The RIPE Project Protocol: Researching Interventions That Promote Ethics in Social Care

The RIPE Project protocol: Researching Interventions that Promote Ethics in Social Care

Ann Gallagher, Anna Cox

Abstract

Background: Recent reports into failures in residential care resulting in avoidable suffering for older people and their families have highlighted the need for, and importance of, ethical practice. Although there is a wide range of training available for care -givers, there is no mandatory requirement for ethics education as there is for registered nurses. Little is known about the impact of ethics education on the ethical competence of care home staff.

Aim: To determine the impact of three ethics educational interventions on the moral sensitivity, work-related moral stress, ethical leadership, and empathy of care-givers in residential care homes.

Method: A pragmatic cluster randomised trial exploring the effectiveness of three ethics educational interventions for care -givers working in residential care homes for older people. Baseline data will be collected before randomising each care home to one of three ethics educational interventions: 1) conventional ethics teaching within care homes for older people; 2) reflective ethics discussion groups within care homes for older people; and 3) experiential learning – immersing participants in a care recipient’s role within a simulation suite at the University of Surrey; or a control arm 4) where care-givers will receive no educational intervention.

Conclusion: At the time of publication, the research team are recruiting to the project. The project interventions, data collection and analysis will be completed by December 2016. The research team would be pleased to work withother researchers interested to replicate the study and to compare findings. More detailed information regarding the recruitment process and interventions is available on request.

Introduction Previous care home research (Gallagher ics educational interventions for care et al 2014) supports the value of ethics -givers working in residential care homes Recent reports into failures in residen- education in care homes. Little is known for older people. Baseline data will be tial care resulting in avoidable suffering about the impact of ethics education on collected before randomising each care for older people and their families (De- the ethical competence of care-givers in home to one of three ethics education- partment of Health 2012, Care Quality residential care homes. There have been al interventions: 1) conventional ethics Commission 2014, Learner 2014) have no previous comparative intervention teaching within care homes for older peo- highlighted the need for, and impor- studies evaluating a range of approaches ple; 2) reflective ethics discussion groups tance of, ethical practice. It is estimated to ethics education in this area. within care homes for older people; and that there are approximately 1.5 million 3) experiential learning – immersing par- care-givers in social care (Wills 2015). The RIPE (Researching Interventions to ticipants in a care recipient’s role within Although there is a wide range of train- Promote Ethics in social care) project is a a simulation suite at the University of ing available for care-givers, there is no pragmatic cluster randomised trial which Surrey; or a control arm 4) where care mandatory requirement for ethics edu- sets out to remedy this research gap by -givers will receive no educational inter- cation as there is for registered nurses. exploring the effectiveness of three eth- vention. The same data collection methods will be used after the interventions to ascertain the impact of each approach Corresponding Author details Author details in comparison to a control group. Data Ann Gallagher, Anna Cox, collection methods will be quantitative Professor of Ethics and Care Research Fellow, (using measures to evaluate the impact International Care Ethics (ICE) Faculty of Health & Medical Sciences, of the interventions on moral sensitivity, Observatory, Faculty of Health & University of Surrey, Duke of Kent work-related moral stress, ethical leader- Medical Sciences, University of Building, Stag Hill Campus, Guildford, ship and empathy) and qualitative (gain- Surrey, Duke of Kent Building, Stag Hill Surrey, GU2 7TE ing the perspectives of care-givers and Campus, Guildford, Surrey, GU2 7TE Email: [email protected] their managers through semi-structured Email: [email protected] interviews). (See FIGURE 1 for project overview). Working Papers in the Health Sciences 1:11 Spring 2015 ISSN 2051-6266 / 20150064 1 Researching Interventions that Promote Ethics in Social Care

Pre-assessments: Moral Sensitivity Questionnaire (MSQ);

The Work-Related Moral Stress (WRMS) Questionnaire Ethical Leadership Questionnaire (ELQ); The Interpersonal Reactivity Index (IRI); Individual interviews within selected care homes.

Intervention 1 Intervention 2 Intervention 3 Control group Experiential learning – immersing No intervention Conventional ethics Reflective ethics discussion teaching within care homes groups within care homes participants in a care recipient’s role within a simulation suite at the University of Surrey

Immediate post intervention feedback

Post assessments (1 month): Moral Sensitivity Questionnaire (MSQ); The Work-Related Moral Stress (WRMS) Questionnaire; Ethical Leadership Questionnaire (ELQ); The Interpersonal Reactivity Index (IRI); Individual interviews within selected care homes.

Post assessments (3 months): Moral Sensitivity Questionnaire (MSQ); Focus groups in selected care homes.

Figure 1: Researching Interventions that promote Ethics in Social Care In the light of findings, this 24 month pro- iii. To evaluate/measure the im- Summary Literature Review ject will develop an evidence-based so- pact of experiential learning, on cial care ethics education programme for the moral sensitivity, work-relat- The three approaches to ethics educa- care-givers in residential care homes for ed moral stress, ethical leadership, tion have not been evaluated systemati- older people that can be rolled out across and empathy of residential care cally although there is some evidence for the UK. Researchers will work actively -givers working with older people; effectiveness, for example, in relation to with the Ethox Foundation to apply for iv. To explore care-givers’ experienc- conventional teaching and simulation and funding for the educational programme es of care-giving within a residential also relating to the value of clinical ethics as we draw conclusions from the RIPE care home setting for older people, committees, similar to reflective ethics project. specifically considering challenges discussion groups, in other settings. A and enablers to ethical care practices; review of the literature was conducted Aim of the Project v. To explore residential care-givers’ for each approach to ethics education, a perceptions of induction, training, summary of these reviews is given below. To determine the impact of three educa- support and supervision, and ethics tional interventions on the moral sensi- resources within their organisation; 1. Conventional ethics teaching tivity, work-related moral stress, ethical vi. To explore residential care Face to face classroom-based teaching in leadership, and empathy of care-givers in home managers’ perceptions applied ethics is well-established in rela- residential care homes. of induction, training, support tion to healthcare professionals, although and supervision, and ethics re- less so in relation to social care, especially Objectives: sources within their organisation; residential care with older people. There i. To evaluate/measure the impact vii. To explore residential care- is a good deal of literature regarding the of conventional ethics teaching on -givers experiences of conven- aims and learning/teaching methods uti- the moral sensitivity, work-relat- tional ethics teaching in re- lised on ethics education programmes ed moral stress, ethical leadership, lation to their care practice; particularly for nurses and doctors. So- and empathy of residential care viii. To explore residential faer (1995), for example, examined four -givers working with older people; care-givers’ experiences of re- types of teaching methods namely, dis- ii. To evaluate/measure the impact flective ethics discussion groups cussion, student-led seminars, structured of reflective ethics discussion groups in relation to their care practice; debate and role play. The methods were on the moral sensitivity, work-relat- ix. To explore residential care-givers’ not evaluated separately to understand ed moral stress, ethical leadership, experiences of experiential learn- which method was more effective, how- and empathy of residential care ing in relation to their care practice. ever Sofaer (1995) concluded that as a -givers working with older people; result of the health care professionals’

Working Papers in the Health Sciences 1:11 Spring 2015 ISSN 2051-6266 / 20150064 2 participation in the experimental learn- They defined ‘moral case deliberation’ is then a good deal of research on differ- ing, they were able to reflect analytically as a specific form of clinical ethics, with ent approaches to ethical or moral delib- and participate in informed discussion. the objective of stimulating ethical reflec- eration, but no consensus regarding the Johnson (1983) argued that small group tion in daily practice, which improves the most appropriate approach or effective- discussions are very effective in increas- quality of care. They tried to understand ness. This study provides an opportunity ing the ethical knowledge of health care how and where to most effectively organ- to test different approaches to ethical or professionals. ise moral case deliberation. In evaluating moral deliberation in relation to the prac- the implementation of moral case delib- tice of UK residential care-givers, a group Park (2009) reported that because nurses eration, van der Dam et al concluded that under-researched thus far. encounter clinical issues on a daily basis heterogeneous composition of moral that require ethical judgement they need case deliberation as well as having moral 3. Experiential learning to be trained, prepared and supported in case deliberation separate from existing Simulation-based learning evolved in making ethical decisions. It has been sug- structures has benefits though some par- high-hazard professions, such as aviation, gested that newly qualified nurses lack ticipants reported negative experiences. nuclear power, and the military, with the ethical confidence as nursing education However the effect of moral case delib- aim of maximizing training safety and does not prepare them well in dealing eration on care-givers’ ethical sensitivity minimizing risk. Simulation has lagged with ethical issues (Woods, 2005). Woods was not evaluated. Førde et al (2008) ex- behind in health care for a number of (2005) argued that there is a need for plored the views of eight clinicians who reasons, including: cost; lack of rigorous new approaches in teaching nursing eth- evaluated six committees’ deliberations proof of effect; and resistance to change ics to health care professionals as the tra- on 10 clinical cases. The research con- (Ziv et al., 2006). Healthcare organisa- ditional ethics education tended -to em cluded that clinicians found the clinical tions are now embracing simulation as a phasize the acquisition of philosophical ethics consultations useful, but it is vital learning experience and we are currently and theoretical knowledge that has cre- to use a systematic approach to explore in what has been described as the ‘gold- ated a gap between theory and practice. cases during the consultations. en age of medical simulation’ (Carroll and As Park (2009) maintained, the teaching Messenger, 2008), with high expectations of nursing ethics should address the day Garcia (2001) argued that whether the for the impact of this major innovation to day ethical issues in care delivery. But different methodologies used in clinical on future health care provision. Whilst there was no specific teaching method ethics work well or not depends on cer- the literature on medical simulation is suggested to address the day to day ethi- tain external factors, such as the mental- vast, evidence emerging from the litera- cal issues encountered by care-givers. ity with which they are used. Steinkamp ture is limited, for example, a review of and Gordijn (2003) analysed and com- high-fidelity medical simulations (Issen- Schluter et al (2008) explored nurses’ pared four methods of ethical case de- berg et al., 2005) identified only 109 out moral sensitivity and hospital ethical cli- liberation namely: Clinical Pragmatism, of 670 articles were sufficiently robust to mate. They argued that one way of ad- The Nijmegen Method of ethical case be included. Similarly, a review of simu- dressing the ethical dilemmas and sup- deliberation, Hermeneutic dialogue, and lation-based learning in nurse education porting nurses in resolving the ethical Socratic dialogue. The researchers main- (Cant & Cooper, 2009) suggests that dilemmas is to make sure that as well as tained that there is no one ideal method simulation using manikins is an effective other health care professionals, nurses of ethical case deliberation, thatfi ts to all teaching and learning method, but ac- have a grounding in ethical decision mak- possible kinds of moral problems. Every knowledged that the generalizability of ing. We know of no evidence to date that method has its strengths and weakness- results may be limited due to the quality examines the experience of residential es and this should be considered while of study designs. care-givers in relation to the impact of choosing a method for deliberation. conventional face to face ethics educa- There was no discussion of how to eval- Bradley (2006) classified simulation into tion. uate the impact of these methods on four types: part-task trainers; comput- the ethical practice of health and social er-based systems; simulated patients and 2. Reflective ethics discussion groups care-givers. In ‘clinical pragmatism: a environments; and integrated simulators. There has been a good deal of research method of moral problem solving’, Fins Within a health care setting, simulation attention given to ethical issues in health- et al (1997) presented a method of moral has mainly focused on increasing knowl- care practice, for example, in relation to problem solving in clinical practice that edge and experience regarding technical the activity of groups discussing ethical is- is inspired by John Dewey’s philosophy. care interventions. However, simulat- sues in clinical ethics committees or prac- This method integrates clinical and ethi- ed patients (SPs) have become popular tice discussion groups. One approach to cal decision-making. Clinical pragmatism in medical education over the past two supporting ethical reflection and ethical focuses on the interpersonal processes decades and focus predominantly on re- practice is a ‘moral case deliberation’ ap- of assessment and consensus formation lational skills. Most commonly the SP is a proach whereby healthcare professionals as well as the ethical analysis of relevant trained actor or a patient who has been interrogate their moral and/or ethical moral considerations. The steps in this prepared for simulation and the learner questions during a structured dialogue method are delineated and then illustrat- plays their own (current or future) pro- about a particular case study. Such dia- ed through a detailed case study. The im- fessional role, practicing the skills re- logue is usually facilitated by an ethicist. plications of clinical pragmatism for the quired for that position without any risks Van der Dam et al (2011) discussed their use of principles in moral problem solving to a patient. There is also another very experience of organising ‘moral case de- were discussed but there was no discus- different approach to SPs in which the liberations’ in two Dutch nursing homes. sion on how to evaluate its effects. There student/professional can adopt the role

Working Papers in the Health Sciences 1:11 Spring 2015 ISSN 2051-6266 / 20150064 3 of a patient or care recipient in order to ed in each care home in this arm of the approached to play the role of ‘care-giv- develop an insight into their experience, study. These sessions will use a range of ers’ within the simulated care home. with the intention of increasing their em- learning and teaching strategies including pathy for the population they interact face to face teaching, directed reading, Evaluation Methods with in their current or future profession- direction to online resources, role play, al roles. What appears to be common to use of DVDs and situation-based discus- The impact of three educational inter- the development of these interventions sions. ventions will be evaluated quantitatively is a need to provide an educational ex- and qualitatively: perience which does not solely impart 1) Moral Sensitivity Questionnaire (MSQ) knowledge and theory but facilitates a INTERVENTION 2 - Reflective ethics dis- (Lutzen et al 2010, Kulju et al 2013) – pri- deeper understanding of the lived expe- cussion groups within care homes mary outcome; rience of the patients or care recipient This arm will involve a series of meetings, 2) The Work-Related Moral Stress with whom they engage. facilitated by a specialist in ethics, in care (WRMS) Questionnaire (Lutzen et al homes to discuss ethical aspects of prac- 2010); Compared to the literature relating to tice situations. Six once monthly sessions 3) Ethical Leadership Questionnaire other forms of simulated learning there will be facilitated in each care home. This (ELQ) (Langlois et. al., 2104) is only a small body of work published in intervention provides space and time for 4) The Interpersonal Reactivity Index this area which focuses mainly on train- care-givers to talk through an aspect of (IRI) (Davis 1980, Davis & Franzoi, 1991) ing medical students (Crotty, Finucane & practice they find ethically challenging. It 5) Semi-structured individual interviews Ahern, 2000; Wilkes, Milgrom & Hoffman, may be a situation where they felt they with a sample of participating care-giv- 2002; Varkey, Chutka, & Lesnick, 2006; did the right thing or where they were ers, managers/leaders pre and post inter- Pacala, Boult, & Hepburn, 2006; Zenni et unsure what the right thing to do was. vention; al., 2006; Latham et al., 2011; Fornari et In the group discussions there will be 6) Focus groups with a sample of care al., 2011), nursing students (Penny, 2008; opportunities to try out different frame- -givers post intervention. Dearing & Steadman, 2009; Eymard, works to enable participants to analyse Crawford & Keller, 2010; Haddad, 2010; different approaches to ethical reflection. Tremayne, Burdett & Utecht, 2011), phar- Sample Size macy students (Zagar & Baggarly, 2010; INTERVENTION 3 - Experiential learning Whitley, 2012) and one example of resi- – immersing participants in a care recip- Table 1, below, gives the smallest differ- dential care-givers (Vanlaere et al, 2012). ient’s role ence in mean total MSQ score change It appears that to date, studies evaluating The experiential arm of the RIPE project from baseline to one month post-inter- the impact of immersion into another’s is informed by an intervention developed vention between any two selected pair role in order to engender ethical practice and delivered within a care ethics lab of interventions that can be found sig- are weak in methodology with poor gen- ‘sTimul’ in Belgium (Vanlaere et al, 2012). nificant with a 2-sided 5% level test with eralizability. Robust research is required Care-givers will have the opportunity to 80% power. This smallest difference has to substantiate the efficacy and- effec play the role of an older person’s care been calculated for a number of differ- tiveness of this form of simulation-based home resident according to the profile ent scenarios to enable a final selection education in relation to the moral/ethical they adopt for the simulation. Each sim- to be made of numbers of care homes to competence of residential care-givers. ulation session will last for one and a half be enrolled into the study (the scenarios days in the simulation suite at the Uni- are numbers of care homes, for each of which the smallest difference is listed for The Interventions versity of Surrey (including one overnight stay) and will include discussion groups 5 different scenarios of between subject data variability (standard deviations of INTERVENTION 1 - Conventional ethics facilitated by an ethics expert. Students in the second year of their adult nursing (sigma) 1.5, 2, 2.5, 3 and 3.5). The calcu- teaching within care homes lations have been carried out assuming, Six once monthly sessions will be facilitat- studies at the University of Surrey will be

Table 1: Standard Deviations (SD) and statistically significant changes for varying care home sizes.

No. of n/homes SD1.5 SD 2.0 SD 2.5 SD 3.0 SD 3.5

8 2.62 3.49 4.36 5.23 6.1 12 2.14 2.85 3.56 4.27 4.98 16 1.85 2.47 3.08 3.7 4.32 20 1.65 2.21 2.76 3.31 3.86 24 1.51 2.01 2.52 3.02 3.52 28 1.4 1.86 2.33 2.8 3.26 32 1.31 1.74 2.18 2.62 3.05 36 1.23 1.64 2.06 2.47 2.88 40 1.17 1.56 1.95 2.34 2.73

Working Papers in the Health Sciences 1:11 Spring 2015 ISSN 2051-6266 / 20150064 4 additionally, 8 participants per care home be the corresponding baseline total MSQ be randomised and the care-givers who and an intra-cluster correlation coeffi- measurement and an indicator variable have consented to participate in the cient of 0.3. This is based on Lutzen et al for intervention vs control (the estimate study will be given details of their ethics (2010), which quoted MSQ group mean for this giving the intervention statistical education intervention. Those in the con- differences as low as 1.5, and the figures significance). trol group will not receive details of an in the table. It was decided to enrol 28 intervention. nursing homes into the study (14 in Sur- Secondary objective statistical analyses rey, 14 in SE1) will be carried out analogously using ap- Immediately following the interventions, propriate data subsetting and/or differ- all participants (including student nurses Recruitment of Care Homes ent questionnaire scores and considering from the experiential learning arm) will data gathered at 3 months post-interven- be given feedback forms to collect their Twenty-eight residential care homes from tion. perception of the experience and their Surrey and South East London will be re- Procedure views on what they have learned. cruited to the RIPE study. As 8 care-givers will be required to participate in the Managers of identified care homes will One month post-intervention the Moral study from each home we will only ap- be sent a letter inviting their care home Sensitivity Questionnaire, The Work-Re- proach care homes with at least 20 beds, to participate and an information sheet lated Moral Stress Questionnaire, the we anticipate that smaller care homes on the project. The letter will advise Ethical Leadership Questionnaire and would not have sufficient staff numbers managers that they will receive a phone Interpersonal Reactivity Index will be dis- to release 8 care-givers for an education- call in one week’s time from a -mem tributed to all participating care-givers. al intervention. The participant informa- ber of the project team offering them a Care-givers within the homes selected tion sheets inform staff that participation chance to request further information or for interview will also be invited to partic- is dependent on there being sufficient ask questions and, if appropriate, to ar- ipate in a follow-up interview. number of staff within their care home range a visit to the care home. If during willing to take part in the project. the telephone call, the manager is inter- Three months post-intervention the Mor- ested in participation a visit to the care al Sensitivity Questionnaire (primary out- Ethical Considerations home will be organised. During this visit, come measure) will be distributed again permission will be sought to recruit eight to participating care-givers. In selected The RIPE project proposal and accom- care-givers from their care home to par- care homes a focus group will be run panying documents (participant infor- ticipate in the RIPE project, and with per- within the care home in order for par- mation sheets, consent forms and re- mission, a consent form will be signed. ticipants to discuss the perceived impact cruitment text) were submitted to the Managers will be given a set of selection of the specific intervention they have -ex University of Surrey Ethics Committee for criteria in order to identify appropriate perienced, any change in culture within ethical review. A favourable ethical opin- care-givers for invitation to the project their organisation as a result of the study ion was obtained. who have: and any support they require in terms of developing/maintaining ethical practice in the future. Data Analysis • Completed their induction to the care home; • A contract to work at least 20 hours per At the end of the study the International Interviews and focus group data will be Care Ethics Observatory at the University analysed using thematic analysis as de- week in the care home; • Some flexibility in order to attend eth- of Surrey will host a one day conference scribed by Braun and Clarke (2006). This where all participants and the managers is a six- phase process: ics education sessions during the week or at weekends. of participating care homes will be invit- 1. Familiarising yourself with the data ed to hear presentations of the results, 2. Generating initial codes Identified care-givers will be given a letter as well as offering their own experience 3. Searching for themes of participation and contributing to the 4. Reviewing themes inviting them to take part, an information sheet on the project and a consent form. planning of future research in the area. 5. Defining and naming themes All care homes and care-givers who par- 6. Producing the report When staff have been informed ade- ticipate in the RIPE study will receive a quately, consent will be obtained from certificate of participation at the close of An analysis of variance (ANOVA) will be the study. carried out as follows for the primary the first eight care-givers who are willing study objective: testing whether there to participate in each home, arrange- is a difference in mean total MSQ score ments will be made with the care home Conclusion between any one of the 3 active inter- to collect baseline measures (the Moral vention groups and the control group at Sensitivity Questionnaire, the Work-Re- At the time of writing, the RIPE Project one month post-intervention against a lated Moral Stress Questionnaire, the research team are recruiting care homes null hypothesis of no difference. The de- Ethical Leadership Questionnaire and to the project. The project interventions, pendent variable in this ANOVA will be Interpersonal Reactivity Index) and in- data collection and analysis will run un- the individual subject one month post-interviews (in selected homes). Permission til December 2016. The research team tervention total MSQ scores for one of has been sought to utilise the validated would welcome communication with the interventions and for the control. measurement tools. Following collection researchers interested to replicate the Independent variables in the ANOVA will of baseline measures the care home will study. A detailed version of the study

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