Chapter 5 : Nursing and   Ethics

Section. 4 Readings

ACKNOWLEDGING THE NEED FOR ETHICS

 IN THE NURSING CURRICULUM

Debra Block D'Amato

NSNA IMPRINT

 I  RECENTLY EMBARKED on my first experience in medical ethics. The professor in a recent course required each student to do a project and offered several suggestions as to what students might do.  The project I undertook was researching information on ethical situations faced uniquely by nursing students, that is, as students of nursing, not as nurses.

   I found that the field of bioethics , largely developed within the last two decades, has not yet been expanded to consider ethical problems faced by the nursing student.  Therefore, the information available is quite limited.

   Prior to acknowledging a need for bioethics, health care professionals studied general ethics for guidelines.  Often they took their guidance from religious traditions and training.

   The present secular age, when philosophers and various professional are recognizing the needs and demands of the health care professions for clarification of ethical issues and principles, gave birth to bioethics.  Initially, it seems bioethicists directed their remarks, articles, and texts mainly toward doctors.  Problems were considered from the perspective of the physician almost exclusively.  It has since expanded to include other health care providers, including nurses.  Nursing students, however, so far have been almost completely overlooked.

   In my attempt to acquire information on this topic, I wrote letters to several schools, publications, and associations.  Most of the responses I received were either incorrect, not helpful, or did not lend themselves to the question at hand.  I was not the first student to attempt this project, and the others also found many closed doors.

   This was so despite the fact that many ethical problems are faced by nursing students with no clear-cut  ethical approach or consensus about handling them.  Such problems deserve the attention of ethicists.

   There are at least three major areas of concern for students informed consent, experimentation, and educational practices.

   Nursing students are involved in the provision of health care and their problems are as significant to them as are the other problems of providers.

   For example, in relation to informed consent:  Should nursing students inform patients that they are, in fact, students especially in those cases where patients mistakenly believe otherwise?  Should a patient be informed that the student is about to perform a procedure for the first time, for example, an injection?  Experimentation also must deal with informing patients, trying a new technique for turning a patient or changing an I.V.  Should the patient be made aware of the experimental nature of the seemingly innocuous procedure?

   Educational problems mostly have to do with the interactions of students and their instructors or school administrators.  Students may be faced with instructors who are “burned out” or whose teaching capacity is inadequate or irresponsible.  When knowledge of their character becomes common among nursing students, often the names of these instructors are deleted when school registration schedules are printed.  How then can a student avoid unfit instructors or initiate their release?  Are not nursing students entitled to a choice?

   At times, instructors f the same nursing course do not always agree on answers to a question on departmental exams.  For example, in a course where the student has one instructor for lecture

Another one for lab, and a required text book, all providing different answers to the same questions, which source should the student believe and follow?  Instructors usually expect students to answer according to their teachings, but the students remain confused as to the correct answer.  Ought there not be a departmental regulation or procedure to resolve such conflicts established before they occur?

  Students within a nursing program are expected to perform in a certain way.  Often expectations and criteria for evaluations are not made clear enough at the beginning of the semester.  What then are the rights of students?  Doesn’t an instructor have a duty to make all expectations, standards, and criteria clear at the onset of the course of instruction?

   Ethical problems also can involve student, instructor, and patients.  For example, the administration of a medication which the student nurse knew according to the standard references to be too strong a dosage for the patient.  In this actual situation, the student approached the instructor before taking action for fear of causing harm to the patient.  The instructor insisted that the student give the medication.  An adverse reaction took place, emergency counter measures were instituted and the patient was saved and stabilized.

   The instructor subsequently blamed the student for not questioning the physicians order.  What should the rights of the student be?  Even with a board of appeals, would there be any protection from academic retribution?  The student was put into a situation that was highly stressful and unfair, if not illegal.  The patient was put in possibly a life-threatening situation.  Yet, in the case this case the instructor’s behavior was not questioned.

   Another student nurse observed the entire incident and made no report.  Was the witness correct in doing nothing and, if not, to whom should the report be made?  To the hospital authorities?  To the school?  To the supervisor?

   All of the situations I have discussed could happen to any student in any school or hospital.

   Through my research while there are many articles dealing with ethics.  I was able to find only a few articles which were helpful in any way.  In the magazine Nursing and Health Care, Sept. 1980 edition, I found an article entitled “Ethics as a Component of the Curriculum.” Which deals with the need for ethics to be included in the nursing curriculum, but I found no articles or discussion of cases faced by nursing students as students.

   Nurse Educator, March-April, 1980, published an article by Mila Ann Aroskar entitled “Ethics of Nurse-Patient Relationship,” and describes how educators can provide students with a knowledge of ethics and values clarification, but again this type of article is focused on issues from the perspective of the nurse and not from those of nursing students.

   “Values Clarifications as a Teaching Strategy in Nursing,” by C. Weber, an article which appeared in the Journal of Nurisng Education (Vol. 17, No. 2, February 1978), proved to be a helpful tool for students and for instructors for teaching students to formulate their own values, while respecting people whose views differ from their own.

   Nursing Educator (Spring 1983), published an article by C.S. Pollok dealing with legal actions which are initiated by nursing students against instructors, entitled “Diminishing Faculty Liability.”

   Another article in Nursing Educator by B.J. Carmack (Spring 1983) on academic dishonesty offered a bibliography on a few articles which they considered helpful.

   An article in the American Journal of Nursing by Pollok, Poteet, and Whelen in April 1976 on students’ rights did likewise.

   The National Library of medicine sent me an article by V. Beardshaw from Nursing Times (March 1982) entitled, “A Question of Conscience,” which dealt with a third-year psychiatric student nurse who refused to take part in a specific treatment because of her ethical beliefs and strongly expressed the need for student nurses to take a stand.

   The references I have included here show that there is a limited amount of information available, yet in contrast to the number of people and places I contacted who should

Be concerned about such matters, the response was small.  Some of the places that offered no help including nursing schools, nursing organizations, and nursing publications, including Imprint

Imprint which has published precious little thus far.

   The project was quite valuable for me in that it demonstrated a definite need for more information on this subject.

   Most of the unhelpful responses were unhelpful because the people I reached misunderstood my request and referred me to people I reached misunderstood my request and referred me to or sent me information geared more for nurses and not for nursing students.  This seems to be a “blind spot” of nursing educators.

   The emphasis and growth of bioethics is young and originally directed more toward physicians, but in recent years offering assistance to nurses.  It is still considered an expanding field and, therefore, it could still expand enough to encompass the ethical issues and dilemmas faced by nursing students.

   This now leads me to express my own feelings about what should be done.  To begin with, ethics should be considered more formally within the nursing curriculum and perhaps made mandatory, along with the study of legal aspects of providing nursing care.

   Instructors, administrators, and students alike need to work together to initiate such educational reforms.

If, in fact, your school does not offer such courses, my suggestion would be to do some on an individual basis, using any and all information available.

   Until there is material which addresses the unique ethical problems of nursing students, students can help themselves by studying general ethics as adopted for physicians or nurses for a clearer understanding of ethical theories, principles, and dilemmas, and then applying what they have learned to their own situations as students.

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