Ethics education in nursing

Jenny Song About the author: Jenny Song, RN, PGDipNsg, MEd, is a senior nurse educator in the bachelor of nursing programme, Waikato Institute of Technology (Wintec), Hamilton, New Zealand. Her correspondence address is [email protected] This article was accepted for publication in July 2018.	ABSTRACT Aim: The aim of this research was to explore the experiences of a group of nurse educators responsible for teaching ethics to undergraduate nursing students, and to discuss the ethical challenges they encountered in their classroom practice. Background: Nurses face ethical issues daily in practice and, because of the growing complexity of nursing, there have been calls internationally to strengthen the teaching of ethics to nursing students. The growing literature on moral distress experienced by practising nurses suggests that nursing educators are facing greater challenges teaching ethics in undergraduate nursing programmes. Methods: A case study approach was used to explore the experiences of seven nursing educators working at a large tertiary institution. The participants were interviewed to ascertain their experiences of teaching ethics to nursing students, and to explore challenges they faced and how best these challenges could be overcome. Findings: The participants agreed there was a need to have ethics taught throughout the whole undergraduate nursing curriculum. One of the major challenges they identified in teaching a culturally diverse student body was the dominance of the Western philosophy of individualism embedded in New Zealand nursing’s Code of Ethics. Despite such hurdles, the nurse educators in this study were confident teachers who all had positive experiences teaching ethics to students. Conclusion: The participants in this study agreed that ethics education needed to be embedded throughout all nursing courses in their institution. Teaching ethics should not be the responsibility of only some nurse educators – it should be taught across the three years of the programme, by all nurse educators involved in both theory and clinical practice. In addition, all teaching staff needed to recognise the multifaceted issues that influence students’ understanding of ethical issues, and to integrate cultural safety principles into their teaching.
KEYWORDS nursing ethics, undergraduate nursing education, case study, nursing students

INTRODUCTION

NURSING ETHICS IS AN indispensable element of the undergraduate nursing curriculum because developing sound ethical judgement, both within the classroom and in practice, lies at the heart of nursing (Benner, Tanner & Chesla, 2009; Gibbons & Jeschke, 2016; Yeom, Ahn & Kim, 2017). Although the significance and centrality of ethics in nursing education has consistently been acknowledged, there is little evidence to suggest that newly-trained nurses are any better at making sound ethical decisions in their practice now than were their historic counterparts (Woods, 2005). What is clear is that nurses now face greater ethical challenges than they did in the past – an increasing number of studies in the field of nursing ethics have confirmed that nurses today suffer from “moral distress” as a result of conflicting demands made of them within today’s complex health-care settings (Burston & Tuckett, 2013; de Casterlé, Izumi, Godfrey, & Denhaerynck, 2008; Jameton, 2013; Woods, Rodgers, Towers, & La Grow, 2015).

Given these difficulties, the purpose of this research was to shift the focus of inquiry to nurse educators; that is, to identify and explore what experiences and challenges nurse educators have encountered teaching nursing ethics to nursing students in a tertiary education environment. The research question posed was: What are the experiences and challenges of nurse educators in teaching nursing ethics to undergraduate nursing students?

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LITERATURE REVIEW

A review of a range of national and international empirical studies of nurses’ experiences in their practice found that nurses frequently experienced ethical challenges in situations such as where they were unable to provide all the care patients needed (Cameron, Schaffer & Park, 2001; Park, 2009). Ethical conflict, and the resulting moral distress caused by having to make moral compromises, have become a growing area of international research (Jameton, 2013; Ulrich et al, 2010; Woods et al, 2015). This is why “ethics education” in nursing has received increasing attention.

Studies have consistently concluded that ethics education has a significant impact on the development of nursing students’ moral sensitivity and moral judgement skills (Grady et al, 2008; Numminen, van der Arend, & Leino-Kilpi, 2009; Park, Kjervik, Crandell, & Oermann, 2012). As health-care ethicist Professor Megan-Jane Johnstone has argued, there is now a much greater need for equipping nursing students with a solid foundation for ethical decision-making, because of what she sees as “contexts where the health security of people is being threatened by ideologically driven public policy” (Johnstone, 2017, p19). Comprehensive health-care programmes around the world are under attack from budget cutting, so it is vital to explore what student nurses are taught about ethics, and how they are taught it, to enable them to deal with the consequent pressures on their practice (Johnstone, 2017).

Research on the challenges involved in teaching nursing ethics has documented three key components for greater student success: a well-balanced combination of theory and practice (case studies, or personal narratives, to illustrate theory); pragmatic considerations, such as the time devoted to teaching and learning; and the degree to which ethical issues are embedded in the overall curriculum (Cannaerts, Gastmans & Casterlé, 2014; Numminen et al, 2009; Parsons, Barker & Armstrong, 2001). In light of nursing education’s growing reliance on internet resources, more recent researchers have explored the best manner in which ethical issues should be taught – whether online, face-to-face, or in combination (Trobec & Starcic, 2015; Yang, Chang, Clark, & Chao, 2017). In some studies, educators felt they faced greater challenges due to a lack of teaching resources (Solum, Maluwa, Tveit, & Severinsson, 2016). Other research has found the educator’s level of experience and training contributes to the quality of ethics training (Dekker-Groen, van der Schaaf, & Stokking, 2011).

In terms of theoretical approaches to teaching ethics, Russell (2014) contends that virtue ethics can shape the values of students to align with the values of the nursing profession, using theory-based strategies. Benner, Sutphen, Leonard and Day (2010) have argued that more clinical practice observations are needed in nursing education to help nurses bridge the theory-practice divide, especially in relation to ethical practice. The problems encountered by nurses in their practice can be traced back to the principle-based way ethics is sometimes addressed in nursing education and “contained” within narrow boundaries of rationality (Benner et al, 2009). According to Rubin (2009), qualitative and ethical distinctions in nursing practice are impeded by a narrowly constructed rational approach adopted by many nurses, regardless of the nature of various clinical problems. They have become “stuck in an unchanged form of practice”, which contributes to what Rubin (p174) calls “ethical blindness”.

Regarding the essential content of ethics in undergraduate nursing education, Corley (2002) and others (Doane, 2002; Johnstone, 2017; Parsons et al, 2001) have argued that a principled approach to teaching nursing ethics can lead to a justification of unwise nursing actions, rather than to the development of sound ethical judgements. Nursing students are taught to think dogmatically about ethical principles and, as a result, cannot easily negotiate their way through the complex ethical situations they meet in their everyday practice (Benner et al, 2009; Johnstone, 2017). For example, Görgülü and Dinç (2007) examined students’ reaction to ethics courses in Turkish nursing education programmes and noted that ethics courses were teacher-led and principle-based, with students having limited opportunity to contribute meaningfully to the course.

Much literature has argued that new ethical issues emerge because of changing socioeconomic and cultural contexts, such as advances in medical technologies, improved information technology, and the emergence of multicultural societies (Epstein & Turner, 2015; Gibbons & Jeschke, 2016; Harding, 2013; Heikkinen et al, 2006; Numminen, Leino-Kilpi, van der Arend, & Katajisto, 2010; Sellman, 2011). Some changes in nursing philosophy and the culture of nursing – such as shifting from a disease-centred approach to a focus on patient-centred care – reflect an ethical shift from treating people as passive consumers of health-care services towards establishing a respectful and equal relationship with clients (Cribb, 2013). Ironically, this change of emphasis brings more complex ethical challenges for nurses in practice.

Studies conducted in New Zealand have shown that moral distress among nurses is an issue of great concern, requiring more attention from nursing educators in course programmes. Woods et al (2015) conducted a national survey and found high levels of ethical conflict a reality across all settings. This conclusion was confirmed by Sinclair, Papps and Marshall (2016), who argued that nursing students in New Zealand faced significant ethical issues, such as suspected neglect of patients and unsafe nursing practice environments.

Cultural safety has been widely practised in health services in New Zealand, focusing on promoting positive changes to the health status of indigenous Māori (Nguyen, 2008). The concept of cultural safety has become a key issue in all ethics courses, in response to a rapidly growing bicultural and multicultural society. Woods (2010) suggests that a greater emphasis on cultural safety in ethics education will ensure nurses are competent in providing culturally-safe nursing practice. Because ethical values in nursing are shaped by sociocultural contexts (Johnstone, 2016), nurse educators need to critically examine the content of undergraduate nursing curricula and extend cultural safety into their teaching (Harding, 2013; Richardson, Yarwood, & Richardson, 2017; Woods, 2010).

These arguments beg the question as to the quality of the nursing ethics programmes being offered. This was the reason for conducting this case study, to determine what issues nursing educators in a large tertiary institution in New Zealand considered difficult in teaching ethics and how they negotiated such issues. Given the prominence in the literature of the problematic nature of teaching narrowly to principle-based codes, questions were prepared to find out the educators’ experiences of teaching the New Zealand Nurses Organisation Code of Ethics (NZNO, 2010).

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METHODS

This study was conducted as a qualitative analysis, using a case study approach. As Stake (2005) suggests, a case is studied to facilitate insight into an issue by scrutinising the case’s contexts and detailed activities. Following ethics approval from Waikato University’s Faculty of Education research ethics committee, an information sheet for participants was sent to all nursing lecturers (n=22) at a selected tertiary institution. All nursing lecturers who have been involved in teaching nursing ethics at this institution became potential participants. A self-selecting sample of seven nursing educators was recruited and interviewed. All participants were female, and each had more than 20 years’ working experience as a registered nurse (RN) and more than five years’ teaching nursing.
 
Semi-structured interviews with open-ended questions were used to collect data. Five descriptive themes emerged through use of interpretive thematic data analysis. Pseudonyms were used to protect the identity of participants. 

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FINDINGS

This study was devised to explore nursing educators’ experiences of teaching ethics, looking especially at the difficulties they had encountered in their teaching. Key concepts and ideas from the interviews were compared and contrasted, using thematic analysis, to identify patterns. The results revealed that nurse educators experienced multifaceted challenges. Five themes emerged. First, every participant agreed how vital it was to teach nursing ethics in the nursing programme. Second, all seven respondents voiced their concern about using a principle-based approach to teach nursing ethics. They all challenged the Western principles embedded in the Code of Ethics, the premise of universality inherent in it and its blindness to cultural difference. Third, each participant acknowledged how difficult it was to teach ethics in a changing nursing context. The points they raised related to the multicultural nature of society and the need for continuous professional development. Fourth, the participants reiterated that ethics was fundamental to nursing practice and could not be treated simply as content confined to a single course. The final theme that emerged was the insistence that encouraging and supporting students to examine their own values and beliefs through reflection on personal experience was the starting point in bridging the divide between the theory of ethical conduct and the reality of practice.

Ethics as the core of nursing

The participants saw nursing ethics as the corner-stone of the nursing profession. Through contemplation of their professional responsibilities, students started to understand who they were, how they fitted into the society, and how they acted as professional nurses. One participant, Frances, insisted that, “as students become educated nursing professionals, it is essential [to teach ethics] in terms of the professional requirement of understanding what professional ethical nursing is”. One example was the use of social media. Adele pointed out that social media – such as Facebook, Twitter and YouTube – were popular among nursing students and it was important they were aware of their professional responsibilities when using these platforms.

Code of Ethics necessary, but not sufficient

All participants believed the Code of Ethics (NZNO, 2010) was not a sufficient framework for teaching nursing ethics. Although it provided principles for nurses to guide their practice, all the respondents reflected on the limitations of using a principled approach to teaching ethics. The participants gave a variety of reasons for their views.

Frances described the challenges of teaching ethical principles in terms of their ambiguity.“…[I]f you look at the principle of ‘doing no harm’, it says you will not do future harm. So it means, doing no harm and any future harm. It is quite challenging in terms of what is the intention versus what is the outcome.”

The participants agreed that principle-based ethics needed to be used with caution, because the universality of ethical principles was problematic. Amy argued that all kinds of cultural factors affected people’s understanding of ethical issues and, therefore, culturally safe nursing practice must be promoted and included in ethics education. She gave an example of the principle of confidentiality from a Māori perspective: “We may feel that we breach confidentiality by discussing patients’ information with family members, but for some patients we are caring for, this is what they would like us to do.”

The participants all noted that the principles of nursing ethics consisted of values and beliefs that could differ from the students’ own cultural norms. Tensions would arise if nurse educators did not help students understand these dynamics. For all participants, cultural safety issues formed an important component of nursing ethics and needed to be addressed in ethics education.

Rapid social change

Participants shared concerns that there was the potential for ethical conflict to arise because of advances in technological capability to treat illness. They considered that the difficulty in teaching ethics lay in the changing nature of the world. Cathy commented that ever-changing health-care environments and “particularly the change of cultural and social parameters . . . affect nursing students’ understanding as well as teachers’ own understanding of ethics”.

The participants noted the multicultural nature of New Zealand society. Amy suggested “adding cultural safety to the code might be appropriate, as society is changing and nursing is changing”. Daisy went further and suggested RNs might need to regularly update their clinical practice to maintain ethical competence.

The need to embed ethics in all course offerings

Participants emphasised the importance of embedding ethics across the nursing curriculum. Cathy said it was important to introduce ethics alongside other nursing topics, such as the professional self, dementia, the power of attorney, professional boundaries, nursing care plans and therapeutic communication. Ray, a senior nursing educator, said ethics “. . . needed to be woven throughout the whole nursing programme”.

The participants all shared the concern that teaching ethics to first-year students could be challenging because of the absence of any practice experience. As Adele noted, most first-year students had a limited grasp of the complexities of a nursing workplace. Cathy added, “ . . . ethics is a contextual topic. So, understanding ethics in nursing practice may not be the same as in other practice situations”. The consensus was that story-telling was essential in teaching ethics, because narratives provided the context in which ethical practice happened and made the abstract “real”.

Bridging the divide between theory and practice

Offered narratives of varying levels of complexity, students were better able to understand the contexts and attributes of situations they would meet. Such scenarios were a way to bridge the theory/practice divide. As Adele stressed, it was the best way to convey important ethical lessons to those who did not have many clinical experiences. Molly commented that ethics education in nursing had to be practical for students, so they could convert their theoretical knowledge into practical skills.

The participants also stressed the crucial role ethical concepts and ideas played in the development of the students’ “professional self”. All participants saw “reflection on action” as key in learning ethics; they underscored the value of self-reflection as a transformational process, either using reflective writing, or group discussion.

All participants agreed that ethics education in undergraduate nursing programmes needed to be taught by nurses with extensive practical experience, rather than by experts who could teach ethical principles, but not from a nursing perspective. They said it was exciting to see students having good, robust discussions on ethical issues – such as end-of-life care and whether to treat or not to treat patients – in class and during clinical debriefings. All participants in this study were confident in their ability to teach ethics from a nursing perspective.

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DISCUSSION

The nurse educators felt passionately about ethics as a topic and also felt a strong sense of responsibility towards students’ achievement. They all recognised the significance and relevance of the Code of Ethics (New Zealand Nurses Organisation, 2010) as a guide for nursing practice. This finding was consistent with research that suggests codes endorse professional responsibilities and function as a guide for conduct (Benjamin & Curtis, 2010; Butts & Rich, 2008; Jansen & Roodbol, 2014).

Importantly, however, what this study has shown is that although a code of ethics is a necessary reference in a nursing programme, it is not sufficient for teaching nursing ethics; although it provides principles for nurses to guide their practice, its universalistic perspective cannot be justified in our contextually variable world. Codes of ethics posit a view that an ideal nurse is one who can freely exercise choice in the light of universal ethical principles, such as autonomy, beneficence and non-maleficence (Heikkinen et al, 2006; Pattison, 2001). However, principle-based ethics need to be used with caution – codes of ethics present these principles as universal, when in fact they are based on Western attitudes and may be at odds with the beliefs and preferences of nurses and patients of other cultures.

Parsons et al (2001) and others (Corley, 2002; Benner et al, 2009) have argued that nurse educators need to pay attention to everyday ethical comportment and recognise the importance of fostering students’ analytical skills in developing their capacity as moral agents. Harding (2013) suggests the globalisation of nursing education has led to Western values being embedded in nursing curricula. For example, the values of informed consent and advance directives are based on the culturally constructed value of individualism. Harding says the cultural context in which ethics are constructed is important, and argues that the ideology of individualism places the individual as the fundamental unit in most Western countries, while the family or community is placed at the centre in Māori and Pacific cultures and in countries such as China and Japan. As a result, the values of minority groups in New Zealand such as Māori and Pacific people may be overlooked.

Likewise, because the dominant international language in most professional and academic interactions is English, the values of both English and American cultures have influenced nursing education worldwide. Nurse educators must be aware that culturally constructed ethical values are not universal values, but are hegemonic cultural norms, reflecting a predominantly European worldview (Harding, 2013). Within health literature, the importance of culturally safe practice has been widely addressed, emphasising that cultural awareness, cultural sensitivity and cultural competence are keys to ensure culturally safe care (Arieli, Friedman, & Hirschfeld, 2012; Oda & Rameka, 2012).

Given that most nursing students will have had no or limited clinical experience, there is a consensus that nursing educators need to offer more narrative approaches to help students understand the contextual features and attributes of situations they will meet. Sullivan and Benner (2005) argue that ethical nursing identity is initially fostered in the academic setting and that the classroom often represents the professional world for students. Although it is desirable for students to act consistently with ideals, moral development is a dynamic process, and students will live in a state of uncertainty when dealing with ethical conflict in their practice (Russell, 2014). The role of educators is to help students navigate through this uncertainty and to create opportunities for them to understand the uncertainty as part of their moral action (Doane, 2002). Approaches to teaching should therefore emphasise deep understanding through reasoning and critical thinking (Doane, 2002).

Vanlaere and Gastmans (2007) also emphasise the importance of self-reflection, asserting that a positive outcome of teaching is the transformation of the learner from a passive recipient of others’ thoughts to an active constructor of meaning through reflective activities and critical thinking. The development of professional ethical identity requires the student to integrate classroom teaching into clinical practice, as well as develop cognitive capacities and critical thinking skills to address the inescapable moral elements underlying all nursing practice (Benner et al, 2010).

All the participants mentioned they were confident in their teaching of ethics to students. Görgülü and Dinç (2007), however, found most nursing educators were not confident in teaching ethics, indicating many educators lacked confidence in their own knowledge of ethics. Nurse educators in this study, however, had extensive nursing and teaching experience and their confidence came from engaging in post-graduate study about ethics topics, as well as work experience in nursing and teaching fields. Some of the respondents had sat on ethics committees as expert nurses. They all had a great deal of practical knowledge and quite sophisticated reasoning skills. They also voiced strong opinions about respecting human rights and exercising social fairness. In this sense, they were a particularly strong group of ethical leaders in their institution.

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LIMITATIONS

This research was conducted at only one tertiary education institution in New Zealand, with a limited sample of participants, which limits the generalisability of the findings. The convenience sampling method may also have limited generalisability, as the self-selecting participants may have been those who were more confident teaching ethics to nursing students. The small sample size may also not be representative of nurse educators in New Zealand as a whole. That said, qualitative researchers use “cases” to more intimately understand a social phenomenon within a particular historical, cultural and social context – rather than emphasising the generalisability of the findings. What would be fruitful now would be to initiate a larger study to make comparisons among different nursing schools on nursing educators’ views about teaching ethics.

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CONCLUSION

The findings of this research reiterate the importance of promoting undergraduate nursing students’ ethical awareness and the importance of teaching ethics in a nursing programme. Nurse educators in this study expressed their overall confidence in teaching ethics, while acknowledging some difficulties. The challenges of teaching ethics in bicultural and multicultural New Zealand imply there is insufficient emphasis on cultural safety in the NZNO (2010) Code of Ethics. As this study has shown, Western philosophical ideas of individualism embedded in ethical principles are a major challenge in teaching ethics to a culturally diverse student body. As the nurse educators in this study have suggested, although the Code of Ethics is central to teaching ethics, teachers also need to highlight more culturally specific ethical views that genuinely address the interests and aspirations of marginalised cultural groups, such as Māori and Pacific people.

The study findings highlight challenges to teaching ethics in the changing context of nursing, as well as the changing context of the field of ethics itself. Nursing ethics is situated in the real world, which is made up of multi-layered social and cultural elements. This implies that ethics education needs to be relevant to the realities of contemporary nursing practice. It must be taught in a way that bridges the divide between abstract ethical theory and practical experiences – especially given the age range and inexperience of the first-year student body. A narrative approach, with a variety of teaching methods – such as group discussion and reflective writing – may be worth considering. The need to use supportive strategies to scaffold learning and move nursing students towards a deeper understanding of nursing ethics is an important finding of this study.

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RECOMMENDATIONS

The following recommendations arise from this study:

1. Nursing ethics education is best addressed by threading ethical issues throughout the nursing programme, in addition to specific ethics courses.
2. Nursing educators must create a learning environment that better reflects professional nursing practice. A narrative approach to teaching ethics, with a variety of case-based teaching methods, is recommended.
3. Moral development is a dynamic, ongoing process for students and teachers alike. In recognition of this process, nurse educators must use supportive scaffolding strategies to promote students’ critical self-reflection on ethical issues, and to provide a safe learning environment to move students towards a deeper understanding of nursing ethics.
4. Nurse educators must recognise the multifaceted issues that influence students’ understanding of ethical principles and integrate cultural safety principles into nursing ethics.

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ACKNOWLEDGEMENT

I would like to thank Professor Brian Findsen and Dr Deb Hill for guiding my research and taking time to read my writing. My sincere thanks go to the participants for their time and energy.

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