Research Article
Anita Jennings1*
1Faculty, Ryerson, George Brown, Centennial Collaborative BScN Nursing, Sally Horsfall School of Nursing, George Brown College, Toronto, Ontario, Canada
*Corresponding Author: Anita Jennings, PhD, Faculty, Ryerson, George Brown, Centennial Collaborative BScN Nursing, Sally Horsfall School of Nursing, George Brown College, Toronto, Ontario, Canada, Tel.: +416-415-5000. Ext 6669; E-mail: ajenning@mail.georgebrown.ca.
Received Date: January 04, 2019 Accepted Date: February 06, 2019 Published Date: February 14, 2019
Citation: Jennings. A (2019). The Ethics of Teaching in the Clinical Arena. POJ Nurs Prac Res. 3(1):1-7. DOI: https://doi.org/10.32648/2577-9516/3/1/1
Copyright: ©2019. Jennings. A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Clinical practicum forms an important component in undergraduate nursing education and involves clinical nurse educators who are primarily involved in teaching student nurses. Twelve clinical nurse educators participated in this grounded theory study, and these participants taught in a number of undergraduate nursing programs in a large metropolitan city in Ontario, Canada. The results from this study revealed four important concepts that underpinned their teaching and, in this article, the author explains one foundational concept: The ethics found in the pedagogical practices of clinical nurse educators. This result provides a deeper and broader understanding of the ethical issues that clinical nurse educators encounter in their teaching practice, how these considerations contribute to student learning and some of the challenges that they encounter in the clinical arena.
Introduction
The purpose of an undergraduate nursing education is to prepare student nurses to think critically and to act safely and independently [1,2,3]. Undergraduate nursing curricula consist of theoretical and practice components and, in the practice courses, student nurses learn to care for individuals of diverse ages in a variety of clinical settings. The purpose of a practicum is to enable students to integrate concepts taught in the classroom into practice, and to familiarize themselves with the practice environment context thereby enabling them to become effective practitioners of nursing [4-7].
Nursing as a professional discipline involves teaching substantial amounts of nursing theory and related skills so that students can effectively care for their patients. Nursing education in the clinical arena includes the integration of those theoretical concepts into practice, the application of that knowledge, the experiential conceptualization of knowledge, and socialization into the profession [8,9]. In this article, the author addresses one concept, that of ethical considerations using data from a larger study [10,11].
Literature review
Clinical supervision[1] is an essential element in nursing education as it enables learners to consolidate their knowledge and facilitate professional growth [6,12]. In nursing, supervision is defined as a “formal process of professional support and learning which enables individual practitioners to develop knowledge and competence, assume responsibility for their practice and enhance consumer protection and safety of care in complex clinical situations” [13].
The clinical nurse educator in most cases is a seasoned nurse with knowledge and expertise in clinical or administrative nursing [5,7,14,15,16]. Some of the main functions of a clinical nurse educator’s role are as follows: to guide students in integrating theoretical concepts in practice and in planning care for the patient; to instruct students in learning skills and procedures; and to engage students to critically think about their nursing practice in planning how they care for their patients.
Nurse educator Paton (2007), whose study examined the teaching practices of nurse educators also explored the ethical practices of the participants [17]. Paton (2007) conducted a phenomenological study of clinical nurse educators in Alberta, Canada, and interviewed nine clinical nurse educators in 32 unstructured interviews. She analyzed the data using a Heideggerian interpretive approach and situated the study in “philosophical literature on the notions of tacit knowledge” and practical wisdom (p. 488). Paton explored with the participants their experiences of “making sense of situations characterized by a misfit between what is known and what was expected to be known for a given situation, that is Unready to hand immersions” (p.489). Paton explains this Heideggerian concept of unready to hand as the “knowledge required to guide a teacher in her/his teaching that does not fit the context and [where] the smoothness of activity is interrupted” (p.493). Participants portrayed their moral commitment to students and the profession by maintaining respectful relationships with students and doing good for the patients. In doing so, participants revealed their ethical knowledge in their teaching and in their interactions with students in the clinical arena in ways similar to those seen in this study.
Although both studies share some similarities, there are two important differences. The results reported in this study reveal in more depth the ethical decision-making process that participants engaged in on a consistent basis and how they contributed to student learning in significant ways by modelling ethical concepts in their instruction. Secondly, the author, by using a grounded theory approach was able to highlight some of the challenges that the participants encountered and their effect on instruction. This aspect was missing in Paton’s study. Examining the ethical nature of teaching in nursing adds another layer to understanding clinical teaching and this information is largely missing in the nursing literature.
Methods
The author utilized a grounded theory methodology in this study. In this approach researchers are able to investigate social problems or situations where little is known about the problem or where individuals have to adapt according to the context [18,19].
The two research questions which guided this study were as follows:
- How do clinical nurse educators approach teaching undergraduate student nurses in the clinical arena?
- What challenges do clinical nurse educators encounter while instructing undergraduate student nurses in the clinical arena?
Study design
A grounded theory approach developed by Charmaz (2010, 2011) was utilized in the study design [20,21]. Charmaz uses a constructivist lens that aligns and supports a constructivists and critical lens used by the author to theorize participants’ approach to their teaching in the clinical arena.
Grounded theory methodology focuses on the systematic generation of a theory drawn from data analysis that documents the meanings of events and/or interactions of individuals and the language they use to convey those meanings [18-28]. Using this method, researchers move beyond the individualist, person-by-person experiences and generate an emergent theory at a broader conceptual level. Adherence to this method is further documented in another publication [10].
The pedagogical practices of clinical nurse educators emerged as the central concept in this study which also revealed four main concepts, one being the ethics of instruction that is embedded in the teaching practices of the participants and which is the focus of this paper.
Ethical considerations
The study received ethics approval from the Ethics Boards found in the participating education institutions. The study was considered low risk as the participants were independent practitioners and the study received approval through an expedited process. Informed consent was obtained before and throughout the study.
Participants
The author selected a total of 12 participants and all these participants were mainly involved in instruction in the clinical arena. All participants had obtained graduate degrees, reflecting the required education qualifications of current clinical nurse educators hired in undergraduate nursing programs. Four participants had graduate degrees in education and eight participants had received graduate degrees in nursing. 11 participants were hired on a part-time or contract sessional basis and one participant was hired full-time; 11 participants taught throughout the academic year; one taught part of the time in the winter term only; and some also taught throughout the calendar year.
Eight participants taught in two to three different schools of nursing, in Toronto, Canada, while the remaining four taught in one school of nursing. The employment experiences of these participants reflect the current employment situation of clinical nurse educators hired to teach in undergraduate nursing programs. Moreover, the varied experiences of participants enabled them to compare and contrast curricula development and implementation across many education institutions thereby adding in significant ways to nursing education in the clinical arena.
Data sources, study procedures and data analysis
Data sources in this study included face to face interviews, transcripts, memos, and field notes. The author conducted two rounds of interviews with each of the 12 participants. From these transcripts the author made comparisons within the data, developed and populated categories, checked for relevancy of the concept amongst participants using a constant comparison approach. The author used an interactive, comparative, and iterative process. In this method the researcher goes back and forth between data collection and analysis iteratively, as each informs and advances the other [18,19,20,26,27,28,29,30].
The interviews were semi-structured in nature and included both open-ended and close-ended questions. After the fifth interview, the author began examining the data for emerging concepts. The author employed focused, axial and theoretical coding to develop the emerging concepts [20,24]. The author used criteria of credibility, transferability, and auditability, as these measures encompass both methodological and interpretive rigor [31,32].
Results
Results from this study indicate that teaching in the clinical arena is both complex and multi-layered. Clinical nurse educators require sound knowledge of nursing, knowledge of pedagogy and more than five years of nursing experience in order to most effectively guide students in developing their knowledge of nursing practice [10]. Education scholars Campbell (2003, 2003a), Fenstermacher (2009), and Hansen, (1998) have established that teaching is a moral activity and data from this study supports that claim [33-36]. Similar to the ethical issues that are embedded in nursing practice, the author suggests that teaching in nursing contains intrinsic ethical aspects which have yet to be comprehensively addressed in the nursing education literature and practice.
The concept, Ethics in teaching represents the participants’ experiences, thoughts and viewpoints framed within the author’s interpretation of the meaning expressed in their words or actions [20,24]. This concept encompasses the following three sub-concepts: the personal and professional values that guided the participants’ instructional activities; the ethical situations that they encountered while teaching in the clinical arena; and the sources of ethical conflict. The author provides one excerpt to illustrate each concept.
Personal and professional values
Participants described many experiences that exemplified their personal and professional values about their teaching, and the transcripts also revealed many ethical situations that demonstrated the participants’ values about their teaching. Participants mentioned several values such as honesty, respect, and fairness that they considered important in their interactions with students, patients, and colleagues. In the following excerpt, Jessie’s portrays her ethical values in her teaching and in her decision making:
I had another student, and it was a surprise to her to see mom’s bottle-feeding. She’s right, on the benefits of breast-feeding. She [sic-the student] could not understand why they were bottle-feeding. I agreed with her 100% but I said we have to look at the mother’s decision. Whether we agree with it or not, and she [the student] was very surprised about it….I said [to her], “It was very good of you as your role was to educate and to accept the mother’s decision although you did not agree with her in bottle-feeding her baby.”
Jessie articulates her values as well as her reasoning for her decision making. In assessing the situation and the student’s response, Jessie was able to discern the ethical issues inherent in the case, and she gently guided the student in examining the salient ethical features of the situation. The student seemed to focus mainly on the benefits of breast-feeding and less on the ethical issues of autonomy of the patient and/or respecting the mother’s decision. Jessie acknowledged the student’s response and guided the student in integrating the professional value of respecting the patient’s autonomy in her nursing practice. Jessie’s manner and tone also illustrates her respect for the student and her action denotes the importance of upholding and modelling that same ethical principle of respecting a student’s autonomy. Also, Jessie demonstrated her values of compassion and empathy for both patient and student in the situation.
Participants’ personal and professional values seemed to guide them in recognizing the ethical issues inherent in a situation, and influenced their actions while they maintained focus on the needs of patients and students alike. Campbell (2003, 2003a) claims that an ethical teacher demonstrates values of honesty, integrity, fairness, and compassion in her/his teaching practices and in her/his interactions with students [33,34].
Also, values not only inform a teacher’s moral responsibility to students, students also learn the importance of values through their interaction with teachers [33,34,35,37,38,39]. The student nurse in her interaction with Jessie learned the importance of respecting a patient’s wishes and, at the same time, became aware of her personal beliefs and biases. In this situation, Jessie guided the student in acknowledging her biases, which is an important aspect of learning.
Jessie’s action suggests that she had carefully reflected on the many complexities in the situation before making her decision. Reflection in action enables educators to carefully consider students’ viewpoints in real time, whilst simultaneously monitoring their personal response as they additionally integrate theoretical concepts into their practice [40]. Such fluency in teaching takes a considerable amount of experience and expertise. Jessie’s formal preparation in education and her 10 years’ experience in teaching enabled her in developing her ethical knowledge of teaching and guided her in her interactions with students.
Encountering ethical situations
Karin encountered an ethical issue where she had to carefully consider the learning needs of the student and balance it with the student’s ability to safely administer medications to the patient. This excerpt also reveals the teaching context of participants.
I had a student who wanted to give insulin. I want to give insulin, it was a 12hr shift, and I said OK you could give the 5 o’clock insulin. Great I can’t wait [student states]. At 4:30pm, I started asking him about insulin, what type of insulin it is, when do you expect it to peak, etc. etc. and he couldn’t answer any question. I said you are not prepared; giving insulin is more than stabbing a patient with a needle. You need to have the knowledge and you don’t. Try again tomorrow.
Karin realized that the student was focused on performing the skill rather than integrating the required knowledge needed to administer the medication safely to the patient. In assessing the student’s knowledge and recognizing the learning opportunities inherent in the situation, Karin weighed the pros and cons of her decision. Karin considered the student’s learning needs in relation to the importance of safe patient outcomes in the learning context. Her values related to nursing and teaching guided her in requiring the student to possess in-depth knowledge of the medication before the student could be considered able to administer the medication safely.
Throughout the data, participants seemed keenly aware of their ethical responsibility to students and patients and their commitment to professional values and standards. All study participants mentioned frequently and detailed several experiences where they had to balance the learning needs of the student with the student’s ability in providing safe care to patients. The College of Nurses of Ontario (CNO), the regulatory body for nurses in the province of Ontario, states that “while planning the learning experience, the educator will place the safety and well-being of the client above all other objectives” [41]. Some participants provided this standard as a guide in their decision-making whereas other participants were guided by their personal values in addition to following the standard.
Encountering ethical conflict
Some factors emerged that made teaching ethically difficult in the clinical arena and the two most common factors were the high teacher-student ratio and the lack of inclusion of participants’ input into decisions related to the clinical curriculum. The high teacher-student ratio emerged as the most common cause of stress and a source of ethical conflict amongst the participants.
Margaret identifies the teacher-student ratio as ethically problematic because of the challenge of weighing the learning needs and abilities of each of the eight students in the group against their current level of ability to provide safe care to patients. Thus, this is not simply a problem of teaching overload, but an issue within the specific context in which teaching occurs.
Having eight students is a lot. When you are starting to do medication and watch them do medication it is a lot. I think that’s the biggest disadvantage to clinical teaching compare to teaching in the classroom, I would say. You want to give each student a good chunk of your time and when you have eight students giving medications and all are due at 10 am you really can’t. If 1 student takes half an hour, you have seven students who have to give meds by 10 am. I find this is the biggest challenge and huge disadvantage to clinical. In the other program I have five students, it is different as I can focus and spend a lot of time with 1 student in this program and focus my time and give that opportunity. As opposed to eight students it quite difficult and you are running especially if someone has meds round the clock. You don’t have time.
Margaret had eight students in her group and some students were assigned to administer medications. She needed to ensure that each student possessed the required knowledge and abilities to administer the various medications safely to that patient. Additionally, as each patient may have several medications, Margaret had to ensure that each student possessed in-depth knowledge of each medication so that she/he could administer the prescribed medications in a safe manner. Also, the short time frame to administer medication to each patient as determined by professional guidelines and/or unit policy was another source of stress expressed by participants. In addition, Margaret had to consider a number of obligations to students, patients, and the profession, thereby adding to the complexity of ethical decision making in her teaching practice.
Discussion
Clinical nurse educators are required to make ethical decisions on a consistent and timely basis and this result adds another layer of complexity to teaching in the clinical arena. The results from this study also revealed that participants seemed to possess a deeper and more nuanced understanding of safe patient care. Also, clinical nurse educators contribute in significant ways to the scholarship of teaching, an aspect of their contribution that is yet to be acknowledged by nurse educators and nurse administrators in the schools of nursing.
In the following section, the author further explains each of the above-mentioned exemplars and situates each in the relevant literature.
Personal and professional values
In the above-mentioned exemplar, participant Jessie appeared to be very present in her teaching and was able to discern the ethical issues in that situation and guide the student’s response from an ethical perspective. Jessie guided the student in her moral reasoning and in coming to a decision informed by professional nursing values. In doing so, Jessie contributed to the student’s understanding of integrating important ethical concepts into her nursing practice. In being present, teachers are able to ground their observations in many dimensions at once: intellectual, cultural, physical, spiritual, ethical, and emotional [42].
Hansen (1998) explains that teachers ought to be fully present in their teaching as teaching is simultaneously a moral act and an intellectual challenge, and that teaching is
a moral endeavour because the practice involves assisting students to broaden their horizons. It entails helping students to become more knowledgeable rather than less so, more interested in learning and in communicating rather less so, more expansive in their thinking and in their human sympathies. (p.649)
This quote not only describes the moral responsibilities of teachers but also reveals an important ethical assumption. Ethical teaching relies on building a professional relationship, a caring partnership between nurse teachers and students. All participants described in detail the importance of building partnerships with their students and frequently mentioned words such as building partnerships, using hope and encouragement and caring in their interviews.
The author found that different factors influenced newer clinical nurse educator participants in their decision making compared to those more seasoned participants. Newer educator participants with six years or less of teaching experience mentioned those professional values outlined by the College of Nurses of Ontario (CNO) as guiding their teaching decisions. On the other hand, participants with more than 10 years of teaching experience frequently mentioned their commitment to patients and patient safety as the main motivations guiding their decisions [10]. Perhaps not surprisingly, these factors that guided seasoned participants in their decisions seem to be more personal and internalized than those mentioned by participants with fewer years of teaching experience.
Ethical decision making in teaching
Participants described many ethical situations that they encountered in their teaching practice and frequently mentioned the importance of considering the learning needs of students and weighing these in relation to the students’ ability to provide safe care to patients. For instance, on instructing students in performing procedures such as administering oxygen to patients, participants described how they needed to ensure that all students were given the opportunity to meet course objectives, and at the same time consider the implications of their decision on the students’ ability to provide safe care to patients. Each factor added to the complexity of ethical decision making in the clinical arena. Balancing different and sometimes oppositional needs required careful deliberation by participants amidst the busyness found in nursing units.
Unlike the reasoning demonstrated by the seasoned participants, the author found that participants with five years or less of teaching experience found negotiating this balance difficult and stressful. This result has important implications for nurse administrators to consider when hiring clinical nurse instructors and planning professional development for instructors.
Participants and ethical conflict
Participants were regularly engaged in making ethical decisions in their teaching and engaged several interrelated roles simultaneously; those of teacher, caregiver to the patient, an educator to the student, the patient, and the unit nurses. These multiple commitments increase the likelihood of encountering conflicting obligations. It seems that most participants encountered ethical conflict mainly when instructing students on how to safely administer medication. Margaret explains that she needed to consider the individual student’s learning needs, the learning needs of the group, the patients, and the unit’s policies. The excerpt reveals the ethical conflict that Margaret experienced as she tried to fulfill conflicting and divergent obligations to each student and to the patients for whom the students provide care. Also, Margaret needs to meet timing requirements in the curriculum that determine when students should begin to administer medication and at the same time negotiate her ethical responsibilities as a nurse educator to student learning and safe patient care. In addition, student nurses may not have had adequate knowledge in the administration of medications, yet because the curriculum prescribes when student nurses should administer medications there are often challenges with student readiness. All these factors add to the conflicts that Margaret experiences and the ethical complexity of her teaching involving students and patients alike.
The author found that both new and seasoned clinical nurse educator participants struggled with making appropriate ethical decisions and it seems that tensions between the prescribed curriculum and clinical imperatives were the main source of ethical conflicts. Participants also mentioned the lack of opportunity to share and discuss their problems with other clinical nurse educators, the lack of adequate knowledge of the curriculum, and the lack of support from the course leaders as contributing factors. All these factors add to the complexity surrounding teaching and ethical decision making in the clinical area.
The participants identified many problems directly related to the curriculum, and these problems echo similar concerns made by other nurse scholars (e.g. Benner, Stuphen, Leonard, and Day 2010; Ironside, 2004, 2005; Schaar, Titzer and Beckham, 2015; Tanner, 2006) who collectively argue for the need for radical transformation in both curricula development and pedagogy in nursing education [16,43,44,45,46].
The ethical issues expressed by participants’ echoes similar concerns expressed by other nurse educators. For instance, Dinkelman, Margolis, and Sikkenga (2006) and Kopala (1994) state that clinical nurse educators have additional responsibilities compared to nurse educators teaching in the classroom [47,48]. Clinical nurse educators have competing responsibilities as they are directly responsible to students, to patients for whom the students provide care, to the educational institution, to hospital organizations where the clinical instructor operates, to their professional expectations, and to school-practice partnerships [48].
Stokes (2007) found that nurse educators experience moral conflicts in teaching nursing students in the health care environment as result of their obligation to those patients for whom the nursing students provide care, commitment to the students they educate, and to the education institutions in which they work [49].
Stokes (2007) also reports that clinical nurse educators in particular encounter moral conflicts in relation to failing a student nurse in the clinical arena [49]. The source of this tension stems chiefly from the need to apply two opposing philosophical perspectives of justice and care. The assumptions that underpin each philosophical approach direct a nurse educator’s understanding and approach in a given situation. For instance, the approach used by most educational institutions in relation to student’s success in academia is premised on an ethic of justice. In an ethic of justice approach, principles such as fairness, equity, and rational deliberation are paramount. The education institution focuses on quantifiable measures and objective assessment in making its decisions as its focus is to protect and promote the well-being of the student. Nurse educators teaching in the classroom, which is a less complex teaching context, tend to use an approach premised on justice. By contrast, most clinical nurse educators tend to chiefly use an ethic of care approach in their judgment [49]. An ethic of care approach focuses on responsiveness, attentiveness, and the contextual nature of the situation. The clinical nurse educator has a close relationship with students in the clinical arena and the intimate aspect of patient care in the nursing context may emphasize the significance of the ethics of care perspective. Clinical nurse educators tend to focus on both the patient and student simultaneously and thus use both the justice and the care approach in varying degrees. Balancing when and how to use each approach is difficult for seasoned and new clinical nurse educators alike.
Overall, the transcripts suggest that all nurse educators, including clinical nurse instructors, should be provided the opportunity to participate in sharing their teaching and learning experiences within a learning community so that the individual educator can benefit from the shared exploration of their common experiences. This result is echoed by other nurse researchers [14,16]. In a learning community of nurse educators, individuals are provided the opportunity to share, discuss problems, and bring solutions forward that could benefit nurse educators and student nurses [50].
Conclusion
Data from this study provide clear evidence of the complexity and often competing obligations of ethical decision-making for clinical nurse educators. One easy strategy to support clinical nurse educators would be to provide opportunities for instructors to share their experiences and to learn with other clinical nurse educators who had encountered similar situations. Also, structuring learning opportunities for clinical instructors to share important information such as patient safety could be an important element in orientation programs for nurse educators and nurse administrators to consider given the importance of safe patient care in undergraduate nursing education. Also, the ethical issues that instructors encounter should be addressed by individuals in leadership positions in their nursing programs.
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[1] The terms “clinical supervision” and “clinical instruction” are used interchangeably in practice and in the literature and in this article the author uses the term clinical instruction. Also, this definition closely resembles the definition adopted by Canadian nursing regulatory bodies and identifies expectations and accountabilities of a clinical educator.
