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Developing an ethical basis for student-teacher interaction
Developing an Ethical Basis for Student-Teacher Interaction TERESA WEHRWEIN,
This article first reviews the literature on the development of ethical content within nursing curricula and its impact on nursing education. This is followed by a discussion of faculty responsibility for the preparation of ethically competent graduates. Faculty behaviors that appear to be related to ethically sound education practices are discussed along with examples of positive and negative behaviors. The article concludes with five principles to use in developing an ethical basis for student-teacher relationships. These principles include mutual respect, open communication, demonstration of linkages between ethical principles and behavior, facilitating students' understanding of their behaviors, and recognition of legitimate individual differences in ethical positions. (Index words: Clinical; Education; Ethics; Nursing; Teaching) J Prof Nurs 12:297-302, 1996. Copyright © 1996 by W.B. Saunders Company
HE NATURE of the relationship that develops between a teacher of nursing and the nurse student has the potential to impact the novice nurse's development in both intended and unintended manners. In situations ranging from demonstration of fundamental patient care skills to theoretical doctoral seminars, the behavior of the faculty serves as a reference point for the student to assess his or her own behavior. The student has the opportunity to observe the learning experience and to make judgements not only about the technical quality of the educational offering but also the methods that were employed to carry out the interaction. It is this author's premise that the relationship between a faculty member and student is not a nurse/caring relationship in the sense of nursing as caring for persons with health-related needs. The student, while learning the ways of nurse/caring within the relationship, has not come into the relationship with the expectation of health-related services for himself or herself. The student has come to learn, to
T
*Director, Henry Ford Hospital School of Nursing, Detroit, MI. Address correspondenceand reprint requests to Dr Wehrwein: 2746 Stoodleigh,RochesterHills, MI 48309. Copyright© 1996 by W.B. SaundersCompany
8755-7223/96/1205-0009503.00/0
PHD, RN, CNAA*
gain the knowledge and the experiences in nursing to be able to nurse in future unique client situations. To achieve these skills the student expects to receive accurate and current knowledge regarding the activities of nursing and also the understanding of how to use these tools in the interest of their anticipated client population. It is in the use of these nursing behaviors with clients that the student is able to demonstrate an appreciation of the whole person and his or her cultural identity. This is when a nursing care event occurs. For students to be able to develop the intellectual and interactional skills in establishing a caring relationship, they must have personal interaction experiences in which their own uniqueness and talents are valued and developed. They require learning situations in which they are afforded respect, sensitivity, and fairness; in essence, a relationship in which they are able to experience caring behaviors from their teachers. They must experience a situation in which faculty create a learning environment that supports growth and nurtures diversity. What are the ethical education considerations in the nursing student-teacher relationship? Is it only the obligation to acquaint students with the theories and principles used to examine ethical dilemmas and guide choices? Although content on the nature and complexity of ethics appears to be essential in nursing education, knowledge alone is not adequate. The faculty member must also explore the nature of the student-teacher relationship with recognition of the potential for ethical learning that exists within the human interactional context of that relationship. This role modeling itself may provide more of the basis for the students' long-term understanding of ethical practice than the isolated intellectual exercise of classroom discussions of the ethical dilemmas experienced by others. Students are not fully prepared to be empowered to act on ethical decisions made in the practice environment without confronting the risks that are inherent in their own ethical dilemmas in the real world of health care delivery. The first section of this article reviews the literature
Journal of ProfessionaINursing, Vol 12, No 5 (September-October), 1996: pp 297-302
297
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on the ethical content within nursing curricula. This will be followed by a discussion of faculty responsibilities for the development of ethically competent graduates. The article will conclude with reflections on educational practices that could encourage the development of caring ethical nursing practice. Historical Review of Ethics in the Nursing Curriculum In the past the formal study of ethics was not emphasized within nursing curricula. In 1977, Aroskar found that only six baccalaureate nursing programs reported that they required a course in ethics, and none reported that they had a faculty member whose primary specialty was nursing ethics. In the 1980s, nurse leaders began to voice broader concern for ethical issues. The ethical standards of the profession as stated in the American Nurses Association's (ANA) Codefor Nurses With Interpretive Statements (1976) was augmented with the publication of Nursing: A Social Policy Statement (ANA, 1980). This document dealt with the nurse-client relationship and also with nursing as a service to the total society.
Although content on the nature and complexity of ethics appears to be essential in nursing education, knowledge alone is not adequate.
In 1986, the American Association of Colleges of Nursing issued a report that identified values to be developed in nursing students. Specifically, the report addressed the need for nurses to have the ability to make sound ethical judgements in both their professional and personal lives. A potential barrier to the implementation of this initiative was reported by Killeen (1986), who found that 45 per cent of entry-level nursing textbooks included no ethics content and that the space devoted to ethical issues was consistently limited. A positive note in the findings, however, was the observation that the (then) more recently written textbooks were more likely to contain ethics content. Today this situation is much improved with full chapter presentations on nursing ethics in most major undergraduate textbooks. Numerous books devoted solely to nursing ethics in a variety of settings for both graduate and undergraduate students have been pub-
lished. Most significant is the increasing number of nursing faculty trained in ethics and available to teach this component of the curriculum. Strategies for Teaching Ethics Although there has been an improvement in the educational resources available for use in the development of nursing ethics experiences, the literature does not provide explicit direction as to the best use of these experts and materials to achieve the desired educational outcomes. Felton and Parsons (1987) reported that educational level was related to moral development using Rest's Defining Issues Test. This instrument is based on Kohlberg's model for moral development. Although the DIT has been more fully tested with women than was Kohlberg's original work, the criticism has been made by Gilligan (1982) and others about the exclusion of women in the original theory development. This theory generated the hypothesis of a linear irreversible progression toward high level moral behaviors, and that is significant in analysis of Felton and Parsons' and other works using this instrumentation. Additionally, Felton and Parsons did not speak to the nature of the educational experiences that were associated with improved performance but only that more advanced students had higher scores for moral reasoning behaviors. Pinch (1985) and Cassidy and Oddi (1988) also reported that higherlevel nursing students showed higher levels of ethical decision-making in nursing-related situations when tested with a survey methodology. Again, no attempt was made to explain the experiences that may have been associated with the change in behavior. The literature is inconsistent regarding the benefit of specific educational experiences in improving ethical decision-making, but it generally appears to support the ability of ethical educational experiences to support changes in student outcomes. Bell (1985) and Frisch (1987) both reported improvement in moral reasoning test scores after specific, but different, educational experiences. Kelly (1987) used qualitative methods to assess the impact of an ethical educational experience for senior baccalaureate students and reported positive student outcomes. Wehrwein (1990) concluded that a formal course in ethics appeared to assist students in developing a positive response to the assessment of the ethical behavior in simulated nursing practice situations, In their review of educational studies in nursing ethics, Silva and Sorrell (1991) concluded that the current literature is inadequate to fully determine a
ETHICAL BASIS FOR NURSING EDUCATION
preferred methodology for ethical education in nursing. They suggest that broader-based studies by senior researchers, rather than the uncoordinated and primarily dissertation-level work that is now available, would strengthen the data base. They do, however, concur with the position of the researchers cited earlier that nursing ethics is a valuable component of the curriculum. Gaul (1989) reviewed her own work and that of others to offer several curricular recommendations for nursing ethics. After stating her general support for nursing ethics content, she discussed both the differences seen in current educational practice and the seeming inability of educators to determine what strategies are most effective. Among the concerns she voiced is the ongoing potential for inconsistent implementation of the materials among various levels of a program; a continuing shortage of faculty prepared to lead the study of ethics; and inconsistent student outcomes, particularly in schools that provide major aspects of their ethics content as elective rather than required content. Her recommendations included the provision of classroom content on the ethical theory and principles, small group case analysis, and the development of the student's ability to tolerate ambiguity and value the diverse opinions of others. Although the final suggestion implies a clinical teaching strategy, the main emphasis of her article was the classroom presentation of ethical content. Although these are important experiences, this author believes that the discussion of how to develop ethics learning experiences must more fully explore the role of the dinical faculty-student relationship and the practice experiences they share. It is in this arena that the student has the opportunity to apply the process of ethical analysis in real situations. Ethical Education in the Clinical Practice Setting
The climate in the clinical practice setting has influenced the implementation of the clinical component of ethical education. Gaul (1989) states "Historically, the nurse was expected to be obedient without question and not to participate in or be concerned with ethical decision making" (p. 477). Curtin (Curtin & Flaherty, 1982) also questioned the ability of nurses to act on the judgments made in an ethical assessment of a practice dilemma. This concern is not because the nurse does not have the skills to determine the ethical course of action but rather that the nurse may not be empowered to act. Recognizing that the
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power disparity for nurses within health care settings has limited their participation in ethical decisionmaking processes over time provides further support for the importance of the clinical teaching role in the development of an ethical basis for practice. Aroskar (1988) speaks directly to an ethical mandate for change in the context of the curriculum revolution. She addresses the centrality of moral responsibility in a high-technology health care environment. In reporting both descriptive findings and case examples, she observes that nurses may wish to address ethical issues but that they lack experience and an expectation of success in doing so. She calls on nurses to "create responses" rather than "find answers" (p. 132). This challenges nursing educators to review and redesign curricula to create experiences that empower nurses to act on reasoned ethical choices. The feminist literature provides some direction for nursing education in the exploration of ways to achieve the dual goals of an ethical knowledge base and ethically empowered practice. Symonds (1990) speaks to the reconceptualization of the facultystudent relationship. The currently existing power gradient between faculty and student is seen as inhibiting the development of creativity and caring. Although Symonds defines feminist philosophy in a fairly confrontational manner as women interact with the "man's world" of current experience, her recommendations that view the student as an active experienced individual in the process of both living and learning are most valuable. She suggests the need to review nursing educational practices and critically analyze them to determine if they support a holistic, rather than mechanistic, view of person. Noddings (1984) defines caring as a feminine framework for ethics and describes the caring teacherstudent relationships that support learning. She sees the teacher's highest priority as the facilitation of the student's ethical development. To that end, the teacher, as the one caring, believes that providing for the good of the student is the highest level of ethical behavior. This approach is consistent with a feminist critique of Kohlberg's theory of moral development, which requires the caring teacher to relate with the learner so that growth is enhanced. Crowley (1989) speaks to the use of a feminist pedagogy to develop ethical behaviors in nursing educational interactions. Using the background of an actual case experience of a faculty member and student involved in a patient-related ethical dilemma, she analyzes the responses and discusses potential rationale for the behaviors demonstrated. Crowley then sug-
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gests strategies for a caring approach in faculty behaviors. Referring to Noddings' (1984) writings on the ethic of care, she suggests that the faculty member should move from resolving the student's dilemma by imposing the faculty member's belief in what should have occurred in the situation to one of reflective listening to the student's experience and dilemma. This behavior may have empowered the student to act differently not only in this one case but when confronted with similar issues in the future. Crowley's analysis in this situation provides support for respectful, reflective listening and open-minded faculty position. Rather than being the power person who seeks to correct the wrongdoing, the faculty member who seeks to mentor is anticipated to have the most positive and lasting impact.
• . . the fiterature supports an increased recognition of the importance of ethical education in all aspects of the nursing curriculum.
In her 1994 article that critiques the application of Noddings' theory in the educational setting, Crowley expands on her discussions. She states that the strengths of Noddings' (1984) position include the interactive nature of the faculty-student relationship and the engagement of the parties in maintaining this caring relationship. In this intimate and reciprocal experience, the student is empowered to experiment and grow. The criticisms of Noddings' position most relevant to the content of this article include the exclusivity of the described caring relationship in the light of the reality of the settings in which nursing student-teacher relationships occur. The matrix of responsibilities held by clinical faculty for clients, staff, and other students contrasts with their ability to be engrossed in a relationship with one student at a time. In summary, the literature supports an increased recognition of the importance of ethical education in all aspects of the nursing curriculum. Much of the current literature focuses on the classroom learning experiences that may be useful in developing a student's knowledge of ethical practice. Although this aspect is an essential component of the process, it functions as the infrastructure to clinical experiences in which the student assesses the ethical content of a practice situation, determines his or her own ethical
stance in that situation, and has the faculty-supported opportunity to act on that choice and learn from its consequences. This application of the ethical content in the clinical setting is accomplished with the informed guidance of supportive, prepared, and caring faculty. Qualities of an Ethical Student-Teacher Relationship
The standards and conduct of nursing faculty are an integral part of the ethical milieu of the nursing educational experience. Both in the classroom and clinical laboratory setting, the nurse student observes and makes assessment of not only the level of nursing knowledge a faculty member possesses but also the way in which that person conducts the relational aspects of the educational situations. The literature is limited in its discussion of ethical faculty behaviors in the teaching role. Much of the current writing focuses on academic research ethics, which, although important and potentially significant in discussion of an individual's personal code for ethical conduct, is not specifically related to the topic of this article. Theis (1988) studied senior-level baccalaureate nursing students to determine their perceptions of unethical teaching behavior. Her instrument was based on the principles of respect, beneficence, and justice. Conclusions included support that these principles were important to students. Specific negative faculty behaviors identified included ridicule, invasion of student's privacy, and not obtaining consent from clients to elicit cooperation in student learning experiences. Erlen and McDaniel (1994) discuss the potential for conflict of interest as a source of ethical dilemma in the student-teacher relationship. Although the student example in this article is specific to doctoral candidates, the issues of inappropriate pressure and competing factors, such as employment, could impact faculty evaluation of students at other levels. The other example of conflict of" interest is intervention by academic administration into faculty judgement on student capabilities or achievements. Both of the scenarios are relevant to the student-teacher relationship at any level of nursing education. Recommendations to avoid conflict of interest include avoiding preferential treatment, developing academic policies, providing junior faculty with a senior mentor to assist them in exploring potentially conflicted situations, and finally providing ongoing faculty education. Although these recommendations appear to have merit,
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ETHICAL BASIS FOR NURSING EDUCATION
this author would caution that overly enthusiastic implementation of the first two points could lead to a dehumanized and insensitive learning environment. This situation could by its example encourage students to refrain from caring, personalized interactions with clients. Kelly (1990) also described senior baccalaureate students' perceptions of faculty's ethical behavior in her article that proceeds to propose a theory of respect and caring as an ethic for nursing. Characteristics related to the principle of respect that were reported by Kelly's student informants included listening, being honest, treating students like human beings, demonstrating collaboration, professionalism, and assertiveness. The caring behaviors identified in the article also were interactions that related to clients in the clinical experience and not just situations in the context of the student-faculty relationship. In summary, the literature discussing ethical facultystudent relationships continues to be somewhat limited. Although Theiss (1988), Kelly (1990), and Erlen and McDaniel (1994) each used a different strategy to obtain exemplars for discussion, several themes of the ethical educational relationship emerge when they are viewed together. The ethical faculty-student relationship must consider respect for all individuals, especially, but not limited to, the nursing student. Care must be taken to avoid conflict of interest, and if situations with potential conflict arise, resolution of not only the situation but the source of conflict would appear appropriate. Finally, behavior should be based in consideration of the interests of all parties, which will include health care agency clients and staff as well as the nursing faculty and students in the clinical teaching experience. The discussion of an independent ethic of nursing education, however, appears incomplete, for if nursing is a theoretically based practice discipline, then the ethic of nursing education should be explicit in the ethic of nursing practice. If care is accepted as basic to nursing, then it seems realistic that a nursing ethic would be derived from consideration and examination of the ways to reflect on and analyze an interaction for its integrity in the application of caring behaviors. If a nurse sought to examine the ethics of behavior in a nursing relationship, assessment of the given behavior in light of the unique content of the interaction would be appropriate. Similarly, ethical behavior in the teacher-student relationship also would be assessed within the individual relationship and its context to determine if actions were ethical. Hedin (1989) discussed the need to view educational interactions
and the resulting ethical dilemmas in their broadened context. The expediency of a quick solution that may be possible from decontextualizing an educational encounter does not acknowledge the practice reality that nursing occurs in the community and not in the confines of a laboratory.
Principles for an Ethical Student-Teacher Relationship
What then is an ethical model for nursing education? It is a model that first values the persons (faculty, student, client, and staff) interacting in the nursing educational situation. Ethical educational practice requires respectful behavior that acknowledges diversity and talent as well as assesses, provides, and evaluates the learning opportunities required. An ethical faculty student relationship values the wholeness of the parties and strives to understand significant issues that contribute to the integrity of the parties. It supports that each person is a unique, capable individual with the potential to grow. Ethical education requires disclosure of expectations and the anticipated impact of those expectations. Expectations in this context are not limited to course requirements and rules of conduct but rather should include the way in which the faculty expect nursing practice to occur in the student's clinical laboratory experience. In the assessment of their interactions with students, faculty could reflect on their behavior in consideration of five principles for ethical studentteacher relationships.
1. Respect This is a mutual respect in which the faculty member develops the learning situation with an explicit expectation of reciprocal valuing of person.
2. Communication--Participants should always strive to maintain open honest communication. Communication involves sharing assessment of progress and opportunities for growth in a way that promotes progress, not fear.
3. Boundary setting--Explicit parameters of the learning interaction will promote successful relationships. Faculty should communicate fully the areas of assistance, support, and resources that the faculty member is prepared and, equally important, not prepared or empowered to provide.
4. Consistent behaviors--Faculty must demon-
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strate the linkages between actual professional ethical dilemmas and a personal code for conduct. Facilitating the student's understanding of the need for consistency between personal values and professional behaviors through explication of the basis for behavior is crucial in the relationship. . Personal values--The teacher openly recognizes that differing decisions, based on personal ethical positions, will occur. Educa-
tional practices need not conform student behavior to faculty expectations of response but rather assist the student to develop his or her own appropriate response. Ethical educational practice demands that faculty open themselves to a fair, reasoned, thoughtful, and relational experience with students. Through role modeling of ethical practice, faculty will promote ethical behavior among their students.
References American Association of Colleges of Nursing. (1986). Essentials of college and university for professional nursing. Washington, DC: Author. American Nurses Association. (1976). Code for nurses with interpretive statements. Kansas City, MO: Author. American Nurses Association. (1980). Nursing: A social policy statement. Kansas City, MO: Author. Aroskar, M. A. (1977). Ethics in the nursing curriculum. Nursing Outlook, 25, 260-264. Aroskar, M. A. (1988). Curriculum revolution: A bioethical mandate for change. In Curriculum revolution: Mandate for change (pp. 123-136). New York: National League for Nursing. Bell, S. K. (1985). Effect of a biomedical ethic course on senior nursing student's level of moral development (Doctoral dissertation, West Virginia University, 1984). Dissertation Abstracts International, 45, 3205B. Cassidy, V. R., & Oddi, L. E (1988). Professional autonomy and ethical decision making among graduate and undergraduate nursing majors. Journal of Nursing Education, 2Z 405-410. Crowley, M. A. (1989). Feminist pedagogy: Nurturing the ethical idea. Advances in Nursing Science, 11(3), 53-61. Crowley, M. A. (1994). The relevance of Noddings' ethic of care to the moral education of nurses. Journal of Nursing Education, 3Z 74-80. Curtin, L., & Flaherty, M. J. (1982). Nursing ethics: Theories andpragmatics. Bowie, MD: Brady. Erlen, J. A., & McDaniet, C. (1994). Conflict of interest: Its relationship to integrity in the academic setting. Journal of ProfessionalNursing, 10, 91-96. Felton, G. M., & Parsons, M. A. (1987). The impact of nursing education on ethical/moral decision making. Journal of Nursing Education, 26, 7-11. Frisch, N. A. (1987). Ethics in nursing instruction: Moral reasoning can be enhanced through specific interventions. In Proceedingsand abstracts of the 5th Annual Research in Nursing Education Conference Proceedings (p. 35). New York: National League for Nursing. (ERIC Document Reproduction Service No. ED 291 988).
Gaul, A. L. (1989). Ethics content in baccalaureate degree curricula: Clarifying the issues. Nursing Clinics of North America, 24, 475-483. Gilligan, C. (1982). In a different voice: Psychological theory and women's development. Cambridge, MA: Harvard University Press. Hedin, B. A. (1989). Nursing, education, and sterile ethical fields. Advances in Nursing Science, 11(3), 43-52. Kelly, B. O. (1987). Perception of professional ethics among senior baccalaureate nursing students. Dissertation Abstracts International, 49, 693B. (University Microfilms No. DA8804060) Kelly, B. (1990). Respect and caring: Ethics and essence of nursing. In M. M. Leininger (Ed.), Ethical and moral dimensions of care (pp. 67-80). Detroit, MI: Wayne State University Press. Killeen, M. L. (1986). Nursing fundamentals texts: Where's the ethics? Journal of Nursing Education, 25, 334-340. Noddings, N. (1984). Caring: A feminist approach to ethics and moral education. Berkeley, CA: University of California Press. Pinch, W. J. (1985). Ethical dilemmas in nursing: The role of the nurse and perceptions of autonomy. Journal of Nursing Education, 24, 372-376. Silva, M. C., & Sorrell, J. M. (1991). Researchon ethics in nursing: An integrative review and critique. New York: National League for Nursing. Symonds, J. M. (1990). Revolutionizing the studentteacher relationship. In Curriculum revolution: Redefining student-teacher relationship (pp. 47-56). New York: National League for Nursing. Theis, E. C. (1988). Nursing students' perspectives of unethical teaching behaviors. Journal of Nursing Education, 2Z 102-106. Wehrwein, T. A. (1990). Moral reasoning and decision making in beginning baccalaureate students. Unpublished doctoral dissertation, Wayne State University.
This article first reviews the literature on the development of ethical content within nursing curricula and its impact on nursing education. This is followed by a discussion of faculty responsibility for the preparation of ethically competent graduates. Faculty behaviors that appear to be related to ethically sound education practices are discussed along with examples of positive and negative behaviors. The article concludes with five principles to use in developing an ethical basis for student-teacher relationships. These principles include mutual respect, open communication, demonstration of linkages between ethical principles and behavior, facilitating students' understanding of their behaviors, and recognition of legitimate individual differences in ethical positions. (Index words: Clinical; Education; Ethics; Nursing; Teaching) J Prof Nurs 12:297-302, 1996. Copyright © 1996 by W.B. Saunders Company
HE NATURE of the relationship that develops between a teacher of nursing and the nurse student has the potential to impact the novice nurse's development in both intended and unintended manners. In situations ranging from demonstration of fundamental patient care skills to theoretical doctoral seminars, the behavior of the faculty serves as a reference point for the student to assess his or her own behavior. The student has the opportunity to observe the learning experience and to make judgements not only about the technical quality of the educational offering but also the methods that were employed to carry out the interaction. It is this author's premise that the relationship between a faculty member and student is not a nurse/caring relationship in the sense of nursing as caring for persons with health-related needs. The student, while learning the ways of nurse/caring within the relationship, has not come into the relationship with the expectation of health-related services for himself or herself. The student has come to learn, to
T
*Director, Henry Ford Hospital School of Nursing, Detroit, MI. Address correspondenceand reprint requests to Dr Wehrwein: 2746 Stoodleigh,RochesterHills, MI 48309. Copyright© 1996 by W.B. SaundersCompany
8755-7223/96/1205-0009503.00/0
PHD, RN, CNAA*
gain the knowledge and the experiences in nursing to be able to nurse in future unique client situations. To achieve these skills the student expects to receive accurate and current knowledge regarding the activities of nursing and also the understanding of how to use these tools in the interest of their anticipated client population. It is in the use of these nursing behaviors with clients that the student is able to demonstrate an appreciation of the whole person and his or her cultural identity. This is when a nursing care event occurs. For students to be able to develop the intellectual and interactional skills in establishing a caring relationship, they must have personal interaction experiences in which their own uniqueness and talents are valued and developed. They require learning situations in which they are afforded respect, sensitivity, and fairness; in essence, a relationship in which they are able to experience caring behaviors from their teachers. They must experience a situation in which faculty create a learning environment that supports growth and nurtures diversity. What are the ethical education considerations in the nursing student-teacher relationship? Is it only the obligation to acquaint students with the theories and principles used to examine ethical dilemmas and guide choices? Although content on the nature and complexity of ethics appears to be essential in nursing education, knowledge alone is not adequate. The faculty member must also explore the nature of the student-teacher relationship with recognition of the potential for ethical learning that exists within the human interactional context of that relationship. This role modeling itself may provide more of the basis for the students' long-term understanding of ethical practice than the isolated intellectual exercise of classroom discussions of the ethical dilemmas experienced by others. Students are not fully prepared to be empowered to act on ethical decisions made in the practice environment without confronting the risks that are inherent in their own ethical dilemmas in the real world of health care delivery. The first section of this article reviews the literature
Journal of ProfessionaINursing, Vol 12, No 5 (September-October), 1996: pp 297-302
297
298
TERESA WEHRWEIN
on the ethical content within nursing curricula. This will be followed by a discussion of faculty responsibilities for the development of ethically competent graduates. The article will conclude with reflections on educational practices that could encourage the development of caring ethical nursing practice. Historical Review of Ethics in the Nursing Curriculum In the past the formal study of ethics was not emphasized within nursing curricula. In 1977, Aroskar found that only six baccalaureate nursing programs reported that they required a course in ethics, and none reported that they had a faculty member whose primary specialty was nursing ethics. In the 1980s, nurse leaders began to voice broader concern for ethical issues. The ethical standards of the profession as stated in the American Nurses Association's (ANA) Codefor Nurses With Interpretive Statements (1976) was augmented with the publication of Nursing: A Social Policy Statement (ANA, 1980). This document dealt with the nurse-client relationship and also with nursing as a service to the total society.
Although content on the nature and complexity of ethics appears to be essential in nursing education, knowledge alone is not adequate.
In 1986, the American Association of Colleges of Nursing issued a report that identified values to be developed in nursing students. Specifically, the report addressed the need for nurses to have the ability to make sound ethical judgements in both their professional and personal lives. A potential barrier to the implementation of this initiative was reported by Killeen (1986), who found that 45 per cent of entry-level nursing textbooks included no ethics content and that the space devoted to ethical issues was consistently limited. A positive note in the findings, however, was the observation that the (then) more recently written textbooks were more likely to contain ethics content. Today this situation is much improved with full chapter presentations on nursing ethics in most major undergraduate textbooks. Numerous books devoted solely to nursing ethics in a variety of settings for both graduate and undergraduate students have been pub-
lished. Most significant is the increasing number of nursing faculty trained in ethics and available to teach this component of the curriculum. Strategies for Teaching Ethics Although there has been an improvement in the educational resources available for use in the development of nursing ethics experiences, the literature does not provide explicit direction as to the best use of these experts and materials to achieve the desired educational outcomes. Felton and Parsons (1987) reported that educational level was related to moral development using Rest's Defining Issues Test. This instrument is based on Kohlberg's model for moral development. Although the DIT has been more fully tested with women than was Kohlberg's original work, the criticism has been made by Gilligan (1982) and others about the exclusion of women in the original theory development. This theory generated the hypothesis of a linear irreversible progression toward high level moral behaviors, and that is significant in analysis of Felton and Parsons' and other works using this instrumentation. Additionally, Felton and Parsons did not speak to the nature of the educational experiences that were associated with improved performance but only that more advanced students had higher scores for moral reasoning behaviors. Pinch (1985) and Cassidy and Oddi (1988) also reported that higherlevel nursing students showed higher levels of ethical decision-making in nursing-related situations when tested with a survey methodology. Again, no attempt was made to explain the experiences that may have been associated with the change in behavior. The literature is inconsistent regarding the benefit of specific educational experiences in improving ethical decision-making, but it generally appears to support the ability of ethical educational experiences to support changes in student outcomes. Bell (1985) and Frisch (1987) both reported improvement in moral reasoning test scores after specific, but different, educational experiences. Kelly (1987) used qualitative methods to assess the impact of an ethical educational experience for senior baccalaureate students and reported positive student outcomes. Wehrwein (1990) concluded that a formal course in ethics appeared to assist students in developing a positive response to the assessment of the ethical behavior in simulated nursing practice situations, In their review of educational studies in nursing ethics, Silva and Sorrell (1991) concluded that the current literature is inadequate to fully determine a
ETHICAL BASIS FOR NURSING EDUCATION
preferred methodology for ethical education in nursing. They suggest that broader-based studies by senior researchers, rather than the uncoordinated and primarily dissertation-level work that is now available, would strengthen the data base. They do, however, concur with the position of the researchers cited earlier that nursing ethics is a valuable component of the curriculum. Gaul (1989) reviewed her own work and that of others to offer several curricular recommendations for nursing ethics. After stating her general support for nursing ethics content, she discussed both the differences seen in current educational practice and the seeming inability of educators to determine what strategies are most effective. Among the concerns she voiced is the ongoing potential for inconsistent implementation of the materials among various levels of a program; a continuing shortage of faculty prepared to lead the study of ethics; and inconsistent student outcomes, particularly in schools that provide major aspects of their ethics content as elective rather than required content. Her recommendations included the provision of classroom content on the ethical theory and principles, small group case analysis, and the development of the student's ability to tolerate ambiguity and value the diverse opinions of others. Although the final suggestion implies a clinical teaching strategy, the main emphasis of her article was the classroom presentation of ethical content. Although these are important experiences, this author believes that the discussion of how to develop ethics learning experiences must more fully explore the role of the dinical faculty-student relationship and the practice experiences they share. It is in this arena that the student has the opportunity to apply the process of ethical analysis in real situations. Ethical Education in the Clinical Practice Setting
The climate in the clinical practice setting has influenced the implementation of the clinical component of ethical education. Gaul (1989) states "Historically, the nurse was expected to be obedient without question and not to participate in or be concerned with ethical decision making" (p. 477). Curtin (Curtin & Flaherty, 1982) also questioned the ability of nurses to act on the judgments made in an ethical assessment of a practice dilemma. This concern is not because the nurse does not have the skills to determine the ethical course of action but rather that the nurse may not be empowered to act. Recognizing that the
299
power disparity for nurses within health care settings has limited their participation in ethical decisionmaking processes over time provides further support for the importance of the clinical teaching role in the development of an ethical basis for practice. Aroskar (1988) speaks directly to an ethical mandate for change in the context of the curriculum revolution. She addresses the centrality of moral responsibility in a high-technology health care environment. In reporting both descriptive findings and case examples, she observes that nurses may wish to address ethical issues but that they lack experience and an expectation of success in doing so. She calls on nurses to "create responses" rather than "find answers" (p. 132). This challenges nursing educators to review and redesign curricula to create experiences that empower nurses to act on reasoned ethical choices. The feminist literature provides some direction for nursing education in the exploration of ways to achieve the dual goals of an ethical knowledge base and ethically empowered practice. Symonds (1990) speaks to the reconceptualization of the facultystudent relationship. The currently existing power gradient between faculty and student is seen as inhibiting the development of creativity and caring. Although Symonds defines feminist philosophy in a fairly confrontational manner as women interact with the "man's world" of current experience, her recommendations that view the student as an active experienced individual in the process of both living and learning are most valuable. She suggests the need to review nursing educational practices and critically analyze them to determine if they support a holistic, rather than mechanistic, view of person. Noddings (1984) defines caring as a feminine framework for ethics and describes the caring teacherstudent relationships that support learning. She sees the teacher's highest priority as the facilitation of the student's ethical development. To that end, the teacher, as the one caring, believes that providing for the good of the student is the highest level of ethical behavior. This approach is consistent with a feminist critique of Kohlberg's theory of moral development, which requires the caring teacher to relate with the learner so that growth is enhanced. Crowley (1989) speaks to the use of a feminist pedagogy to develop ethical behaviors in nursing educational interactions. Using the background of an actual case experience of a faculty member and student involved in a patient-related ethical dilemma, she analyzes the responses and discusses potential rationale for the behaviors demonstrated. Crowley then sug-
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gests strategies for a caring approach in faculty behaviors. Referring to Noddings' (1984) writings on the ethic of care, she suggests that the faculty member should move from resolving the student's dilemma by imposing the faculty member's belief in what should have occurred in the situation to one of reflective listening to the student's experience and dilemma. This behavior may have empowered the student to act differently not only in this one case but when confronted with similar issues in the future. Crowley's analysis in this situation provides support for respectful, reflective listening and open-minded faculty position. Rather than being the power person who seeks to correct the wrongdoing, the faculty member who seeks to mentor is anticipated to have the most positive and lasting impact.
• . . the fiterature supports an increased recognition of the importance of ethical education in all aspects of the nursing curriculum.
In her 1994 article that critiques the application of Noddings' theory in the educational setting, Crowley expands on her discussions. She states that the strengths of Noddings' (1984) position include the interactive nature of the faculty-student relationship and the engagement of the parties in maintaining this caring relationship. In this intimate and reciprocal experience, the student is empowered to experiment and grow. The criticisms of Noddings' position most relevant to the content of this article include the exclusivity of the described caring relationship in the light of the reality of the settings in which nursing student-teacher relationships occur. The matrix of responsibilities held by clinical faculty for clients, staff, and other students contrasts with their ability to be engrossed in a relationship with one student at a time. In summary, the literature supports an increased recognition of the importance of ethical education in all aspects of the nursing curriculum. Much of the current literature focuses on the classroom learning experiences that may be useful in developing a student's knowledge of ethical practice. Although this aspect is an essential component of the process, it functions as the infrastructure to clinical experiences in which the student assesses the ethical content of a practice situation, determines his or her own ethical
stance in that situation, and has the faculty-supported opportunity to act on that choice and learn from its consequences. This application of the ethical content in the clinical setting is accomplished with the informed guidance of supportive, prepared, and caring faculty. Qualities of an Ethical Student-Teacher Relationship
The standards and conduct of nursing faculty are an integral part of the ethical milieu of the nursing educational experience. Both in the classroom and clinical laboratory setting, the nurse student observes and makes assessment of not only the level of nursing knowledge a faculty member possesses but also the way in which that person conducts the relational aspects of the educational situations. The literature is limited in its discussion of ethical faculty behaviors in the teaching role. Much of the current writing focuses on academic research ethics, which, although important and potentially significant in discussion of an individual's personal code for ethical conduct, is not specifically related to the topic of this article. Theis (1988) studied senior-level baccalaureate nursing students to determine their perceptions of unethical teaching behavior. Her instrument was based on the principles of respect, beneficence, and justice. Conclusions included support that these principles were important to students. Specific negative faculty behaviors identified included ridicule, invasion of student's privacy, and not obtaining consent from clients to elicit cooperation in student learning experiences. Erlen and McDaniel (1994) discuss the potential for conflict of interest as a source of ethical dilemma in the student-teacher relationship. Although the student example in this article is specific to doctoral candidates, the issues of inappropriate pressure and competing factors, such as employment, could impact faculty evaluation of students at other levels. The other example of conflict of" interest is intervention by academic administration into faculty judgement on student capabilities or achievements. Both of the scenarios are relevant to the student-teacher relationship at any level of nursing education. Recommendations to avoid conflict of interest include avoiding preferential treatment, developing academic policies, providing junior faculty with a senior mentor to assist them in exploring potentially conflicted situations, and finally providing ongoing faculty education. Although these recommendations appear to have merit,
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this author would caution that overly enthusiastic implementation of the first two points could lead to a dehumanized and insensitive learning environment. This situation could by its example encourage students to refrain from caring, personalized interactions with clients. Kelly (1990) also described senior baccalaureate students' perceptions of faculty's ethical behavior in her article that proceeds to propose a theory of respect and caring as an ethic for nursing. Characteristics related to the principle of respect that were reported by Kelly's student informants included listening, being honest, treating students like human beings, demonstrating collaboration, professionalism, and assertiveness. The caring behaviors identified in the article also were interactions that related to clients in the clinical experience and not just situations in the context of the student-faculty relationship. In summary, the literature discussing ethical facultystudent relationships continues to be somewhat limited. Although Theiss (1988), Kelly (1990), and Erlen and McDaniel (1994) each used a different strategy to obtain exemplars for discussion, several themes of the ethical educational relationship emerge when they are viewed together. The ethical faculty-student relationship must consider respect for all individuals, especially, but not limited to, the nursing student. Care must be taken to avoid conflict of interest, and if situations with potential conflict arise, resolution of not only the situation but the source of conflict would appear appropriate. Finally, behavior should be based in consideration of the interests of all parties, which will include health care agency clients and staff as well as the nursing faculty and students in the clinical teaching experience. The discussion of an independent ethic of nursing education, however, appears incomplete, for if nursing is a theoretically based practice discipline, then the ethic of nursing education should be explicit in the ethic of nursing practice. If care is accepted as basic to nursing, then it seems realistic that a nursing ethic would be derived from consideration and examination of the ways to reflect on and analyze an interaction for its integrity in the application of caring behaviors. If a nurse sought to examine the ethics of behavior in a nursing relationship, assessment of the given behavior in light of the unique content of the interaction would be appropriate. Similarly, ethical behavior in the teacher-student relationship also would be assessed within the individual relationship and its context to determine if actions were ethical. Hedin (1989) discussed the need to view educational interactions
and the resulting ethical dilemmas in their broadened context. The expediency of a quick solution that may be possible from decontextualizing an educational encounter does not acknowledge the practice reality that nursing occurs in the community and not in the confines of a laboratory.
Principles for an Ethical Student-Teacher Relationship
What then is an ethical model for nursing education? It is a model that first values the persons (faculty, student, client, and staff) interacting in the nursing educational situation. Ethical educational practice requires respectful behavior that acknowledges diversity and talent as well as assesses, provides, and evaluates the learning opportunities required. An ethical faculty student relationship values the wholeness of the parties and strives to understand significant issues that contribute to the integrity of the parties. It supports that each person is a unique, capable individual with the potential to grow. Ethical education requires disclosure of expectations and the anticipated impact of those expectations. Expectations in this context are not limited to course requirements and rules of conduct but rather should include the way in which the faculty expect nursing practice to occur in the student's clinical laboratory experience. In the assessment of their interactions with students, faculty could reflect on their behavior in consideration of five principles for ethical studentteacher relationships.
1. Respect This is a mutual respect in which the faculty member develops the learning situation with an explicit expectation of reciprocal valuing of person.
2. Communication--Participants should always strive to maintain open honest communication. Communication involves sharing assessment of progress and opportunities for growth in a way that promotes progress, not fear.
3. Boundary setting--Explicit parameters of the learning interaction will promote successful relationships. Faculty should communicate fully the areas of assistance, support, and resources that the faculty member is prepared and, equally important, not prepared or empowered to provide.
4. Consistent behaviors--Faculty must demon-
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strate the linkages between actual professional ethical dilemmas and a personal code for conduct. Facilitating the student's understanding of the need for consistency between personal values and professional behaviors through explication of the basis for behavior is crucial in the relationship. . Personal values--The teacher openly recognizes that differing decisions, based on personal ethical positions, will occur. Educa-
tional practices need not conform student behavior to faculty expectations of response but rather assist the student to develop his or her own appropriate response. Ethical educational practice demands that faculty open themselves to a fair, reasoned, thoughtful, and relational experience with students. Through role modeling of ethical practice, faculty will promote ethical behavior among their students.
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