Iranian Pediatric Nurse's Experience: The Facilitators of the Learning of Ethical Practices.

BACKGROUND: Ethical care is a core value in nursing. Pediatric nurses are in direct and continuous contact with children and their parents. They manage their lives and health. As part of the pediatric nurses' daily work, ethical issues play an important role in making decisions, are important to make decisions, and this capability is only achieved by ethical practice. This study aimed to explore the factors facilitating the learning of ethical practice among Iranian pediatric nurses.
MATERIALS AND METHODS: This study is a conventional qualitative content analysis based on the Graneheim and Lundman method. It was conducted through semi-structured interviews with two focus groups, incorporating 28 nurses working in pediatric wards. Unstructured observation and field notes were other methods of data collection. Purposive sampling continued until data saturation was ensured. All interviews were tape recorded and transcribed in verbatim.
RESULTS: Three main categories and 12 subcategories emerged from this study. The facilitating factors include (1) individual competencies (knowledge, experience, emotional intelligence, and loving children), (2) ethical imprinting (responsibility, reflection, empathy, and ethical beliefs), and (3) an environment that nurtures moral values (organizational, spiritual, family, and cultural environments) as facilitating factors.
CONCLUSIONS: The promotion of nurses' competencies, ethical virtues, and imprinting, as well as improvement of the quality of nursing care must be the top priority of the health team. Undoubtedly, the success of the health care system is not possible without ensuring that pediatric nurses learn ethical practices.

Introduction

Nursing is an ethical profession.[1] Pediatric nurses are in direct and constant contact with children and their parents, managing their lives and health. Ethical decision making is an important part of pediatric nurses’ daily work. Acquiring this capability is possible by ensuring ethical practice learning.[2] Ethical practices are professional behaviors in providing care and are supported by ethical codes and standards.[34] Because nurses are the largest group of service providers in the health system and have a significant impact on the quality of health care,[5] they are morally responsible.[6] They encounter ethical issues in practice and it is sometimes difficult to make a decision.[67] In fact, patient care is considered to be an important concept and is a skill and even an art in the nursing profession.[89] Not only physical needs but also values, beliefs, and convictions of patient should be focused on by nurses to provide holistic care. Ethical knowledge is one of the requirements of nursing education.[10] All functions of this profession are based on ethics.[11] Florence Nightingale believed that some ethical virtues for nurses are sincerity, kindness, and obedience, as well as helping physicians in physical tasks. Over time, expectations regarding nurses’ role have changed, and ethical virtues for nurses have become assertive behavior, kindness, patient support, and risk taking. Ethical practice implies being a good nurse and doing the right thing.[12] Nursing emphasizes not only on being but also on doing, not only on duty and obligation but also on the practical dimension of ethics, and not only on behaviors but also on personalities.[13] The official training course in ethics cannot automatically translate recognizing the good in to doing the good deed. Not only is what should be taught a challenge but also how to teach and how to learn are challenging issues. In fact, making nurses ethical agents is an issue.[14]

Care for vulnerable people as nurses’ duty highlights the need for ethical practice among them.[15] Ethical dilemmas occur especially in pediatric wards with greater intensity than in adults.[16] There are more vulnerable groups in pediatric wards and their rights are more likely to be violated than those of adults. Moral virtues such as honesty, trustworthiness, and being kind and gentle with children can be more clearly observed in pediatric wards due to the nature of the care that is offered to children. In addition, professional knowledge and special skills make working in pediatric wards a distinctive activity.[17] Pediatric nurses do not learn ethical practice easily because care takes place in a variable situation affected by rapid technological advances, evolving models of providing care, exposure to different cultures, and arrival of new people to the clinical environment who evolve from beginners to skilled individuals. All these changes lead to difficulties in decision-making under difficult and contradictory conditions, highlight the ethical challenges encountered in the nursing environment, and complicate ethical learning in important points are made.[14] In the nursing literature, important points are made about moral development based on Kohlberg's model, ethical decision-making, and action; the effect of education on the evolution of morality; and the development of tools.[18192021] Ranjbar et al. (2016) proposed a constructivist grounded theory regarding nursing students’ moral development. In their study, they explored the factors that facilitate moral development in Iranian nursing students. This study was limited to facilitating ethical practice learning.[22] Ethical practice is affected by different cultural and social variables. Exploration of facilitator's factors requires a comprehensive and holistic approach which can be achieved using the naturalistic paradigm. In this qualitative study, we have tried to identify the facilitator of ethical practice learning among pediatric nurses in Iranian culture using qualitative methods.

Materials and Methods

This was a qualitative study involving 28 nurses who were employed in the pediatric ward of an educational hospital in Tehran from 2014 to 2016. All the included nurses were willing to participate in the study and had at least 1 year of experience in their ward. They were interviewed and asked about their experience with the facilitating factors of learning ethical practice. Data was gathered through individual interviews among 14 participants and sessions with 2 focus groups. The importance of the study was explained to the nurses. Semi-structured interviews were conducted at previously designated time and places. The interview began with a general question and subsequent questions were asked based on participants’ answers. The aim of the general question was to determine the understanding and experience of participants, for example, “How did you learn to do things ethically?” The subsequent questions were about the factors affecting learning, for example, “What helped you learn?,” “From who did you learn?” Data collection continued until data saturation was achieved. Unstructured observation and field notes were other methods for data collection. Data analysis was conducted through content analysis based on the Graneheim and Lundman method (2004).[23] Interview notes were written immediately after the interview. Thereafter, the notes were studied several times to understand the gist of what was said. Then, the initial codes (meaning units) were extracted and classified based on the similarities of these codes. Interview analysis was carried out using Software for Qualitative, Quantitative and Mixed Methods Research (MAXQDA). Audit trial, member check, and peer check were performed at each stage and at the end of the analysis. Lincoln and Guba's (1986) criteria of trustworthiness were used to evaluate the data. This criteria include 4 indicators, i.e., credibility, and dependability, confirmability, and transferability.[24] Credibility was achieved through the researcher's interaction with the data and data review by the participants and their colleagues in the research team. During peer checking and reviewing, 4 participants were asked to approve the precision of the typed texts. Further, the research team members coded some of the interviews separately and evaluated their similarities. In case of conflict, they reached consensus after consultation. For transferability and fittingness, all the procedures were completely explained. Thus, we tried to present what the participants told us in exact terms. Moreover, the demographic characteristics of the participants and the studied fields are shown in detail so that the reader can decide about using the results. Confirmability was evaluated through controlling the data by external observers familiar with qualitative research methods, i.e., some parts of the interviews with their codes and extracted classes were evaluated and approved by two observers familiar with qualitative research methods. Dependability of the stages of the study was thoroughly recorded and reported so that others would be able to follow the study.

Ethical considerations

This study was approved by the ethics committee of the University of Social Welfare and Rehabilitation Sciences with 902501007 grant number. All participants signed an informed consent.

Results

Participants in this study included 28 nurses working in the pediatric ward with different degrees of nursing ranging from bachelors to PhD. The participants aged between 23 and 48 years old with a mean of 36 years [Table 1]. Codes were classified based on the common features resulting in 12 subcategories, which were also classified into three main categories. They were (1) individual competencies, (2) ethical imprinting, and (3) an environment that nurtures moral values [Table 2]. These factors are presented in detail in the following pages.

Table 1

Profile of the participants

Table 2

Main categories and subcategories of factors facilitating the learning of ethical practice

Individual competencies

This category emphasized on knowledge, experience, self-confidence, and loving the child as facilitators of the learning of ethical practice.

According to pediatric nurses’ experiences, up-to-date knowledge is necessary in pediatric care. Children are a sensitive group and hence pediatric nurses must be skilled and knowledgeable. Pediatric nurses can act ethically when they have the ability to do the right thing. Ethical nurses understand the developmental needs of the children and act based on evidence. Because pediatric nurse deal with children and their parents, knowledge of psychology is important. One nurse said: “The baby was tired. I knew it was due to the side effects of the drugs. If I didn’t know this, I couldn’t manage the child 's conditions.” Our data showed that experience sometimes acted as a facilitator and sometimes acted as a barrier. One of the nurses said: “The more you work with children, the more you learn about them and the job. It seems as if you find the way to deal with them, and your relationship with them improves.” On the other hand, some nurses believed that being young is a facilitator. They expressed that working in the ward becomes a habit which reduces some of the ethical sensitivities. One nurse said: “Some of our colleagues have several years’ experience and they have no better ethical sensitivity. They only attend to the technical aspects of nursing.” Pediatric nurses’ experiences showed self-direction, self-control, and management giving them self-confidence. Knowledge, skills, and previous successful experiences increase self-confidence. Self-confidence leads to taking the initiative to help the clients, increased speed of decision-making, and implementation of decisions. Therefore, learning facilitates ethical practice. Regarding self-control one nurse said: “The first day, my own child was but when I went to work, I forgot it. I shouldn’t impose my personal and organizational challenges on the patients. When I take care of children, everything is pleasant.” Some special features make pediatric nurses special human beings. Flexibility, dutifulness, supremeness, showing compassion towards the children, patience, forgiveness, and ethical sensitivity were identified as special features. This features lead to feelings of love towards the children. In interviews, some participants expressed that nursing care for children is different from that of adults. Loving children is necessary for successful nursing in the pediatric ward. The pediatric nurse must be able to enter the child's world. When the nurse communicates with the children and their parents, the opportunity is gained for learning ethical practice. This leads to delivering ethical care. Some nurses work for children until their last breath and say this work revives them. A nurse said: “We had 18 patients; I worked for them and was so tired. At this time, a child's mother asked me ‘Doesn’t working and self-sacrificing for the patient make you exhausted?’ I answered It the children and working for them that revive me, they refresh me, actually they grant me things.”

Children’ innocence and their being easily satisfied create a growing interest in nurses to work in pediatric wards. In this situation, nurses try to decrease the distance between them and the patient. It leads to delivery of care with love. Nurses try to use the friendliest forms of care such as touching, playing, and drawing. A nurse said: “A child was crying because of kidney stone. I hugged her from behind, while I whispered poem for her. She found comfort. It is my love that was transferred to her. I think this is pure sympathy.” Sympathy toward the patient is not merely for eliminating pain but is a moral choice. Pediatric nurses who apperceive children's pain and act sympathetically express that sympathy can be transmitted to the child through the least and slightest care. One participant said: “I play with children. I attach a toy on my dress. When I inject a drug, I sing and caress the child. I always put chocolate and candy in my pocket. Because I love the children, if they vomit and urinate on me it is not important to me at all. I do everything I can for their comfort.”

Ethical imprinting

This category emphasized following role models, reflection, empathy, and ethical beliefs as facilitators of ethical practice learning. Ethical imprinting leads to changes in nurses that prepare them for learning ethical practices. Following role models emphasizes the effect of role models. Role models include peers, nursing managers, and teachers. Ethical role models motivate nurses to learn ethical practice. One nurse said: “My role model in nursing was Mr. J. he comes to the ward at 6 o’clock. He thought of as his home. He knew all the patients in detail. He had time for all the patients. He worked until the last breath for the patients and enjoyed it. I really tried to follow his lead in taking care of my patients.”

By thinking about the events occurring in the workplace, especially the behaviors of oneself and peers, pediatric nurses practiced reflection. This led to ethical imprinting. The behaviors of one and peers were effective in both positive and negative aspects. Nurses thought about their own positive behaviors that of their peers and tried to improve their abilities to repeat them and in this process learned ethical practice. They also thought about the negative aspect of the behaviors of oneself and peers and tried to improve their performance by avoiding those behaviors and by replacing them with better behaviors in the same situation, learning ethical practice. One participant said: “One day a child was hospitalized in our ward and did not let me do anything for him. I wanted to change his catheter and he delayed me for several hours. I said I can’t give you drug if you do not let me change your catheter and then you will die. I went out with anger and told him he will die. He next day, when I went to work, I was told that he had died. My thoughts were engaged with this issue for a long time and I thought about it. This event affected my behavior towards children and changed me a lot. I told about it to my colleagues and we thought about it together.”

Studying pediatric nurses’ experiences showed that empathy can lead to ethical imprinting. It implies understanding the sensitivity of the parent about the child and considering the patient as your own loved ones. Nurses’ communication with the parents is inevitable due to their presence at the bedside. Psychological distance between the nurses and parents creates differences in their perceptions. This is due to disregarding ideas, experience, values, and having negative attitudes toward the behavior of parents. Empathy of nurses toward children and parents creates an atmosphere that facilitates the learning of ethical practice. This leads to care according to ethical practice. One nurse said: “When my mother was hospitalized, the behavior of other nurses who took care of her affected me a lot. During that time, I always thought if my patient was my own mother, I took care of her differently and more carefully. This later became my work style and I would assume every patient to be my own loved ones.”

Ethical beliefs include ethical commitments. Nurses said they behaved ethically because they must be ethical. If nurses do not behave ethically nursing errors occurs. Nurses believed that the results of their behaviors would return to them. Nothing in the world remains unanswered. Nurses must achieve self-discovery and behave ethically. They must identify their weaknesses and capabilities and ask help from more capable people. These beliefs incite the inner drive to learn ethical practice. One nurse said: “I always believe that actions speak louder than words, when I do anything for children, I encounter its results and consequences in my life. If what I do is right, I feel calmer and more successful.”

An environment that nurtures moral values

This category included four subcategories of organizational environment, spiritual environment, family environment, and cultural environment as facilitators of ethical practice learning. Environmental reinforcement is a basic strategy to support the learning of ethical practice. Data show that if organizations have rules to support ethical practice they give importance to customer orientation. A social relationship starts by paying attention to patients. It causes patients to be seen, their voices to be heard, and their needs and expectations to be understood. Supportive organizations provide financial support for nurses and as a result encourage and promote ethical practice. Nurses stated that additional shifts due to financial problems reduce the quality of nursing care. Setting the correct standards for ethical practice and planning for education and training helps ethical practice learning. Here, education included group training, training new nurses, and continuous education. Supporting ethical practice by the organization based on the mentioned items facilitates the learning of ethical practice by pediatric nurses. One of the nurses said: “When I see that good communication is important for the ward and the correct working of a nurse is important for the managers, I improve improved myself. When the managers just expect the nurses to wear uniforms and be present that only wearing uniform being in the ward quality of nursing care reduce decreases.” Spiritual environment emphasizes sacred care and belief in God as the supervisor of nursing procedures. Belief in a powerful and supportive supervisor that selects nurses for taking care of children can affect nursing practice. Delivery of spiritual care was identified as a part of ethical practice. Nurses must have a spiritual management to uphold values and maintain the patient's relationship with God. One nurse said: “Taking care of children care is a blessing and gift from God and the root of ethical practice is a belief in God and religion.” Regarding family environment, nurses’ experiences showed that the origin of ethical practice learning is the family. It has two dimensions – family upbringing and supportive family. Learning in the family shapes the personality of the nurses. Based on the opinion of the nurses what parents teach their children is repeated in adulthood. On the other hand, support from one's family enhances the learning of ethical practice among pediatric nurses. Nurses stated that they tell their families about the moral challenges that they encounter in the pediatric ward. Their families discuss these challenges. They think about these situations and make decisions about them. Hence, family members share shared their experiences. A supportive family facilitates the learning of ethical practice. One nurse said: “In our family moral values are important. My father died when he was died. My mother tried to play have the role of both. She assigned me responsibilities in return she had me responsible for them. When I was a nursing student I talked with her about the moral challenges that happened in my relationship with patients. She always guided me.”

Cultural environment included including the dominant culture of the nurses in patient care. Nurse's dominant culture is composed of inner moral values and attitudes in the pediatric ward. Values and attitudes of the nurses affect the care of children. Education and training creates attitudes or changes them. Nurses expressed that college training had a major impact on the culture of child care. The nurses who were educated in major universities are sophisticated and skillful. Their child care routines are more accurate. They are more sensitive in honoring and respecting the rights of children and their parents. If the culture of ethical practice learning is the dominant culture, there are certain consequences. Its consequences are the pervasiveness of ethics learning, availability of learning resources, and the availability of the resources at a local level. Such a culture facilitates the learning of ethical practice. One participant said: “We used to work the same culture in child care that we learned during our student years. My colleague and I were educated in major universities and act similarly. We promised to do things when we are certain about it and consult each other if we are in doubt. Our dominant culture involves peer learning and accuracy in doing the right things.”

Discussion

Pediatric nurses’ experience showed that the phenomenon of ethical practice learning is a challenging process which is affected by facilitators and barriers. In terms of individual facilitating factors, given the complexity of child care, nurses who have higher awareness and knowledge of child health care and are aware of new caring methods and act based on evidence were more successful in ethical practice learning. Similarly, Borhani et al. (2013) demonstrated that individual characteristics are facilitating factors of ethical sensitivity. They mentioned education as the major factor that has a significant impact on the initiation of each task and that awareness of professional ethics and professional tasks can create higher ethical sensitivity.[25] The experience of taking care of children sometimes acted as a barrier and sometimes as a facilitator. Some nurses stated that being young is a facilitating factor and admitted that more work experience reduces ethical sensitivity in child care. Some studies have suggested that personal characteristics such as work and life experience affect ethical sensitivity.[2627] However, in our study job experience had two aspects. Loving child was one of the special characteristics of pediatric nurses and acted as a facilitating factor. Having ethical virtues, such as honesty and truthfulness, patience, seeking justice, and conscientiousness, were among factors identified as affecting the ethical practice of nurses in the study of Pourbandbani (2013). Participants in that study stated that having ethical virtues such as honesty and truthfulness, patience, justice, work ethic, and other virtues are necessary for learning ethical practice.[28] Weaver and Morse (2008) emphasized personal characteristics and interpersonal relationships.[29] Gallagher also counted personality characteristics such as kindness, dignity and poise, a sense of respect for others, and avoiding deception as integral components of an ethical nurse.[30]

Ethical development has been emphasized in literature whereas in our study ethical imprinting and its four components have been discussed as a new finding. Ethical imprinting was discovered to be a facilitator of the learning process. The positive instructors and teachers were identified to be facilitating factors in ethical practice learning.[31] The nurses who are looking for a practice model to improve performance should learn ethical practice,[32] which can indicate the ethical philosophy of virtue in which ethical work becomes is a habit and turns into a virtue and the person performs it on a regular basis.[12] In this study, nurses expressed that they learned ethical practice from events in the workplace. Reflection is a method in nursing education.[33] Abedini in his study mentioned that rethinking and reflection affects the skills and knowledge of students in clinical education and leads to improved abilities and increased self-confidence of nursing students in practice.[34] Study results showed having sympathy with patients and considering patients as loved ones can be a facilitating factor of ethical practice learning among pediatric nurses. Manning (2006) in his study concluded that empathic understanding occurs when a person can have sympathy with another person in an ethical situation and can comprehend his/her situation. She/he must be able to put herself/himself in the other person's place or use her/his previous experience in this field to be able to do this.[35] Philosophy of ethics becomes important when at least two people come in contact. Ethical sensitivity results from direct mutual understanding. Nurses follow ethics if they understand the needs of patients by putting thems in their situation.[25] Ethical beliefs believe include ethical commitments. In a qualitative study on the nurses’ understanding of palliative care it wassuggested that their philosophies (nurses’ beliefs and feelings that it is their duty to do their best for the patient and the important reasons they have for nursing interventions) play a basic role in ethical decision-making.[36] Thus, the identification, detection, and utilization of these beliefs can lead to learning of ethical practice.

An environment that nurtures moral values has been supported in other studies. Some studies have shown that environmental factors affect the ethical aspects of nurses’ behaviors. Support the role of the environment in ethical practice learning, Gigerenzer (2008) stated that learning ethics is only possible by accepting the fact that ethical behavior is a function of mind and environmental structures.[37] An ethical work environment can predict the intensity of moral distress intensity. Therefore, by offering ethical training programs managers of hospitals can promote nurses’ job satisfaction.[38] Hoglund et al. (2007) explained the role of ethical guidelines in creating ethical competencies. They mentioned that the staff's familiarity with the application of ethical guidelines provides opportunities for ethical dialogues and as a result improves the ethical climate in the organization.[39] Positive environment can promote a nurturing workplace, encouragements in the workplace, and the development of the work environment causes employees to develop an interest in their work environment.[40] Available literature has highlighted the effect of education and training on the creation of an environment that nurtures moral values.[526] The results of this study indicate that if we pay attention to the training of novice nurses and use indirect training methods for teaching ethical values, for example, group educations as well as continuous education of pediatric nurses, it can facilitate the learning of ethical practice. Lachmann (2007) reported that, in an ethical work environment, all actions at all levels, policies, and procedures support ethical practice.[41]

Spiritual support has been confirmed to be significant in other Iranian studies under the name of as religious beliefs and God's supervision.[2536] In a study by Taylor et al. conducted on American oncology nurses, it has been emphasized that nurses should provide spiritual support in a variety of ways that are often personal and private. Yet they do so infrequently and with some discomfort.[42] The cultural environment affects the ethical practices of nurses by creating models of professional practice and participation in ethics committees and empowering nurses. It also talks about the effect of coworkers on the ethical practice of nurses, and it has been stated that peer support can affect the performance of nurses in supporting patients and ensuring the patients’ safety and health.[41] This study was conducted only on nurses working in pediatric wards. It is recommended that similar studies be conducted on nurses working in other wards. The fact that the nurses were very busy and had not enough time was a barrier to conducting interviews, which was removed by making appointments in advance and conducting interviews outside of the working hours.

Conclusion

In the current study, individual competencies, ethical imprinting, and an environment that nurtures moral values were identified as facilitating factors of ethical practice learning. Providing learning elements and reinforcement of their facilitators must be the priority of the health team's interventions to support pediatric nurses. Managers can help the learning of ethical practice by selecting and employing qualified people with special features such as knowledge, experience, self-confidence, and the love of children. Nurses can facilitate the learning of ethical practice learning with ethical imprinting. Following role models, reflection, empathy, and strengthening moral beliefs can lead to ethical imprinting. Educational policy makers, nursing managers, and nursing educators can facilitate the learning of ethical practice in pediatric nurses by creating an environment that nurtures moral values. Improvements in the quality of nursing care must be the priority of the health team's interventions. Undoubtedly, the success of the health care system would not be possible without emphasizing and paying attention to learning of ethical practice among pediatric nurses.

Financial support and sponsorship

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.

Conflicts of interest

There are no conflicts of interest.