Nurses in all practice settings are continuously challenged to meet physical, emotional, and spiritual needs individuals' (American Nurses' Association [ANA], 2015; Basler, 2012; Comrie, 2012; Dudzinski et al., 2013; Fry et al., 2011; Park, 2012). Many of these challenges have been embedded in ethical components, and the recognition of these ethical issues by nurses is critical to effectively care for a patient's needs (Crigger & Godfrey, 2014; Robichaux, 2012; Trobec & Starcic, 2015). The complexity of the current health care system and the emphasis on patient-centered care has resulted in increasing demands on nurses to act as patient advocates and moral agents (Numminen et al., 2011; Ramos et al., 2013). Because of the prevalence of ethical concerns in health care, there is a need to explore the process by which health professionals learn to deliver ethically competent care. For baccalaureate-prepared nurses, this process should begin in nursing school.
The importance of moral and ethical development in nursing has been well documented (Barkhordari-Sharifabad et al., 2017; Benner, 1984; Benner et al., 2010; Pedersen & Sivonen, 2012). The acquisition of knowledge is not enough to become a competent, ethical nurse (Benner et al., 2011). Ethical nursing practice requires an active engagement in thinking (Benner, 1984), reasoning (Benner et al., 2011), understanding (Boykin & Schoenhofer, 2001), effective communication (Decker & Shellenbarger, 2012), and reflection (Benner et al., 2011).
The complex health care system across acute, ambulatory, and community-based settings requires nurses to be actively engaged in ethical problem solving, including preventing and intervening in ethical issues (ANA, 2015; Benner et al., 2008; Benner et al., 2010; Comrie, 2012). However, a lingering question remains—has faculty teaching in prelicensure nursing programs designed curricula and implemented course work sufficient to prepare nurses for these ethical duties? Thus, the purpose of this study was to explore the experiences of faculty teaching ethics content in the classroom setting to prelicensure baccalaureate nursing students including their perceptions of preparedness in teaching ethics content and teaching approaches. This descriptive phenomenological study addressed the following research questions:
- What are the experiences of nursing faculty teaching ethics content in the classroom setting in a prelicensure baccalaureate nursing program?
- What are nursing faculty's perceptions of their preparation for teaching ethics content in the classroom setting in a prelicensure baccalaureate nursing program?
The researcher used a descriptive phenomenological design. The phenomenological approach has been used by various researchers across disciplines to examine phenomena in higher education (Begley et al., 2011; Macedo, 2013; Pedersen & Sivonen, 2012; Santos, 2012; Schmidt & Adkins, 2012). Because nursing ethics education was studied in the context of higher education for both preparation of nursing faculty and their experiences, Giorgi's (1985) descriptive phenomenological method was the most appropriate to provide structure and meaning to the data gathered for this study.
Approval for this study was obtained from the Institutional Review Board (IRB) of the researcher's academic setting, Mercer University. No recruitment of participants or study related procedures were initiated until after Mercer University IRB approval was obtained.
Population and Setting
To adequately address the research questions, the participants in this study needed to be able to articulate their perceptions of informal and formal preparations in ethics training in relation to their teaching effectiveness with regards to ethics education in prelicensure baccalaureate nursing programs. Therefore, purposive and snowball sampling (Creswell & Creswell, 2018) through the Nursing Educator Listserv were used to specifically target nursing faculty teaching ethics beyond research ethics. Purposive sampling is a selective sampling process based on participants having certain shared characteristics to enhance the study's impact and effectiveness (Creswell & Creswell, 2018; Creswell & Poth, 2017; Denzin & Lincoln, 2013). Snowball sampling occurs when existing research participants recruit future participants among their colleagues who meet the specific inclusion criteria of the research study (Creswell & Creswell, 2018).
All participants (N = 11) were female, with a range of 4 to 33 years of teaching experience in an academic setting, with an average of 11 years of experience. Experience in teaching ethics courses or ethics content in a nursing program ranged from 2 to 30 years, with 7 years being the average. Most participants (55%) were educated at a master's level. The remaining 45% had a doctoral degree. Ten participants reported having no formal background in ethics.
Data Collection and Procedure
After approval from the Mercer University IRB, potential participants were contacted via the Listserv and invited to participate in this study. Following the receipt of participants' content and demographic information, individual interviews were scheduled, inclusion criteria were confirmed, and the audio recording of the interview was transcribed.
After receiving participants' information, the researcher contacted them to schedule a telephone interview with ensured privacy and confirmed the participant met the inclusion criteria. The researcher then proceeded to describe the study procedures, including a statement indicating that the interview would be audio-recorded with a digital recorder placed next to the telephone while the call was on speaker mode. The audio recording was uploaded to a secure server for verbatim transcribing by a certified medical transcription company.
The interview questions began with a grand tour question (Creswell & Creswell, 2018) exploring the participant's background in personal ethics education with several follow-up questions from the researcher-developed semistructured interview guide. The interview questions were designed to obtain a description of the participants' experiences, teaching ethics, and their ethics-related educational background. All interviews were conducted by the same researcher (S.G.), and each interview lasted between 35 and 80 minutes. Audio-recorded interviews were transcribed by a professional transcriptionist, and the transcripts were reviewed by the researcher and senior researcher.
Data were analyzed by the researcher, according to Giorgi's (1985) approach to phenomenological analysis. With this approach, the goals are to uncover phenomenon through shared experiences with faculty teaching ethics content to prelicensure baccalaureate nursing students, provide meaning to these phenomena, and categorize them into themes. Before coding began, all transcripts were read in their entirety to get a sense of the whole and then were analyzed using first and second cycle coding methods (Saldana, 2013). Codes were grouped into categories, and themes and subthemes were extracted for common themes in an iterative process until data saturation was reached.
The researcher used multiple strategies to ensure trustworthiness of the data. Participants were encouraged to be open and honest in talking about their experiences. The researcher included quotes from the participants to support the themes (Creswell & Creswell, 2018; Denzin & Lincoln, 2013; Munhall, 2012). An audit trail was maintained by documenting initial impressions and subsequent coding decisions in a journal. These coding decisions were in collaboration with a researcher with extensive experience in qualitative research.
Confirmability encompasses hearing the participant's voices in the text, not the researcher's, to diminish potential researcher bias (Creswell & Creswell, 2018; Munhall, 2012). Additionally, transcripts and coding were reviewed for potential biases. Transferability pertains to the reader being able to apply the study to other situations or contexts (Creswell & Poth, 2017; Denzin & Lincoln, 2013; Munhall, 2012).
Participants shared their stories and passions for teaching prelicensure students, along with their desire to make significant impacts with their teaching. Three main themes were identified in the data analysis: Lacking Prior Preparation—Students and Faculty; Difficult Content; and No Place Holder for Ethics Content in Nursing Curriculum.
Lacking Prior Preparation—Students and Faculty
Inconsistencies existed in what exposure to ethics content students had received prior to entering the nursing program. This inconsistency is expressed by a participant who stated, “They may have had an introduction especially if they are a second-degree [seeking student] or…if they've had life experiences. They may have run into some, but most of them had [sic] not had any formal training on ethical principles.” This lack of student preparation required nursing curriculum to include ethics foundation; however, lack of prior preparation also existed among faculty within graduate education given that there are no established standards with respect to graduate education in nursing ethics (Burkemper et al., 2007). Participants reported receiving education about the ethical conduct of research. However, seven of the study participants did not have exposure to any other ethics other than research ethics in their graduate programs or could not recollect if ethics had been incorporated. Another participant stated, for instance, “I don't remember… anything formal as far as ethics.”
Faculty also reported being uncomfortable with ethics content. One participant expressed, “Sometimes I don't feel like I'm giving them the right tools to be able to do that [think], and sometimes, there is no right or wrong [answer].” The same participant discussed how she felt competent clinically. However, in the classroom when applying theory and principles said, “I'm good with raising questions…but don't feel like I'm that good with tying it [ethics] all together.”
Participants expressed the need for faculty to facilitate students' growth in ethics by providing basic knowledge of codes and principles along with linking theory to facilitate clinical application. However, basic knowledge level of ethics content only minimally meets the standard. Ethical and moral development is heavily influenced by an individual's background (i.e., ethnicity, culture, and personal experiences) making the task of understanding perspectives outside of their own difficult (Bourque Bearskin, 2011). Another participant described how factors such as gender and race influence teaching ethics:
The student recognizing that it's their responsibility to realize that how the questions that they ask, the things that they think, what they see in the world, all has a cultural underpinning that is oftentimes different than most that they're working with and that they should not just assume that they understand someone else's experience because of their skin color, gender… and that is actually layered information and how they see the world would impact how they see the client and…shifts the responsibility.
This shift in responsibility away from the client and on to the nursing student, faculty, and bedside nurse presented yet another level of difficulty. One participant considered it unrealistic for any nurse to be well-versed on every nuance of all cultures and have a full understanding of how the client views himself or herself within their culture. One of the participants discussed this specifically and acknowledged the need to approach the patient from a place of “unknowing” and also “recognizing that there may be differences that they're not even aware of.”
No Place Holder for Ethics Content in Nursing Curriculum
Participants described challenges around integrating ethics content within the nursing curriculum. Historically, nursing has had the additive approach to curriculum development as a response to low test scores or new initiatives by accreditation bodies (Benner et al., 2010) creating a saturated curriculum with little room for exploring moral and ethical situations. Participants indicated that marginalization of ethics content in nursing curriculum occurs because it is considered less important; therefore, it is pushed aside to make room for more core nursing content.
Interestingly, none of the participants linked the importance of ethics content with ANA Code of Ethics or accreditation standards. Rather, the participants discussed the national board examination as the benchmark in curriculum decisions. It is not surprising that weaving ethics content throughout nursing curriculum has had its share of challenges. However, participants of this study believe continual work and commitment by faculty is necessary to ensure the ethics content remains within the curriculum and is taught with quality. One participant stated, “It does take an effort on everyone's part to integrate it [ethics] to keep the quality…[and] application of ethical decision-making.”
This study's findings revealed an educational gap in the exposure to ethics content for both students and faculty and the need for intentional curriculum development pertaining to ethics education. Everyday ethics has little to do with legalities and more to do with being present and knowing the personhood so nurses can care and advocate appropriately (Benner et al., 2008). The perceptions of the faculty participants were consistent with literature of previous studies, in that there was a lack of preparedness of both students and faculty with often “forgotten” ethics within the nursing curriculum (Krautscheid & Brown, 2014, p. S21).
Participants identified the need for ethics content to be more intentional and explicit in the curriculum in identifying content to the nursing students as ethics, particularly when ethics is integrated into the curriculum rather than a stand-alone course. As supported by previous literature, if students do not recognize classroom content as related to learning how to think in an ethical manner and manage ethical situations in the clinical settings, valuable opportunities to apply content may be lost (Krautscheid & Brown, 2014).
Consistent with the literature, the participants identified a lack of formal and informal opportunities for faculty to explore ethics along with the philosophical and theoretical underpinnings prior to serving as nursing faculty (Benner et al., 2008). It is imperative nurses within graduate programs learn research ethics; however, there is also the need for graduate students—particularly those with an interest in nursing education—to learn ethics content relevant to clinical practice along with instruction on the various types of pedagogies used to best foster understanding and application of the content by prelicensure nursing students. Additionally, well versed faculty in ethics will result in the student's ability to effectively manage everyday ethics in clinical practice (Krautscheid & Brown, 2014).
The perceptions of the faculty participants were consistent with past research findings of lack of preparedness among students and a varied level of ethics content within the nursing curriculum. This study demonstrated the need for nursing programs to be more intentional with designing and incorporating ethics content within the curriculum. Intentionality with ethics content would involve examining ethics content as a foundation of the core curriculum and unambiguously highlighting the content within the subject matter throughout the curriculum. This process would transfer the once sidelined or hidden curriculum to a more prominent and permanent place within the curriculum. Finally, this study identified the lack of formal and informal opportunities for faculty to explore ethics, including philosophical and theoretical underpinnings. Graduate nursing programs, which ultimately provide the pipeline for the nursing education workforce, should consider offering ethics education in broader ways than research ethics—ways that impact nursing leadership and current clinical practice. Given the dearth of research on exploring or examining the lack of educational preparedness for nurse educators, future research should focus on the facilitators and barriers of ethics education in graduate nursing programs and other certifications for nurse educators.
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