J Dent Educ. 71(8): 1048-1057 2007
© 2007 American Dental Education Association
Effectiveness of Faculty Training to Enhance Clinical Evaluation of Student Competence in Ethical Reasoning and Professionalism
Carole Christie, M.Coun.;
Denise Bowen, R.D.H., M.S.;
Carlene Paarmann, M.Ed.
Key words: ethics, competency-based education, critical thinking, evaluation, competency-based evaluation, dental hygiene education, authentic evaluation, professionalism, professional responsibility, student attitudes
Submitted for publication 12/01/06;
accepted 03/26/07
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Abstract
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This study evaluated the short- and long-term effectiveness of faculty training to enhance clinical evaluation of ethical reasoning and professionalism in a baccalaureate dental hygiene program. Ethics, values, and professionalism are best measured in contexts comparable to practice; therefore, authentic evaluation is desirable for assessing these areas of competence. Methods were the following: 1) a faculty development workshop implementing a core values-based clinical evaluation system for assessing students’ professional judgment; 2) subsequent evaluation of the clinical faculty’s use of core values for grading and providing written comments related to students’ professional judgment during patient care for three academic years; and 3) evaluation of program outcomes assessments regarding clinical learning experiences related to ethics and professionalism domains. Results revealed the clinical faculty’s evaluation of professional judgment during patient care was enhanced by training; written comments more frequently related to core values defined in the American Dental Hygienists’ Association (ADHA) Code of Ethics; and faculty members reported more confidence and comfort evaluating professional judgment after implementation of this evaluation system and receiving training in its application. Students were more positive in outcomes assessments about their competency and learning experiences related to professionalism and ethics. This article shares one approach for enhancing clinical faculty’s authentic evaluation of student competence in ethical reasoning and professionalism.
The purpose of this faculty development project was to enhance authentic evaluation of ethical reasoning and professionalism in the clinical component of a baccalaureate dental hygiene program. Research has documented the effectiveness of several modalities for teaching and evaluation of ethical decision making in professional education including but not limited to patient-based vignettes, simulated cases, classroom-based or online interactive studies and other clinically and expert-oriented learning activities,1–5 formal examinations,4 small group discussions,6,7 essays requiring reflection on extramural program participation,8,9 portfolio assessment,10–12 service-learning,13,14 and ratings of professional judgment during patient care.15–17 Authentic evaluation requires the independent performance of a skill or skills in situations similar to those that students will encounter after graduation. Ethics, values, and professionalism are best measured in contexts comparable to those encountered in practice; therefore, authentic evaluation is the desired mechanism for assessing these areas of competence.15,18
Professionalism often can be defined as aspiring toward altruism, accountability, excellence, integrity, and respect for others. These affective and tangible components of professionalism can at times be competitive with the financial and productivity demands encountered in practice. Students must be taught to use ethical decision-making skills and critical thinking to resolve competing interests, and their competency in ethical reasoning and professionalism must be effectively evaluated in the clinical setting throughout the curriculum.19 Accordingly, as required by the Commission on Dental Accreditation of the American Dental Association, all dental and dental hygiene educational programs have developed competencies and related evaluation mechanisms for the domain of professionalism and ethics.20 The question remains for many faculty members: how do we effectively evaluate ethics and professionalism? In the affective domain, this is perhaps the most challenging aspect of competency-based education. A systematic review of studies measuring professionalism that were published between 1982 and 2002 concluded that there are few well-documented studies of instruments that can be used to measure professionalism in formative or summative evaluation.21
Authentic evaluation is designed to measure students’ performance in the context of situations they will encounter in practice as licensed care providers. Chambers and Glassman argue that ethics, values, and professionalism cannot be measured in contexts that differ from those that the graduate will encounter following the educational program.15 Although evaluation of ethical decision making and professionalism in the clinical setting during patient care offers a unique opportunity for authentic evaluation of this domain, challenges for clinical faculty members abound. One aspect of authentic evaluation that creates difficulty for clinical faculty is its subjectivity relative to other forms of evaluation. This subjectivity is unavoidable when evaluating professional judgment, critical thinking, and decision making in patient care. Informal discussions with students indicate that they perceive professional judgment grades as subjective and personal. Training faculty to consistently relate comments regarding students’ performance in this area to important core values and ethical principles taught throughout the curriculum potentially could reduce the students’ and evaluators’ uneasiness with subjectivity and improve students’ acceptance of this aspect of authentic evaluation.16
Educators also must contend with their own moral outlook and values as characteristics that are distinct from other domain-based skills. Assessment of professionalism must be subjective, personal, accompanied by explanation, performed during periods of stress, and undertaken during routine activities rather than on special occasions.22 Clinical faculty members need to exhibit ethical behaviors and encourage or even invite students to imitate these professionally appropriate actions over time. Clinical faculty are often practitioners themselves in addition to functioning as instructors, and thus serve as role models for students. Because of this relationship, it is incumbent upon clinical faculty members to acknowledge ethical violations and to take appropriate action. They need to learn to internalize their task as role models to ensure that students are able to acquire humanistic practice skills.23 To do so, the faculty needs a system and training to define, discuss, and evaluate acceptable ethical behavior and professionalism.24,25 Training clinical instructors to evaluate ethical reasoning and decision making daily in clinical patient care settings is important because that is where students regularly face ethical dilemmas. Grading or evaluating performance during these "teachable moments" requires rigorous justification by the faculty to demonstrate that ethics and professionalism are not irrelevant to practice, but rather a vital practical and professional skill.17,26
Findings from our previous study documented faculty members’ concerns and doubts about their capacity to evaluate this area of competency including the following: the perception that evaluation of ethics and professionalism places more weight on judgment (subjectivity) than on objectivity; evaluating this area of professional performance creates uneasiness because it is an unfamiliar instructor role; and concerns are raised about potential reprisal or legal actions by the students.16 Faculty members also express a preference for measuring products over processes and concern about the effect of the evaluation of professional behaviors and decisions on faculty-student relationships.15 When faculty and administrators decide not to pursue unethical behaviors, the system designed to foster professionalism and promote ethical reasoning is undermined. Faculty training supports the culture of ethics and professionalism by promoting awareness, helps clinical evaluators to consider ethical reasoning and dilemmas when performing daily evaluations, and sends a message to the entire faculty that the issue of ethics is important to the institution.24,25 A comprehensive faculty training program to foster effective clinical evaluation of ethics and professionalism should provide background and justification for change, outline a structure and a system for evaluation, establish clear expectations for professionalism, allow faculty members to act as role models, and encourage the faculty to embrace the evaluation of ethical reasoning.25,27 This faculty development project was designed to accomplish those goals, and data were collected over a three-year period to evaluate its effectiveness.
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Methods and Materials
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The structure and basis for enhancing evaluation of ethical reasoning and professionalism were derived from the core values identified in the Code of Ethics of the American Dental Hygienists’ Association (ADHA),28 including autonomy, confidentiality, beneficence, nonmaleficence, societal trust, justice, and veracity. These ideals also are identified as ethical principles in the Code of Ethics of the American Dental Association (ADA).29 These universally accepted standards have been revised recently to include simplified language that can be used during clinical evaluation of students. These core values (Table 1
) provide standard terminology and definitions for the faculty to use to reduce the perceived subjectivity and sensitivity associated with evaluating ethical decision making and professional behaviors or professional judgment in the clinic.
Professionalism and ethical decision making are evaluated throughout the curriculum in didactic and seminar courses using test cases, case analyses, case presentations, research and service-learning projects, and ethics and professionalism reports and self-assessments. Because these active learning modalities and evaluation mechanisms do not provide authentic evaluation of this domain in a real world setting during patient care, professional judgment grades issued during each patient care appointment are used for this dental hygiene program’s authentic evaluation of ethics and professionalism. As such, the faculty needed to effectively use this aspect of clinical evaluation to help students attain the competencies in this domain. A decision was made prior to implementation of this faculty development program to attempt to retain the existing numerical system for grading professional judgment while improving its application. Justifications included building upon the faculty’s familiarity with the grading system and avoiding costly and time-consuming modification of computer programs used for evaluating all aspects of patient care. In each clinical course, professional judgment is evaluated on the same five-point scale that is used for each aspect of clinical care provided at each patient appointment. Evaluation of grades issued prior to faculty training identified two areas needing improvement: the faculty’s perception of apparent grade inflation in the area of professional judgment, and a lack of written comments, justification, or narrative provided by faculty members evaluating this area of performance. Although grades were monitored before and after faculty training for informational purposes, the focus of this project was to enhance and improve the clinical faculty’s written comments providing justification for professional judgment grades using core values and principles identified in the professions’ codes of ethics: that is, universally accepted standards.
In fall 2002, all full-time and part-time faculty members responsible for clinical teaching and evaluation were invited to a four-hour faculty development workshop entitled "Incorporating Ethics into Clinical Training and Evaluation" as the main component of the faculty development program. Pre-course study materials also were distributed including summaries, online links, and references for current literature related to competency-based education, authentic evaluation, and teaching and evaluation of ethical reasoning and professionalism, as well as copies of the ADHA Code of Ethics28 and this dental hygiene program’s defined competencies in professionalism and ethics. The faculty were encouraged to review these materials prior to attending the workshop and were informed that the information was important to their participation with peers in case-based activities.
The workshop opened with a brief overview of the content of pre-course materials to provide a historical perspective and review important concepts from the literature. Participants also were asked to independently consider and list the important characteristics that our students must acquire prior to graduation. Responses reported by attendees were similar, and the majority listed seven attributes: professionalism, integrity, ethical reasoning/critical thinking, clinical competence, valued team member, lifelong learning, and leadership. These results were discussed in relation to the existing clinical evaluation system, which clearly emphasized competence in clinical skills rather than the faculty members’ list of desired characteristics related to the affective domain of ethics and professionalism.
Values clarification exercises designed for individual faculty members to assess their own attitudes about the relative importance of these core values comprised the next component of the faculty development workshop. Ethical dilemmas presented from the student-clinician’s viewpoint and the patient’s viewpoint, often conflicting, were used to practice using core values to assess ethical decision making in the clinical setting. Faculty members also individually rated the students’ professional judgment in each scenario and discussed their evaluations with peers in small groups. No attempt was made to gain consensus. Activities were designed to emphasize the individual nature of one’s own values and to demonstrate that students could learn from the individual experiences and professional judgment of each faculty member as long as that individual was confident and comfortable discussing the evaluation with the student. A sample activity follows:
Scenario from patient viewpoint:
Student dismisses patient 30 minutes late because the patient lives 50 miles away in another town, and it is inconvenient to return. The next patient is waiting in the reception area for 45 minutes and paying a babysitter.
Scenario from student viewpoint:
It is the last day of the semester and finishing cases is paramount. The time required for providing the highest quality of care versus completing clinical requirements presents a dilemma.
Once participants were familiar with the core values defined by the ADHA Code of Ethics28 and their own opinions of the relative importance of each of them, they were given a Clinical Evaluation Exercise. The exercise initially required independent review of ten student/patient cases to determine applicable core value(s) and provide a written comment for each example related to the core value(s) assigned. Further, each instructor was asked to assign a grade that might be appropriate for each sample case, remembering that grading should reflect the message sent to the student about the specific violation of the core value(s). As mentioned previously, the existing grading system (0–5 ratings for preventive/periodontal therapy clinics) was used.
After independent evaluation, participants divided into groups based upon the courses in which they taught to discuss five of the ten examples provided and rewrite comments to better incorporate identified core values. Each group then discussed whether consensus could be reached on assigning a grade for the example case or whether that consensus was necessary. Groups also were asked to be prepared to report on one case including grading and comments. Table 2 lists the ten sample cases evaluated.
At the conclusion of this first phase of training, all clinical faculty members were provided laminated cards listing the core values and alternative descriptors to be used for evaluation of students’ ethical decision making and professionalism in the clinical setting during patient care. Table 1
presents an enlarged version of the pocket-sized, laminated reference card that is provided for faculty to carry during all clinical sessions. The faculty were encouraged to discuss and record related narrative justification for grades issued for professional judgment, especially when violations of core values were observed but also when students performed well.
One year later in fall 2003, a follow-up meeting was held with all clinical faculty members to discuss the outcomes of the initial training. Blinded summaries of the students’ professional judgment evaluation scores and associated comments were distributed for review and discussion (Table 3). As data were collected throughout the first year to monitor program outcomes, the absence of a criterion for legal infractions, such as failure to complete accurate documentation of services rendered, was identified as a necessary addition. The faculty agreed, and the laminated evaluation criteria cards were amended to include "legal requirements" in addition to the core values associated with ethics and professionalism. Faculty members expressed renewed commitment to using this system for evaluating students during clinical patient care appointments. The faculty also completed an evaluation of the training program.
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Table 3. Summary of professional judgment evaluation in clinical courses: pre-workshop and three years post-faculty workshop
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Data collection and summaries of faculty comments continued from the fall 2002 semester through the fall 2005 semester. On the clinical evaluation record completed during each patient care appointment, faculty members issue a grade for professional judgment as well as grades for clinical procedures performed (i.e., health history, oral assessment, care planning, debridement, etc.). Space is provided for the faculty to comment on any aspect of the student’s performance. One evaluator, the course director for ethics and primary investigator of this study, evaluated all clinical evaluation records for all clinical courses throughout the study to determine if the faculty provided written comments on professionalism and ethics and whether core values were used as justification when the faculty members did provide a narrative justification for professional judgment grades issued. All encounters between faculty and students in the clinic where an instructor wrote a comment related to the students’ professional judgment were evaluated, and the percentage of comments related to core values and ethical principles was calculated. Annual grade summaries were provided to the clinical faculty, and discussions of evaluation of students’ professional judgment ensued at faculty meetings each fall (2004 and 2005) to reinforce the principles and values desired in our students and to highlight this competency along with those related to technical clinical skills. New faculty members were trained in this system as a part of clinical faculty orientation. Grading and quality of related narrative comments written by the faculty for each class of students were assessed following each semester from fall 2003 through fall 2005 to determine the impact of the training program on the clinical faculty’s evaluation of ethical decision making and professionalism.
Student exit interviews of 2002 graduates (pre-workshop) and 2005 and 2006 graduates (post-workshop) were examined to explore a possible impact of the faculty development program on students’ opinions about their education and competency in the curriculum domain of professionalism and ethics. The format for student exit interviews was revised between 2002 and 2005 to focus on each domain of program competencies; however, they continued to be oral interviews with open-ended questions conducted by the dental hygiene department chair. In both formats, direct quotes/responses were collected during each interview by computer recording. The department chair provided each student with a copy of the program’s competencies organized by domains for reference during the interview.
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Results
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Table 3 summarizes the average grades issued and the frequency of comments made related to core values prior to the faculty development workshop and each semester after faculty training. Prior to the initiation of the faculty development initiative, the professional judgment grades issued averaged 95.4 percent (r=76.0 to 97.8 percent) in Clinical Dental Hygiene I during spring semester of the junior year; 92.35 percent (r=72.7 to 98.8 percent) in Clinical Dental Hygiene II during fall semester of the senior year; and 91.02 percent (r=75.0 to 97.8 percent) in Clinical Dental Hygiene III during spring semester of the senior year. Average grades issued and ranges during the three year post-workshop period were the following: Clinical Dental Hygiene I, 89.08 percent (r=84.60 to 94.36), Clinical Dental Hygiene II, 87.85 percent (r=85.52 to 89.11), and Clinical Dental Hygiene III, 87.58 percent (r=87.29 to 87.74). Narrative comments related to core values or ethical principles were extracted from all written comments in the category of professional judgment. Prior to the faculty development program, faculty members wrote comments related to core values or ethical principles 20.27 percent (N=76) of the time that comments were written to provide narrative justification for professional judgment grades issued. During the three-year period after training, the clinical faculty wrote comments related to core values 34.23 percent (N=494) of the time.
For the three years post-workshop, the percentage of comments related to core values remained higher than pre-workshop percentages, varying in each clinical course. In Clinical DH I, the pre-workshop average was 14.71 percent compared to 34.25 percent, 33.76 percent, and 37.21 percent after training. In Clinical Dental Hygiene II, the pre-workshop average of 23.68 percent increased initially to 35.63 percent then increased to a high of 41.04 percent in the second year and decreased to 33.33 percent in the third year. In Clinical Dental Hygiene III, the pre-workshop average of 20.21 percent increased to 26.27 percent initially, 36.42 percent in the second year, and 25.20 percent after three years.
The post-training faculty survey completed by the participants (N=14) one year after initial training at the follow-up workshop in the fall of 2003 indicated that 100 percent of these faculty members agreed or strongly agreed that the training strengthened their ability to provide well-rounded, criterion-based justification for grade deductions in professional judgment. All clinical faculty members also reported they were more capable of linking core values and ethical principles with grades after the training. Ninety-three percent of the participants agreed or strongly agreed that the faculty development program positively impacted their confidence in discussing professional judgment with students in clinic and enhanced their ability to consistently communicate in a respectful manner with students regarding professional judgment. The majority of faculty members also reported being more confident communicating with students about related grade deductions (86 percent), believed the information helped bolster their sense of objectivity when issuing professional judgment grades (72 percent), and had the opinion that students’ awareness of core values in clinical practice was heightened as a result of the faculty development program (78 percent). Table 4 presents an overview of the results of the post-workshop faculty evaluations one year after training.
Outcomes assessment of the ethics and professionalism domain in the curriculum included exit interviews with graduating students and alumni surveys one year after graduation. The format for student exit interviews was revised between 2002 and 2005; however, they continued to be oral interviews conducted by the dental hygiene department chair. Responses related to all domains and competencies were fewer before revision; therefore, quantitative comparisons can not be made. Qualitative differences were notable. In 2002, graduating students who made comments (N=3) regarding ethics and professionalism directed those comments toward the clinical faculty’s professional judgment or changes needed in this aspect of their education. Examples include: "Confidentiality: among faculty, be careful what you say" or "Need more positive reinforcement mechanism." In 2005 and 2006, exit interview comments made by students (N=16) regarding professionalism and ethics were positively related to students’ perceptions of their competency, and no suggestions for improvement were made. Examples include: "As far as professionalism and ethics, I feel it’s been well rounded and pervasive throughout the curriculum"; "This is ingrained in classes and carried over in clinic"; and "Yes, I feel competent (in this domain) and it has helped me self-assess in clinic what is in the best interest of patients and others involved." Other students made direct reference to the Code of Ethics, commenting, for example, "It was confusing at first. . . . it keeps building upon itself in the past two years and we have learned it" and "It is pervasive throughout the curriculum. . . . sometimes we get so focused on patient care, but ethics is all encompassing." All of the 2005 and 2006 interviewees reported feeling competent and confident in ethical reasoning and decision making.
Alumni surveys included three items related to the professionalism and ethics domain assessing whether 1) their reasoning ability about ethical and professional dilemmas was enhanced by their dental hygiene education; 2) they demonstrated professional conduct in practice by using ethical decision making and problem-solving skills; and 3) their professional decisions are consistent with current dental hygiene standards of care and legal regulations. Results one year after graduation indicated all post-workshop respondents from the classes of 2004 and 2005 (N=21) strongly agreed or moderately agreed with all three of those statements with nineteen (90 percent) or twenty (95 percent) in the strongly agree response categories for each item. Only 70 percent (N=7) of the respondents from 2002 graduates (N=10) strongly agreed that their reasoning ability about ethical and professional dilemmas was enhanced by their dental hygiene education. While these numbers are small, the trend appears to be moving toward a more positive perception about educational preparation in ethics and professionalism. More research is needed to specifically evaluate graduates’ opinions and preparation for practice.
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Discussion
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Published literature recommends authentic evaluation of ethical reasoning and professionalism. Despite the fact that authentic evaluation requires real world application in the patient care setting, most of the published data related to the evaluation of ethical decision making involves classroom- or seminar-based active learning strategies such as vignettes, essays, interactive cases, and patient simulations. These classroom-based strategies have value when teaching students to think critically and formulate ethical decision-making strategies when ethics content also is integrated throughout the professional dental and dental hygiene curricula. In addition, clinical faculty members serving as role models for students during patient care need training to be able to effectively and consistently evaluate professionalism and ethical reasoning. Perhaps more importantly, faculty training is needed to enhance faculty discussions regarding these affective domains of learning with students. Some faculty members believe that the perceived subjectivity and more personal nature of professional judgment grades make evaluation of this area of professional practice more difficult than grading of technical skills. Results of this faculty training program indicated that the clinical faculty members were more confident and more comfortable evaluating professional judgment after being provided with a system for evaluation and receiving training in its application. They also believed they were better able to relate professional judgment grades to core values and ethical principles, and as a result, students were more aware of these principles during patient care.
The evaluation system was based upon the core values of the discipline as stated in the ADHA Code of Ethics28 to provide a common and important framework for teaching, discussing, and evaluating students in the clinical provision of oral health services. Grades issued for professional judgment were slightly lower following the faculty development program than before. Data indicate the frequency of the clinical faculty’s written comments related to core values when evaluating professional judgment increased initially and continued for the three-year period of data analysis from fall 2002 until spring 2005. The initial faculty development program in fall 2002 was reinforced one year later in fall 2003, and new faculty members were trained as they were hired. Comments related to core values increased from approximately one out of five before training to one in three after training. Faculty members also informally remarked that they appreciate the laminated pocket reference card provided for use in the clinical setting when evaluating and discussing ethical reasoning and professionalism with students.
Program outcomes assessment data tend to show graduates’ agreement with the faculty regarding enhancement of their education in ethical decision making and professionalism over the three-year period following the faculty development program. Graduate surveys indicated that the 2004 and 2005 graduates strongly believed that they were well prepared for practice and competent in ethical reasoning and professionalism. Student comments during exit interviews appear to verify that students were more positive and believed they were more competent and confident in the ethical reasoning and professionalism domain in 2005 and 2006 than prior to faculty training.
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Conclusion
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This faculty development program strengthened the authentic evaluation of ethical reasoning and professionalism in a baccalaureate-level dental hygiene program. The system and faculty training program could be adapted to other institutions’ clinical evaluation systems because it is based upon universally accepted core values and ethical principles of autonomy, confidentiality, societal trust, nonmaleficence, beneficence, justice, and veracity as well as legal requirements for practice of dentistry and dental hygiene. Overall, comparison of pre- and post-training data suggests that this faculty training program enhanced evaluation of students’ ethics and professionalism in the academic clinical setting.
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Footnotes
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Prof. Christie is Associate Professor, and Prof. Bowen and Prof. Paarmann are Professors, Department of Dental Hygiene, Idaho State University. Direct correspondence and requests for reprints to Prof. Carole Christie, Department of Dental Hygiene, Idaho State University, Box 8048, Pocatello, ID 83209; 208-282-3796 phone; 208-282-4071 fax; chricaro{at}isu.edu.
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Abstract
Methods and Materials
