Moral Dilemma in Clinical Practice of Nursing Students

Abstract

Moral responsibility is an inseparable part of the professional competence of a nurse. In clinical practice nursing students often find themselves in situations dealing with “moral dilemma”. Are they able and willing to respond appropriately to such situations? Research Questions: What are the most frequent professional dilemmas that students encounter during their clinical practice in the hospital? How do they react in such a situation and are they willing to show moral courage? Purpose of the Study: The aim of the survey was to find out the most frequent professional dilemmas encountered by students during their clinical practice in hospitals and whether they are willing and able to respond adequately to such situations. Findings: It can be stated that during their clinical practice at the hospital each of the surveyed students witnessed or participated directly in a situation of unprofessional behaviour of health care professionals, however, did not want to or could not respond to such unprofessional behaviour. These situations had mostly a negative impact on the students. Conclusion: Although nursing students feel moral obligation to act in “critical” situations, they do not have the courage. It is therefore important to identify and work with moral dilemmas in students´ clinical practice, and by doing so reduce stress in students stemming from such situations while raising moral competence of students and other health professionals to take a stand and thus reduce professional blindness.

Keywords: Clinical practice, nursing students, moral dilemma, clinical learning environment

Introduction

Education in nursing has undergone a dramatic development since the era of Nightingale. Nowadays, nurses are mostly educated at universities where practical education applied in a natural clinical environment forms at least a half of the whole scope of a curriculum. The aim is to provide the students with necessary clinical experience that facilitates and prepares the students to develop their skills, supports their reflexive studying and enables them to gain unique practical experience (Hosoda, 2006, Andrews, Roberts, 2011 in Skřivánková, 2012, s. 384). However, practical training completion binds the students to deal in a professional way with a strong moral responsibility. While studying in this clinical environment the students often find themselves in situations when they solve “moral dilemma” which is in conflict with their moral responsibility. Such professional dilemmas have been defined as ethically problematic. In such situations students find themselves in the roles of witnesses or they participate in something what they think is incorrect, wrong or unethical.

Ethical thinking and educations

Ethic as a philosophic discipline comes from Aristoteles. In human activities he distinguishes theoretical activity (recognition), practical (dealing) and creative (doing, making). As for ethics, it is dealt with practical activity. Thus, it is own for human action to have a specific value. Based on this quality we speak about moral or immoral actions (Anzenbacher, 1989, s. 223).

Ethical education must provide a nurse with tools so that she would be capable of critical judgement under a view angle of ethical principles (Vanlaere, Gastmas, 2007, s. 758). Expressing these principles summarizes the basics of western culture ethical traditions. The following belong to these principal: respect for humans, respecting human dignity, requirement for non-maleficence, requirement for beneficence, justice and informed consent (Kutnohorská, 2009, s. 98).

There are several approaches to ethical education in nursing. The firs one includes the mentioned above principles of correct acting. Examples of such principles can be found in ethical codices of nurses. These principles define, as regards contents, what is morally correct, they concentrate ethics on nurse activity or activities, but they do not concentrate on the nurse as a personality and her conscience and her attitudes (Hoof in Vanlaere, Gastmans, 2007, s. 759). But if the acting is moral is exclusively resolved in the conscience (Anzenbacher, 1989, s. 223).

Responsibility

With on-the-job-training completion, the students are included in multidisciplinary teams at most workplaces. They work under supervision of authorised nurses (moralizes) in nursing process and they are expected to have a specific level of involvement. Responsibility is inseparable from the trust the patients express to them.

Within the clinical practice the students often get into an internal conflict – for example in meeting the standards. In the framework of theoretical education, they learn to work according to standardized processes but in real-life working they become witnesses that these standards are not observed by some medical staff. It can happen that the processes of nursing interventions are not uniform and the students perceive this in a sensitive way. They are not able to orientate themselves in such situations and they do not know which process is the correct one. It happens that some nurses dissuade the students from observing the learned processes because the work “takes long” and they consume a lot of aids. A lot of students are satisfied with this method because the work is faster and their work is quite similar to their “real models”, it means to nurses who are regarded as real professionals. How else we can explain the situation when, for example, a student breaks sterility with joining infusion to a patient into an indwelling cannula and when he or she is warned about that, the reaction is that “the nurses do this routinely”. Alarming is the fact that she is right. On the other hand, there is a group of students who do not like such approach from nurses. They experience this professional malpractice of a nurse. Being present to such moral dilemma places students into situations they do not know or they are not sure how to react. They fight with the decision whether to inform on such malpractice towards the patients and to risk consequences.

Nurse as an important motivational element for students

Meeting academics and nurses is of major influence on students’ motivation. However, nurses in clinical workplaces are those who form and strengthen or decrease motivation in students and, in a way, predetermine the further progress and the direction and the future of nursing itself.

Qualified nurses are a full-scale mirror of that what the nursing is going to be like in the future. By means of nurses the student gains understanding and knowledge of the profession as it is in real via observing them – the way how they respect patients laws and watch them as a human being, how they look after the patient and how they provide them care, as well as their knowledge and skills (Nasrin, Soroor, Soodabeh, 2012).

A lot of students lose their motivation and leave their studies due to the reasons how the nurses treat the patients, how they limit their care only for patient’s technical protection, automatic care without communication and education, or any relationship to the patients. The reason of the mentioned above is insufficient knowledge of nurses what leads to insufficient ability to answer patient’s questions and the patient loses confidence in the nurse. A lot of students are also discouraged by extreme working conditions that are loaded to nurses in some workplaces, working stress and low salaries (Nasrin, Soroor, Soodabeh, 2012).

Moral anxiety and moral courage

Nathaniel (2006) defines moral anxiety as a pain or specific discomfort in confrontation with a situation where the person is aware of the moral problem, recognizes moral responsibility and makes moral judgement, but with respect to the perceived limit he or she acts in a way which is understood as a morally wrong one. Moral distress influences mind, working environment and therefore the quality of care for patients and, last but not least, the quality of educational process. It is important for a highly effective educational environment so that the students were able to manage also these ethically demanding situations.

Moral courage is regarded as the key virtue for medical workers, respectively nurses. Present professional society defines moral courage as an ability to repress fear and to accept measures based on ethical conviction (Nathaniel, A. K. 2006). Moral courage bridges over a gap between consciousness of someone’s personal value and professional duty and affects to them in spite of specific risks such as ridicule, warning, embarrassment and so on.

Aim of the research and research questions

The aim of this empiric survey was identification of key problems (situations) in the context of ethics which accompanies students of nursing during their clinical practice. To reach the set objectives we asked the research questions as follows:

Which most frequent moral dilemmas do the students of nursing meet during their clinical practice completion in a hospital?

How do the students act in such situations?

Research sample

The researched sample was formed by 39 students of the 2^nd year of the Nursing study programme completing clinical practice within the whole Czech Republic and 25 students of the 2^nd year of the Nursing study programme studying in the Slovak Republic.

Focus groups were realised during the student on-the-job training in the environment that was familiar to them. Questions prepared for a discussion were used as a mean to establish a communication on topics directly connected with research questions. The discussion was purposefully managed to relatively closely specified topics.

Each focus group was realised in three stages. The introductory stage was nearly always realized in a very easy atmosphere. It lasted approximately 15 minutes. Consequently, the areas of discussion were introduced to the students: 1. What professionality means to me. 2. Description of a situation that represented a professional (moral) dilemma. 3. Which way this situation has influenced me. The students had 15 minutes to think these topics over and to write down notes to individual topics. At the last stage of focus group the students presented individual experience to chosen problems. The whole time of discussion was 1.5 hour. The course of discussion was recorded with the help of audio technique. Quantitative data will be processed in the following part of the research in a form of a questionnaire.

Gained data analysis and findings interpretation

The Method of patterns recording was used for data processing and evaluation. This method serves for searching and recording repeated patterns, topics and structures in the gained data. We have created basic categories from the obtained data with this method. The following categories showed to us as the important ones.

- hygienic care of patients

- students abuse

- patient’s dignity

The situations in individual categories that caused moral dilemmas to the students are documented with individual students’ statements thenceforward.

(n = 34) belonged to frequent problems the students had to face during their clinical practice and which they felt moral lost and uncertainty.

In the framework of non-self-supporting situation concerning defecation with the consequent hygienic care, a nurse loudly said in front of the patient and me and after a while she added When I discussed the situation with the nurse after a while I mentioned that the patient perceived her words, she posted me away with words:

“After entering the room I could see a trained nurse who was bringing a bedpan for patient’s defecation. She left the patient naked and was standing next to his bed when suddenly her phone started ringing and she answered it. The patient was defecating while she was on the phone."

“During the hygiene of face and chest the patient was completely naked. When I came to help the nurse with the hygiene I covered the patient’s genitals with a towel. The nurse commented my act in front of the patient with words – Don’t fuss about it!”

“A nurse was making hygiene from rectum to pubic symphysis, I was afraid to comment this situation even though I knew her behaviour was risky.”

(n = 45) was marked by the students (especially in CR) as the most frequent area with moral dilemma. They very often mentioned that they are set tasks no by the nurses, but certified nurses with the result, that they do their work.

“Once, during a practice, a nurse asked me to take blood from a patient. While I was preparing the aids she asked me if I have finished secondary medical education. I answered that I had finished grammar school. When she heard that she told me not to do it that she would do it on her own that she does not have time for me. And I had to take the blood samples to the tube post.”

“Once I was 15 minutes late for the practice because I overslept and I did not have time to have breakfast. During rebinding a wound I was sick. A nurse had to take me from the room to have some fresh air. The doctor dropped a hint in front of the patient…“Such a help, that’s all we needed…”

“During a hygienic care I was proceeding very carefully but the nurse commented it in front of the patient. I was told by the nurse not to be so careful because we do not have time… “

It is necessary so that the students were not abused as auxiliary staff but were regarded as those who are coming to study and who are studying.

Another area where students felt moral dilemma was the(n = 17).

“During evening application of antibiotics I spoke to a lady on the next bed who couldn’t fall asleep. I asked he what was wrong and why she could not sleep. The patient started talking while I was applying the antibiotics. A nurse came and interrupted the lady and warned her with a higher voice that she should be quiet and sleep that she could not solve the problems at night. I stood in disbelief. I felt sorrow and nonprofessional behaviour again and I couldn’t dare to say anything to a nurse with several-year practice. “

“During my practice I experienced a situation when a nurse jumped at a patient and held her hand on his mouth not to cry…”

“I was helping a nurse and medical orderly to care of a dead. They were laughing, talking about a reunion they were at. It seemed horrible to me and I said to myself it was good that there was nobody from her family – but they would be under control. I was ashamed of them. But the worst thing for me was when they asked me to empty her wardrobe and to put her things into a black bag. I was trying to fold up the things but the medical orderly took the bag from me and threw the things into it and the nurse did not react at all. In the afternoon her daughter came for the things and the ward sister sent me to hand over the things. I could not look at the lady as I felt ashamed. And I do not know what she said when she came home and opened the bag…”

Following analysis of the found out data it is possible to state that each of asked students have experienced a situation during their clinical practice in hospital when they witnessed or participated in nonprofessional behaviour of medical staff and did not want or were not able to react to such nonprofessional behaviour and felt a “moral dilemma” whether to warn medical staff on nonprofessional behaviour or to be just a silent observer. This dilemma was felt by Slovak students less frequently. We explain this with the fact that during the practice there is a university supervisor present with the student at the workplace. Especially due to this fact there are less frequent situations which were marked by the students as their “abuse”. As for the students from the Czech Republic, they work with moralizers in most cases and these ones work in individual wards. Not all problem situations originated in the context of nurse – student, but also in the context of doctor – nurse – student, doctor – student.

It is very important to identify and work with these moral dilemmas during the clinical practice of the students. And thus decreases stress with students coming out of such situations. To increase moral competences not only of the students, but also of medical staff to be determined to face such facts in a responsible way and decrease a professional blindness.

The students of nursing are the future and the way which the nursing is going to continue. It means that in spite of the routine they need to see further, to see the human as a whole, to see and understand the human being in a man and always act and behave under the view angle of human dignity. For the students, the nurse is a mirror of what the nursing is in reality and she remains the picture which motivates or demotivates the students and influences the future, namely what the nursing will be like!

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