Table 5 Enabling factors and barriers to ethics training programs

Enabling factors

Elaboration

References

 Safe environment

A non-judgemental, safe space inspires reflection, sharing and peer-learning.

Having instructors who are close in age may allow for more open, honest discussions that promote ethical understanding due to the lack of hierarchy.

[51, 55, 59, 75, 77, 103–110]

 Strong role modelling

Good role models who demonstrate ethical behaviour and good professional conduct consistently at work promote the success of ethics training.

[84]

 Clear learning objectives

Clear objectives guide learning and assessment.

[50–52, 86]

 Allow for preparatory work

Students should be given learning materials early.

[75]

 Reflective practice

This refers to good attitudes on the part of the student to engage in reflection, such as through the use of narratives.

[47, 56]

 Practice-oriented

The programs should also be practice-oriented and relevant to doctors, such as by highlighting ethical issues faced in real life.

[51, 52, 82, 111]

 Training programs for teachers

This includes teacher workshops to assist teachers in developing curricula and acquiring appropriate and relevant teaching skills.

[70]

 Devoted educational or health institute, manpower and resources

This may include dedicated ethics experts responsible for teaching, and expert input in the design of curricula.

[64, 70, 79]

Barriers

Elaboration

References

 Poor role models

This may include a culture of bullying and other unethical behaviour exhibited by negative role models.

[61]

 Lack of structured curricula

This may lead to important topics not being identified or covered.

This could also be due to curricular crowding leading to sacrifices in the ethics curriculum.

[79, 80, 112]

 Lack of time and/or opportunity for formal ethics and professionalism instruction

Lack of time was identified as a key limitation for tutors to provide teaching and for students to attend such teaching due to competing demands.

[52, 55, 59, 60, 73, 79, 83, 96–98]

 Difficulties in adapting and improving curricula in response to increased sensitivity to ethical concerns

This may lead to outdated curricula.

[103,113]

 Lack of an agreed framework that ethics curricula can be designed from and adapted to local settings

This may thus lead to difficulty in adapting curricula to be relevant to the unique ethics situations in different hospitals or different specialties.

[62, 81]

 Unsupportive institutional culture towards ethics teaching

This may result in having unwilling, underprepared, undertrained teachers

[51, 79, 87, 96–98, 103, 114]

 Poor attitude and resistance to learning

This refers to students who do not seek to improve or are unwilling to be open to ethical discussions or challenge their current understandings and perceptions.

[51, 83, 97, 98]