argumentative essay
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/8046448
Nursing Ethics Education: are we really delivering the good(s)?
Article in Nursing Ethics · February 2005
DOI: 10.1191/0969733005ne754oa · Source: PubMed
CITATIONS
78 READS
2,526
1 author:
Some of the authors of this publication are also working on these related projects:
Nursing ethics education View project
Euthanasia and nursing viewpoints View project
Martin Woods
Victoria University of Wellington
98 PUBLICATIONS 243 CITATIONS
SEE PROFILE
All content following this page was uploaded by Martin Woods on 04 June 2014.
The user has requested enhancement of the downloaded file.
UN CO
RR EC
TE D
PR O O F
NURSING ETHICS EDUCATION: ARE WE REALLY DELIVERING THE
GOOD(S)?
Martin Woods
Key words: applied ethics; nursing ethics; nursing ethics education; nursing ethics research
The vast majority of research in nursing ethics over the last decade indicates that nurses may not be fully prepared to ‘deliver the good(s)’ for their patients, or to contribute appropriately in the wider current health care climate. When suitable research projects were evaluated for this article, one key question emerged: if nurses are educationally better prepared than ever before to exercise their ethical decision-making skills, why does research still indicate that the expected practice-based improvements remain elusive? Hence, a number of ideas gleaned from recent research about the current nature of nursing ethics, and especially teaching nursing ethics to student nurses, are analysed and critiqued in this article, which concludes with a cluster of ideas and conclusions based on that analysis. It is hoped that such a review may serve as a catalyst for nurse educators to re-examine their teaching practices with a view to enhancing good (i.e. ethical) nursing practice through educational means.
Introduction In the last few years there has been much debate among nurse educators concerning the best ways to teach ethics to nurses to enable them to contribute fully to the moral issues that continue to arise in their practice.1�6 Gone are the days when nurses were not expected even to contribute to solving the ethical problems that arose in health care settings (i.e. when nurses received very little formal classroom ethics education but plenty of the ‘be a virtuous woman’ variety). Faded too, but sometimes lingering, are some of the more naive ideas of the ‘progressive-expansive’ era of nursing and nurse education that reached its peak around the 1970s and 1980s. By then, nurses had finally managed to replace the ‘work ethic’ of the previous age with a more ‘democratic’ one that looked outwards to a rapidly developing professional responsiveness to the increasing health care needs of society.7 Yet, concerning ethics, nurses were still largely subjugated by the medical profession, nursing ethics itself being cursorily dismissed as
Address for correspondence: Martin Woods, School of Health Sciences, Massey University, Private Bag 11 222, Palmerston North, New Zealand. E-mail: m_woods@massey.ac.nz
Nursing Ethics 2004 12 (1) # 2004 Arnold 10.1191/0969733004ne754oa
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:7
UN CO
RR EC
TE D
PR O O F
‘a legitimate, if very limited, term referring to a field that is a sub-category of medical ethics’(p. 17).8 In the 1980s and 1990s, nurse frustration over nursing not being fully recognized as a discipline that was able to respond effectively to moral positions in health care practices found its voice.9,10 Yarling and McElmurry’s now famous complaint that ‘professional nurses are conceived in moral contradiction and born in compromise’ (p. 67)11 highlighted a growing frustration over powerlessness and a lack of autonomy among practising nurses who felt increasingly compromised by their medical colleagues, especially in those decisions relating to their own ethical practice.12 This seemed to occur even though nurses were increasingly better prepared through a much improved ethics education that was delivered at a much greater depth.13
In the last decade nurses have been more educationally prepared than ever to contribute to the issues that currently beset modern health care, but they still find that they are not fully able to do so.14 In New Zealand, and probably in most other compatible countries, well-educated nurses continue to argue that their ethical contribution to health care situations is often received in ways that are either dismissive or condescending.15 This is curious because most student nurses now receive structured, formalized lessons in ethics that are considerably more carefully planned and reflective of the moral issues that confront nursing practice than in any previous era. Research also continues to show that the inclusion of such courses in the nursing curriculum do actually increase student nurses’ moral reasoning abilities.16 However, do these courses really prepare them to respond effectively to the demands of the modern health care system? Is it possible that this phenomenon could be associated with a number of persisting ideas in nursing (i.e. that nurses are still obliged to follow the ‘moral lead’ of the medical profession14), medicine (i.e. nursing ethics is but an offshoot of medical ethics8) and/or society itself?17
There is always the possibility that, even now in nurse education, nursing ethics may still be considered by some to be no more than yet another topic to be slotted into the curriculum, and not as a subject that needs a considerable amount of time devoted to it within a well-planned and delivered curriculum. In a pilot study, Parsons and coworkers found that the majority (72.8%) of a sample of educators taken from six UK universities believed that insufficient time was allocated for the purpose.18 Equally disturbing are the apparently small numbers of nurses (and perhaps nurse educators) who have studied or researched nursing ethics at advanced or postgraduate level to enable them to guide more successfully the future generations of nurses.19,20 Despite the debate about hours, content, methods and levels of delivery, there still remains a nagging feeling that insufficient numbers of nurses are emerging from their undergraduate (or postgraduate) education with an appropriate ethical awareness of their individual or collective moral capacity. It is not clear if such nurses can confidently face their crucial role in meeting the growing ethical demands of modern health care practices.21
I will argue in this article that, although nursing ethics education methods may have improved considerably in recent years, and nursing ethics has established itself as a vital and key topic in any nursing curriculum, carefully planned adjustments are still needed to current educational approaches to nursing ethics at all levels to enable newly qualifying nurses finally to ‘deliver the (ethical) goods’ as comprehensively and effectively as they desire.
2 M Woods
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:8
UN CO
RR EC
TE D
PR O O F
Nursing ethics research There have been a number of strikingly familiar findings in the field of nursing ethics studies over the last decade.14 Overall, these reveal three major annoying and ever persisting phenomena:
. Many nurses feel concerned about the clinical dilemmas they face, but take no action, or are uncertain about what action to take,22 or feel that they are overruled by physicians,23,24 or cannot always overcome ‘the barriers’ and suffer some form of moral distress.25,26
. If they do take ethical action or advocate on behalf of their patients, nurses find themselves ostracized by other personnel and then seek covert or subversive ways to promote their own moral survival.27�35
. Newly graduated nurses do not assert themselves in the face of moral conflict, choosing instead to find ways to cope with their own moral distress, often by passive acceptance or compromise, sometimes at the expense of doing what they have been taught is the right thing to do.15,36
It is this last point that is the most disturbing phenomenon: the lack of ethical confidence among newly qualified nurses is of great concern. If newly qualified nurses, the recipients of a far more carefully planned and applied ethics education, still feel compromised in their practice, what chance have they to advance better practices in health care? Must such nurses continue to face the frustrating and sometimes soul- destroying moral challenges that their predecessors had to face, and, even worse, continue to face the prospects of becoming morally apathetic or distressed, subversive or bitter?
What follows is a brief, but hopefully significant, review of a handful of different, yet related, pieces of research in nursing ethics education and practices that centre upon various aspects of this phenomenon. The chosen research projects reflect participant backgrounds where there is a reasonably similar approach to nurse education (i.e. in higher centres of learning, with access to current research, receiving a specific ethics education, etc.), and offer some useful insights into the possible causes of this ongoing issue. These studies are described in Table 1.
Recent studies of nursing ethics education Even though participant student nurses had been exposed to ethics education in formalized courses, and even though they had morally ‘matured’ (professionally speaking), the majority of the research findings revealed that essentially they still faced considerable ethical difficulties once in professional practice. In one US study, the main difficulties encountered were lack of confidence, being ignored or overruled, feeling stressed and being condemnatory of ‘the system’ or of the administration and others.36
In a UK study, similar difficulties were eased to an extent by maturity and experience,37 or, as in another US study, by the use of previously learned decision- making models (although interdisciplinary conflict remained a considerable issue that impacted upon later professional work practices).38 Indeed, even during nursing students’ educative years, it was found in a Swedish study that the most common
Nursing ethics education: are we really delivering the good(s)? 3
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:8
UNCO RRECTED PRO
O F
Table 1 Recent nursing ethics education research
Reference Study Results
Kelly, 199836 22 new graduate nurses in the USA took part in a grounded theory study about their concerns and influences on nurses in the 2 years following graduation.
The newly qualified nurses found ways to cope with their moral distress rather than asserting themselves in the face of moral conflict. Coping mechanisms included: avoiding patient interactions, leaving the unit, working less hours, leaving nursing.
Nolan and Markert, 200137
Performed a longitudinal study of nursing students to examine the effectiveness of ethics courses in the UK by exploring their ethical understanding and changes in their understanding and approaches to practice over 4 years of training. The data collection tool was a questionnaire and responses to 5 vignettes describing ethical dilemmas in health care.
The students’ ability to think from an ethical perspective progressed as they became more mature as individuals and professionals within the system. This did not, however, grant such nurses immunity to ethical difficulties in the workplace.
Cameron et al., 200138 Used a part phenomenological, part ethical enquiry to study nursing students’ experiences of ethical problems and use of ethical decision-making models. Involved 73 senior baccalaureate nursing students in the USA who were asked to answer 2 questions: (1) What is nursing students’ experience of an ethical problem involving nursing practice? and (2) what is nursing students’ experience of using an ethical decision-making model?
Each student described one ethical problem, from which emerged main themes such as the nursing students’ experience of conflict, resolution and rationale. The majority of the students described using an ethical decision-making model as ‘helpful’. Yet, as before, interdisciplinary conflict remained a considerable issue that impacted upon their later professional work practices.
Edlund-Sjoberg and Thorell-Ekstrand, 200139
A study involving 46 Swedish nursing student participants postulated, that nursing students need their own direct experiences from patient care and the ability to reflect ethically to be able to respond to future ethical demands in the workplace. The study involved the examination of written assignments in the form of student reports submitted during clinical education in medicine and surgery.
The most common ethical problem described by the students was violation of the integrity of either a patient or a relative and disrespect for their autonomy by other medical and nursing staff. The action taken by the students in these situations was often to play a passive role owing to fear of ‘not being accepted by the staff’, which could easily occur if a student nurse wished to ‘stand her ground’ on a particular ethical issue.
4 M
W ood
s
N u
rsin g
E th
ics 2
0 0
4 1
2 (1
)
Y :/
A rn
o ld
/ N
E /
a rticle
s/ n
e 7
5 4
o a
/ n
e 7 5
4 o
a .3
d [x
] T
u e sd
a y,
1 9
th O
cto b
e r
2 0
0 4
1 5
:3 3
:8
UNCO RRECTED PRO
O F
Table 1 (Continued)
Reference Study Results
Vallance, 200315 Interviews were carried out with 9 newly qualified nurse participants (7 women and 2 men) using a grounded theory approach to investigate how nursing students learned ethics and whether or not their ethics education prepared them for practice.
As learners in the practice setting, the participants were found to have tried to hold on to their ‘ethical ideals’ regarding patient care, which were, at times, significantly challenged by other nurses in the practice setting. They learned the art of passive acceptance or compromise, sometimes at the expense of doing what they had been taught was the right thing to do. This disturbing phenomenon stayed with them after they entered the health care workforce as qualified nurses.
Woods, 199720 A grounded theory study of the everyday moral decision making of experienced registered nurses involved 8 participants, each with several years’ experience as nurses in a variety of settings.
The study concluded that morally competent nurses had, often in the absence of formalized ethics education, developed an ethic during their training, which was later adapted, modified, improved and further ‘refined’ through experience into a truly professional nursing ethic.
N u
rsin g
eth ics
ed u
ca tion
: are
w e
really d
eliv erin
g th
e g
ood (s)?
5
N u
rsin g
E th
ics 2
0 0
4 1
2 (1
)
Y :/
A rn
o ld
/ N
E /
a rticle
s/ n
e 7
5 4
o a
/ n
e 7 5
4 o
a .3
d [x
] T
u e sd
a y,
1 9
th O
cto b
e r
2 0
0 4
1 5
:3 3
:9
UN CO
RR EC
TE D
PR O O F
ethical problem described by the students was the breach of a patient’s (or his or her relative’s) ethical rights by other nurses, and disrespect for their autonomy by other medical and nursing staff.39 The actions taken by students in these situations were often to play a passive role owing to fear of ‘not being accepted by the staff’, which could easily occur if a student nurse wished to stand her or his ground on a particular ethical issue. This moral passivity has been noted in other research, not only among nursing students but sometimes among their ‘buddy nurses’ and even their lecturers as well.15,20
One New Zealand study indicated that, as students ‘navigated through’ the ethical dilemmas that faced them in the clinical arena, the predominant feature was one of resolving their main concerns by concentrating on the ‘ideal versus real’ dichotomy.15
Such focusing included the following developments:
. Formulating patient-focused ‘ethical ideals’;
. Testing the ideals in the ‘real world’;
. Widening the ethical perspective;
. Enduring powerlessness;
. Preserving patient-focused ‘ethical ideals’.
These findings were similar to those in Kelly’s US study,36 where student nurses were found to have tried to hold on to their ethical ideals regarding patient care but found that they were at times significantly challenged by other nurses in the practice setting. Subsequently, many learned the art of passive acceptance or compromise (or ‘fitting in’), sometimes at the expense of doing what they had been taught was the right thing to do. This disturbing and stressful pheno- menon stayed with them after they entered the health care workforce as qualified nurses.
Several elements of research examined above revealed findings that stron- gly related to previous research on nursing ethics education in New Zealand.20 This study concluded that morally competent nurses had, often without any significant degree of formalized ethics education, developed an ethic during their training, which was later adapted, modified, improved and further ‘refined’ through experience into a truly professional nursing ethic. These refinements related to behaviours that under- pinned the development of a ‘nursing ethic’, for example:
. Exhibiting appropriate nursing values and moral character;
. Establishing a purposeful relationship;
. Being personally involved;
. Committing to expert caring;
. Maintaining trust;
. Advocating for others.
However, the same nurse participants also related numerous occasions on which they made ethically effective or ineffective decisions according to circumstances that were heavily influenced by a whole range of contextual factors that were often beyond their control. The net effect was that nurses could respond to ethical issues in many different ways, ranging from complete passivity through to ‘desk banging’ or much wider moral protests. Most chose a ‘middle path’, which was predominately either compromising or ‘subverting the system’.
6 M Woods
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
UN CO
RR EC
TE D
PR O O F
The implications of the research for nurse education In all the previous examples concerning nursing ethics education, a number of key points were raised again and again. They are as follows:
. The ethic that served as the central guide or driving force behind the moral decisions and actions of nurses had its theoretical origins, development and usefulness in everyday nursing practice as much as in any learned bioethical theory.
. The development of moral values in nursing appeared to be related to exposure to good nursing practice in the form of ethical role models and experiential learning as much as to any formal classroom learning. (The notion of ethics being a skill that is better learned by nurses within and from real situations in practice may not necessarily be a new one in nurse education, yet it must also be accepted that it is still at least a much debated one.)
. There is no denying that nursing students need some sort of formal education within an organized curricular structure to enable them to understand and apply themselves to ethics and ethical dilemmas in practice; but this education must be realistic.
In relation to the need for structure and organization within the teaching of nursing ethics, exposure to some form of organized ethical philosophizing and theorizing was of some value when they reflected on their experiences in the clinical arena.22 Yet, as noted in studies from New Zealand15,20 and the UK,37 the students’ ability to think from an ethical perspective progressed as they became more mature as individuals in practice. Although problematic, and subject to criticisms of subjectivity and personal conscience arguments, this was at least towards a more applied nursing centred ethic rather than an abstract, formal and sometimes ‘detached’ ethic per se. Similarly, in the Swedish study39 it was found that nursing students needed their own direct experiences from patient care to enable them to reflect ethically and be able to respond to future ethical demands in the workplace.
One question persists: If these messages are so clear and nursing ethics is now taught to a much greater depth and relevancy to nursing practice, why do research projects in nursing ethics continue to reveal that newly graduating nurses feel unable to respond effectively to the moral problems in their professional practice?
Adjusting educational approaches in nursing ethics Current approaches to nursing ethics education may require yet another overhaul (or at least some fine tuning) if they are to meet the future requirements of nurse education at all levels. Newly graduated nurses need to be able to respond effectively to the demands of future health care needs in a climate where their ethical input is both recognized and highly valued. The following are five relatively concise but fundamental suggestions for continuing adjustment to be based around the main conclusions of the previously outlined research projects.
Nursing ethics education: are we really delivering the good(s)? 7
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
UN CO
RR EC
TE D
PR O O F
Continue to challenge the clinical contexts/health care structures
There is little doubt that the’constraints of the system’ argument is as troublesome for nurses now as it was 20 years ago. Nurses do indeed work within a health care system that continues to place controls over their practice.14 In New Zealand and Australia, the ethical problems caused by shortages of trained staff, the inability of the medical profession to recognize nurse autonomy, and the pressures within an increasingly demanding health care system continue to be frequent causes of anxiety for nurses.40
However, nurses also maintain that they offer professional care, are quite capable of making good ethical decisions, and have a commitment to a social contract or partnership with society. According to the International Council of Nurses Code, ‘The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations’ (p. 2).41 It still remains for nurse educators at least to encourage nursing students always to act ethically, irrespective of any institutionalized pressures to conform on either party.
If challenging ‘the system’ through educational means is necessary, then ways must be found to prepare student nurses to do so appropriately, not least by example from their own role models. This may be seen as an idealistic notion, but it is also a necessary one. As Darbyshire once ruefully claimed: ‘We must rediscover our passion for and about nursing as a real social force with an ethic of good immovably embedded within it’.(p. 508)42 To achieve this may require more than classroom idealism or philosophical abstractness. Whether the forces of seemingly immovable ‘concrete realism’ prevail in the health care system or not, nursing ethics educators should be committed, in both classroom and clinical areas, to those ideals that promote ethical nursing practice, and actively oppose those that do not, but can nurse educators alone achieve this?
Use appropriate role models and the experiences of practising nurses
It is questionable if student nurses should be encouraged to be ethically rigorous in the classroom if in the clinical context they see and experience very different responses, some of which are highly negative.15,36 To overcome this, the voices of student nurses must be strengthened to help them to overcome feelings of powerlessness while in the practice setting. To support them in this endeavour, as suggested in research, student nurses should be ethically educated by lecturers in the classroom and also in practice by their ‘buddy’ nurses and clinical tutors. This notion may not be particularly new in the field of many disciplines, including medicine,43 but recent research continues to show that student nurses are still not being properly guided by appropriately appointed role models in clinical practice. Many continue to complain that they learn ethics by resolving to do the opposite of the nurses that they were forced to work with in the clinical learning environment.15
Student nurses must be placed with good ethical role models (i.e. those who are morally competent) and removed from the influence of those who are morally incompetent or indifferent. ‘Morally competent’ nurses were noted to be those who, regardless of the constraints of the system, still found ways to act morally by closely adhering to some type of nursing ethic.20 Student nurses need to be in situations and relationships with morally competent ‘buddy nurses’ that can lead them to these
8 M Woods
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
UN CO
RR EC
TE D
PR O O F
necessary insights. Such valuing and validating of the students’ knowledge would have the potential to strengthen students, and ‘buddy nurses’ may deepen their ethical experience base as they discover what they intuitively know alongside other nurses, but how should student nurses be philosophically prepared for such learning?
Rethink the underlying philosophy
It is apparent in many of the research projects noted earlier that student nurses can very quickly differentiate between ‘idealism’ and ‘reality’ (i.e. between what can be at times abstract theoretical whimsy and practical wisdom gleaned from concrete reality). They can clearly perceive a considerable gulf between those ethical ideas and ideals that are delivered in the classroom and the deeds of those around them in practice. Standard philosophical and theoretical ethics approaches, such as the principles/rules, code of ethics, deontology and utilitarianism approaches may be of some value, but they will fail without very close attention to the realities of modern nursing practice. Nurse educators should consider an overall approach to teaching nursing ethics that is based on a philosophy that is at least grounded in practical rather than abstract views of reality, and one that promotes the learning of applied ethics in every and any nursing context. This may not be a revolutionary idea in nursing ethics education, but why do we still find pleas for more clarity and more applied research from eminent academics?4
In nursing and nursing ethics education, much may be gained from a re-examination of the reflective and analytical benefits of contextualizing every ethical idea, ideal or theory. In the education of professionals, ‘real world’ practice does not present itself as a series of neat structures that respond to various theories.44 Real world practice is that which occurs in actual situations in actual contexts. In this world, knowledge as practical wisdom is gained by experiences in the learning situation rather than through rational but often thwarted attempts bluntly to apply theory to practice. A great deal of learning depends on adequate reflection and analysis of practice or cognition, which then serve to enhance or guide future practice. Learning via the means of detached theorizing will only lead to a negation of real world events because of the misguided emphasis on structure or method over choice(s) in practice. How then are ethical concepts and theories to be taught and attached to practice, and which ones in particular?
Bridge the theory�/practice gap There are many possible philosophical and theoretical approaches to teaching ethics to nurses,3,11,14,19,45�65 yet the selection of the most appropriate ethical approaches to teaching undergraduate (and postgraduate) nurses remains a cause of considerable dispute among nursing academics and educators.2�6
In part, and perhaps cynically, it sometimes seems likely that the choice of the most appropriate ethics frameworks or approaches for ethics education in nursing reflects the lecturer’s preference or background as much as the needs of the students in practice. Perhaps the choice is based on personally interesting elements gleaned from a favourite ethics textbook rather than a highly considered and integrated nursing ethics programme. Nevertheless, it must be accepted that ethics cannot be entirely antitheoretical or without sufficient guiding frameworks. It must also be recognized
Nursing ethics education: are we really delivering the good(s)? 9
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
UN CO
RR EC
TE D
PR O O F
that, while the great debate over the most appropriate theoretical approaches lingers on, there remains a vast and potentially confusing range of philosophical and theoretical approaches from which lecturers can choose. These are listed in Table 2.
Clearly, there are several arguments that could support the educational use of each approach or combinations of theoretical approaches, but there is insufficient space here to examine them all carefully and offer a more rounded critique. However, it can still be argued that some of these approaches must be better than others in transferring ideas from classroom to clinical practice. Two central ideas seem to predominate within the nursing ethics research on teaching ethics to nursing students:
. If nursing is the intersubjective and caring profession par excellence, then it follows that nursing ethics education should at least contain a core element that is grounded in the contemporary moral interpretations of nursing rather than solely within the wider fields of health care ethics or bioethics. Such an approach would therefore reflect the importance of the nurse�/patient relationship and the meeting of the patient’s needs in a morally acceptable fashion, and offer a critical examination of the persistent and problematic contextual concerns that still beset nurses.
. If nurses do have to assimilate the more objective and rationalistic approaches that are still popular in medical ethics education66 then the traditional methods of ethical decision making, based on the teaching of principles, rules or norms, may still be seen as being of considerable value. It could be argued that, if nursing ethics per se is an integral part of the wider health care ethics arena, then a carefully chosen assortment of the main ethics approaches noted earlier may be of use to nurses in different ways.
This pluralistic and more pragmatic approach to teaching nursing ethics may not entirely satisfy either those who favour contemporary (nursing centred) approaches only, or the ‘traditionalist’ (moral philosophy centred) approaches, but it may provide at least an acceptable compromise. If nurses concentrate their moral role on particular
Table 2 Theoretical approaches and teaching methods for nursing ethics education
Theoretical approaches Teaching methods
Moral philosophy45�47 Standard ethics lectures and tutorials Values approaches48,49 ‘Games’67,68
Human rights approaches50 Classroom debates69
Virtue ethics3,51,52 Model emulation70
Codes of ethical53 Case studies (both classroom and clinically based)71,72
Moral principles/rules54 Relational narratives73
Traditional theoretical ethics (especially deontology and utilitarianism)55
Reflective practices27,74,75
Multicultural ethics56 Clinical supervision16,39,76
Casuistry57,58 Or . . . many and varied combinations of some or all of the above
Narrative ethics59
An ethic of care approach60�62
Hegemonic, critical social, systems analysis11,14
Ethics of ‘moral compromise’63,64
Pragmatic ethics19,65
10 M Woods
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
UN CO
RR EC
TE D
PR O O F
(especially nurse�/patient) relationships, and also on the ethical requirements of the wider health care context, then they should be able to equip themselves to use any appropriate ethical approach that lends itself to achieving these goals. Thus, student nurses need to be conversant with a variety of ethics approaches while at the same time balancing the needs of the broader social and political structures within which their profession is practiced; but how do nurse educators actually teach them this?
‘Deliver the good(s)’ . . . in more pragmatic ways
There are a number of arguments and counter-arguments concerning the possible delivery of an appropriate nursing ethics education.67�76 Some of these focus on structural matters such as the qualifications or background of the lecturer, the most appropriate course content and in which order, and the number of hours that should be allocated. Some arguments focus on more philosophical matters such as the most desirable underlying philosophical approach that should frame the whole course. Yet other equally absorbing and potentially time consuming debates feature the best ways to deliver the ‘goods’, both theoretical and applied, to students in the classroom, clinical area, or both. (Table 2).
This article is not concerned with a full analysis and critique of these teaching methods, and indeed there is a real need to move on from some of these debates and focus more attention on actually providing nursing students with some much needed support and encouragement in their ethical endeavours. If the previously outlined research on nursing ethics and nursing ethics education tells us anything about this very urgent need, it tells us this:
. There is a real danger of distancing or disassociating from reality the nursing students at any level if the emphasis is placed too heavily on the abstract rather than the applied, the ‘case’ rather than the real, and the theory rather than the contextual reality. There are clearly identifiable cognitive problems for students when simulating reality (i.e. in game playing, case studies or even general debates) instead of applied theorizing in the clinical setting.
. In any nurse education curriculum there has to be some classroom teaching of ethics. Research tells us that there should be a significantly strong emphasis on the analysis and appropriate responses of personal and professional values, health care contexts, ethical problems and methods of moral decision making. However, the emphasis should always be an applied one, using ‘real world’ situations from nurseing. In the early stages of nurse education this will be based on the promotion of commonly understood nurse values and, later, on ethical situations experie- nced by practising nurses and the students themselves in the form of shared narratives. Later still, theoretical ideas fully applied in the clinical setting will be the norm.
Conclusion The implications for nurse education in this article are that nurse educators should be very concerned about the problems that their students are most likely experiencing in
Nursing ethics education: are we really delivering the good(s)? 11
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
UN CO
RR EC
TE D
PR O O F
assimilating the requirements of a good ethics preparation for practice within their educative programmes. Research shows that undergraduate student nurses, as well as newly or even longer qualified nurses, are struggling to maintain an adequate ethical responsiveness in a variety of health care settings. The remedy may be difficult because the problems are multifaceted and systematic, but the greater use of more pragmatically orientated, clinically focused and critical methods of ethical respon- siveness may at least ensure that future nurses are fully aware of the value of a nursing-focused ethic in a rapidly changing health care system. This in turn could enable improvements and new and more innovative ethical developments to occur within their own practice, nursing ethics education and the health care arena itself.
References 11 Woods, M. The ethical preparation and practice of nurses: a pilot research project. (Occasional
Paper.) Palmarston North: Massey University, 1992. 12 Allmark P. Uncertainties in the teaching of ethics to students of nursing. J Adv Nurs 1995; 22:
374�/78. 13 Birkelund R. Ethics and education. Nurs Ethics 2000; 7: 473�/80. 14 Leino-Kilpi H. The need to research the teaching of ethics and the outcomes of such teaching
[Editorial Comment]. Nurs Ethics 2001; 8: 297�/98. 15 Gastmans C. A fundamental ethical approach to nursing: some proposals for ethics education.
Nurs Ethics 2002; 9: 494�/507. 16 Weber JR. Teaching moral reasoning to student nurses. J Holistic Nurs 1992; 10: 263�/74. 17 Giarelli E. A historical study of nursing ethics education in the United States �/ 1873�/1933
[Dissartation]. New Brunswick, NJ: Rutgers State University of New Jersey, 1989. 18 Veatch RM. Nursing ethics, physician ethics, and medical ethics. Law Med Health Care 1981;
(Oct): 17�/19. 19 Mayberry M. Ethical decision making: a response of hospital nurses. Nurs Adm Q 1986; 10(3):
75�/86. 10 Caffrey RA, Caffrey PA. Nursing: caring or co-dependent? Nurs Forum 1994; 29(1): 12�/17. 11 Yarling R, McElmurry B. The moral foundations of nursing. ANS Adv Nurs Sci 1986; 8(2):
63�/73. 12 Grunstein-Amado R. Differences in ethical decision making processes among nurses and
doctors. J Adv Nurs 1992; 17: 129�/37. 13 Gallagher U, Boyd K. Teaching and learning nursing ethics. London: Scutari Press, 1991. 14 Peter E, Lunardi VL, Macfarlane A. Nursing resistance as ethical action: literature review.
J Adv Nurs 2004; 46: 403�/16. 15 Vallance E. ‘Navigating through’ a grounded theory of the ethical context of undergraduate nursing
education [Thesis]. Palmarston North: Massey University, 2003. 16 Haywood JM. The relationship of moral development stages to ethics content in nursing curricula
[Dissartation]. Nashvilla, TN: Peabody College for Teachers of Vanderbilt University, 1996. 17 Wuest J. Professionalism and the evolution of nursing as a discipline: a feminist perspective.
J Prof Nurs 1994; 10: 357�/67. 18 Parsons S, Barker PJ, Armstrong AE. The teaching of health care ethics to students of nursing
in the UK: a pilot study. Nurs Ethics 2001; 8: 45�/56. 19 Woods M. Nursing ethics education and contemporary concerns: a reflective report. (Occasional
Paper) Palmerston North: Manawatu Polytechnic, 1994. 20 Woods M. Maintaining a nursing ethic: a grounded theory of the moral practice of experienced nurses
[Thesis]. Palmerston North: Massey University, 1997.
12 M Woods
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
UN CO
RR EC
TE D
PR O O F
21 Johnstone M-J. Bioethics: a nursing perspective, fourth edition. Sydney: Churchill Livingstone, 2004.
22 Penticuff JH, Walden M. Influence of practice environment and nurse characteristics on perinatal nurses’ responses to ethical dilemmas. Nurs Res 2000; 49: 64�/72.
23 Erlen JA, Frost B. Nurses’ perceptions of powerlessness in influencing ethical decisions. West J Nurs Res, 1991; 13: 397�/407.
24 Sleutel MR. Intrapartum nursing care: a case study of supportive interventions and ethical conflicts. Birth 2000; 27(1): 38�/48.
25 Fry ST, Harvey RM, Hurley AC, Foley BJ. Development of a model of moral distress in military nursing. Nurs Ethics 2002; 9: 373�/87.
26 Schroeter K. Ethical perception and resulting action in perioperative nurses. AORN J 1999; 69: 991�/1002.
27 Woods M. A nursing ethic: the moral voice of experienced nurses. Nurs Ethics 1999; 6: 423�/33. 28 Lützén K, Schreiber R. Moral survival in a nontherapeutic environment. Issues Ment Health
Nurs 1998; 19: 303�/15. 29 Åström G, Furåker C, Norberg A. Nurses’ skills in managing ethically difficult care situations:
interpretation of nurses’ narratives. J Adv Nurs 1995; 21: 1073�/80. 30 Gaudine AP, Beaton MR. Employed to go against one’s values: nurse managers’ accounts of
ethical conflict with their organizations. Can J Nurs Res, 2002; 34(2): 17�/43. 31 Hutchinson SA. Responsible subversion: a study of rule bending among nurses. Sch Inq Nurs
Pract 1990; 4: 3�/17. 32 Rodney P, Varcoe C. Towards ethical inquiry in the economics evaluation of nursing practice.
Can J Nurs Res, 2001; 33: 35�/57. 33 Spence K. Ethical issues for neonatal nurses. Nur Ethics 1998; 5: 206�/17. 34 Sundin-Huard D, Fahy K. Moral distress, advocacy and burnout: theorizing the relationships.
Int J Nurs Pract 1999; 5: 8�/13. 35 Wurzbach ME. Acute care nurses’ experiences of moral certainty. J Adv Nurs, 1999; 30: 287�/93. 36 Kelly B. Preserving moral integrity: a follow up study with new graduate nurses. J Adv Nurs
1998; 28: 1134�/45. 37 Nolan PW, Markert D. Ethical reasoning observed: a longitudinal study of nursing students.
Nurs Ethics 2001; 9: 243�/58. 38 Cameron ME, Schaffer M, Park H-A. Nursing students’ experience of ethical problems and
use of ethical decision-making models. Nurs Ethics 2001; 8: 432�/47. 39 Edlund-Sjoberg M, Thorell-Ekstrand I. Ethical reflection on patient care situations �/ a study in
a group of Swedish nurse students. Int Nurs Perspact 2001; 1:(1) 15�/22. 40 Chiarella M. The legal and professional status of nursing. Edinburgh: Churchill Livingstone, 2002. 41 International Council of Nurses. Code of ethics for nurses. Geneva: ICN Press, 2000. 42 Darbyshire P. Preserving nursing in a destitute time. J Adv Nurs 1993; 18: 507�/508. 43 Schnieder W, Snell L. CARE. An approach for teaching ethics in medicine. Soc Sci Med 2000;
51: 1563�/67. 44 Schön DA. The reflective practitioner: how professionals think in action. Aldershot: Arena Ashgate
Publishing, 1995. 45 Cartwright T, Davson-Galle P, Holden RJ. Moral philosophy and nursing curricula:
indoctrination of the new breed. J Nurs Educ 1992; 31: 225�/28. 46 Holt J, Long T. Moral guidance, moral philosophy, and moral issues in practice. Nurs Educ
Today 1999; 19: 246�/49. 47 Webb J, Warwick C. Getting it right: the teaching of philosophical health care ethics. Nurs
Ethics 1999; 6: 150�/56. 48 Glen S. Educating for interprofessional collaboration: teaching about values. Nurs Ethics 1999;
6: 202�/13. 49 Raya A. Can knowledge be promoted and values ignored? Implications for nursing
education. J Adv Nurs 1990; 15: 504�/509. 50 Austin W. Using the human rights paradigm in health ethics: the problems and the
possibilities. Nurs Ethics 2001; 8: 183�/95.
Nursing ethics education: are we really delivering the good(s)? 13
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
UN CO
RR EC
TE D
PR O O F
51 Sellman D. The virtues in the moral education of nurses: Florence Nightingale revisited. Nurs Ethics 1997; 4: 3�/11.
52 van Hooft S. Moral education for nursing decisions. J Adv Nurs 1990; 15: 210�/15. 53 Han S-S, Ahn S-H. An analysis and evaluation of student nurses’ participation in ethical
decision making. Nurs Ethics 2000; 7: 113�/23. 54 Edwards S. Nursing ethics. Nurs Educ Today 1994; 14: 136�/39. 55 Crigger NJ. Universal prescriptivism: traditional moral decision-making theory revisited.
J Adv Nurs 1994; 20: 538�/44. 56 Kikuchi JF. Multicultural ethics in nursing education: a potential threat to responsible
practice. J Prof Nurs 1996; 12: 159�/65. 57 Le Veille Gaul A. Casuistry, care, compassion, and ethics data analysis. ANS Adv Nurs Sci
1995; 17: 47�/57. 58 Zimmermann M. Ethics and nursing: a contribution to nursing education. Pflege 1998; 11:
219�/23. 59 Diekelmann N, Diekelmann J. Learning ethics in nursing and genetics: narrative pedagogy
and the grounding of values. J Pediats Nurs 2000; 15: 226�/31. 60 Carse AL. The ‘voice of care’: implications for bioethical education. J Med Philos 1991; 16: 5�/28. 61 Tschudin V. Ethics in nursing: the caring relationship, second edition. Oxford: Butterworth-
Heinemann, 1992. 62 Peter E, Gallop R. The ethic of care: a comparison of nursing and medical students. Image J
Nurs Sch 1994; 26: 47�/51. 63 Fry ST. The ethics of compromise [Editorial]. Nurs Outlook 1989; 37: 152. 64 Winslow BJ, Winslow GR. Integrity and compromise in nursing ethics. J Med Philos 1991; 16:
307�/23. 65 Callery P. Moral learning in nursing education: a discussion of the usefulness of cognitive-
developmental and social learning theories. J Adv Nurs 1990; 15: 324�/28. 66 Beauchamp TL, Childress JF. Principles of biomedical ethics. New York: Oxford University Press,
1994. 67 Yankou D. Educational innovations. Using gaming to help nursing students understand
ethics. J Nurs Educ 2003; 42: 212�/15. 68 White GB, Davis AJ. Teaching ethics using games. J Adv Nurs 1987; 12: 621�/24. 69 Candela L, Michael SR, Mitchell S. Ethical debates: enhancing critical thinking in nursing
students. Nurs Educ 2003; 28(1): 37�/39. 70 Pang MS, Wong KT. Cultivating a moral sense of nursing through model emulation. Nurs
Ethics 1998; 5: 424�/40. 71 Dinç L, Görgülü RS. Teaching ethics in nursing. Nurs Ethics 2002; 9: 259�/68. 72 Holland S. Teaching nursing ethics by cases: a personal perspective. Nurs Ethics 1999; 6:
434�/36. 73 Tschudin, V. (ed.) Ethics: education and research, Harrow: Scutari Press, 1994. 74 Durgahee T. Reflective practice: decoding ethical knowledge. Nurs Ethics 1997; 4: 211�/17. 75 Hargreaves J. Using patients: exploring the ethical dimension of reflective practice in nurse
education. J Adv Nurs 1997; 25: 223�/28. 76 Nylund L, Lindholm L. The importance of ethics in the clinical supervision of nursing
students. Nurs Ethics 1999; 6: 278�/86.
14 M Woods
Nursing Ethics 2004 12 (1)
Y:/Arnold/NE/articles/ne754oa/ne754oa.3d[x] Tuesday, 19th October 2004 15:33:9
View publication statsView publication stats