- Email: [email protected]
Involvement of nursing students in unethical classroom and clinical behaviors
Involvement of Nursing Students in Unethical Classroom and Clinical Behaviors GAIL A. Hn.nERT, DNSC, RN* A study was conducted to determine the incidence of unethical classroom and clinical behaviom among nursing students, to find out their opinions about the unethical nature of these behaviors, and to Investigate the relationships among demographic data, unethical classroom behaviors, unethical clinical behaviors, and opinions about the behaviors. A questionnsire listing 11 unethical classroom and 11 unethical clinical behaviom was completed by 101 senior nursing students. FindIngs indicated a lower incidence of unethical classroom behaviors and a higher percentage of students who thought these behaviors unethical than had been reported in comparable previous studies. Total unethical classroom behaviors were significantly higher for female than for male students. The opinion that a behavior was unethical was significantly related to the incidence of six items on the scale. Total unethical classroom behaviors were significantly positively related to tots! unethical clinical behaviors (p < 0.001). Recommendations are made to faculty members for dealing with each of the factom that appear to contribute to unethical behaviors. It is suggested that future studies investigate a multifactoral model of unethical behavior and include nonnursing students and nursing students from other settings. J Prof Nurs 1:230-34, 1985
cal school and falsifying information about a patient concerning a laboratory examination, history, or physical examination. 4 However, there is nothing in the literature to document the incidence of unethical behaviors in the classroom and in clinical settings indulged in by nursing students, nor have studies addressed the relationship between behaviors in these two areas. Therefore, the purpose of the present study was to explore answers to the following questions: 1. What is the incidence of unethical behaviors of nursing students in both the classroom and clinical settings? 2. Do students believe that these behaviors are unethical? 3. Are these beliefs related to whether or not the students engage in the unethical behaviors? 4. What is the relation of age, sex, and transfer status to the total number of unethical behaviors in each setting? 5. What is the relationship between unethical behaviors in the classroom and those in clinical settings?
THE PAST 30 years, educators have become inconcerned about the incidence of cheatIingNcreasingly or academic fraud in institutions of higher learning. Surveys have substantiated this concern, indicating that cheating has indeed been on the rise.t-4 Informal conversations with nursing faculty members have identified concerns about the increase in academic dishonesty among their students and the greater incidence of unethical behaviors in the clinical setting. Faculty members question whether or not the two types of behaviors are related. Carmack interviewed 21 nurse educators and found that half (sic) thought plagiarism, one type of academic dishonesty, was increasing. Eleven educators believed that there was a relationship between academic dishonesty and subsequent professional dishonesty. Sierles et al. surveyed medical students and found a significant correlation between cheating in medi-
Methods SAMPLE
The sample consisted of 101 senior baccalaureate nursing students who were surveyed during the last month of their final semester before graduation. Average age was 24.6 years, with a range of 21-49 years. Ninety of the students were females, with 55 per cent of the sample composed of students who had transferred into the program in either their sophomore or junior year. Transfer status was included as a variable in this study, because over half of the sample was made up of transfer students and because that group differed from nontransfer students on a number of characteristics. The transfer group included more men, more married students, more commuters, and more minority members than the nontransfer group. In
* Assistant Dean for Undergraduate Studies, School of Nursing, Widener University. Address correspondence and reprint requests to Dr. Hilbert: School of Nursing, Widener University, Chester, PA 10113. 230
HILBERT
°
NURSING STUDENT INVOLVEMENT IN UNETHICAL BEHAVIORS
addition, transfer students tended to be older than nontransfer students. B A S E L I N E DATA
Students are informed of the policy on academic fraud during their initial orientation to the university. The student handbook includes this policy, including a definition of academic fraud. The initial clinical nursing course contains material on unethical clinical behaviors, and this topic is reviewed with students in subsequent courses. INSTRUMENT
Unethical behavior was defined as a broad range of actions that may occur in the classroom and in clinical settings and that are generally considered by educators as being dishonest or fraudulent (Table 1). A questionnaire was developed that contained a listing of 22 unethical behaviors, half of which occur in the classroom and half of which pertain to clinical settings. The unethical classroom behaviors were obtained from a previously used instrument and were based on a literature review.3 The items were assumed to have content validity. The list of unethical clinical behaviors was compiled from a survey of 16 nursing faculty members. These items were also assumed to have content validity. Subjects were instructed to indicate whether or not they considered each behavior to be unethical and how many times they had engaged in each behavior in the current academic year (fall and spring semesters). They were also asked to indicate age, sex, and transfer status. Coefficient alpha was calculated as a measure of internal consistency. Alpha for the total 22-item scale was 0.668. It should be noted that use of coefficient alpha may not be appropriate, because this scale was criterion-referenced rather than norm-referenced.6 PROCEDURE
Subjects were contacted at the end of lecture classes and were asked to participate in the study. Informed consent was obtained and subjects were assured that there was no way that they could be identified from their questionnaires. Results
Table I gives the incidence of unethical behaviors in the classroom and clinical areas. In the classroom,
231
27 per cent of students had copied a few sentences from a reference source without footnoting, 19 per cent had worked with another student on an assignment when not allowed, and 17 per cent had added a few items to a bibliography. Other percentages were not high but are of concern because of the serious nature of the behavior. Ten per cent of students had turned in an assignment done by someone else, and 2 per cent had taken an exam for another student. In responding to questions on clinical behaviors, a surprisingly high number of students admitted to having taken hospital equipment (59 per cent), and over half admitted to having discussed patients inappropriately. Again, some percentages were noteworthy only because of the serious nature of the behavior. Nineteen per cent had recorded medications, treatments, or observations falsely, 12 per cent admitted to having called in sick when they were not, 7 per cent had taken hospital medications for personal use, and 4 per cent had come to the clinical area while under the influence of drugs or alcohol. Table 1 also gives opinions about the ethical nature of each of the questionnaire items. There was a fairly high agreement about the unethical aspects of classroom behaviors, with the following exceptions: working with another student on an assignment when the instructor did not allow it (60 per cent agreed that it was unethical), adding a few items to a bibliography that were not used (72 per cent), and copying a few sentences from a reference source without footnoting (80 per cent). There was also fairly high agreement on the unethical aspects of clinical behaviors. However, only 65 per cent of students thought that taking hospital equipment was unethical. Other areas of low agreement were eating food intended for or belonging to a patient (72 per cent agreement), calling in sick for the clinical area when they were not (76 per cent), and discussing patients in public places or with nonmedical personnel (77 per cent). A series of t-tests was done to determine whether there were significant differences in the incidence of unethical classroom and clinical behaviors between males and females and between transfer and nontransfer students. The only significant finding was that females engaged in more unethical behaviors in the classroom than males (p = 0.027). A Pearson correlation coefficient indicated that age was significantly negatively related to the number of times that a homework assignment was done for another student. In other words, younger students did this more often (p = 0.033). All other
232 T A B L E 1.
JOURNAL O F PROFESSIONAL N U R S I N G
•
JULY-AUGUST 1985
Opinions About and Extent of Involvement in Unethical Behaviors Percentage Who Considered This Unethical
Range for Times Done
Percentage Who Did This
Classroom behaviors Getting exam or quiz questions from someone who had taken the exam or quiz earlier in the day (or week)
84
0-6
9
Copying from someone else's exam or quiz paper or receiving answers from another student during an exam or quiz
96
0-5
4
Allowing someone to copy from an exam or quiz paper or giving answers to another student during an exam or quiz
96
0-5
7
Using notes, books, etc., during a closed-book exam or quiz
98
0-1
4
Taking an exam or quiz for another student
99
0-2
2
Copying a few sentences from a reference source without footnoting it in a paper
80
0-8
27
Adding a few items to a bibliography that were not used in writing the paper
72
0-2
17
Turning in a paper purchased from a commercial research firm
96
0
0
Turning in an assignment that was done entirely or in part by someone else (but not by a research firm)
90
0-5
10
Doing a homework assignment for another student
81
0-3
6
Working with another student on an assignment when the instructor did not allow it
60
0-5
19
76
0-4
12
Coming to the clinical area while under the influence of drugs, including alcohol
98
0-2
4
Breaking something that belonged to the patient and not reporting it
93
0
0
Not reporting an incident involving a patient
94
0-10
7
Clinical behaviors Calling in sick for the clinical area when you were not
65
0-3
59
Eating food intended for or belonging to a patient
72
0-5
9
Taking medications from the hospital for personal use
94
0-20
7
T a k i n g hospital equipment (including "greens") to use at home
Recording that medications, treatments, or observations were done when they weren't
100
0-12
19
Discussing patients in public places or with nonmedical personnel
77
0-20
54
Failing to provide information to a patient about treatments, medications, or recommended health behaviors
83
0-6
12
Not questioning an order when in doubt
85
0-3
17
correlations for age and unethical behaviors were nonsignificant. A series ofchi-square tests was done to determine the correlation between students' opinions about the unethical nature of a behavior and whether or not they engaged in it. The behaviors that were found to have a significantly lower incidence on the basis of the opinion that the behavior was unethical are shown in Table 2. In order to answer the question about the relationship between unethical behaviors in the classroom and those in clinical settings, a Pearson correlation coefficient was used for the total unethical classroom behaviors and the total unethical clinical behaviors
for each student. The result was a coefficient of 0.571 (p < 0.001). This finding indicates that there was a significant relationship between classroom dishonesty and dishonesty or unethical behavior in the clinical area. Discussion
The incidence of each unethical behavior in the classroom was lower than that reported by Pemberton in a survey of 3,000 undergraduate and graduate students from all colleges at a large state university, using an instrument that included all of the behaviors listed for the present study. 3 For example,
HILBERT
°
233
NURSING STUDENT INVOLVEMENT IN UNETHICAL BEHAVIORS
40 per cent of her subjects admitted to having received an exam from someone who had taken it earlier, as compared to 9 per cent for the present study, and 32 per cent of her subjects admitted to having allowed someone to copy from an exam or quiz paper, compared to 7 per cent for this study. There is no basis of comparison for the incidence of unethical clinical behaviors. Some of these behaviors have Iow percentages but are alarming because of the seriousness of the behaviors. For example, four students reported coming to the clinical area while under the influence of drugs or alcohol. Seven admitted not having reported an incident involving a patient, with one subject saying this had been done ten times. Seven subjects had taken medications from the hospital for personal use, with one student having done this 20 times. Nineteen admitted to having recorded medications, treatments, or observations falsely. One may question whether or not the low incidence of unethical classroom and clinical behaviors is a result of the reluctance of the subjects to admit such behavior. Erickson and Smith have indicated that few individuals report such deviant behaviors if they have not engaged in them but that those who do engage in such behaviors tend to underreport. 7 In the present study, students were close to graduation and did not seem concerned about retaliation. In fact, the investigator was amazed by the number who returned their questionnaires and consent forms together, making identification of subjects possible. In regard to opinions about the unethical nature of the classroom behaviors, a slightly higher percentage of students in the present study thought such behaviors were unethical than in Pemberton's study.~ Behaviors for which the differences were greatest were copying sentences from a reference source without footnoting (20 per cent higher in the present study) and doing a homework assignment for another student (12 per cent higher). Barnett and Dalton asked student opinions about the same classroom behaviors in a survey of a random sample of 802 freshmen and seniors at a state university.8 Most responses were comparable to those of the present study, with the following exceptions: getting an exam or quiz question from someone who had taken the exam earlier (24 per cent higher for the present study), turning in an assignment done by someone else (22 per cent higher), and working with a student on an assignment when not allowed to (12 per cent higher). Again, there is no basis for comparison of the un-
TABLE 2.
Significant Chi-Square Values for Incidence of Unethical Behaviors According to Belief About the Unethical Nature of the Behavior
Behavior Adding a few items to a bibliography that were not used in writing the paper
Chi-Square (X2)
Degrees of Freedom (dO
Probability (P)
6.575
2
0.037"
Coming to the clinical area while under the influence of drugs
11.395
2
0.003I"
Taking hospital equipment (including "greens") to use at home
10.410
2
0.006t
Eating food intended for or belonging to a patient
25.760
2
0.000t
Taking medications from the hospital for personal use
11.932
1
0.001
* P ~> 0.05. t p >~ 0.01. p >i 0.001.
ethical clinical behaviors. Those with low agreement about their unethical nature are those that do not dkectly affect patient safety but have only an indirect relationship to the quality of care. The finding that more females than males cheated in the classroom is in contrast to other reports in the literature. 1-4 Hetherington and Feldman commented that they thought males cheated more because of poorer academic performance in college.~ It was observed for the present sample that the males, with one exception, were doing well academically. It may have been that the females were more inclined to cheat because of pressure to get passing grades. The opinion that a behavior is unethical was significantly related to a lower incidence of that behavior for only six of the 22 questionnaire items. For the remaining items, it is assumed that engaging in those behaviors was related to other factors. The case for multiple causative factors is strengthened by the finding that there was a significant relationship between unethical classroom and unethical clinical behaviors. This suggests that something other than situational variables was operating. Barnett and Dalton identified six factors in the research literature that have a significant influence on cheating behavior: (1) pressure to get good grades, (2) situational factors having to do with testing conditions, (3) intelligence, (4) personality factors (such as need for approval), (5) lack of clarity as to whether
234
JOURNAL OF PROFESSIONAL NURSING
or not a behavior actually is cheating, and (6) level of moral reasoning. 8 This model appears useful for both classroom and clinical settings, in that factors 1, 2, and 5 are plausible influences on unethical behaviors in the present study. Recommendations
The results of this study indicate that some nursing students have opinions that differ from those of faculty members on the unethical nature of classroom and clinical behaviors. They also engage in these behaviors to varying degrees. If one accepts a multicausal model for the determination of such behaviors, a number of recommendations are indicated. Since there is lack of agreement on the part of students as to the unethical nature of some of the behaviors surveyed, it is important for faculty members to inform students about what is considered cheating and plagiarism. At the beginning of the clinical phase, additional information should be given about what constitutes unethical practices in this area of performance. Since faculty members at the school from which the sample was drawn did supply this information, it appears that repetition is important. It is also important that faculty members be in agreement as to what is unethical and take a stand when unethical behavior is detected. As Carmack has stated, faculty members often let their humanistic values stand in the way of doing something that will "hurt" a student.~ They may be able to control another factor contributing to cheating by structuring the environment in such a way as to eliminate situational variables. Barnett and Dalton suggest that faculty members have attentive proctors, minimize the use of past examination material, and be supportive of each other in dealing with instances of
JULY-AUGUST 1985
cheating. 8 Although faculty members have little influence on personality factors, intelligence, and levels of moral development, being aware of the pressures nursing students face may lead to changes in requirements that are causing u n d u e stress. Finally, early detection of students with severe emotional problems is important. The data indicate that a small number of students are engaging in some rather serious behaviors, such as taking medications for h o m e use or coming to the clinical area under the influence of drugs or alcohol. Faculty members should be alert to warning signs that a substanceabuse problem is developing and refer students for counseling. Suggestions for future research include investigation of multiple factors that contribute to unethical behavior. Samples should include nonnursing students from the same university as well as nursing students from other settings as a basis for comparison. References
1. BairdJS: Current trends in collegecheating. Psychologyin the Schools 17:515-22, 1980 2. Hetherington EM, Feldman SE: Collegecheating as a function of subject and situational variables.J Educ Psychol 55:212-18, 1964 3. PembertonC: Student and FacultySurveyson AcademicHonesty at the Universityof Delaware. (Institutional Research Study 83-32.) Newark, DE, Universityof Delaware, 1983 4. SierlesF, Hendricks I, Circle S: Cheating in medical school. J Med Educ 55:124-25, 1980 5. Carmack BJ: Exploring nursing educators' experience with student plagiarism. Nurse Educ 8:29-33, 1984 6. Waltz CF, Busell RB: Nursing Research: Design, Statistics and Computer Analysis. Philadelphia, E A. Davis, 1981 7. EricksonML, Smith WB: On the relationship between selfreported and actual deviance:an empiricaltest. Humboldt J Soc Rel 2:106-13, 1974 8. Barnett DC, DaltonJC: Why collegestudents cheat. J College Student Personnel 22:545-51, 1981
cal school and falsifying information about a patient concerning a laboratory examination, history, or physical examination. 4 However, there is nothing in the literature to document the incidence of unethical behaviors in the classroom and in clinical settings indulged in by nursing students, nor have studies addressed the relationship between behaviors in these two areas. Therefore, the purpose of the present study was to explore answers to the following questions: 1. What is the incidence of unethical behaviors of nursing students in both the classroom and clinical settings? 2. Do students believe that these behaviors are unethical? 3. Are these beliefs related to whether or not the students engage in the unethical behaviors? 4. What is the relation of age, sex, and transfer status to the total number of unethical behaviors in each setting? 5. What is the relationship between unethical behaviors in the classroom and those in clinical settings?
THE PAST 30 years, educators have become inconcerned about the incidence of cheatIingNcreasingly or academic fraud in institutions of higher learning. Surveys have substantiated this concern, indicating that cheating has indeed been on the rise.t-4 Informal conversations with nursing faculty members have identified concerns about the increase in academic dishonesty among their students and the greater incidence of unethical behaviors in the clinical setting. Faculty members question whether or not the two types of behaviors are related. Carmack interviewed 21 nurse educators and found that half (sic) thought plagiarism, one type of academic dishonesty, was increasing. Eleven educators believed that there was a relationship between academic dishonesty and subsequent professional dishonesty. Sierles et al. surveyed medical students and found a significant correlation between cheating in medi-
Methods SAMPLE
The sample consisted of 101 senior baccalaureate nursing students who were surveyed during the last month of their final semester before graduation. Average age was 24.6 years, with a range of 21-49 years. Ninety of the students were females, with 55 per cent of the sample composed of students who had transferred into the program in either their sophomore or junior year. Transfer status was included as a variable in this study, because over half of the sample was made up of transfer students and because that group differed from nontransfer students on a number of characteristics. The transfer group included more men, more married students, more commuters, and more minority members than the nontransfer group. In
* Assistant Dean for Undergraduate Studies, School of Nursing, Widener University. Address correspondence and reprint requests to Dr. Hilbert: School of Nursing, Widener University, Chester, PA 10113. 230
HILBERT
°
NURSING STUDENT INVOLVEMENT IN UNETHICAL BEHAVIORS
addition, transfer students tended to be older than nontransfer students. B A S E L I N E DATA
Students are informed of the policy on academic fraud during their initial orientation to the university. The student handbook includes this policy, including a definition of academic fraud. The initial clinical nursing course contains material on unethical clinical behaviors, and this topic is reviewed with students in subsequent courses. INSTRUMENT
Unethical behavior was defined as a broad range of actions that may occur in the classroom and in clinical settings and that are generally considered by educators as being dishonest or fraudulent (Table 1). A questionnaire was developed that contained a listing of 22 unethical behaviors, half of which occur in the classroom and half of which pertain to clinical settings. The unethical classroom behaviors were obtained from a previously used instrument and were based on a literature review.3 The items were assumed to have content validity. The list of unethical clinical behaviors was compiled from a survey of 16 nursing faculty members. These items were also assumed to have content validity. Subjects were instructed to indicate whether or not they considered each behavior to be unethical and how many times they had engaged in each behavior in the current academic year (fall and spring semesters). They were also asked to indicate age, sex, and transfer status. Coefficient alpha was calculated as a measure of internal consistency. Alpha for the total 22-item scale was 0.668. It should be noted that use of coefficient alpha may not be appropriate, because this scale was criterion-referenced rather than norm-referenced.6 PROCEDURE
Subjects were contacted at the end of lecture classes and were asked to participate in the study. Informed consent was obtained and subjects were assured that there was no way that they could be identified from their questionnaires. Results
Table I gives the incidence of unethical behaviors in the classroom and clinical areas. In the classroom,
231
27 per cent of students had copied a few sentences from a reference source without footnoting, 19 per cent had worked with another student on an assignment when not allowed, and 17 per cent had added a few items to a bibliography. Other percentages were not high but are of concern because of the serious nature of the behavior. Ten per cent of students had turned in an assignment done by someone else, and 2 per cent had taken an exam for another student. In responding to questions on clinical behaviors, a surprisingly high number of students admitted to having taken hospital equipment (59 per cent), and over half admitted to having discussed patients inappropriately. Again, some percentages were noteworthy only because of the serious nature of the behavior. Nineteen per cent had recorded medications, treatments, or observations falsely, 12 per cent admitted to having called in sick when they were not, 7 per cent had taken hospital medications for personal use, and 4 per cent had come to the clinical area while under the influence of drugs or alcohol. Table 1 also gives opinions about the ethical nature of each of the questionnaire items. There was a fairly high agreement about the unethical aspects of classroom behaviors, with the following exceptions: working with another student on an assignment when the instructor did not allow it (60 per cent agreed that it was unethical), adding a few items to a bibliography that were not used (72 per cent), and copying a few sentences from a reference source without footnoting (80 per cent). There was also fairly high agreement on the unethical aspects of clinical behaviors. However, only 65 per cent of students thought that taking hospital equipment was unethical. Other areas of low agreement were eating food intended for or belonging to a patient (72 per cent agreement), calling in sick for the clinical area when they were not (76 per cent), and discussing patients in public places or with nonmedical personnel (77 per cent). A series of t-tests was done to determine whether there were significant differences in the incidence of unethical classroom and clinical behaviors between males and females and between transfer and nontransfer students. The only significant finding was that females engaged in more unethical behaviors in the classroom than males (p = 0.027). A Pearson correlation coefficient indicated that age was significantly negatively related to the number of times that a homework assignment was done for another student. In other words, younger students did this more often (p = 0.033). All other
232 T A B L E 1.
JOURNAL O F PROFESSIONAL N U R S I N G
•
JULY-AUGUST 1985
Opinions About and Extent of Involvement in Unethical Behaviors Percentage Who Considered This Unethical
Range for Times Done
Percentage Who Did This
Classroom behaviors Getting exam or quiz questions from someone who had taken the exam or quiz earlier in the day (or week)
84
0-6
9
Copying from someone else's exam or quiz paper or receiving answers from another student during an exam or quiz
96
0-5
4
Allowing someone to copy from an exam or quiz paper or giving answers to another student during an exam or quiz
96
0-5
7
Using notes, books, etc., during a closed-book exam or quiz
98
0-1
4
Taking an exam or quiz for another student
99
0-2
2
Copying a few sentences from a reference source without footnoting it in a paper
80
0-8
27
Adding a few items to a bibliography that were not used in writing the paper
72
0-2
17
Turning in a paper purchased from a commercial research firm
96
0
0
Turning in an assignment that was done entirely or in part by someone else (but not by a research firm)
90
0-5
10
Doing a homework assignment for another student
81
0-3
6
Working with another student on an assignment when the instructor did not allow it
60
0-5
19
76
0-4
12
Coming to the clinical area while under the influence of drugs, including alcohol
98
0-2
4
Breaking something that belonged to the patient and not reporting it
93
0
0
Not reporting an incident involving a patient
94
0-10
7
Clinical behaviors Calling in sick for the clinical area when you were not
65
0-3
59
Eating food intended for or belonging to a patient
72
0-5
9
Taking medications from the hospital for personal use
94
0-20
7
T a k i n g hospital equipment (including "greens") to use at home
Recording that medications, treatments, or observations were done when they weren't
100
0-12
19
Discussing patients in public places or with nonmedical personnel
77
0-20
54
Failing to provide information to a patient about treatments, medications, or recommended health behaviors
83
0-6
12
Not questioning an order when in doubt
85
0-3
17
correlations for age and unethical behaviors were nonsignificant. A series ofchi-square tests was done to determine the correlation between students' opinions about the unethical nature of a behavior and whether or not they engaged in it. The behaviors that were found to have a significantly lower incidence on the basis of the opinion that the behavior was unethical are shown in Table 2. In order to answer the question about the relationship between unethical behaviors in the classroom and those in clinical settings, a Pearson correlation coefficient was used for the total unethical classroom behaviors and the total unethical clinical behaviors
for each student. The result was a coefficient of 0.571 (p < 0.001). This finding indicates that there was a significant relationship between classroom dishonesty and dishonesty or unethical behavior in the clinical area. Discussion
The incidence of each unethical behavior in the classroom was lower than that reported by Pemberton in a survey of 3,000 undergraduate and graduate students from all colleges at a large state university, using an instrument that included all of the behaviors listed for the present study. 3 For example,
HILBERT
°
233
NURSING STUDENT INVOLVEMENT IN UNETHICAL BEHAVIORS
40 per cent of her subjects admitted to having received an exam from someone who had taken it earlier, as compared to 9 per cent for the present study, and 32 per cent of her subjects admitted to having allowed someone to copy from an exam or quiz paper, compared to 7 per cent for this study. There is no basis of comparison for the incidence of unethical clinical behaviors. Some of these behaviors have Iow percentages but are alarming because of the seriousness of the behaviors. For example, four students reported coming to the clinical area while under the influence of drugs or alcohol. Seven admitted not having reported an incident involving a patient, with one subject saying this had been done ten times. Seven subjects had taken medications from the hospital for personal use, with one student having done this 20 times. Nineteen admitted to having recorded medications, treatments, or observations falsely. One may question whether or not the low incidence of unethical classroom and clinical behaviors is a result of the reluctance of the subjects to admit such behavior. Erickson and Smith have indicated that few individuals report such deviant behaviors if they have not engaged in them but that those who do engage in such behaviors tend to underreport. 7 In the present study, students were close to graduation and did not seem concerned about retaliation. In fact, the investigator was amazed by the number who returned their questionnaires and consent forms together, making identification of subjects possible. In regard to opinions about the unethical nature of the classroom behaviors, a slightly higher percentage of students in the present study thought such behaviors were unethical than in Pemberton's study.~ Behaviors for which the differences were greatest were copying sentences from a reference source without footnoting (20 per cent higher in the present study) and doing a homework assignment for another student (12 per cent higher). Barnett and Dalton asked student opinions about the same classroom behaviors in a survey of a random sample of 802 freshmen and seniors at a state university.8 Most responses were comparable to those of the present study, with the following exceptions: getting an exam or quiz question from someone who had taken the exam earlier (24 per cent higher for the present study), turning in an assignment done by someone else (22 per cent higher), and working with a student on an assignment when not allowed to (12 per cent higher). Again, there is no basis for comparison of the un-
TABLE 2.
Significant Chi-Square Values for Incidence of Unethical Behaviors According to Belief About the Unethical Nature of the Behavior
Behavior Adding a few items to a bibliography that were not used in writing the paper
Chi-Square (X2)
Degrees of Freedom (dO
Probability (P)
6.575
2
0.037"
Coming to the clinical area while under the influence of drugs
11.395
2
0.003I"
Taking hospital equipment (including "greens") to use at home
10.410
2
0.006t
Eating food intended for or belonging to a patient
25.760
2
0.000t
Taking medications from the hospital for personal use
11.932
1
0.001
* P ~> 0.05. t p >~ 0.01. p >i 0.001.
ethical clinical behaviors. Those with low agreement about their unethical nature are those that do not dkectly affect patient safety but have only an indirect relationship to the quality of care. The finding that more females than males cheated in the classroom is in contrast to other reports in the literature. 1-4 Hetherington and Feldman commented that they thought males cheated more because of poorer academic performance in college.~ It was observed for the present sample that the males, with one exception, were doing well academically. It may have been that the females were more inclined to cheat because of pressure to get passing grades. The opinion that a behavior is unethical was significantly related to a lower incidence of that behavior for only six of the 22 questionnaire items. For the remaining items, it is assumed that engaging in those behaviors was related to other factors. The case for multiple causative factors is strengthened by the finding that there was a significant relationship between unethical classroom and unethical clinical behaviors. This suggests that something other than situational variables was operating. Barnett and Dalton identified six factors in the research literature that have a significant influence on cheating behavior: (1) pressure to get good grades, (2) situational factors having to do with testing conditions, (3) intelligence, (4) personality factors (such as need for approval), (5) lack of clarity as to whether
234
JOURNAL OF PROFESSIONAL NURSING
or not a behavior actually is cheating, and (6) level of moral reasoning. 8 This model appears useful for both classroom and clinical settings, in that factors 1, 2, and 5 are plausible influences on unethical behaviors in the present study. Recommendations
The results of this study indicate that some nursing students have opinions that differ from those of faculty members on the unethical nature of classroom and clinical behaviors. They also engage in these behaviors to varying degrees. If one accepts a multicausal model for the determination of such behaviors, a number of recommendations are indicated. Since there is lack of agreement on the part of students as to the unethical nature of some of the behaviors surveyed, it is important for faculty members to inform students about what is considered cheating and plagiarism. At the beginning of the clinical phase, additional information should be given about what constitutes unethical practices in this area of performance. Since faculty members at the school from which the sample was drawn did supply this information, it appears that repetition is important. It is also important that faculty members be in agreement as to what is unethical and take a stand when unethical behavior is detected. As Carmack has stated, faculty members often let their humanistic values stand in the way of doing something that will "hurt" a student.~ They may be able to control another factor contributing to cheating by structuring the environment in such a way as to eliminate situational variables. Barnett and Dalton suggest that faculty members have attentive proctors, minimize the use of past examination material, and be supportive of each other in dealing with instances of
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cheating. 8 Although faculty members have little influence on personality factors, intelligence, and levels of moral development, being aware of the pressures nursing students face may lead to changes in requirements that are causing u n d u e stress. Finally, early detection of students with severe emotional problems is important. The data indicate that a small number of students are engaging in some rather serious behaviors, such as taking medications for h o m e use or coming to the clinical area under the influence of drugs or alcohol. Faculty members should be alert to warning signs that a substanceabuse problem is developing and refer students for counseling. Suggestions for future research include investigation of multiple factors that contribute to unethical behavior. Samples should include nonnursing students from the same university as well as nursing students from other settings as a basis for comparison. References
1. BairdJS: Current trends in collegecheating. Psychologyin the Schools 17:515-22, 1980 2. Hetherington EM, Feldman SE: Collegecheating as a function of subject and situational variables.J Educ Psychol 55:212-18, 1964 3. PembertonC: Student and FacultySurveyson AcademicHonesty at the Universityof Delaware. (Institutional Research Study 83-32.) Newark, DE, Universityof Delaware, 1983 4. SierlesF, Hendricks I, Circle S: Cheating in medical school. J Med Educ 55:124-25, 1980 5. Carmack BJ: Exploring nursing educators' experience with student plagiarism. Nurse Educ 8:29-33, 1984 6. Waltz CF, Busell RB: Nursing Research: Design, Statistics and Computer Analysis. Philadelphia, E A. Davis, 1981 7. EricksonML, Smith WB: On the relationship between selfreported and actual deviance:an empiricaltest. Humboldt J Soc Rel 2:106-13, 1974 8. Barnett DC, DaltonJC: Why collegestudents cheat. J College Student Personnel 22:545-51, 1981