From Workshop to E-Learning: Using Technology-Enhanced “Intermediate Concept Measures” As a Framework for Pharmacy Ethics Education and Assessment

Abstract

Workshop analysis of scenarios or vignettes has traditionally been used to develop and demonstrate the moral reasoning underpinning professional decisions. However, in order to facilitate sufficiently individualized interaction to accommodate the assessment of student competencies related to decision-making through scenarios, such workshops are traditionally used with small groups. There are associated resource implications for the scheduling of sessions and implications for tutor time where large cohorts of students are targeted. In addition, the requirement that students be face-to-face is problematic when students are in practice placements that are geographically removed. This paper demonstrates how technology and an assessment tool, known as an “intermediate concept measure” (ICM), might help address these limitations. It introduces the background to ICMs and presents the ICM as a tool that has potential to support professional education. It also shares learning experienced by one pharmacist using ICMs in pharmacy education, provides an example of how a profession-specific ICM might be formatted, suggests how the methodology might be used in undergraduate and postgraduate education and provides samples of measurables that may be incorporated into evaluation and assessment systems; both for educational interventions delivered face-to-face or partly or entirely online. The limitations of the methodologies and suggestions for further research are included.

1. Introduction

Workshop analysis of scenarios or vignettes has traditionally been used to develop and demonstrate the moral reasoning underpinning professional decisions, but, in order to facilitate sufficiently individualized interaction to accommodate the assessment of student competencies related to decision-making through scenarios, such workshops are traditionally used with small groups. There are associated resource implications for the scheduling of sessions and implications for tutor time where large cohorts of students are targeted. In addition, the requirement that students be face-to-face is problematic when students are in practice placements that are geographically removed. This paper shows how technology and an assessment tool, known as an “intermediate concept measure” (ICM), can help address these limitations. Intermediate concepts represent professional concerns, such as the professional “duty of care” and the patient’s right to consent, confidentiality and “patient best interests”, which are described in terms of guiding ethical standards for the professional [1,2]. They are referred to as “intermediate” in the context that they lie between the “surface level” rules, norms and codes governing the practice of the profession and the deeper level or “bedrock schema” reasoning processes, the development of which represents highly abstract moral judgment strategies. These “bedrock schema” serve as a default system that is activated when more automatic and context-specific interpretive systems fail or provide incomplete or inconsistent information.

ICMs were originally developed for dental students in order to assess moral judgments within a professional context, i.e., the ability to both identify appropriate applications of the intermediate concepts in a profession-specific dilemma scenario and interpret how an individual’s actions may affect the outcome of a dilemma caused by a conflict of concepts [2,3]. The design of professional ethics courses is often organized “around intermediate level concepts” [2] (p. 347). ICMs incorporate a short profession-specific “dilemma” scenario, written to incorporate ethical conflict(s), and are generally validated by a group of practitioners considered “experts” in the profession. The dilemma and series of action and justification options are presented in sequence (Appendix 1). The action and justification options proposed, which students must both rate and rank, include those with a focus on self-interest, maintaining rules and norms and acting in the patient’s best interests or in societal interests [4,5]. The methodology includes the opportunity to have small groups that seek to agree on the preferred action and justification options from the proposed list.

Professional ethics education as proposed in “Moral Development in the Professions: Psychology and Applied Ethics” [6] incorporates moral sensitivity, moral reasoning, or “judgment”, motivation, or “justification”, and implementation, or “character”, to act as intended, as interactive elements in the development of a professional, in what is known as the Four Component Model (FCM) of professional development [2,3,6]. These components are represented as interactive elements in the development of a professional, as depicted in Figure 1.

The FCM proposes that moral reasoning processing takes place at three levels:

(i)

Developmental bedrock schemas, reflecting preferred decision-making schemas at an abstract level, as measured by a psychometric measure known as the Defining Issues Test (DIT) [4,7]. While the impact of educational interventions may be measured using a pre-post intervention design using the DIT as the measure [5], the discussion surrounding the measurement of the impact of professional ethics programs is beyond the scope of this paper.

(ii)

Intermediate-level moral concepts are designed to cover a broad range of situations that require significant professional interpretation by participants in an educational intervention. Reasoning about intermediate concepts is, in part, a reflection of the individual’s preferred approach to decision-making through dilemmas. The methodology outlined in this article draws from intermediate concepts and the FCM [2], but presents a format of ICM that is used to enhance the development of moral reasoning (Figure 1) in a manner that also accommodates some demonstration and assessment of related competencies.

(iii)

The more concrete, or surface level, processing incorporates rules (or legislation governing the practice of pharmacy) and codes of conduct or ethics, as generally included in professional ethics programs. However, the most difficult aspect of using professional codes as a framework for decision-making is that it is difficult to recognize when the endless variables in real-life scenarios, as included in a given dilemma scenario, are actually covered by the code. Practitioners typically engage surface-level moral reasoning when it accommodates the dilemma proposed and move to intermediate-level approaches only when a satisfactory action plan is not evident from the legislation or the professional Code of Conduct (CoC).

Figure 1. The Four Component Model of professional education [8]. DIT, Defining Issues Test.

Figure 1. The Four Component Model of professional education [8]. DIT, Defining Issues Test.

The reality is that pharmacists regularly face ethical dilemmas, where there is a conflict of moral values creating a situation in which there is no obvious right or wrong answer [9], but where there are two or more options that are individually convincing, mutually exclusive and jointly demanding and none of which is necessarily in line with the letter of the law or a literal interpretation of the CoC. Recent research into the challenges encountered by pharmacists when faced with ethical dilemmas suggests that both undergraduates and practicing pharmacists would benefit from a structured means by which to build and maintain competencies related to dilemma review [8,9,10,11,12,13,14,15,16]. Latif’s research [17,18], while it reports on pharmacists in the USA, rather than in Ireland, nonetheless indicates that community pharmacists are a rare exception to the expectation that moral reasoning competencies generally increase with age. The ability to reason through dilemmas to choose between available options and to justify decisions in a coherent manner should they be subjected to external scrutiny should be targeted as distinct competencies in pharmacy education [19].

Ethical development is a particularly relevant priority for contemporary pharmacy education, as research by Wingfield and colleagues has shown that “there is little research literature specifically addressing ethics in pharmacy practice and almost none addressing fundamental philosophical issues or values for pharmacy ethics” [20] (p. 2382). Their outcomes prioritize the teaching and assessment of “ethical competence” before practice and the development and updating of this competence in practicing pharmacists [20]. Research has presented many examples of potential conflict of interest dilemmas regularly faced by pharmacists (e.g., [8,12,13,14,15,16,18,21,22,23]), and scenarios presented in pharmacy-specific ICMs seek to capture examples of these dilemmas for teaching and learning purposes.

Research in other professions, e.g., dentistry [3], physical therapy [24] and business [25], indicates that even relatively short profession-specific educational programs can lead to significant improvements in moral development, especially when the design, development and delivery of the intervention is context appropriate. It is envisaged that ICM inclusion in pharmacy education would be constructively aligned with other aspects of professional programs [26,27], that rubrics that articulate grading expectations would be provided at the outset to guide both learning and assessment (samples are in Appendix 2 and Appendix 3) and that students would have been introduced to decision-making frameworks, such as Principlism [28] and value-based ethics [29,30], prior to engagement with the ICM, e.g., first-year students would have been introduced to both frameworks, through lectures and workshop activities, prior to engaging with ICMs. There is no suggestion that ICMs, presented in any of the configurations described in this article, could independently comprise a program of professional development.

The teaching and learning methodologies reported in this article use profession-specific ICMs to support technology-enhanced learning (TEL), entirely online or in a mix of face-to-face and online, or “blended learning”, approaches, at undergraduate and post-graduate levels in pharmacy education. The general format by which ICMs are incorporated into educational interventions is as follows:

• Upon review of a previously unseen scenario (Appendix 1: Box 1), a student is forced to declare a “position” [31] when recording online her/his reflection or “independent review” of the dilemma therein (Appendix 1: Part 1). Constructivism, which proposes that learning is an active process, wherein new information is added to “prior knowledge”, which may have been derived from personal experience, as well as formal teaching and learning [26,27,32,33], is the key learning theory employed.
• The rating and ranking of action (Appendix 1: Part 2a) and justification options (Appendix 1: Part 2b) challenges the student to revisit the scenario, where the options posed prompt consideration of a broader range of potential professional concepts and dilemmas, while also forcing a choice between less than ideal circumstances. The discovery of “differences between expert and novice groups enables the educator to judge individual performance against a valid standard” [2] (p. 358), and the validation process grounds the ICM in the thinking and reasoning of respected practitioner and educator members of the profession, making it more likely to engage those undertaking professional ethics programs.
• Part 3 of the process randomly allocates students to groups of five to seven members, who, having committed to individual choices regarding the rating and ranking of action and justification options offered, must agree and make a group decision regarding the ranking process within a defined time frame. This inevitably involves constructivism in the form of negotiation and active discussion, debate and persuasion, as the group seeks to complete the task by the deadline imposed. Peer debate forces deeper reflection on the decisions made.

As all contributions are recorded online, they collectively provide the student with a record of how she/he and the rest of the group reasoned through the dilemmas, provide an unambiguous declaration of group member’s different individual “starting positions” and facilitate assessment of the demonstrated competencies by subsequent review of records in the virtual learning environment (VLE) [34].

To the authors’ knowledge, pharmacy profession-specific ICMs have not been previously developed, and the presentation of ICMs in the online environment has not been reported in the literature. This article seeks to share the methodology that has been developed for the use of ICMs in pharmacy ethics education, to outline, using a specific example, how it is currently being piloted in various contexts in pharmacy education and to present some suggested outcome measures as available through the interrogation of the reporting functionality available in the VLE.

2. Technology-Enhanced Learning: Blended Learning in Pharmacy Ethics Education

Technology has enhanced the potential of ICMs to support the use of the workshop analysis of scenarios or vignettes to demonstrate the moral reasoning behind professional decisions, while also helping to address staffing and resourcing issues where student numbers are large. This potential for enhancement may be considered to occur in each of the three parts of the ICM process, variously motivating student engagement in the process of dilemma review and discussion and providing the opportunity for the demonstration of competencies related, in particular, to team work. This process has been adapted to different formats to suit undergraduate and post-graduate programs. Examples of regularly used “adaptations” are outlined below:

(i)

Undergraduate level: a blended learning approach aligned with a series of workshops, each student generally having online access during the workshop(s).

(a)

ICM Part 1.

Students review a previously unseen dilemma scenario (Appendix 1) and are required to answer the first question posed: “what is/are the ethical concepts in this scenario?” While this could be presented as a paper-based exercise, in which case, the workshop leader could either review answers and provide feedback at a later stage or invite samples of suggestions from students in order to influence subsequent discussion, access to a VLE by students engaged in face-to-face learning provides an opportunity for more comprehensive and interactive feedback to the group in the classroom or workshop setting. Where large numbers of students post contributions in real time, the use of word clouds as facilitated by Feinberg’s “Wordle” software [35] where the size of the word is indicative of the number of times it appears in a document, can support timely feedback and formative assessment in a manner not possible for a single workshop leader with a paper exercise.

The word cloud in Figure 2 was produced by collating all answers to Question 1 (Appendix 1) provided by one class group. This collation took less than one minute.

Figure 2. What is/are the ethical concepts in this scenario? [35]

Figure 2. What is/are the ethical concepts in this scenario? [35]

The word cloud (Figure 2) was then used as a focus through which to stimulate further discussion on the dilemma scenario. It has been the experience of the authors that students respond actively to data and feedback that represents their own (individual or peer-group) opinions, especially when it is provided while the memory of their own independent opinions is fresh, and this approach appears to support active engagement in the dilemma discussions that follow.

Grading of Part 1 (Appendix 1) may, of course, be guided by the related rubric or guide (Appendix 2) and the use of the rubric online means that it is visible to the student as a guide when answering whatever questions are posed (the Sample 5 question format in Appendix 1). In context, a rubric is considered to be an assessment instrument that gives students information on how the tutor will be assessing their performance. Rubrics can increase transparency in assessment, because they make public the criteria for the judgment of student performance. The rubric may also guide grading and online feedback as a tutor or assessment design deems appropriate.

(b)

ICM Part 2: Rate and rank the action and justification options (Appendix 1).

Where a scenario and its lists of action and justification options are deemed to represent what an “expert” would suggest, student completion of the rating and ranking exercise under “live exam” conditions supports the claim that students are provided with the opportunity to demonstrate whether they can identify and define professional dilemmas in a given scenario when prompted to do so. In context, ICMs are considered representative of “expert” opinion, where validation has involved review by a group of pharmacists considered appropriately experienced. If a student ranks as most preferred an action option considered by experts to be the “worst” option, this suggests that the student has not recognized the dilemma. While it rarely happens, with either first- or fourth-year cohorts of pharmacy students, it prompts an individual review with the student(s) after the workshop or session, the identity of the individual involved being easily tracked through the VLE. In this manner the process supports the professionalization process in use in the degree program.

Further potential to enhance learning may include the manner in which the students can be given immediate feedback as to how they collectively rated the options presented or ranked the three most and least preferred options. Functionality on the VLE permits visual presentation of the variety of opinion amongst the peer group, examples of which are presented for the first two action options (Appendix 1) in Figure 3.

Figure 3. Part 2 (a): extract of group rating of the first two action options provided (Appendix 1).

Figure 3. Part 2 (a): extract of group rating of the first two action options provided (Appendix 1).

In the example shown in Figure 3, the student that suggested that (b) (“Refuse to supply or to discuss the matter with Charlie, as to do so would put a pharmacist at risk of being charged with professional misconduct”) was highly defensible might reconsider, whereas the spread of response to (a) (“A correctly written prescription has been prescribed. Dispense without further discussion”) is likely to generate interactive discussion and debate amongst the group.

A further “teaching and learning” use to which this information was put is that when the three most and three least preferred options have been clarified, the six remaining action options are then extracted for use in a later workshop that seeks to focus on motivations and intentions that might underpin decision-making through dilemmas. These six action options, considered by this peer group to be neither “very defensible” nor “not defensible”, are likely to demonstrate examples of behaviors that might be subjected to external scrutiny by supervisors or by a fitness-to-practice process after a dilemma “event”, as proposed in the scenario. The subsequent workshop requires students to work in groups of three to post to the VLE what they believe might be the intention of a pharmacist that would chose each of these six action options.

This scenario (Appendix 1) has, on occasion, been adapted to the hospital context by describing Celine as working in a small hospital on a Sunday morning. This type of variation supports students’ understanding that dilemmas are likely to be encountered in any practice context. It also provides the flexibility to use the same scenario with two half-class groups to a useful effect, e.g., when applied to two half-class cohorts of fourth-year students, somewhat different outcomes regarding most and least preferred options were reached, and this provided a further opportunity to explore the concept that context does matter when reasoning through dilemma scenarios.

(c)

ICM Part 3: group work.

Teamwork, combined with group problem solving, is required to reach a group outcome as to the most “preferred” course of action. All students post individual choices online prior to being assigned to a group. Peer feedback is continuous as students debate and negotiate their way to a group decision. Criteria highlighted in the rubric (Appendix 3) guide the demonstration of the targeted competencies in a manner such that student behavior can be observed and assessed. VLE records provide evidence of the standard to which students have engaged in the process.

The potential for the online use of ICMs to facilitate demonstration and assessment of targeted competencies, as outlined in the Core Competency Framework for pharmacists in Ireland (CCF) [19], is summarized in Figure 4.

Figure 4. Intermediate concept measure (ICM) as a framework for demonstration and assessment of professional attributes [36]. VLE, virtual learning environment.

Figure 4. Intermediate concept measure (ICM) as a framework for demonstration and assessment of professional attributes [36]. VLE, virtual learning environment.

The extent to which ICM Part 3 is completed online may be adapted to the stage in which the program and/or choices are made with respect to curriculum design. ICMs are introduced to first-year students in the final of a series of three workshops, and while Parts 1 and 2 are completed online, the group work is face-to-face with the potential to upload agreed upon group decisions online. Students must engage in the process in a manner considered satisfactory by the workshop leader, but no percentage or grade is allocated to the activity.

Fourth-year undergraduate students, however, complete the process online over a 10-day period, guided by the rubric (Appendix 3), and the group work required to complete Part 3 of the ICM accounts for 7.5% of the overall module.

(ii)

Post graduate MPharm: online learning while interns undertake a 12-month placement under the direction of a tutor at a location in the Republic of Ireland (ROI).

Pharmacy students in the ROI who have completed a primary degree in pharmacy (B.Sc.Pharm or B.Pharm) apply to enter the National Pharmacy Internship Program (NPIP), which is delivered by the Royal College of Surgeons in Ireland (RCSI) on behalf of the Pharmaceutical Society of Ireland (PSI). Interns complete this year in approved training establishments under tutor supervision, and the author does not meet the interns face-to-face during the program. Interaction and assessment is based on three one-week cycles. Three questions, rather than the five presented in Appendix 1, were used in the independent review of the dilemmas scenario (referred to as Phase 1/Week 1), action options were presented in Phase 2/Week 2 without the subsequent provision of justification options, and the group sizes (Phase 3/Week 3) were up to seven rather than groups of up to five, with undergraduate students. The NPIP curriculum design included the development of a series of 17 podcasts, including one on principlism as a “tool to reason with”, and podcasts were made available for download. An outline of the process is provided in Figure 5.

Figure 5. Professionalism and ethics dilemma review process, assignment of the National Pharmacy Internship Program (NPIP) [37]. ROI, Republic of Ireland.

Figure 5. Professionalism and ethics dilemma review process, assignment of the National Pharmacy Internship Program (NPIP) [37]. ROI, Republic of Ireland.

Multiple small groups engaged in teamwork, or team-based learning, can be observed and facilitated simultaneously by one academic, thereby accommodating the demands of large cohorts in geographically removed locations. Notwithstanding that significant staff time demands result from the support of multiple discussion fora and online feedback processes, the methodology nevertheless supports a means by which the expertise of a skilled “ethics education facilitator” can be made available to large cohorts of students, and geographically remote students can be supported as they develop competencies related to ethical reasoning. The objectives included that intern engagement in the online environment be increased, that a means by which moral reasoning competencies could be assessed in the context of the NPIP be developed and that a review of the outcomes quantify the extent to which individual and group decision-making by interns reflected “expert” opinion. Data gathered, directly from the VLE during the first three years of the NPIP highlights how the use of ICM methodology in the VLE provides a framework by which objective data related to intern performance and activity can be gathered. Intern downloading of podcasts, interactions online and intern and group performance, as determined by the grades achieved, were reviewed to provide the summary presented in Figure 6.

Figure 6. Outcomes of a professionalism and ethics dilemma review assessment in the NPIP [38].

Figure 6. Outcomes of a professionalism and ethics dilemma review assessment in the NPIP [38].

The results provided in Figure 6 show that in, e.g., 2011, 88% of interns downloaded the podcast on principlism, while the average download rate across the 17 podcasts was lower at 49%. Furthermore, 83% of interns referred to at least three of the four principles (autonomy, beneficence, non-maleficence and justice) introduced in that podcast [28], indicating that students had internalized the material on the podcast, and 88% of interns achieved 70% or more when completed assignments uploaded during Phase 1/Week 1 were graded. The scenario provided in Appendix 1 was used in 2011.

When interns (2011) responded individually (Phase 2/Week 2), 52% of interns’ most preferred action options aligned with collated expert opinion, showing that students recognized the norms of the profession in this regard, and 82% of interns included the option most preferred by the experts amongst their top three choices (Phase 3/Week 3). Most interns (96% in 2011) changed their ranking of the most and/or least preferred action options in order to agree with the group decision, thereby reflecting a requirement for debate and negotiation to complete the task.

3. Summary

This article introduces the background to ICMs and presents the ICM as a tool that has potential to support professional education. It also shares the learning experienced by one pharmacist using ICMs in pharmacy education, provides an example of how a profession-specific ICM might be formatted, suggests how the methodology might be used in various ways in undergraduate and postgraduate pharmacy education and provides samples of measurables that may be incorporated into evaluation and assessment systems, both for educational interventions delivered face-to-face or partly or entirely online.

There are limitations to any inferences that can be taken from the use of ICMs to support the development, demonstration and assessment of professional attributes as proposed, including, but not limited to, the following:

• The examples outlined all relate to the ROI and cultural/legal variations, including legislation specific to the medication(s) referred to in the scenario, must be considered before deciding whether these might be generalizable to other jurisdictions.
• Profession-specific intermediate concepts central to other professions may differ from those for pharmacy and need to be considered in order to write appropriate ICMs for educational initiatives other than for pharmacy or for multidisciplinary group work.
• The technology itself raises concerns: (1) Assessment strategies need to evolve to manage the risk of plagiarism and impersonation. (2) Technology creates a different communicative space, with a permanent record of all interactions. Educators have a responsibility to seek to protect these incoming students from naivety in this regard. (3) The VLE must be adapted to accommodate the automation of teaching and learning where viable. Reservations regarding reduction in group size derive at least partly from the time pressures (on tutors/academics moderating and/or assessing group work) associated with those changes. (4) Strict cut-off times mean that there will inevitably be late-comers, and the accommodation of these participants, essential where assessment is involved, can be challenging [39]. (5) It can be challenging to accommodate “repeat” assessments for individuals when the focus is on group work.
• Feedback from the students [39] highlights that the tutors must pay particular attention to netiquette guidelines that prompt timely engagement by all group members, so that those engaging in the early stages do not become prematurely disheartened with the online team work process.

Several areas merit further consideration, including:

• The potential for the FCM to be used as an overarching approach to professional ethics education in pharmacy, wherein all four components would be specifically targeted.
• The establishment of a multisite collaborative investigation of the use of these methodologies in undergraduate pharmacy education.
• The adaptation of the teaching and assessment techniques outlined in this article to continuing professional development initiatives for practicing pharmacists.
• The review of how these methodologies might be adapted to incorporate interprofessional and interdisciplinary learning through the use of multidisciplinary online groups.
• The use of the VLE in online and blended learning programs merits further review as a means of supporting teaching and assessment methodologies aligned with competency-based assessment, such as those currently being introduced for pharmacy programs in the ROI [19]. The approaches used have the potential to support assessment challenges surrounding professional attributes, i.e., in order to assess competencies, the related behaviors must first be demonstrated in a manner that can be externally observed. The use of the online environment facilitates the demonstration of professional attributes, such as teamwork, in a manner that can be observed and assessed, even where resources (e.g., tutor time) are relatively restricted.