The formation of an ethical framework for practice is an essential aspect of nursing students’ development. Benner and colleagues have examined how nursing, like other professional practice disciplines, addresses and integrates three important elements of education—intellectual (knowledge-based), practical (skills-based), and ethical experiential learning.1 The researchers refer to these, metaphorically, as apprenticeships that are integrated into clinical learning experiences (for example, when students provide care to patients).1 These apprenticeships help to form the basis of professional practice and thus a student's professional identity.
Given the myriad ethical issues and dilemmas that commonly arise in nursing, the ethical component of nursing education is especially important. This article discusses how nursing instructors influence the ethical development of students in the clinical setting.
INTEGRATING ETHICS INTO EDUCATION
In some schools of nursing, ethics is integrated into all courses in the curriculum, whereas others offer a course dedicated to health care ethics. Students learn about the American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements2; ethical theory; and concepts such as autonomy, beneficence, fidelity, nonmaleficence, and justice.3 They're also exposed to the standard ethical views and laws pertaining to specific aspects of health care, such as confidentiality, informed consent, surrogate decision making, and the right to refuse treatment.
Students then learn how to apply theory to specific cases and to use moral reasoning to establish justified ethical stances about what one ought to do. One effective classroom teaching strategy is to actively involve students in the evaluation or analysis of cases, practices, and policies.4 Krautscheid reported using embedded ethical dilemmas in a high-fidelity patient simulation exercise to promote student confidence in ethical decision making.5 This strategy promoted affective and psychomotor learning, and students reported feeling more confident in their ability to advocate for ethical behavior.5 Through these exercises, students gain knowledge of the ethical expectations of health care professionals and begin to develop the skills of moral reasoning and ethical analysis that will help them determine the right thing to do in complex real-life cases. These skills are especially important when laws or policies provide unclear or ambiguous direction or permit discretion. The classroom also offers a safe environment in which students can explore the ethical issues they will face as nurses—without the high-stakes pressure of a clinical encounter.
Creating an ethical framework for practice, however, requires going beyond the traditional boundaries of academic learning. For a professional practice discipline, this type of learning takes place in the clinical environment, where the student responds relationally with empathy and caring to the patient, who is in a vulnerable state. This relationship provides reflective opportunities, during which the student can develop her or his professional identity.
Clinical instructors should provide opportunities appropriate to each student's level of education and training, allowing the student to develop increasingly independent engagement with patients and ethical competency in the clinical setting. For example, the instructor of a new student may explain simple acts—such as following through on a promise to return to a patient's bedside to evaluate the effectiveness of pain medication—in terms of the ethical principle of fidelity. The instructor of a more advanced student might engage the student in conversations about more complex ethical questions, such as, “Should a person with a known history of alcoholism receive a liver transplant before a patient whose liver has been damaged by a natural disease process?”
Erdil and Korkmaz conducted a study of nursing students’ perception of ethical problems in the clinical setting.6 The nursing students described the violation of several ethical principles (primarily due to the unprofessional behavior of physicians and nurses), including respect for autonomy, privacy, and intimacy, as well as the principles of do no harm, beneficence, and justice.6 The investigators concluded that clinical nurse educators can play an essential role in helping students develop an aptitude for ethical understanding.
But what, specifically, is the role of clinical instructors in helping students to develop the ethical component of their training? And, without substantial background and formal training in the field of ethics, how can clinical instructors succeed?
IDENTIFYING ETHICALLY RELEVANT ASPECTS OF CASES
Experienced nurses understand the nature of ethically charged situations—both in terms of the emotions patients are likely to experience and the psychological dynamics that can exist between patients and their loved ones—as well as the implications of different courses of action for patients, families, the public, and the institution. This knowledge is essential when teaching nursing students the reasoning and analysis needed to determine the morally right course of action. A background or training in ethics isn't required (although an ethics background can be of great help in resolving ethical dilemmas in practice). What's needed is practical experience and the kind of emotional intelligence and sensitivity that are hallmark characteristics of excellence in nursing practice.
As students increasingly participate in direct patient care, they'll likely experience challenges to their beliefs about health care practices, systems, and policies.7 McCarthy and Gastmans have described moral distress as “the psychological, emotional and physiological suffering that nurses and other health professionals experience when they act in ways that are inconsistent with deeply held ethical values, principles or commitments.”8 In one study of students who had completed clinical work on acute inpatient psychiatric units, the researchers reported that students experienced substantial moral distress owing to nurses failing to talk meaningfully to patients, the hierarchical power structure of the units (in which physicians were at the top), the withholding of information from patients, and a lack of ethical advocacy among nursing instructors.9
The clinical instructor is vital in helping the student understand the nature of ethically challenging cases—and for putting those cases into appropriate practical and moral contexts.6, 10, 11 Rees and colleagues studied the wide variety of professional and ethical dilemmas experienced by nursing students and concluded that one way clinical instructors can help students better understand and evaluate these negative experiences is by prompting them to reflect on them through written and oral narratives.10 In addition, clinical educators can use postclinical discussions to debrief students about an ethical situation they witnessed during their clinical work. For example, a student might be confused about why family members are permitted to press for life-prolonging treatment for terminally ill or dying patients. Take the case of a patient dying of heart disease who is put on life support following cardiac arrest, after which clinicians discover the patient has an advance directive indicating no aggressive treatment at the end of life. The student might wonder why clinicians, and the hospital, would go along with the family's request for continued treatment when this appears not to be in the patient's best interests—especially, when it's not what the patient wanted.
In this case, the clinical instructor can explain the institutional and practical reasons for providing aggressive care, as well as factors that make going against the family's wishes more ethically complicated than it might at first appear. For example, the instructor can note that overriding the family's wishes may require a court order or otherwise result in litigation. This could present serious negative publicity for the facility and thus be to the detriment of patients in the long term. Patients who would otherwise benefit from the facility's services, for instance, might be reluctant to seek care there. In addition, high-quality professional staff might be hesitant to work for an organization with a controversial reputation, regardless of whether that reputation is deserved. And, potential donors could be dissuaded.
The instructor could also explain that any litigation might not be resolved in time to make a significant difference in the patient's care (for example, the patient might not be expected to live long enough for the legal proceedings to be completed). In addition, the instructor can point out that many patients want their loved ones to make these decisions, even if the decisions seem contrary to the patient's expressed wishes. For example, circumstances may be different from what the patient imagined they would be when she or he provided the advance directive. In this case, the patient's directive might be viewed as conditional: no aggressive end-of-life care unless the family believes circumstances warrant it.
These ethical dilemmas are not simply within the purview of specialists in ethics. They are features of clinical practice and organizational realities that experienced clinical instructors are familiar with and thus present an important opportunity for ethical instruction in the clinical setting.
GUIDING STUDENTS TO BE ETHICALLY MOTIVATED AND COURAGEOUS
Moral courage is “the individual's capacity to overcome fear and stand up for his or her core values. It is the willingness to speak out and do that which is right in the face of forces that would lead a person to act in some other way.”12 In the clinical setting, instilling moral courage in students primarily involves modeling such behavior. By setting a positive example for students, clinical instructors can help inculcate moral courage and the confidence to speak up among those who might otherwise be swept up in an unethical status quo. Whereas classroom teaching helps students understand what one ought to do, role modeling by the clinical instructor assists students in developing the resolve to do it, particularly when doing the right thing might not be easy. The following examples of ethical situations help to illustrate this point.
In one scenario, a group of medical students and their medical professor exit the room of a patient in contact isolation, but do not wash their hands. The nursing instructor points out this deficiency, despite her discomfort in correcting the group of professionals. In doing so, she demonstrates moral courage and advocacy for patient safety. Students who witness this interaction receive a lesson in the moral principle of nonmaleficence. In health care, ethical practice involves an equal commitment not only to do what is best for patients, but also to do no harm. In this case, preventing harm means ensuring the patient's infection wasn't transmitted to others.
In another scenario, a nursing student is assigned to a patient who has undergone a vaginal delivery and has a recent history of drug abuse. The patient has received an oral dose of pain medicine but continues to report severe vaginal pain. The student shares this information with the patient's nurse, who responds, “She's just drug seeking. I wouldn't place too much emphasis on what she's saying.” The student is uncomfortable ignoring an apparently competent patient's report of severe pain and request for medication and wonders whether she should defer to the experienced nurse or pursue the patient's complaint. She seeks guidance from the instructor, who confirms that when a patient is in continued pain, this should prompt further assessment and a report to the patient's provider that pain control is insufficient. The instructor also confronts the nurse who was inclined to ignore the patient's statements. She does so professionally and politely, yet assertively, explaining that patients with a history of drug abuse have the right to adequate pain control, and it cannot be presumed that such patients are “drug seeking” simply because they say they are experiencing severe pain. Indeed, if this presumption is widespread among the staff, the instructor would be modeling a morally courageous response to an immoral status quo, especially if she takes this issue up the chain of command.
Ethical behavior is often confrontational—indeed, in many cases, the only ethical response to unethical practices or an ethically questionable status quo is to confront those who engage in or perpetuate it. Clinical instructors should model appropriate confrontational behavior, as the nurse did in the above scenario. One would hope the instructor would stand up for what's right regardless, but doing so has the added benefit of providing students with practical ethical instruction. This might run counter to a nurse's natural impulse to insulate the offending party from embarrassment in front of others, especially those of subordinate status, such as students. However, the potential benefits of an ethical lesson for students strongly supports letting them observe the instructor's response to an ethically questionable situation. The instructor can then privately debrief the students about what she did and why, discussing the situation in more detail.
Even in everyday events, the instructor's role modeling helps to instill moral character in students. For example, an instructor who is consistently on time for clinical lessons provides a good example of moral character by prioritizing the promotion of patient welfare (beneficence) and honoring one's commitment to caring for patients (fidelity). When a nursing student arrives late for the clinical experience, the instructor may reprimand the student for failing to meet a professional obligation. Having set a clear example for the student, the instructor can correct her or his behavior with valid authority and in terms of the student's moral duty to patients.
In another example of modeling ethical behavior, a nursing student and instructor realize the student has prepared and administered an extra dose of medication to a patient. The patient incurs no ill effects. Although one might be tempted to take no further action, the instructor does the right thing. She has the moral courage to implicate self-involvement in this medication error by completing an incident report and notifying the appropriate authorities of the mistake. Crigger and Godfrey discuss the importance of addressing mistakes as part of a model for developing professional identity formation and professional ethics13: “Identification of a slip is the beginning of reconciliation rather than condemnation. Mistakes are part of being human, and although it is preferred that they not occur, they do and subsequently should be used as a means for professional growth.” The instructor in this example, therefore, is modeling ethical behavior that can leave a lasting impact on the formation of the student's own ethical framework.
FROM THE CLASSROOM TO CLINICAL PRACTICE
Translating classroom teaching of professional ethics to clinical practice is essential to successfully preparing students to be nurses. The clinical instructor provides ethical learning opportunities for students by identifying ethically relevant aspects of cases to which students might not be attuned and by modeling ethical behavior (especially when unethical behavior might be an easier option). This type of instruction requires no formal background in ethics and complements didactic classroom training. Thoughtfully addressing the acquisition of ethically relevant knowledge and the inculcation of ethical behavior by nursing students is an achievable and vital objective of clinical instruction.
In 2015, the ANA revised its Code of Ethics for Nurses with Interpretive Statements to allow for improved application of the code to the types of ethical dilemmas nurses are increasingly encountering.2 To become more familiar with the code and how it can be applied to practice, visit www.nursingworld.org/ethics.