Introducing an
Ethical Scenario Review Record
to
Enhance Ethical Reflection
and
Client Choice
Presented by:
Closing The Gap Healthcare Group (CTG)
at
OACCAC Knowledge and Inspiration 2011
Sheila Ritcey
Kathy Underwood
Background
CTG established an ethics program in 2004 in response to a recommendation by
Accreditation Canada and to assist clinicians with the increasingly complex and ethically
challenging situations found in the community. A comprehensive ethics education
program was introduced with a goal to build ethical decision making capacity and
understanding across the company. The Ethics Scenario Review Record (ESRR) was
introduced in 2005 and was used by clinicians to document ethical issues and to provide a
catalyst for small group discussion. When a review of knowledge transfer did not indicate
the expected progress, the ESRR was integrated into the performance review process.
This presentation explores how the inclusion of an Ethics Scenario Review Record
(ESRR) in professional performance reviews facilitates clinical reflection and the transfer
of ethical knowledge, attitudes and skills into clinical practice, enhancing client choice
and experience.
The model supports evolution from a principle based model and the accompanying
moral distress that caregivers experience to the relational ethics essential for client
centered care
Role of Ethics
The Evolving Role of
Ethics
“Epiphany”
and
Knowledge
Transfer
 Moral Distress
 Client driven
care
 Satisfaction
Relational
Ethics
INDIVIDUAL
Reflection
Education
• Normative ethics
• Principles
• Language
Moral
Distress
Inclusion in
Performance
review
Ethical
Scenario
Review
Corporate
Reflection
Limited
Impact
Method
32 completed ESRR’s were reviewed for the following:
 Ethical principles involved
 Types of ethical situations encountered
 Rating on seven components of ethical knowledge, skill and application of
skills to the clinical scenario
 Overall rating of ethical skills
Ethical Principles
Results:
Many scenarios identified more than one ethical principle.
Ethical principle(s) involved in the selected scenarios
How to do no harm
Autonomy (e.g. right to live at risk)
How to do the most good/prevent harm
Meeting client's expectations
Informed Consent (e.g. right to know)
Making amends when something goes wrong
Reporting professional or ethical misconduct
Response
Percent
59.4%
53.1%
50.0%
46.9%
25.0%
3.1%
0.0%
Analysis:
4 ethical principles were identified as the primary challenges for caregivers
 Duty to do no harm
 Duty to bring about the greatest amount of good
 Duty to meet the clients reasonable expectations
 Right to autonomy i.e. to live at risk
Ethical Situations Identified by Caregivers
Results:
 Ethical dilemmas 50%
 Locus of authority 44 %
 Moral distress 6%
Analysis:
Ethical dilemmas (50%), locus of authority issues (44%) accounted for 94%
of ethical situations identified. Moral distress was a minor factor.
Rating on Seven Components of Ethical Decision Making
 Demonstrate knowledge of theoretical concepts and vocabulary
 Demonstrate application of theory
 Ability to identify personal values
 Ability to identify impact of personal values on the situation
 Identify ethical approaches to address the situation
 Brainstorm a range of practical approaches to address the situation
 Ability to reflect and learn from the situation i.e. how will I approach the situation
the next time
Results:
 The desired goal for each component is 80%
 The goal was achieved in some categories and very close in others. However
goals were not met in understanding ethical approaches and reflecting and
learning from experience
Analysis:
Therapists struggled with clients choosing to live at risk and ignore or partially follow
professional recommendations. They struggled most with the ability to respect choices
which were in sharp conflict with their own values. However there was also clear
evidence of a shift by some clinicians from a principles based normative model to a
relational ethic.
Overall Rating of Acceptable Decision Making Skills and Knowledge
Method:
A skill rating was assigned to each component of the decision making model. The rating
scale included three broad categories: yes, partial or no.
 6-7 yes rating = High competency
 4-5 yes rating = Moderate competency
 <4 rating = Low competency
Results:
75% of clinicians achieved a High rating.
Analysis:
Clinicians who fell into the low or moderate categories also displayed significant
paternalistic tendencies. These clinicians described a high awareness of their personal
values but did not indicate respect for client values.
Those with a high rating displayed the ability to respect client decisions that differed
from their professional recommendation. They had moved out of their comfort zone into
the uncertainty of relational ethics and asked the ethical questions that emerged from
specific situations within a specific context.
Conclusion / Next Steps
Results indicate that inclusion of the ESRR in performance review is a catalyst for
transfer of knowledge into practice. The comments of clinicians reflect a change in
perspective, a shift from focus on the person as a bearer of rights to understanding
another’s situation, their individuality, their experience and culture. “I find myself
thinking differently, I find myself respecting the clients choices - It’s really that simple”.
CTG will share results with all staff and implement the ESRR as part of all performance
appraisals. Future ethics education will focus on ethical issues identified here and will
emphasize the caring and connection found in relational ethics.