Professional Ethical Competence in nursing: the role of nursing instructors.

Teaching ethics to nurses leads to their involvement in providing high quality care, enable them to duly encounter ethical issues. One of the key elements of educational systems is nursing instructors. Even though lots of studies show the role of instructors in students' learning, their role in promotion of professional ethics has been attended to less. The objective of this study is surveying the experience of nursing students with respect to the role of instructors in promotion of professional ethics. This qualitative study enrolled 15 undergraduate nursing students from three nursing schools in Teheran whom depth interview was performed. The interview was semi-structured with open ended questions. The analysis was accomplished by use of qualitative content-analysis method. Data analysis demonstrated 2 main themes and 7 subcategories in regard to the role of instructors in promotion of professional ethics in nursing students including: 1) the effective professional role model 2) facilitating creative learning. The effective professional role model encompasses individual characteristics and beliefs, clinical skills and professional commitment of role model. Creative learning facilitates by encouraging critical thinking and decision-making, Providing supportive learning conditions, providing proper space for sharing knowledge followed by evaluation and creative feedback. The findings of this study provides a background for strengthening the role of instructors in promotion of professional ethics with more emphasis on research which increase capability of instructors at nursing education centers.

Introduction

The purpose of nursing education is not only teaching rational and mental skills but, in this arena, more emphasis is put on promotion of moral, spiritual, and communicative values for serving people (1). In other words, in nursing, simultaneous promotion of both professional ethical competence and technical capabilities are given attention too.

Teaching ethics leads to train nurses committed to and responsible for presenting high quality care (2). Most clear-sighted moral theorists insist on the role of education in promoting nurses’ capability in facing with ethical issues (3). Nursing instructors are significant elements of education. They can increase students’ capabilities in various fields including their self-esteem (4) and taking advantage of learning opportunities (5). The more the contribution of instructors, as meta-cognitive guides, in teaching ethics, the more is the ethical reasoning and decision-making capability of nursing students (6). According to Duquette the nursing instructors are much effective in shaping ethical values of students (7). There are some studies that found nursing instructors affecting the ethical knowledge (2) and moral function (8) of students.

Although in the process of teaching the nursing instructors are more insisting on ethical principles such as justice, beneficence, non maleficence and autonomy, however, problems arise when the students face with the organizational realities of nursing work. Therefore, it is required that nursing instructors prepare nursing students for management of ethical context of their work environment (9). Regarding the fact that the professional ethical competency is highly connected to patients care, therefore, one cannot examine ethical competency as context-free (10). In other words, development of professional ethics in relation to different students and educational systems has specific features. This is due to the nature of ethical issues which takes different dimensions in various socio-cultural contexts. Thus, examining professional ethical competency in different cultures and work circumstances may lead to discovery of new findings.

In Iran undergraduate nursing students should pass 135 units including 26 basic sciences course units, 20 general course units, and 89 specialized course units for getting bachelors degree. A course on nursing history, development and ethics equivalent to one course unit was offered since 1983 and then upon reconsideration of the curriculum a separate course under this title was eliminated in 1995; however issues on nursing ethics were included in all specialized courses. Despite this emphasis and due to the fact that a successful training depends on various factors including qualification of the instructors, content of the texts, teaching method, individual backgrounds of students and methods of evaluation of professional ethics, the extent of success in learning the ethical topics differs at various faculties.

their role as the teachers of ethics has not been attended too much (2). Moreover, in the process of education in Iran, no adequate investigation has been made into the ethical competency of nursing students and, therefore, more qualitative studies are needed for explaining the experience of undergraduate nursing students in relation to the role of instructors especially in this context. This paper reports on the role of nursing instructors, which is one part of a larger study. The aim of the larger study was to explore how nursing students achieve ethical competency. One aspect of the findings was the impact of nursing instructors on students’ competencies from their perspective.

Method

We performed this study to survey the role of nursing instructors in nursing students competency from their perspective. The proposal of this qualitative study was approved by the research ethics committee at Tarbiat Modares University in Tehran in 2008. Therefore 15 undergraduate nursing students with different levels of education from three nursing faculties in Tehran were selected for interview. All participants were informed about the purpose of the study by the first author, both verbally and in writing. The participation was voluntary and all the participants were assured regarding their confidentiality and anonymity.

Main questions were asked focusing on their ethical sensitivity and practice, their experience of working with instructors, and their view on instructors’ role in fostering ethical competence.

After obtaining informed consent, the nursing students were scheduled for interviews at their first convenient. Participants were asked to narrate their experience of achieving ethical competence. All interviews started with the question: “Please tell me about your experience of achieving ethical competence in nursing care?” The students were encouraged to talk freely about their own experiences of learning ethical competence in educational period. During the interviews, the researchers focused on nursing students’ experiences of the role of their teachers in this process. Each interview was audio-taped and lasted between 50 to 75 minutes (with an average of one hour), and then transcribed verbatim and analyzed before the next interview. This process was continued until data saturation occurred.

A descriptive design was used incorporating qualitative content analysis. This approach allows the researcher to explain and interpret the data (11) and elaborate the dominant and major themes of the participants’ experiences (12). The specific procedure of qualitative content analysis used in the present study was based on methods described by Granheme and Landman (13).

Through the interview, the investigator bracketed her own ideas about teachers’ role in achieving ethical competence and focused on the experiences of each participant.

The data collection and analysis were conducted concurrently according to the method of constant comparison. Initially, all interviews and the entire diaries were transcribed into texts. Then the texts were read several times and the meaning units were identified. A total of 500 meaning units were identified. In the next step, the meaning units were condensed and grouped into categories. During the analysis, the intension was to reduce the number of categories by subsuming similar categories into broader categories. Finally, the condensed meaning units were abstracted to an interpretive level to reveal their implicit meanings. The abstractions were read and compared, and those relating to the same content were grouped together.

The credibility of data collection and data analysis was established by member checks and peer checks, external audit and prolonged engagement. The findings were given to all participants, to check for the accuracy of their meaning interpretation. Three expert supervisors carried out the peer checks and two persons outside the study conducted a thorough review of the study and reported their opinions about the accuracy of the data of one third of interviews. The prolonged engagement with the data and participants also helped to gain a better understanding of the field of research. The maximum variations of sampling (in terms of the type of school, level of education, and age) provided the data on a wide range of views and perceptions, as well as enhanced the credibility and conformability of the data.

Results

The mean age of the participants was 22 years. Data analysis showed two main themes and 7 subcategories related to the effective role of instructors in promoting professional ethics in nursing students including: 1) the effective professional role model including the individual’s subthemes and psychological state, clinical skills, responsibility and professional commitment; and, 2) enhancing creative learning which its subthemes including encouraging critical thinking and decision-making, establishing a supportive learning field, having good theoretical knowledge, providing opportunity for fair evaluation and feedback.

Effective Professional Role Model

According to the participants view in this study, models play an effective role in practical education of professional ethics and the instructors have been an important behavioral model in this direction. They considered promotion of professional ethics dependent on the model-centered role of nursing instructors. They believed that students, by observing ethical behavior of instructors, learn how to act ethically. According to the results, the ethical models are not restricted to instructors and many people can show a role model for them. However, they considered the instructors as one of the most effective models and, from the beginning of their entry to nursing course, have always experienced the influence of the instructors on their function in both technical and ethical fields. From the viewpoint of students, the model role of instructors is reporting as the following subthemes:

Individual characteristics and beliefs of role model

Most participants in this study considered the individual features such as responsibility, honesty, patience, cheerfulness, kindness, being practical, and etc as the basic elements of the individual features of nursing instructors in promoting professional ethical competence.

The second student participating in this study stated:

“I remember one of our instructors to be such patient and cheerful that every time they entered the ward, even on being much tired, had a smile and, by this behavior, taught us to be kind and cheerful to patients.”

Another participant stated concerning the importance of honesty of nursing instructors:

“When the instructor is honest, the student, too, learns to behave appropriately. One of our instructors, in the training session or in the classroom, used to tell us that an instructor may not know all the questions you ask (any time they didn’t know the answer to our question with certainty, honestly revealed that they didn’t know the answer and would need to study about the case concerned). I always remember them as a model of honesty.”

The study subjects believed that the nursing instructors should undertake religious principles and values, and establish education based on these values, which help students learn ethical nursing.

A participant stated such in this regard:

“When the instructor him/herself believes in religious principles, surely does what God approves. Of course, this belief should be heartfelt and pure not hypocritical. Some of our instructors are known to be moral thinking, being both religious-minded and ethical nurses. If the belief is real, training, too, is done correctly.”

Another student said:

“If there are instructors with the idea that God is observing them, training goes on very well. I am satisfied with most of our educators. Some may seem to be not so much believing, but when you work with them you find them much committed to some values and emphasis on seeing the God observing our deeds.”

Clinical skills of role model

Considering the care as the essence of nursing, all students considered the necessity of clinical skills for instructors; they also insisted on the model role of the instructors from clinical viewpoint.

Another participant said:

‘If someone who is teaching knows how to do nursing tasks and is skillful, he/she would be able to teach the students well. When a student becomes skillful, he/she provides good care for patients. When a student does his/her task well, ethical nursing comes into being. For example, if he/she has learned how to insert a catheter into a blood vessel, he/she will not pierce ten points for finding a blood vessel. Inflicting no harm is an ethical act. We had instructors who provided such a care for the patients that the medical students came there to learn and we took pride of them.”

Professional commitment of role model

According to nursing students participating in the study, the instructors’ interest in nursing profession has an effective role in learning. Such instructors provide good care by establishing good relationships with patients and spending adequate time on them, which show their responsibility toward patients and provide full-of-commitment care for them.

A student participating in the study said:

“You know everybody needs a model and selects this model according to his/her views. In my opinion, the instructors can be very good models. Some of these instructors from whom I learned good nursing practice; one of them, for example, remained at ward even after their work; and, if the patient’s care had not been ended, worked for him/her. The students, too, by seeing such a sympathetic instructor, learn good care.”

Part of the experience of a nursing student in relation to passing a training course with an interested and committed instructor is as follows:

“We had an instructor such interested in their work that, as soon as came to the patient’s bed, turned up their sleeve and started work and arranged the surroundings of the patient. They made good relationship with patients and worked with such interest that every uninterested student would change to an interested one by seeing them. ”

Facilitating Creative Learning

Encouraging critical thinking and decision-making

The participants in the study believed that the instructors confront nursing students with ethical issues, are effective in promotion of professional ethical competence by means of different teaching methods and creating learning situations.

In this respect, one of the students stated:

“If the instructor, at any ward, discusses the ethical problems of each patient, the student will learn more how to face the ethical problems in his/her work afterwards and how to solve them.”

The instructors helps in reasoning and decision-making capabilities of students, were in the focus of students’ attention. They believed that instructors who confront the students with tough positions increase their decision-making capabilities.

A student expressed his/her experience in this regard:

“During the lecturing, one feels sleepy. If, at the end of the class, you ask such student what he/she has caught, the answer will be: nothing. Well, it will be better if the materials presented become more applied and understandable. For example, one of our instructors discussed a topic on difficult-to-cure diseases and cancer, and explained on a cancer-afflicted patient whose life was difficult to continue and urged to follow an easy death. By hearing such an example, we had to ask whether we would be allowed to help him/her. Such examples help the students contemplate. .”

Another student, with respect to the instructors’ knowledge of different ethics teaching methods said:

“When we jointly discuss the topic at class, we learn more. When we learn how to provide the best care, we will have an ethical care. Discussion on the subjects, especially ethical issues helping critical thinking, indicates that he/she accepts nothing without reason and contemplates on the subjects. .”

Providing supportive learning conditions

The participants stated that the nursing students would have a great role in creating supportive learning conditions. They said that, they provide better care for patients as teamwork. In their opinion, when the instructors allow the students to make mistake without punishment and humiliation, a proper environment full of respect will be provided which facilitates learning. Psychological support more prepares learning environment, creativity, increases capability of solving ethical problems and strengthens honesty in students.

In this regard, a participant stated:

“Once I had drawn a drug into the syringe; my instructor came and saw that I had made a mistake regarding the dose drawn. They told me to come out of the patient’s room and reminded me of my mistake and did not humiliate me in front of the patient. Then, I thought that we are all members of one family and I must care more such that no harm is inflicted on the patients by my error.”

Sharing knowledge

In addition the participants insisted on the instructors’ theoretical knowledge. The participants did not consider the expert’s knowledge of nursing sufficient for promotion of the professional ethical competence, rather more emphasized on coexistence of both technical and ethical knowledge.

Concerning technical knowledge, a student said:

“If good and ethical care is to be delivered, the nursing student should enjoy nursing knowledge. In my view, the educators bear a great role in this arena. When the educator has a proper knowledge of nursing, he/she teaches students scientifically at the same time. One of our instructors was so informed of cardiac care unit (CCU) and taught it so well that all of us learned it in depth. When we learn a job well and do it properly, it is ethical.”

Part of the lecture of a participant concerning ethical knowledge is as detailed below:

“Until the latest semesters, when I was undergoing practical training with one of the instructors acquainted with ethics, I had no knowledge of ethical work. Only in our courses and practical training, general issues were mentioned about patients’ rights, respecting patients, good patients’ relationships, confidentiality and privacy. But, when we were undergoing practical training, they explained ethical issues about the cases which we may encounter during our work; I learned ethical principles.”

Evaluation and creative feedback

Nursing students more emphasized on the observance of ethical aspects of care, especially fair evaluation of their work as an encouragement of ethical development and progress. They also determined the role of instructors technical knowledge in assessment of their weaknesses and strength when facing ethical issues, and considered this evaluation as effective.

A participant said:

“Some of the instructors in practical training do not care whether we observe the ethical issues or not. But, some encourage us when we make good relationship with patients or observe their private limits, and influence observance of ethical principles in evaluation. When the students learn that they are evaluated for observing ethical issues, they try to be committed to them and, gradually, observance of professional ethics becomes institutionalized.”

In this respect, another student said:

“Some of our instructors do evaluate our technical skills and knowledge and, at the same time, have items for evaluation of professional ethics; for example, patients relationship, informed consent, patients privacy, etc. When the student is to be evaluated, he/she will try to observe ethical issues, too.”

Discussion

The findings of this study emphasize the importance of the role of nursing instructors in promotion of students’ professional ethical competence in the process of nursing education. The importance of the instructors’ role in students’ learning is not limited to the findings of the present research and the statements of the students participating in this study; this issue has, also, been referred to previous studies. But, the findings of this study are more perfect ones concerning the effects of nursing instructors on learning ethical matters by students.

The students participating in this research considered the role of instructors as a model promoting ethical issues. They reported that the individual’s characteristics such as kindness, flexibility, honesty, etc are important in this process. Similar findings were reported by Görgülü et al. (14). Parsons et al believe that the role of virtue-based morality for education is very effective, and consider the role of moral models especially the model instructor as vital for teaching ethics (15). Usually, people are inclined to select individuals as role models to share their values and beliefs with (16).

Spiritual aspects are one of the essentials of ethical competence, to the effect that the more the nurses are spiritual and show their spiritual aspects in their work, the more they succeed in ethical issues. All humans have spiritual nature (17). Few works are done in the world lacking value and psychological bases; ethical education is not an exception to this rule. Thus, it is necessary that instructors be informed of their own psychological and belief values, making proper use of them in different educational situations (18). According to Fahrenwald for moral character development in nursing students, it is essential that the students be involved with instructors who possessing ethical and professional values (19).

Participants in this study insisted on the role of instructors as clinical models. According to them, instructors’ competence in clinical skills helps nursing students learning their skills properly and not to harm patients due to clinical insufficiency. The findings of Donaldson et al. confirm the finding that the nursing instructors hold an important role as a model for strengthening clinical skills of students. In their opinion, practical education should be associated with teaching clinical skills, explaining what they should do and giving them training opportunities (20).

One of the significant consequences of teaching ethics to students is increasing their capacity for autonomous ethical decision-making (21). According to the participants in this study, the instructors, by use of different methods, help creation of this capability. Regarding the fact that the essence of nursing work is patients’ care, the educational methods which can promote both theoretical capabilities and technical skills of students are important. Learning only based on experiences means learning from mistakes. Lipp refers to different methods in teaching ethics and considers use of these methods as essential in promotion of students’ capabilities of critical thinking and solving ethical problems (22). In recent years, it has been demonstrated that nurses should be knowledgeable doers, not easily accepting the past routines and blindly follow others’ guides (23). So, the role of instructors in creating such capabilities can be very important. Regarding the fact that ethical, legal and professional nursing issues are interconnected in the context (24), the nursing instructors should be careful to confront nursing students with ethical issues in the context of education and teach them the strategies for facing with ethical dilemmas. The findings of Benner show that this capability is created in students during experiencing ethical issues. Therefore, one should not ignore the role of practical education in ethical training (25). The nursing instructors should ask themselves whether their task is increasing technical skills and know-how in students. If so, do these skills prepare students for future work? Or, should the instructors try to teach the students other skills such as critical thinking, judgment skills, ethical and social responsibilities? (26). Even though, some authors believe that critical thinking cannot be taught (27), but, many authors insist on the role of teaching in increasing critical thinking capability of students; and, particularly, consider the role of instructors as effective in creating this capability (6).

One of the interesting findings of this study is the mere fact that the students generally consider the instructors’ competence from technical and ethical view points as mixed and interrelated. One can not imagine a nurse to be ethical but not to perform his/her work skillfully and on the basis of scientific principles. Therefore, promotion of professional ethical competence requires that the nursing instructors concern necessary nursing knowledge. Also, the participants in this study considered nursing and ethical knowledge as essential for nursing instructors and attached importance to this factor in learning nursing ethics. Miller et al. believe that good work in nursing includes a technically and scientifically convenient work associated with ethical feeling and social responsibility (28). Woods et al. emphasized that, even though the model-centered role of instructors was important for creating ethical attitude of nursing students, but, alongside it, preparing students from the philosophical viewpoint and developing their knowledge in the arena of ethics was an important task of nursing instructors (29).

As nursing has a holistic view toward patients; in interviews, too, this fact has been considered. Participants in the study considered the knowledge of instructors as effective in promotion of professional ethical competence in association with ethical knowledge. Because, if the instructors consider different aspects of care and organize their teachings based on that, the students not only will concern the technique, but also will pay enough attention to different aspects of care including ethical ones. The first and the most significant factor affecting ethical education are the role of skills and knowledge of nursing instructors (30). Bolmsjö et al. take the view that ethical competence requires ethical knowledge, carefulness in determining ethical problems and creativity in indicating possible solutions. Therefore, holding one-dimensional and technical knowledge is, in their view, not sufficient for teaching ethics, and they emphasize on a mixture of all kinds of skills and knowledge (31).

Promotion and development of students’ autonomy is one of the features of good instructors (20). The students in this study believed that if the instructors give freedom of practice to students and, at the same time, keep adequate supervision on and protection for their work, they, in fact, will create proper conditions for their independent work, so they would be able to assume the responsibility of their acts. The significance of facilitating capabilities of instructors has been referred to in texts. These capabilities include promotion of problem-solving and critical thinking, creation of a positive atmosphere for learning, and interest in helping students in learning (6, 32). Moreover, mutual respect, free relationship, demonstrating relationship between ethical principles and behavior, enhancing the student’s perception of their own behavior and knowing different ethical conditions are fundamental principles in the relationship between instructors and students (8).

Data resulted from the present study demonstrates that repetition and continuation of professional ethics requires convenient and fair assessment of ethical behaviors of students and giving them effective feedback. The students participating in the study of Carter et al. expressed their benefits from instructors’ feedback (20).

Conclusion

Instructors are one of the important and key elements of developing nurses’ ethical competence. This study, conducted on the basis students’ experience of their relations with instructors, explains this role properly which seems useful for educational, research and managerial purposes. Division of instructors’ roles into two main features of effective professional role model and facilitator of learning and paying attention to the sub-conceptions of these two can be effective in attracting the attention of instructors to the development of their model role. On one hand, the descriptive framework presented in this article concerning the nursing instructors’ role can be the basis of other qualitative and quantitative studies for making the issue clearer. And, finally, educational management on the basis of the results of this research can be effective in designing the evaluation indexes of the successful nursing instructors in professional ethics and the ways of strengthening these two features.

Table 1

Examples of the process of analysis

Meaning unit	Condensed meaning unit	Subcategory	Theme
If the instructor, at any ward, discusses the ethical problems of each patient, the student will learn more how to face the ethical issues in his/her work afterwards and how to solve them	Encourage student to discusses the ethical issue	Encourage critical thinking and decision-making	Facilitating creative learning
I had made a mistake regarding the dose drawn. They told me to come out of the patient’s room and reminded me of my mistake and did not humiliate me before the patient.	Doing fair evaluation	Providing supportive learning conditions
When the educator knows and understands the nursing knowledge well, he/she teaches nursing students scientifically at the same time.	Being knowledgeable	Sharing knowledge