Upholding Ethical Standards

L&D coordinators, educators, and others involved in learning and teaching practices are facilitators of learning. We use an educational design process and adult learning principles to close or narrow gaps in knowledge, skill, and practice (Harper and Maloney, 2021). A core responsibility of anyone working in this role is to do so ethically, to the highest standard, and according to established evidence-based practices.

Maintaining and Preserving Content Integrity

This article supports anyone working in L&D or education in improving their knowledge of this core concept to ensure their practice maintains the highest standard. We’ll commence by picking apart and defining key terms and finish with some practical tips on how to use this knowledge and the skill of evaluating and maintaining content integrity in your everyday practice.

What is “Content”?

Content is the presentation of information or education. Usually, its purpose is to be delivered to an audience via a certain channel. In healthcare, content may describe an educational or informational activity, resource or initiative. All elements of a piece of content, across any medium, should be created honestly to ensure they are correct, trustworthy, sound and ethical. At Ausmed, this includes all of the following:

• Courses
• Training modules
• Lectures
• Podcasts
• Articles

What is “Integrity”?

A person with integrity knows, says and does the right thing. It describes the “quality of being honest and having strong moral principles.” In nursing, “personal integrity is the core value for providing ethical health care and for making every effort to support a workplace culture that thrives on honesty, accountability, advocacy, and competence.” Ethics are fundamental to nursing practice. Integrity and trust are key components of ethical behaviour because, quite simply, it is ‘doing the right thing’.”

What is “Content Integrity”?

A broad term that relates to all functions undertaken to ensure that an educational activity is fair, balanced, based on the best available evidence, and free of influence.

What Influences Our Decisions?

Maintaining content integrity relies on sound decision-making. So, let’s just pause a moment and consider. What influences your decision-making? Well, lots of factors, really! Some identified factors include:

• Competency
• Current knowledge
• Ethics, morals and values
• Resource availability and reliability
• Risk versus reward
• Timeframe
• Bias

Making the Right Decision

Making the right decision is so critical in nursing that the National Board—the Nursing and Midwifery Board of Australia (NMBA) — created a national framework for the development of decision-making tools for nursing and midwifery practice (Nursing and Midwifery Board of Australia, 2020). It outlines core principles that lay the foundation for the development of any decision-making tool and then templates to assist in the development of such tools.

Defining Key Terms

Let’s investigate “bias” and “conflict of interest” in the context of health and aged care education.

What is “Commercial Interest”?

A commercial interest is ‘any entity (company) producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients or an entity that is owned or controlled by an entity that produces, markets, resells or distributes healthcare goods or services consumed by or used on patients (ANCC, 2023).

What is “Conflict of Interest”?

The potential for conflicts of interest exists when an individual who is in a position to control or influence the content of the educational activity has a relevant (financial) relationship (within the past 12 months) with a commercial interest organisation and the products or services of the commercial interest organisation come into contact with a patient (touch, or are consumed by); and the content of the educational activity is related to the products or services of the commercial interest organisation. Or, it is an entity that advocates for the use of the products or services of commercial interest organisations. Exceptions are made for nonprofit or government organisations and non-healthcare-related companies (ANCC 2023).

What is a “Relevant Relationship”?

Relevant relationships with a commercial interest organisation include:

• Any personal relationship that is currently in effect or has been in effect at any time in the past 12 months.
• This includes relationships that a family member or significant other may have with a commercial interest organisation
• Where the content expert has received a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest. (stock and stock options, excluding diversified mutual funds), grants, contracts or other financial benefits, directly or indirectly, in the work provided.
• An employee of a commercial interest entity cannot plan or present an activity related to the products or services.

What is “Bias”?

Like conflict of interests, bias can “interfere with the presentation of content that is fair and balanced, and based on best available evidence” (Dickerson & Bernard, 2018). Bias refers to a “tendency or inclination to cause partiality, favouritism, or influence” with examples of potential bias including:

• Being the author of a book.
• Being an author of research conducted

(Dickerson & Bernard, 2018).

Evaluating Conflict of Interest (COI)

The following steps are simple and effective in evaluating, mitigating, and managing any conflicts of interest so as to maintain content integrity.

1. Identify Individuals

Identify any individuals who are in a position to control or influence the content of an educational activity:

• If an individual is not able to control or influence the content, no COI exists.
• If an individual is able to control or influence the content, COI exists, and steps must be taken to manage it and disclose it to learners.

2. Evaluate Relationships

Evaluate any relevant financial relationships (within past 12 months) that have been declared with commercial interest organisations:

• If no relevant financial relationship with a commercial interest organisation is present, no resolution is required, and no conflict of interest can be declared to learners.
• If a relevant financial relationship with a commercial interest organisation does exist, but the content of the educational activity does not relate to the organisation's products or services, then no resolution is required, and no conflict of interest can be declared to learners.
• If a relevant financial relationship with a commercial interest organisation does exist and the content of the educational activity relates to the products or services of the commercial interest organisation, a resolution is required.

3. Mitigate COI

Actions taken to mitigate a COI may include but are not limited to:

• Remove the individual from participating in all parts of the educational activity.
• Revise the role of the individual with a COI so the relationship is no longer relevant.
• Do not award contact hours for a portion or all of the activity (if an accredited activity).
• Evaluate and monitor activity for bias prior to and during activity.
• Evaluate and monitor activity for bias prior to and during activity and assess learner feedback for bias after activity.

4. Disclose COI

A COI must be disclosed to learners:

• By the subject matter expert or provider before any learning occurs.
• On any learning material delivered by the subject matter expert or the provider (i.e. on handouts or online).

Maintaining Content Integrity

Disclosure of any COI by an educator, subject matter expert, or education provider is a transparent and safe means of demonstrating that content integrity is a priority and that all efforts are being made to safeguard the integrity of the education.

Even if a COI is identified, we can still preserve content integrity by following the relevant steps mentioned above, particularly disclosing it to learners/staff.

Example of disclosure: No conflicts of interest

“I declare that this learning activity is free of any conflicts of interest, including financial, commercial, institutional or other relationships that might lead to any bias in the content.”

Example of disclosure: Conflict of interest(s) exists

“Before we begin this educational session, I’d also like to add my disclosures in relation to receiving financial remuneration for participating on advisory boards in reviewing education material and providing presentations.”

How Does Content Integrity Apply to L&D?

Maintaining content integrity applies to each of these circumstances. Why? We need to ensure that the person, material, resource or information being delivered to a healthcare worker or clinician (the learner) is safe, reliable and free from bias and any relevant conflicts of interest. We need to have determined (through a systematic process) whether that piece of content has undergone the relevant checks and balances such that we are confident it has ‘integrity’. This applies when:

• Creating resources
• Procuring a supplier of education
• Reviewing a tender document submission
• Engaging a subject matter expert
• Coordinating an in-service
• Facilitating a product demonstration from an external vendor/supplier

Practical Tips

• Wherever possible, use generic or non-proprietary names of medications or products.
• Know your scope.
• Know when to outsource - for example, you do not have a clinical background, so know when you need to use someone in your team or organisation who does.
• Be okay with answering with, “I don’t know, but I can find out.”
• Have a list of sources where you can find information.
• Remember that thinking is not knowing.
• Most importantly, identify breaches in content integrity and then take action.

References

• American Nurses Credentialing Center 2023, 2015 Primary Accreditation Provider Application Manual, 2023 edn, Maryland, American Nurses Association.
• Dickerson P & Bernard A 2018, ‘What's in a Word? Understanding Terms in Continuing Nursing Education and Professional Development’, J Contin Educ Nurs. vol. 49, no. 1, pp. 19-25, viewed 26 August 2024, https://pubmed.ncbi.nlm.nih.gov/29384584/
• The Nursing and Midwifery Board of Australia 2020, Decision-making Framework (DMF), Ahpra, viewed 26 August 2024, https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Frameworks.aspx
• Harper, M & Maloney, P (eds.) 2021, Nursing Professional Development: Scope and Standards of Practice, 4th edn, Association for Nursing Professional Development, viewed 26 August 2024.

Author

Zoe Youl 

Zoe Youl is a Critical Care Registered Nurse with over ten years of experience at Ausmed, currently as Head of Community. With expertise in critical care nursing, clinical governance, education and nursing professional development, she has built an in-depth understanding of the educational and regulatory needs of the Australian healthcare sector.

As the Accredited Provider Program Director (AP-PD) of the Ausmed Education Learning Centre, she maintains and applies accreditation frameworks in software and education. In 2024, Zoe lead the Ausmed Education Learning Centre to achieve Accreditation with Distinction for the fourth consecutive cycle with the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation. The AELC is the only Australian provider of nursing continuing professional development to receive this prestigious recognition.

Zoe holds a Master's in Nursing Management and Leadership, and her professional interests focus on evaluating the translation of continuing professional development into practice to improve learner and healthcare consumer outcomes. From 2019-2022, Zoe provided an international perspective to the workgroup established to publish the fourth edition of Nursing Professional Development Scope & Standards of Practice. Zoe was invited to be a peer reviewer for the 6th edition of the Core Curriculum for Nursing Professional Development.