, then, was analyzed using directed content analysis approach.

A3: Conducting interviews

A purposive sampling and semi-structured individual interviews were conducted to achieve medical ethics’ tasks and competencies expected from faculty members. Fourteen participants were selected purposively from different disciplines including clinicians, medical ethicists and managers. The experts had related experiences or educational activities in medical ethics for minimum five years. In this phase, we have sought the view of experts about the questions including:

What competencies are needed for a faculty member in the field of medical ethics?
What are the expected tasks of a faculty member in the field of medical ethics?

Interviews lasted from 30 to 90 minutes depending on interactions between the interviewer and interviewee.

B- Stage 2: Holding expert panel

A list of competencies was compiled to be later assessed by the expert panel. Participants from different disciplines were purposively selected with maximum variation in specialty (medical ethicist, clinical specialists and managers) and gender. The 16 recruited experts had experience in the field of medical ethics attended a session lasted about two and half hours. At the beginning of the session, a moderator explained session’s goals and presented a list of expected competencies derived from the previous phases. Then, participants were asked to comment further on them, and the session was continued to reach a consensus on core competencies by calculating Quantitative content validity indicators (CVR, CVI). CVR was calculated using C.H. Lawshe method and CVI using the Waltz & Bausell method, respectively, and CVR and CVI values ranged from +1 to -1. Competencies with an I-CVI of 0.79 or higher remained in the final list, and competencies with an I-CVR of 0.49 or higher considered evidence of good content validity.

C- Stage 3: Developing EPAs framework

In this stage, a taskforce, composed of experts from the fields of medical education and medical ethics, was established to develop a set of EPAs along with emerging competencies. Core EPAs framework drafted by two taskforce members (JM and MKM) based on the extracted codes from prior literature review and interviews in two sessions

D- Stage 4: Validating EPAs framework

This stage assessed the validity of EPAs. To evaluate EPAs, experts examined EPAs from necessity and relevance perspectives. Hence, the list of EPAs was sent to 11 experts of medical ethics through an e-mail to respond the questionnaires’ items based on a three-point Likert scale (high importance, moderate importance, and low importance). Finally, items with scores 70% or higher remained in the list.

E- Stage 5: Mapping EPAs to core competencies

Mapping EPAs to core competencies intended to create consistency in education and assessment of EPAs along with the different competencies and to address the shortcomings of snapshot, subjective judgments of complex tasks. Experts consisted of 10 faculty members of medical ethics and medical education mapped EPAs to core competencies, independently. Participants checked the relevance of each EPA to the competencies. The degree of relevance for each EPA with related competencies was as follows: minus for less than 50 percent, plus for 50 to 59 percent, plus-two for 60 to 69 percent, plus-three for 70 to 79 percent, and plus-four for more than 80 percent.

Step A: Reviewing the literature and conducting the interviews

In terms of presenting medical ethics courses for faculty members, 10 articles on faculty’ medical ethics curricula and 10 medical schools’ websites were reviewed. Then, 60 codes were extracted using content analysis of articles and curricula.

In interviews, 14 experts were asked about expected duties and competencies of faculty members participating in faculty development courses on medical ethics. Then, 235 codes were extracted which classified into six categories: teaching and research in the field of medical ethics, organizational ethics management, communication skills, ethical reasoning, policy-making, and ethical decision-making (Table 1).

Table 1. Summary of categories and subcategories, as well as participants’ sample quotes about the competencies and duties of faculty members in medical ethics

Quote Sample	Subcategories	Categories
“Faculty members have the most significant role in teaching medical ethics to learners because learners face them daily. (No 2. female)	Teaching medical ethics	Teaching
“[Faculty members] should be trained in more specialized medical ethics topics that are related to their field of specialty so that they can be referred to or consulted with when needed in their group”. (No 11. female)	Providing educational advice in medical ethics field
It is possible to entrust the training of undergraduate students to clinical faculty members who are not ethics experts but are familiar with ethics.” (No 5. female)	Facilitation in medical ethics
“You can contact faculty members in various fields and encourage them to consider joint dissertations with students in medical ethics.” (No 4. female)	Conducting and supervising dissertations in medical ethics	Research
“In addition to supervising research ethics committees, faculty members should consider ethical aspects in conducting and designing studies.” (No 3. male)	Conducting projects in medical ethics
“In prescriptive or recommended “developing codes, guidelines or instructions, outside of the target discipline is intangible and inapplicable for that target discipline’s specialists.” (No 5. female)	Providing advice to individuals or committees regarding codes of ethics in research
“Faculty members with the competency of medical ethics can be present in research committees as peer reviewers.” (No 2. female)	Peer reviewing projects in the field of medical ethics
“Faculty members can help by having ethical oversight in writing treatment guidelines with considering medical ethics issue.” (No 13. female)	Developing guidelines
“Faculty members should know the principles of management, policy-making, and policy-evaluation so that later they can ethically manage the issues happening in public healthcare domain, such as ethical issues in quarantine, vaccination, or compulsory healthcare system programs.” (No 5. females)	Management of organizational ethics’ activities	Management of organizational ethics in healthcare
“Decision-makers should be familiar with the philosophical perspectives of ethics when decisions are made regarding the general principles of management, especially in areas such as resource allocation.”(No 12. male)	Planning of organizational ethics’ policies	Management of organizational ethics in healthcare
“Sometimes, patients argue with us…Someone shouts at the ethics faculty members in front of their students, and then you want them to resolve conflicts in such situations, lead and guide, and ethically solve the issues.” (No 7.male)	Resolving conflicts based on principles of ethics	Communication skills
“Teamwork skills are required to resolve ethical issues of various stakeholders.” (No 8. male)	Teamwork in medical ethics field	Communication skills
... Critical thinking taught me that such actions are immoral and any moral argument about them is weak and unjustifiable.” (No 8. male)	Critical analysis of ethical problems	Moral reasoning
“Faculty members should be able to review and analysis problems and challenges and make decisions to solve them.” (No 2. female)	Resolving ethical problems	Moral reasoning
“If we want medical ethics and related concepts to be spread and breach in medical teams, we have no choice but to use the power and capacity of collaboration all colleagues in the ethics field.” (No 5.female)	Cooperation in the dissemination of medical ethics	Ethical policy- making and decision- making
“Country’s resources are limited, if we use, for example, 5% of health resources for certain patients, is it right? Or, we should spend this 5% on the common diseases of the country, to benefit more patients; Some special patients die because we did not provide facilities. The different perspectives we have are important. Managers at general levels, not at philosophical level, but at related details (for example, justice and resource allocation) should be trained and receive consultation, and then face problems.” (No 12. male)	Providing advice to managers, policy-makers and planners in the field of medical ethics
“Faculty members should participate hospital’s ethics committees as they can make better decisions and discuss problems. We need committee members who are scientists familiar with ethics, but we don’t have enough of such members.” (No 14.male)	Ethical decision-making
“Discussing or developing medical ethics in the academic environment without the leading of stakeholders seems meaningless.” (No 12.male)	Leadership in promoting medical ethics

Step B: Holding an expert panel

At this stage, extracted tasks and competencies were sent to the experts attended the meeting to discuss the items. Their revisions on the quality of writing style and content for competencies and task were received. Moreover, based on CVR and CVI indices to identify main competencies, the competency of Management of organizational ethics in healthcare for faculty members did not achieve the required score and discarded from the list of competencies. Finally, core competencies included teaching, research and scholarship, communication skills, moral reasoning and decision-making, policy-making and ethical leadership (Table 2)

Table 2: CVIs and CVRs calculated for medical faculty members’ expected core competencies

CVR	CVI	Competencies
1	1	Teaching of medical ethics
1	1	Research and scholarship in the field of medical ethics
0	1	Management of organizational ethics in healthcare
0.75	0.87	Communication skills
1	1	Moral reasoning
0.75	1	Policy-making, decision-making and ethical leadership

Step C: Compile a list of EPAs

At this stage, the taskforce extracted 25 EPAs from the tasks approved in the previous phases.

Step D: Validating the list of EPAs

The closed-ended questionnaire, included 25 EPAs from the literature review and interview phases, was sent to 11 medical ethics professionals, to which 8 (72.2%) responded. Their completed questionnaires were analyzed, and the items with a score above 70% in terms of necessity and relevance were retained. Analysis revealed that none of the 25 items had an I-CVR less than %70, and two Items with I-CVI less than %70 were excluded. Tables 3 presents experts' responses.

Table 3: Percentage of medical ethics scores on the importance and relevance of medical ethics faculty members’ expected EPAs

	EPA list	Importance				Relevance
No	Title	High	Moderate	low	No idea	High	Moderate	Low	No idea
1	Teaching medical ethics to faculty members through faculty development programs	100				100
2	Providing consultation and feedback to faculty members in medical ethics	100				87.5		12.5
3	Direct teaching of medical ethics to students	100				100
4	Integrated teaching of medical ethics to curricula through role modeling, etc.	82.5	12.5			87.5	25
5	Doing Facilitation in various situations of medical ethics education	75	12.5		12.5	75	12.5		12.5
6	Identifying and determining research priorities in medical ethics	87.5	12.5			75	37.5
7	Designing, implementation and cooperation in projects in medical sciences	100				100
8	Publishing and disseminating science findings‏ of medical ethics projects	87.5	12.5			87.5	12.5
9	Providing consultation to research ethics committees	100				100
10	Ethical guidance and supervision of research projects	87.5	12.5			87.5	12.5
11	Ethical peer reviewing and critique of research projects	87.5	12.5			100
12	Developing codes of conduct and ethical guidelines in original, prescriptive and developmental research	87.5	12.5			100
13	Managing and directing planning activities in medical ethics field	87.5	12.5			62.5	37.5
14	Providing ethical guidance and supervision of treatment guidelines	70	12.5	12.5		75	12.5	12.5
15	Leading change management in advancing medical ethics at micro and macro levels	87.5	12.5			75	12.5	12.5
16	Decision-making on resource allocation	87.5		12.5		62.5	37.5
17	Managing the Conflict in communications and interactions based on ethical principles	87.5		12.5		87.5		12.5
18	Collaborating in team activities related to the field of medical ethics	100				100
19	Identifying and critically analyzing ethical issues and dilemma	100				100
20	Providing evidence-based solutions to ethical issues and challenges	100				100
21	Conducting ethical reflecting on personal and organisational activities	100				100
22	Planning, cooperation and directing activities related to the development and influence of medical ethics in healthcare system	87.5	12.5			100
23	Providing advice to managers, policy makers and planners in promoting medical ethics programs	75	12.5		12.5	87.5			12.5
24	Guiding organizational ethics committees	87.5	12.5			100
25	Evaluating the quality of ethical decisions and policies	87.5	12.5			100

Step E: Mapping EPAs to core competencies

Table 4 presents the relationship between EPAs and core competencies of medical ethics for faculty members.

Table 4. Mapping of EPAs to core competencies in medical ethics training faculty development programs for faculty members

teaching	Research and scholarship	Communication skills	Moral reasoning	Policy-making, decision-making, and leadership	EPA Titles	No.
++++	-	+++	+++	-	Teaching medical ethics to faculty members through faculty development programs	1
-	-	++	++++	-	Providing consultation and feedback to faculty members in medical ethics	2
++++	-	+	+	-	Direct teaching of medical ethics to students	3
+++	-	++++	+++	-	Integrated teaching of medical ethics to curricula through role modeling, etc.	4
++	-	++++	+	-	Doing Facilitation in various situations of medical ethics education	5
-	++++	+	-	++	Identifying and determining research priorities in medical ethics	6
-	++++	+	-	+	Designing, implementation and cooperation in medical ethics projects	7
-	+++	+	-	+++	Publishing and disseminating science findings‏ of medical ethics projects	8
-	-	+++	++++	+	Providing consultation to research ethics committees	9
-	+	++	+++	-	Ethical guidance and supervision of research projects	10
-	-	+	+++	++++	Ethical peer reviewing and critique of research projects	11
-	++++	-	+	++++	Developing codes of conduct and ethical guidelines in original, prescriptive and developmental research	12
-	+	-	+	++	Providing ethical guidance and supervision of treatment guidelines	13
-	-	++	++	++++	Leading change management in advancing medical ethics at micro and macro levels	14
-	-	++++	++++	++	Managing the Conflict in communications and interactions based on ethical principles	15
-	-	++++	+	+	Collaborating in team activities related to the field of medical ethics	16
-	++	-	++++	+	Identifying and critically analyzing ethical issues and dilemma	17
-	+	-	++++	+	Providing evidence-based solutions to ethical issues and challenges	18
-	-	-	++++	+	Conducting ethical reflecting on personal activities and organisational activities	19
-	-	+++	+	++++	Planning, cooperation and directing activities related to the development and influence of medical ethics in healthcare system	20
-	-	++++	++++	++++	Providing advice to managers, policy makers and planners in promoting medical ethics programs	21
-	-	++	++++	++	Guiding organizational ethics committees	22
-	-	-	+++	++++	Evaluating the quality of ethical decisions and policies	23

Empowerment of human resources is considered as one of the main strategies to achieve resources with appropriate competencies, to lead the organizational change process (21). Faculty development programs intend to enhance professional knowledge and skills to adapt to the growing changes; training and development of faculty members plays a valuable role in balancing professional knowledge and skills (22). Research showed that lack of medical ethics’ knowledge and awareness is a significant challenge leading to unethical practices (23, 24).

In the present study, teaching skill was identified as a core competency for faculty members in medical ethics education. Creating educational opportunities is detrimental to empower faculty members who can teach medical ethics in active ways and relevant to their field’s topics. Furthermore, for integrated medical ethics teaching, faculty members should teach professional behaviours to students in various educational opportunities through courses as well as act as professional role models (25). The role of medical teachers as a creditable role models for students is necessary for teaching professional and ethical behaviours (11, 26). In the study by Bligh et al. the following major competencies were considered required for medical teachers: teaching skills, effective communication skills, professionalism, expert knowledge and role modeling (27).

Research and scholarship in the field of medical ethics is considered as a core competency for faculty members in this study. In our study, faculty members must be competent to design and conduct high-quality original research, developmental and prescriptive research. In this category, the set of outcomes mainly related to determining research priorities, methodology design, implementation, application and dissemination of results as well as evidence-based practice in the field of medical ethics is required. Scholarship highlighted encouraging the participation of faculty members in developing their innovative practice in the medical ethics field. Thomas (2003) recommended that providing professional incentives that value scholarship in medical ethics, even when it is not a faculty member’s primary research area, is necessary for promoting scholarship activities in medical ethics (28). In this study, besides the research ability to generate the medical ethics studies, the scholarship capability to explore intervention for solving ethical problems and challenges, as well as the ability of informed decision making to choose the best professional practice in professional activities were emphasized.

Effective communication skills with different stakeholders to implement and teach medical ethics at the interpersonal and team level, was identified as another core competency in the present study. According to the our findings, to convey ethical values and beliefs to medical students in all three areas of knowledge, attitude and behavior, and institutionalizing medical ethics in the healthcare system, medical teachers should have high-level, effective communication skills (29).

According to current study, ethical reasoning and decision-making competency is another core competency for medical ethics’ faculty members, which other studies referred to it as a multidimensional skill consisting of individual and organizational competencies (30). Moral reasoning capability required for training and development of professionalism in various dimensions (31). Ethical reasoning and decision-making competencies have not only used for resolving ethical conflicts along with communication skills in the education system, but also for existing research aimed at assessing such ability (32). Furthermore, based on our findings, the competency of managing organizational ethics in healthcare did not earn necessary votes to be considered as a core competency because, apparently, participants interpreted it as the capability of management at different levels in schools.

To implement competencies in practice and workplace, EPAs in the competency-based curriculum should be used. EPAs translate essential competencies for medical education related to required tasks and duties (33). Ethics faculty members’ opinions on EPAs showed that most of the tasks, except two items, assigned to faculty members after attending medical ethics faculty development courses, received essential scores in terms of necessity and relevance to the essential role and core competencies. These two items were as follows: “Decision-making on resource allocation”, and “Managing and directing planning activities in medical ethics field." These two items, possibly, due to the direct role of managers and educational administrators in promoting it at the organizational level, are less significant in faculty members’ professional duty list. According to the present findings, the score of moral reasoning competency was equal to or greater than 70% of those of other 11 EPAs, indicating the importance of this competency and the need to address it further; meanwhile, in existing studies, this competency and tools for its measurement were discussed (33, 34).

Studies on EPAs required for faculty members in medical ethics were not adequate whereas such studies were required to conduct practical and edifying courses for faculty development programs. Moreover, the participation of various experts from the clinical and medical ethics departments and educational administrators in this study, especially those who had research or activities in the field of medical ethics, was valuable to obtain various stakeholders’ viewpoints. In addition, a multi-stage method together with quantitative and qualitative study methods helped explain the study topic. As a limitation, few articles addressed medical ethics curricula or faculty members’ tasks in medical ethics. Another limitation was the lack of determination of entrustment decisions level regarding EPAs in faculty development programs in medical ethics.

Medical teachers are significantly effective in moralizing the healthcare system and faculty members should attain core competencies and EPAs for medical ethics education. In this study, the competency components of faculty members in the field of medical ethics in five competency domains have been defined as teaching, research and scholarship in the field of medical ethics, communication skills, moral reasoning, and decision-making, policy-making and ethical leadership. Faculty development programs can be designed in the field of medical ethics for faculty members to help them acquire core competencies and EPAs.

EPA: Entrustable Professional Activity

CVI: Content Validity Index

CVR: Content Validity Ratio

Acknowledgements

The authors thank all participants in the present research.

Ethical considerations

The present study was approved by research ethics committee of Tehran University Medical Science with IR.TUMS.MEDICINE.REC.1398.736 code of ethics. The interviews with interviewees' preferred time and location were conducted. Written informed consent was obtained from all the participants. And withdrawal of consent right at any time explained and information confidentiality was conserved. All methods were carried out in accordance with relevant guidelines and regulations.

Competing interests

The authors have no competing interests.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Consent for publication

Not applicable.

Funding

No funding

Authors' contributions

JM and MKM made substantial contributions to the conception and design of the manuscript. JM undertook the acquisition of data. JM and MKM made substantial contributions the analysis and interpretation of data. Draft of the manuscript was written by both authors. MKM consultation and revise the manuscript. All authors reviewed entire manuscript for edits, feedback and approval.

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No competing interests reported.

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Mapping the Competencies and Entrustable Professional Activities of Medical Ethics for Faculty Members

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