Introduction

Aged-care ethics are traditionally associated with end-of-life issues, consent to treatment, tube feeding, resuscitation, and euthanasia, although many other questions are literally “consuming” the health- and social-care professionals “in the mundane” (Dauwerse, van der Dam, and Abma 2012; Saarnio et al. 2012; Stenbock-Hult and Sarvimäki 2011).

The rapid growth of elderly patients receiving acute and long-term care has made professional training interventions a necessity both in hospital and residential settings (van der Dam, Molevijk, and Widdershoven 2014; Dauwerse, van der Dam, and Abma 2012). The peculiar challenges of elderly patients and residents (e.g., poor physical health and autonomy, cognitive dysfunction, resistance to care, falls) require specialist care from all the professionals they meet on a daily basis, who are frequently asked to take sudden, appropriate decisions in a short time and in a small place (Boddington and Featherstone 2018; Sammet 2007). As a consequence, safety concerns related to understaffing and task-oriented turnover are often reported from frail elderly patients and their relatives (Pennestrì et al. 2022a; Bökberg et al. 2019; Sammet 2007). The staff not only have to be confident with the technical care they provide every day (the hard skills of administering drugs and therapy and supporting the activities of daily living), but even more the staff should be ready to manage the critical issues raised by the complex patients they assist (the so-called “soft skills” of communication, critical thinking, and consistent decision-making under non-ideal circumstances), putting ethics strongly into focus (Peterkin and Skorzewska 2018; Abma et al. 2012; Mann, Gordon, and MacLeod 2009; Kälvemark Sporrong et al. 2007). Providing high-quality, safe, and patient-oriented care under financial and human constraints is one of the most important challenges “in a world growing old” (Callahan, Ter Meulen, and Topinkova 1995), with “everyday ethics” becoming a substantial part of the bioethical debate (Bolmsjö, Sandman, and Andersson 2006).

The need to make conflicted decisions every day can trigger the ethical challenges described in literature as moral dilemmas (“what is the best action among different options all of which seem right?”; “what is the right action among different options all of which seem wrong?”), moral uncertainties (“what is the right action in this context?”), and moral distress (“I recognize the right action, but I am not able to take it due to environmental and/or organizational constraints”, e.g. insufficient personnel, task-oriented care, physical barriers) (Giannetta, et al. 2021a, b; Greason 2020; Giannetta et al. 2020; Fourie 2017; Fourie 2015; Jameton 1984).

Ethical challenges are often described in a negative light as they are associated with burnout, psychophysical strain, and self-blame (Wong 2020; Mudallal, Othman, and Al Hassan 2017; Wagner 2015; Saarnio et al. 2012; Theorell and Karasek 1996; Freudenberger 1974). However, this perspective is increasingly questioned by the literature (Tessman 2020; Tigard 2018): conflicting moral choices express the individual ability to be critical and aware, perceive when something is not working, and promote change. The true question, therefore, is not how to silence moral conflict but how to educate it—in order to make it functional rather than dysfunctional (improving patients’ well-being, staff members’ professional confidence, and organizational efficiency).

Unfortunately, most of the operators receive no such education before they work, and when they work, they hardly find the motivation and time they need to fill these gaps, as ethical training programmes are sometimes perceived as “yet another course” which takes away further time of the little available for ward activities, shedding light on individual inadequacy (Dauwerse, van der Dam, and Abma 2012).

The discontinuity between “the high ideals of the healing professions” and the workplace demanding reality (Rothenberger 2017) may explain the growing rates of early retirement (Johnson Foundation Wingspread Center 2017), substance abuse (Oreskovich et al. 2015), and burnout (Perni et al. 2020) especially among the youngest, further exacerbated by the increase in complex and chronic elderly patients (Schoenbaum 2017). Cynical and task-oriented approaches to work can help professionals avoid morally demanding situations in the short-term, but they easily become detrimental to the health of patients in the long-term, as elderly patients need particular attention, individual responsiveness, and patient-centred coordination from the team (Perni et al. 2020; Rushton and Edvardsson 2017; van der Elst, Dierckx de Casterlé, and Gastmans 2012; Jakobsen and Sørlie 2010). Therefore, providing health- and social-care professionals with a “consequence-free” opportunity (Salas et al. 2008) to

  1. a)

    train these skills,

  2. b)

    talk about moral issues with no fear of vindication from any member of the team (Raemer et al. 2016),

  3. c)

    increase moral awareness up to a functional point (which means not to exacerbate problems but to capture and manage them before they get worse),

  4. d)

    compare their experiences in light of different perspectives and settings,

can help them enhance ethical reflection and coping strategies and improve cooperation.

Although the need for ethical support is clearly perceived in elderly care (van der Dam, Molevijk, and Widdershoven 2014; Dauwerse, van der Dam, and Abma 2012), including educational interventions for non-professional caregivers (Moreira et al. 2018), there is no “one-size-fits-all” method yet (if ever there will be). Therefore, experimenting with training sessions on a local level is important to test the effectiveness of different training methodologies, share knowledge, identify room for improvement, and reapply positive experiences in similar contexts (same type of professionals, same type of settings, same type of patients, same type of problems (West et al. 2016; Eddy, Jordan and Stephenson 2016).

The authors hypothesize that 1) it is more beneficial to recognize ethical challenges than remove them; 2) the operators already have some degree of implicit moral values and priority scales which they should learn to take advantage of in order to increase control over conflict situations, rather than feeling impeded or frustrated; 3) training sessions can help professionals to enhance this skill, once clear goals and specific educational techniques are set.

The authors worked on these hypotheses on a limited population of twenty health- and social-care professionals employed in different acute and residential aged care settings, testing an educational intervention built on their direct experience. The aims of this paper are to describe the educational intervention, describe the feedback of the direct participants, and contribute to the international research efforts on developing

  • ethical competence in care organizations (Kälvemark Sporrong et al. 2007),

  • targeted interventions for specific patients and professionals (Stolt et al. 2018) (elderly patients and the professionals who assist them) (van der Dam, Molevijk, and Widdershoven 2014), and

  • mixed teaching methodologies (Xu 2016; Macer 2008; Royse and Newton 2007).

After the pilot intervention, the authors plan to design a follow-up to test its effectiveness in a before-after observational study.

Methods

Teaching Methodology and Materials

Different methods of teaching have been adopted to pursue different educational targets.

Overall, the training session was inspired by the ethics round method (Kälvemark Sporrong et al. 2007), in which

  1. 1)

    the experience of participants in real-life situations was the main driver of educational content;

  2. 2)

    two participants of the same group described one ethical challenge each, drawing from their personal workplace experience, to share their real-life concerns and start a group discussion;

  3. 3)

    the discussion was moderated by experts in ethics with solid teaching experience with healthcare students and professionals, to stimulate participation and help them focus on the matter at hand;

  4. 4)

    the discussion involved different professionals from different settings.

In order to build the training on real workplace experience, the research team investigated the environmental determinants of ethical challenges in aged care during a two-year multidisciplinary project. Firstly, reviews of the literature were conducted to retrieve peculiar ethical challenges in aged care from the perspective of elderly patients and residents, their relatives, and the professionals who assist them in different settings (Pennestrì et al. 2022b; Giannetta et al. 2021a, b; Pennestrì 2021). Secondly, a group of voluntary health- and social-care professionals were recruited from a big teaching and research hospital and two nursing homes in the region of Lombardy, where ageing is particularly pronounced and community care professionals are being introduced to improve care pathways for elderly and chronic patients (Pennestrì 2021). This group took part in quantitative and qualitative surveys to investigate a) relevant correlations between professional characteristics, workplace characteristics, and exposure to moral distress episodes (quantitative survey) (Giannetta, et al. 2021a, b); b) in more depth, the way these professionals experienced moral distress, how they critically assessed the specific situation, and how they try to cope and manage the psychophysical residues they eventually felt (qualitative survey) (Villa et al. 2021). Among them, thirdly, a smaller group of voluntary participants representative of all the types of health- and social-care professionals involved in the project took part in a training session designed for their specific experiences.

The intervention was divided in two sessions. In the morning session, part one, participants were introduced to the ethical challenges most frequently associated with aged care by the literature. Then, participants were given back the results of the quantitative and qualitative surveys they previously took part in, after individual consent was given and anonymity ensured. The main goal of this session was to focus on common problems and needs, avoid interprofessional bias, ageism, or individual self-blame, and adopt a growth mindset to promote a critical exchange of ideas, preparing ground for the afternoon discussion.

In the afternoon session, interactive exercises were conducted by nursing ethics, medical ethics, and moral philosophy experts to stimulate the reflection of participants, help them identify values behind different courses of action, and train their ability to handle them on a daily basis. Building on the simulation of real cases drawn from the experience of two participants, the group had to walk in the shoes of the people involved in these episodes (colleague, patient, team, administration, patient’s relatives), work on the ability to share their opinions, discuss with the team, and take final decisions under non-ideal circumstances.

Teaching materials were drawn from the literature in support of both sessions. Seven of the ten tools included in the Toolbox of teaching strategies in nursing education (“concept mapping,” “game,” “role playing,” “case study,” “debate,” “online”) (Xu 2016) and two of the Moral Games for Teaching Bioethics (the “health journey” and the “hot seat”) (Macer 2008) have been adapted according to the context and the experience of educators. The training session was performed remotely in order to comply with the safety measures necessitated by the COVID-19 pandemic, which particularly affected the area where the research was performed. More details are represented in table 1.

Table 1 Training session programme

Team Composition and Round Preparation

The research team was composed of two full professors in philosophy with background in moral philosophy, bioethics, and nursing ethics; one full professor in general nursing and nursing theory; one associate professor in nursing science; one researcher with a PhD in philosophy and mind sciences and a background in medical humanities, bioethics, and health- and social-care policy; and one researcher with a PhD in nursing and public health and a background in nursing ethics and research methodology.

The team learnt from the literature on ethics intervention in care organizations that

  • raising awareness and developing a climate of dialogue may help the professionals cope with the mundane moral issues in elderly care (Dauwerse, van der Dam, and Abma 2012);

  • participants give high value to teamwork education supported by professionals who facilitate learning opportunities, reflection, and debriefing (Eddy, Jordan, and Stephenson 2016);

  • local-driven methodologies are the rule, when providing education within a certain context, in comparison to standardized methodologies (Stolt et al. 2018);

  • ethical support in elderly care works better when a) the group is composed of different operators rather than a single type of professional audience; b) “ethics and values become a part of what every person does every day rather than being present only in formal ethics decisions” (van der Dam, Molevijk, and Widdershoven 2014);

  • such a type of ethical support can be part of a programme of organizational quality improvement (van der Dam, Molevijk, and Widdershoven 2014).

The research team tried to capitalize on this information to design the contents and methods of the intervention, and each member took part in the round preparation. Each professional received an electronic brochure before the intervention from the impersonal email account of the research project, in which the training programme and main goals were described. The ethical training was approved by each competent ethical committee. The data represented here are anonymous.

Participants and Research Context

Twenty participants took part of the training session (table 2).

Table 2 Training session participants

The training intervention took place on June 18, 2021, virtually, on Microsoft Teams platform. The intervention took a total of eight hours, including two breaks and a final hour to administer and collect the questionnaires.

Assessment

Ten questions were administered at the end of the training to investigate the participants’ experience. All the questions were written in Italian and administered through a Google Forms link.

  1. 1.

    How useful did you find the ethical round in order to train your strategic reflection skills? [On a 0–10 scale].

  2. 2.

    Did you find the contents useful to your daily practice? [On a 0–4 scale].

  3. 3.

    Do you have more educational needs in relation to the topic? [Yes/No].

  4. 4.

    If so, which ones?

  5. 5.

    How did you find the training methodology and the teaching materials? [On a 0–4 scale].

  6. 6.

    Is the total length of the course consistent with the training goals? [On a 0–4 scale].

  7. 7.

    Was the platform on which the training was performed adequate to the same objectives? [On a 0–4 scale].

  8. 8.

    Can you describe a positive aspect of the training experience? Can you describe a second one?

  9. 9.

    Can you describe a negative aspect of the training experience? Can you describe a second one?

  10. 10.

    Can you provide a recommendation to improve further training experiences? Can you provide a second one?

The use of differing scales between question 1 and the following numerical rates was due to the former being designed by the authors to get an impression of the pilot intervention effectiveness directly from the participants, while the latter are employed in the assessment of training interventions by healthcare professionals in Italy and were compulsory.

Ethical Considerations

The research did not collect personally identifiable information. Participation was not mandatory. The ethics committee responsible for each single facility approved the intervention.

Results

Utility of the Intervention to the Enhancement of Strategic-Reflection Skills

All the participants answered the first question (Fig. 1).

Fig. 1
figure 1

Utility of the ethical round in order to train strategic and reflection skills

The utility of the ethical round for the enhancement of strategic-reflection skills was rated with the maximum score of ten by 57 per cent (12) of the participants; 19 per cent (4) rated with the score of nine; 24 per cent (5) with the score of eight. One participant answered twice. Although it was impossible to identify his/her answer, the redundant score was among the top three.

Utility of the Intervention in Daily Practice

Seventeen participants answered the questionnaire from the second question onwards (Fig. 2).

Fig. 2
figure 2

Utility of contents to daily practice

47 per cent (8) of the participants rated the ethical round utility for daily practice with the maximum score of four; 47 per cent (8) with the score of three; 6 per cent (1) with the score of two (Fig. 3).

Need for More Education on the Topic

Fig. 3
figure 3

Need for more education on the topic

59 per cent (10) of the participants declared that they perceived no need of further education on the topic, while 41 per cent (7) declared that they perceived a need (Fig. 4).

Fig. 4
figure 4

Training methodology and teaching materials

Further Educational Needs Perceived

The seven participants who declared they perceived further educational needs were asked to mention them explicitly (table 3).

Table 3 Further educational needs perceived.

Training Methodology and Teaching Materials

66 per cent (11) of the participants rated the training methodology and the materials employed with the maximum score of four; 28 per cent (5) with the score of three; 6 per cent (1) with the score of two.

Training Length Adequacy (Fig. 5)

Fig. 5
figure 5

Training length adequacy

47 per cent (8) of the participants rated the training length with the maximum score of four; 41 per cent (7) with the score of three; 12 per cent (2) with the score of two.

Platform Adequacy (Fig. 6)

Fig. 6
figure 6

Platform adequacy.

47 per cent (8) of the participants rated training platform adequacy with the maximum score of four; the same percentage rated the platform adequacy with the score of three; 6 per cent (1) rated the platform adequacy with the score of two.

Tips for Improvement (Table 4)

Table 4 Tips for improvement

Further Notes From the Pilot Intervention

In addition to the quantitative results, the researchers collected observations throughout the entire intervention. These notes were useful to provide a more comprehensive assessment of the pilot experience. First of all, there were no technical difficulties in using the internet platform, so the participants were able to take part in the entire meeting. During the morning session, questions from participants were allowed but interaction was not the main focus. However, some participants took initiative and some conflicting views emerged. For instance, one physical therapist with long experience in a nursing home expressed the need to introduce aged-care ethics in undergraduate university courses, as ethical education is often discontinuous with the evolving challenges of the workplace environment: this observation seems highly consistent with the literature mentioned in the introduction; then she expressed surprise about moral distress episodes being more frequent in acute settings (as shown by the quantitative survey). A medical doctor working in residential care replied to offer a potential explanation for what concerns the medical profession: according to her, working as a physician is less demanding in nursing homes than in hospital wards, as residential care requires fewer conflicting choices from a clinical perspective. The highest workload in aged care seems to fall on nurses—working as patients advocates both in clinical and relational terms (spending most of the time with patients administering treatments, listening to their needs, and mediating with doctors) (Pennestrì, et al. 2022a).

During the afternoon session, the experience of the training educator was fundamental in overcoming hesitancy and engaging the participants to take part in the hot-seat exercises. In the first simulation, the main player (hospital physical therapist) easily dropped into the role he was assigned and demonstrated remarkable ease in relinquishing his concerns. He was helped by the facilitator to receive comments by the other participants. In the second simulation, participation from the other professionals was more spontaneous and no more interventions were required from the facilitator; the main player (a hospital nurse) demonstrated equally remarkable ease in releasing her concerns and no researchers had to animate the exercise at all. In the final discussion, after the full professors’ interventions, the remaining time was dedicated to asking the professionals what they thought about the entire training session and the concluding ethical remarks. Most of the professionals who replied found the opportunity to analyse their daily routine with a critical attitude the most valuable part of the intervention. Some of them added that this opportunity should be maintained and repeated over time in order to keep their critical attitude alive while back at their daily routine. A hospital geriatrician concluded by observing how the training session was “liberating and heartening,” as professionals are generally left alone when dealing with their work-related emotional residues and concerns.

Although live interaction can be more satisfying when dealing with such topics, the training session demonstrated the feasibility of conducting interactions remotely under exceptional circumstances.

Discussion

Improving the care of patients requires improving care of the providers (Bodenheimer and Sinsky 2014). Our research supports the potential of bioethics in helping the professionals face common but demanding moral dilemmas arising in the caring routine (Saarnio et al. 2012; Bolmsjö, Sandman, and Andersson 2006), offering some evidence of usefulness from those directly involved. A less-stressed worker is a person who has developed a certain agility in moving through real-world difficulties thanks to a well-developed ability to recognize values and dilemmas, balance conflicting priorities and interests, and increase control over demanding situations, rather than feeling controlled and frustrated by them. Applied ethics should make a difference in real-world settings, enhancing the ability to take consistent decisions, accept non-ideal circumstances, identify room for corrections, and ultimately improve the well-being of “everyone involved, including patients.” This ability can turn workplace difficulties into professional and human growth opportunities, and this is why moral distress can be given a positive value (Tigard 2019).

For this purpose, it is fundamental to exercise critical thinking and learn to communicate properly (Profetto-Mc Grath 2005; Macer 2008), but these soft skills are rarely introduced to students before they work, and even more rarely are they introduced and/or enhanced after students commence their professional careers. Group frameworks and individual algorithms have been suggested by the literature to support well-founded moral decisions, both for nurses in all settings (Crisham, 1985) and different health- and social-care professionals taking care of the elderly in different settings (Van der Dam et al. 2014). Indeed, acting on conscious principles is associated with reduced moral stress, improved team cooperation (van der Dam, Molevijk, and Widdershoven 2014), increased confidence, and individual accountability (Lasala, 2009).

The combination of a critical attitude and a growth mindset can promote great improvements in the management of chronic ethical challenges, when time to reflect and plan is available and when extended cooperation is provided (including patients or residents, colleagues, relatives, and managers), to manage care goals may changing over time. Learning to identify values behind actions is therefore a fundamental bioethical skill for managing non-ideal chronic situations, as it helps in breaking down complexity, comparing the benefits and risks of each decision, and improving consistency at the individual and team level (Goethals, Dierckx de Casterlé, and Gastmans 2013; Macer, 2008).

Walking a day in colleagues’ shoes can help one adopt a comprehensive perspective on an issue, understanding the relevance of problems that were previously underrated or solving one’s own working issues by asking for help from the right person with the right words and/or using other competences and point of view; in other words, to align efforts and improve cooperation. Indeed, the participants appreciated the opportunity to engage with different professionals about real case reports and frequently asked for more exercises of this type.

Consistency with the ethical round method—starting from daily experience and analysing it in the light of values and principles rather than starting from values and principles before introducing real-life experience—may have helped the professionals maintain focus and grasp the practical dimension of principles and values. Once the participants gained confidence with ethical values based on real work experience, they seemed more prone to consider them as inner tools to enhance practice (something to take advantage from) rather than as external moralistic bans on their actions and behaviour. The quest for more practical cases, more interactive discussion, and more time to discuss these topics can be interpreted as a consequence of this changed perspective. Ethical education provides these opportunities, although there is no privileged moral theory in this respect: the goal is enhancing the ability to make consistent decisions based on values and principles that the professionals already have. What the participants were doing was exercising their own ethical abilities, refining them through the use of arguments and principles, and elaborating their personal ability to face hard situations with more competence and less stress.

Though all the participants found the training session useful in enhancing their reflective and strategic skills, two of them considered it of little practice at work. There may be room for improvement in this regard. If those participants did not catch a clear connection between values and real-work challenges, this part of the training can be enhanced with more time for case reports and philosophical analysis. If those participants expected more focus on the problems of their single profession, our goals may need to be explained more clearly—a single-profession view was not the aim of the pilot experimentation, which rather provided a consequence-free opportunity for inter-professional and inter-facility engagement through a limited number of participants. The literature supports that such a limitation can help moral deliberation in the case of elderly patients’ ethical issues (van der Dam, Molevijk, and Widdershoven 2014), and moral deliberation can help solve these issues better than formal meetings and pronouncements (Dauwerse, van der Dam, and Abma 2012).

The training methodology was considered adequate by all the participants, though nearly half recommended repeating the training face-to-face. This is something that the authors took into consideration. Granted the impossibility of delivering the training face-to-face, the virtual platform and tools to provide the intervention and administer the questionnaires were considered adequate from all the participants. Therefore, the COVID-19 outbreak provided the context for a natural (though tragic) experiment to verify the extent to which this type of education can be provided under this type of constraint.

At the same time, we deliberatively chose not to explore COVID-19 as a specific determinant of moral issues among workers, as one of the participants recommended we do. First of all, the study was designed before the outbreak of the COVID-19 pandemic. Second, this variable was explicitly excluded in the empirical survey which provided background for the ethics round, in order to avoid potential biases. Taken these precautions for granted, it is reasonable to assume that delivering such an intervention during the COVID-19 pandemic could have interfered to some degree in the experience of participants.

Limitations

This paper is characterized by three main limitations:

  1. 1.

    Lack of follow-up or before-after intervention assessment.

  2. 2.

    Quantitative rather than qualitative assessment of the intervention given the limited number of participants involved.

  3. 3.

    Use of a national standard survey as a primary assessment tool.

Testing the training effectiveness before and after intervention could evaluate the benefits perceived by the healthcare professionals in terms of better team cooperation, better interprofessional and professional–patient communication, enhanced moral distress prevention, and reduced burnout rates: overall, improved control over ethically demanding situations. Such methodology would certainly add scientific value to the present paper. Lack of comparisons is consistent with most of the current literature on educational trainings in healthcare, and specific indicators to measure the effectiveness of educational training are encouraged by the literature (Stolt et al. 2018; West et al. 2016; Eddy, Jordan, and Stephenson 2016). This gap is gradually being filled by comparative studies employing small numbers of elderly patients as intervention effectiveness proxies, both in terms of symptoms, functional outcomes, and individual responses (Bökberg et al. 2019; Moreira et al. 2018). However, the lack of a control group and using patients as proxies still prevents a rigorous scientific assessment of the benefits provided by the intervention. Indeed, it’s hard to measure the effectiveness of ethical training sessions delivered to larger numbers of healthcare participants, even more when interactive simulation and debate are recommended from multimethod educational approaches (Royse and Newton 2007).

The authors question if education can be measured with the same approach employed to measure the effectiveness of hard technical skills, focusing on the variation of biomarkers and physical function in the short and medium term. This is a limitation recognized also by authors introducing a before-after assessment of educational interventions in this field (Moreira et al. 2018). Rather, a more realistic goal is to stimulate awareness and wait for the soft skills to prove beneficial in unexpected contingencies. We are not meaning that benefits can’t be measured at all. Training benefits could be assessed indirectly by investigating the well-being of health- and social-care professionals in specific circumstances within their job, on the one hand introducing some degree of professional-reported experience measurements including different domains and subdomains, similarly to the collection of Patient-Reported Experience measurements (PREMs), on the other hand employing these indicators to analyse the ethical and organizational challenges in validated procedures of Health Technology Assessment (Vanni et al. 2020).

The primary goal of the research project was to design a multimethod pilot intervention to help professionals cope with the ethical challenges associated with aged care in different settings, testing the impressions of a representative sample of all the type of professionals working in different aged-care settings, and contributing to fill the educational gaps raised by the literature. Therefore, time for a quantitative follow-up or repeated qualitative interviews was not available. The authors have considered both the hypotheses for a research project follow-up.

Conclusion

Moral issues can hardly be removed in a context characterized by increasing care demand and decreasing human and financial resources, but they can be recognized and addressed with common efforts, a critical attitude, and a growth mindset. Enhancing these skills in qualified workers can help them accept the reality of work, release pressure, focus on room for improvement, and identify common goals to reach with the team. Introducing these skills before graduation can help the future health- and social-care professionals reduce unreal expectations and decrease frustration and subsequent early retirement rates.

The participants’ recommendations for improvement can be met by dedicating more time to case reports and more time to discussion and extending the number of training sessions. Ethical rounds can be performed during exceptional circumstances such as COVID-19 too, provided the adoption of adequate teaching tools.