Developing and Evaluating an Innovative Ethics Education Strategy for Undergraduate Medical Education

Abstract

Background Medical ethics education is complex due to various reasons, and this is compounded by the context-dependent nature of the content. The social nature of the discipline with an intricate relationship between the cultural context and demands of professional conduct renders its implementation in the medical curriculum an uphill task for educators all over the world. The distinctive, non-western socio-cultural context and the scarcity of relevant resources in some developing countries further add to the complexities of ethics education in these regions. This thesis, therefore, aimed to develop and refine a contextually relevant strategy to deliver medical ethics education in the specific contexts of Saudi Arabia and Pakistan, and evaluate its impact on student learning. Together these countries represent the Middle Eastern and South Asian socio-cultural contexts. This project included a thorough review of the literature to explore the design and delivery of undergraduate medical ethics education from a global perspective and to identify gaps in the literature on medical ethics education. The socio-cultural construct of the educational environment in developing countries was examined through relevant educational theories to discern its effect on the delivery of medical ethics education. Based on these explorations, the need for a theoretically appropriate and contextually relevant strategy for medical ethics education in the studied socio-cultural context was established. The project then proceeded to develop this strategy in a robust and evidence-informed manner. Firstly, an educational model was developed to guide the design and delivery of context-relevant ethics education in developing country contexts. This newly developed Contextually Relevant Ethics Education Model (CREEM) informed the empirical part of this project. The empirical part of the project was conducted in Saudi Arabia and Pakistan, in two phases. During Phase 1, a new strategy was developed and refined to guide the delivery of medical ethics education in the context of developing countries. The strategy was named as the Workbook Based Ethics Learning (WBEL). In phase 2, the educational impact of the newly developed WBEL was evaluated. Methods The project employed an exploratory sequential mixed methods research design, conducted in two countries with non-western contexts: phase 1 was conducted in Saudi Arabia and phase 2 in Saudi Arabia and Pakistan. Both these countries share common contextual factors and constraints related to medical ethics education. Phase 1 of the project employed an exploratory design using qualitative consultative feedback to develop and refine the medical ethics education strategy. This phase included interviews with teaching faculty and focus group discussions with students. These study participants had used a preliminary version of the strategy in the form of a workbook for the delivery of ethics education in the undergraduate medical program, during the previous year. This workbook was a collection of reading material on various topics in medical ethics and writing exercises to assess students’ learning. The workbook was also shared via email with external experts in the field of ethics education for their critical review, as a part of the research design. This led to an evidence-based development and refinement of the ethics workbook, which formed the basis of the WBEL strategy. The strategy was then implemented in phase 2 of the project. During phase 2 of this research, the participants, early clinical year MBBS students of King Abdulaziz University (KAU), Jeddah, Saudi Arabia and Jinnah Sindh Medical University (JSMU), Karachi, Pakistan, attended a medical ethics course delivered through the refined WBEL strategy developed in phase 1 of the study. A pre-post-test design, using Script Concordance Test (SCT), Key Feature Questions (KFQ) items, and students’ feedback was used to evaluate the impact of the novel strategy. Results The participants in phase 1 of this project included students, teaching faculty and external experts who accepted the invitation to participate. This included 13 out of 56 early clinical years students of Rabigh Medical College, KAU) four out of five faculty members of KAU who had taught using the workbook; and 11 out of 20 external experts in the field of ethics education who responded to the invitation to participate. The analysis of qualitative data from all three groups of participants provided insight into the use of the newly developed educational strategy. The analysis of phase 1 data generated twenty-one sub-themes within four main themes: design features, content, teaching tools and writing exercises given in the preliminary version of the workbook. The themes were used to develop a coding framework that was agreed upon after the consensus of two reviewers. The framework was used to derive inferences from the data. These findings helped to improve the clarity and alignment of the workbook, improved content on history, philosophy, and differing perspectives from religious and cultural aspects. The data helped to enrich the design of the workbook with interactive, authentic learning activities. The findings also led to the development of a guide for facilitators to effectively use this strategy. Findings of phase 1 of this project also led to the evolution of the workbook from a teaching and learning instrument to an educational strategy, the WBEL. This workbook-based ethics learning strategy (WBEL) was based on the CREEM model and incorporated the whole spectrum of medical ethics education in the given context. Phase 2 of the project evaluated the impact of the newly developed workbook and WBEL on students’ learning during a 30-hour medical ethics course at KAU and JSMU. Out of the total of 125 students, 90 completed the pre- and post-test measures, and 103 returned the feedback forms at the two sites. The McNemar test was used to explore the significant difference between students’ pre and post-test scores. These were found significant in 10 of 60 SCT items and 12 of 20 KFQ items. The feedback from students showed that the majority of participants (97%) considered the course to be of value. Ethics case discussions (91%), movie clips (87%), classroom quizzes (84%) and reflective writing (78%) were considered as highly useful for learning during the course. Conclusion This project on medical ethics education contributes to the body of literature in several ways. First, it identified gaps in the literature on ethics education in developing country contexts and explored them through the contemporary principles of medical education and the cultural context of these regions. Secondly, the project drew on an in-depth review of the literature to design an innovative educational model (CREEM), to guide the design of contextually-relevant ethics education. Next, based on the newly designed model, the project created a novel educational strategy, WBEL, for delivery of medical ethics education in developing countries like Saudi Arabia and Pakistan. Finally, the project evaluated the impact of the strategy. The evaluation revealed promising results in terms of feasibility, acceptance, and effectiveness. In addition to these contributions, the project demonstrated a systematic approach to developing and evaluating a needs-based innovative educational strategy. The approach can be employed by educators in similar contexts to develop other educational innovations.