Abstract
Background:
Undergraduate nursing students have been documented to experience ethical distress during their clinical training and felt poorly supported in discussing the ethical issues they encountered.
Research aims:
This study was aimed at exploring nursing students’ perceived opportunity to discuss ethical issues that emerged during their clinical learning experience and associated factors.
Research design:
An Italian national cross-sectional study design was performed in 2015–2016. Participants were invited to answer a questionnaire composed of four sections regarding: (1) socio-demographic data, (2) previous clinical learning experiences, (3) current clinical learning experience quality and outcomes, and (4) the opportunity to discuss ethical issues with nurses in the last clinical learning experience (from 0 – ‘never’ to 3 – ‘very much’).
Participants and research context:
Participants were 9607 undergraduate nursing students who were attending 95 different three-year Italian baccalaureate nursing programmes, located at 27 universities in 15 Italian regions.
Ethical considerations:
This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after the research protocol was approved by an ethics committee.
Findings:
Overall, 4707 (49%) perceived to have discussed ethical issues ‘much’ or ‘very much’; among the remaining, 3683 (38.3%) and 1217 (12.7%) students reported the perception of having discussed, respectively, ‘enough’ or ‘never’ ethical issues emerged in the clinical practice. At the multivariate logistic regression analysis explaining 38.1% of the overall variance, the factors promoting ethical discussion were mainly set at the clinical learning environment levels (i.e. increased learning opportunities, self-directed learning, safety and nursing care quality, quality of the tutorial strategies, competences learned and supervision by a clinical nurse). In contrast, being male was associated with a perception of less opportunity to discuss ethical issues.
Conclusion:
Nursing faculties should assess the clinical environment prerequisites of the settings as a context of student experience before deciding on their accreditation. Moreover, the nursing faculty and nurse managers should also enhance competence with regard to discussing ethical issues with students among clinical nurses by identifying factors that hinder this learning opportunity in daily practice.
Keywords
Introduction
The clinical learning environment (CLE) is a complex social environment influencing academic learning outcomes and the quality of competences achieved, as well as future professional advancements. 1 According to a recent concept analysis 2 in the context of nursing education, the CLE has been defined as the place where nursing students apply theory to practice while caring for patients. Given the CLE’s relevance in developing clinical, ethical, cultural, communicational and technical competences by constituting half of the total duration of their undergraduate education, 3 students’ perceptions of CLE should be measured and taken into account. 4
Recent literature has reported that although nursing students are generally satisfied with their CLE, 5,6 being in a clinical setting can prove to be challenging experience, due to a number of factors. 7 Specifically, nursing students may become disillusioned when caring is not the primary focus of nursing as they previously believed. Administrative expectations, such as completing paperwork and tasks, can take away time from patient-centred care resulting in poor communication, listening, and assessment of patient preference and values; moreover, students can be exposed to poor caring practices threatening ethical principles 8 thus rising ethical issues.
An ethical issue or problem occurs every time when profound moral questions of ‘rightness’ or ‘wrongness’ underlie professional decision-making and the beneficent care of patients. 9 The frequency with which nursing students experience these ethical issues can influence the degree to which they are engaged in moral behaviour. Moreover, when a moral element threatens a nurse’s or a student’s moral integrity, it can cause moral distress; this can also occur when they are unable to make any ethical choice in a given situation or when they feel underestimated and ignored in attempting to resolve an ethical issue. 9 –12
Nursing students are fresh from ethical notions taught in the classroom; moreover, those newly enrolled start their clinical experience with a personal vision of care and being a caring nurse, which is usually idealistic. 13 Therefore, students are in the best position for detecting ethical issues when entering the CLE, in which policies and procedures, unsafe working conditions, understaffing, organisational norms and hierarchical decision-making may give rise to a significant number of moral dilemmas. Unprofessional behaviour among health care staff, problems stemming from hospital management, inefficient communication, or team disagreements regarding the plan of care, or other issues – all influencing the quality of life, dying and death, patients’ right to confidentiality, privacy and autonomy – have been reported as the most common ethical issues experienced by nursing students. 14 –17
Unfortunately, nursing students frequently felt there was ‘no one to turn to’ to receive support for their moral distress. 11 In their naturalistic inquiry qualitative study of seven female nursing students who had completed their 13-week clinical learning experience in acute inpatient psychiatric units, Wojtowicz et al. 11 have reported that although students had many questions about what they perceived as overmedication, they could not turn to nurses to share their moral distress. Students perceived their clinical nurses as being inaccessible about these issues, instead of serving as role models or supporting the student on how to deal also with these challenges.
In contrast, as suggested by a qualitative content analysis describing the experience of nursing students, among the essential requisites of the role of clinical nurses, the ability of promoting ethical competence has been documented. 18 Despite this, nursing students have reported the lack of support and supervision by clinical nurses 15,16 and over three-quarters of them were assigned to nurses who were not used to debating those ethical issues encountered in the practice. 15 Nursing students have reported feeling undermined and their learning held back when working in non-supportive clinical environments. 19
To date, although the clinical environment has been documented to trigger moral distress 14 –17 that can reach several degrees 20 decreasing the quality of the experience, 11 nursing students’ perceptions regarding opportunity to discuss ethical issues experienced in their practice have never been explored.
Therefore, the purposes of this study were to explore nursing students’ perceived opportunity to discuss ethical issues that emerged during their clinical learning experience and associated factors. The research questions were as follows: (1) Do nursing students perceive the opportunity to discuss ethical issues that emerge in the clinical practice with the nursing staff? (2) What factors influence their perceptions with regard to the opportunity to discuss, or not, ethical issues that emerge in the clinical practice?
Methods
Design
A national cross-sectional study was performed in 2015–2016.
Setting
On a preliminary basis, the National Commission (‘Conferenza Nazionale dei Corsi di Laurea delle profession sanitarie’) including all Italian bachelor of nursing science (BNS) programmes were approached. Among other strategic purposes, the Commission harmonises nursing education across the nation by developing different initiatives such as the establishment by consensus of the nursing curriculum aims and contents defined, par national low, as composed by 180 credits and 3 years in length. According to the national curriculum, the main aim of the first year of nursing education is to the develop knowledge and competence on the fundamentals of nursing care and basic sciences, including safety in the CLE; in the second year the main aim is to develop nursing competences regarding different clinical conditions (e.g. surgical, medical, neurological); in the third year specific target groups (maternal and child, psychiatric care) as well as contents related to ethical issues and dilemmas are the main focus.
After the invitation was sent by the National Commission, a total of 27 out of the existing 43 nursing programmes expressed their willingness to participate, and therefore, a network of BNS (‘SVIAT network’;
Participants
In each participating nursing programme, eligible students were those (1) who were attending or had just ended their clinical learning experience at the time of the survey, (2) whose last clinical experience had lasted at least 2 weeks and (3) who were willing to participate in the study, as expressed through a written informed consent. Students were approached and informed regarding the study aims and the freedom to participate in the research process by a reference researcher of the SVIAT 21 network appointed in each nursing programme.
Data collection process and instruments
The data collection process was performed through a questionnaire composed of four sections:
Socio-demographic: by collecting data on, for example, age, gender and civil status.
Previous clinical learning experience: students were required to recall the number of previous clinical experiences performed and in which settings (e.g. only in hospital).
Current clinical learning experience: students were required to focus their attention on the last clinical experience and to indicate its duration; they were also required to indicate the supervision model adopted by the unit according to the following options: (1) ‘I was supervised by a clinical nurse’ (= by a clinical nurse involved also in the care of patients, and who received a specific training); (2) ‘I was supervised by the nursing staff’ (= by all nurses who cared for the patients and supervised students without any specific training); (3)’I was supervised by a nurse identified on a daily basis by the head nurse’ (= by one nurse decided on a daily basis, who cared for patients and supervised students without any specific training); (4) ‘I was supervised by the nurse teacher’ (= by a nurse working at the faculty level and with mainly teaching and researcher functions); (5) ‘I was supervised by the head nurse’ (= by the chief nurses performing mainly management functions). 22,23 Moreover, students were required to rate the effectiveness of the clinical experience on the degree of competence learned using a 4-point Likert-type scale (from 0 – none to 3 – very much).
The Clinical Learning Quality Evaluation Index (CLEQI) tool 24 measuring the quality of the learning processes was also included in the questionnaire. The tool was chosen on the basis of the following considerations: (1) its national relevance and current use by the majority of the involved nursing programmes, (2) its intent to evaluate the quality of the clinical learning processes as enacted in the practice and (3) its good psychometric properties that have been published elsewhere by authors. 24 The tool comprises five factors, namely, the ‘Quality of the tutorial strategies’ (6 items), the ‘Learning opportunities’ (6 items), the ‘Self-directed learning’ (3 items), the ‘Safety and nursing care quality’ (4 items) and the ‘Quality of the learning environment’ (3 items). Overall, the CLEQI score may range from 0 to 3; a higher score reflects a higher quality of learning processes that have been perceived by the students in the specific environment.
The opportunity to discuss ethical issues with nurses in the last clinical learning experience. This was investigated by an item formulated as follows: ‘Did you have the opportunity to discuss ethical issues and their implications during your last clinical learning experience?’ Answers were based on a 4-point Likert-type scale (from 0 – never to 3 – very much). Aiming at ensuring that a common concept of ‘ethical issue’ was considered by participants, the following definition was reported in the questionnaire: ‘An ethical issue or problem occurs every time a profound moral question of “rightness” or “wrongness” underlies professional decision-making and the beneficent care of patients’. 9
Data were collected via paper and pencil and via Google Drive, according to the resources available in each BNS nursing programme. The nursing programmes that decided to adopt paper and pencil used one or more classroom(s) where students were left free to fill in the questionnaire without any restriction in time. Instead, the nursing programmes that administered the questionnaire via Google Drive, sent the link to students using their university email account and they had 2 weeks to complete it. Only one reminder was sent via email. Once the data were collected, they were imputed in an Excel file and sent to the coordinator centre (Udine University) for data analysis.
Ethical considerations
The study protocol was approved by the ethics committee of the University of Milan (Italy). Students were left free to participate or not in the study and their participation was not incentivised. Moreover, the questionnaire included spaces for indicating the name and the surname of the participant; students were left free to fill in also this part according to their preference.
Data analysis
Descriptive and inferential statistic tests were performed using the SPSS Statistical Package (version 24.0). On a preliminary basis, the description of frequencies, average percentages (with standard deviations (SD)), and ranges or confidence intervals (CI) at 95% were calculated. The dependent variable (having had the opportunity to discuss ethical issues with nursing staff) was considered a continuous variable when correlations were searched with other continuous variables and a categorical variable by creating three groups: (1) those students who perceived ‘never’ to discuss ethical issues, (2) those who perceived ‘enough’ opportunity to discuss ethical issues and (3) those who discussed ethical issues ‘much’ or ‘very much’. Bivariate analyses were performed using the chi-square test with dichotomous variables and using analysis of variance (ANOVA) and Kruskal–Wallis test for continuous variables.
Correlations were also calculated using the Spearman’s rank-order correlation (ρ) according to the nature of the variables. With the intent of identifying cluster effects, if any, the intraclass correlation (ICC) was computed both under random and fixed effect assumptions at the hospital unit (1) level which hosted the students in the last clinical experience (e.g. medical, palliative care: discussing ethical issues may express different cultural patterns and occurrences at the units levels) and at the nursing programme (2) level (e.g. emphasis in the curriculum may have developed different expectations among students with regard to ethical issues discussion).
Moreover, factors associated with the opportunity to discuss ethical issues in the clinical setting as perceived by students were assessed using a multivariate logistic regression analysis by calculating the odds ratio (OR, CI 95%). Participants were divided in two sub-groups according to the following evidences: (1) nursing students should be offered to discuss ethical issues every time these are encountered in the practice, and not occasionally; 11,18 (2) the median and the mode values emerged in the 4-point Likert-type scale (from 0 – never to 4 – very much) scoring the end-point variables. Thus, two groups were created: the first including who scored the opportunity to discuss ethical issues from ‘much’ to ‘very much’ and the second including those who scored from ‘never’ to ‘enough’.
Only those variables significantly associated with the end point at the bivariate analysis were included in the model. The model’s goodness of fit was evaluated by checking the Hosmer–Lemeshow test. The statistical significance was set at p < 0.05.
Results
Participants
There were 9607 students involved out of the 10,480 eligible; they were attending their education in one of the 95 participating BNS programmes, located in 27 universities out of the 43 available in 15 different Italian regions, as reported in Figure 1.
Number of participants according to regions where the nursing programme was attended by students (= 9607).
The majority of the students were female (76%) and unmarried (95%), and the average age was 22.9 (4.1) years (from 18 to 57 years). The three-year nursing programmes were represented roughly equally, with 30%, 34% and 35% being first-, second- and third-year students, respectively. Most of the students reported having a secondary high school (70.2%), with an average score ranking in the third upper quartile. Almost 70% of the students had never attended previous degree courses before starting the nursing degree. About one-third (n = 3301) of students had previous work experience and one in five were working during their nursing education.
Overall, 4707 (49%) students perceived to have discussed ethical issues ‘much’ or ‘very much’; among the remaining, 3683 (38.3%) and 1217 (12.7%) students reported the perception of having discussed, respectively, ‘enough’ or ‘never’ the ethical issues emerged in the clinical setting with the staff.
Students reporting ‘never’ and ‘enough’ discussion of ethical issues as compared to those who reported ‘much’ to ‘very much’ were significantly more often female and without children; specifically, those who reported ‘never’ were older, mostly graduated from high school, and with no previous work experience before the degree; they were attending mostly the second and the third year of nursing education and mainly worked during their student career as compared to those who reported to have discussed ethical issues ‘enough’, ‘much’ or ‘very much’. The characteristics of the study population are presented in Table 1.
Participants according to their perception of the opportunity to discuss ethical issues in the clinical environment.
CI: confidence interval; CLEQI: Clinical Learning Quality Evaluation Index; SD: standard deviation; ANOVA: analysis of variance.
aOn a 4-point Likert-type scale (0 = none; 3 = very much).
bThe last clinical experience was that under evaluation.
cChi-square for dichotomous variables, and ANOVA and Kruskal–Wallis test for continuous variables.
Previous and current clinical learning experience
As described in Table 1, participant students reported on average 4.9 (95% CI, 4.8–5.0) clinical experiences, mostly performed exclusively in a hospital setting (68.1%).
The length of the last clinical experience was on average 5.8 (95% CI, 5.7–5.8) weeks; more than half were supervised by a clinical nurse and about 40% by the nursing staff. Overall, in their last clinical experience, students perceived to have learned clinical competences to an extent from much (47.8%) to very much (30.5%). According to the CLEQI tool, they scored the overall learning environment 1.91 out of 3 (95% CI, 1.90–1.93).
As reported in Table 1, students who reported to have ‘never’ discussed ethical issues with the nursing staff attended significantly more frequently their clinical trainings only at the hospital (p < 0.001); their last learning experience was shorter (p < 0.001), they were supervised mostly by nursing staff (p < 0.001) and they perceived to have learn less competences (an average of 1.56 out of 3 vs 1.90 and 2.35, p < 0.001) as compared to those students reporting to have discussed ethical issues ‘enough’, ‘much’ or ‘very much’. Moreover, all the CLEQI factors scored significantly lower among students who reported to have discussed ethical issues ‘never’ as compared to those who perceived to have discussed ‘enough’, ‘much’ or ‘very much’ (all p < 0.001).
Significant correlations were found between the opportunity perceived by students to discuss ethical issues that emerged in the clinical practice and both the overall CLEQI score (ρ = 0.474, p < 0.01) and the score of CLEQI factors (Table 2). The ICCs at the unit level (e.g. medical ward, palliative ward) were 0.024 (under the random effects assumptions) and 0.017 (under the fixed effects assumptions); at the nursing programme levels were 0.078 and 0.073, respectively, thereby indicating that around 1.7% and 2.4% of the residual variability of the students’ perception to discuss ethical issues was attributed to the units attended while around 7.3%–7.8% to each nursing programme.
Correlation between the opportunity to discuss ethical issuesa and the CLEQI factors and total scores.
CLEQI: Clinical Learning Quality Evaluation Index.
aAs continuous variables, Likert-type scale from 0 to 3: 0 no discussion (1217; 12.7%), 1 enough discussion (3683; 38.3%), 2 much discussion (3328; 34.6%) and 3 very much discussion (1379; 14.4%).
*p < 0.01.
Factors promoting the discussion of ethical issues
In the multivariate logistic regression analysis, the end point was the opportunity to discuss ethical issues with the nursing staff (from ‘much’ to ‘very much’) as compared to those students who did not (from ‘never’ to ‘enough’). The multivariate model has explained the 38.1% of the overall variance. Having increased learning opportunities (OR = 2.155, 95% CI = 1.889–2.458) and self-directed learning opportunities (OR = 1.799, 95% CI = 1.648–1.964), as well as experiencing an environment where safe and good quality of nursing care (OR = 1.696, 95% CI = 1.499–1.919) and higher quality of the tutorial strategies (OR = 1.277, 95% CI 1.133–1.440) have been provided, increased the likelihood of discussing ethical issues that emerged in the clinical practice (Table 3).
Factors promoting the discussion of ethical issues that emerged in the clinical practice.
CI: confidence interval; CLEQI: Clinical Learning Quality Evaluation Index; OR: odds ratio.
aOn a 4-point Likert-type scale (0 = none; 3 = very much).
§Reference group.
Moreover, also a higher perception of having learned clinical competences (OR = 1.196, 95% CI = 1.092–1.311) and a higher quality of the learning environment (OR = 1.127, 95% CI = 1.003–1.266) were associated with the increased likelihood of discussing ethical issues. Conversely, being supervised by a nurse teacher prevented the likelihood of discussing ethical issues (OR = 0.532, 95% CI = 0.367–0.772), as reported in Table 3.
At the individual level, having children (OR = 1.438, 95% CI = 1.081–1.913) was positively associated while being male (OR = 0.774, 95% CI = 0.682–0.877) was negatively associated with the perception of having had the opportunity to discuss ethical issues.
Discussion
The study was aimed at gaining a deeper understanding of nursing students’ perceived opportunity to discuss ethical issues that emerged during their clinical learning experience with the nursing staff, as well as the associated factors. Ethical issues encountered in the clinical practice may cause severe moral distress that can negatively affect students’ caring competences. Specifically, when moral distress is not properly addressed, students tend to avoid patient contact, lose caring competences 25 and are discouraged to undertake a career in a specific care setting. 11 Furthermore, moral blunting and desensitisation have been documented to be increased among third-year as compared to second-year students in a recent survey of 373 undergraduate nursing students when they were not involved in ethical discussion. 16
We have involved a large sample of BNS programmes and their students, and the main characteristics, such as age, the prevalence of women, the secondary education attended and the working conditions during and before the degree, are in line with those documented at the national levels. 26
According to the findings, baccalaureate nursing students perceived a lack of opportunity to discuss ethical issues, with one in eight reporting they did not ever perceive the opportunity to discuss these issues with the staff during their clinical learning experience. Strengthening ethical content in theoretical courses is not sufficient to prepare students for the complex situations they encounter in practice: they should be given the opportunity to voice their ethical concerns in order to develop autonomous and professional decision-making. Students learn how to analyse and address ethical problems as future professionals only when they have had the opportunity to discuss ethical issues during their education; 18 in contrast, when there is a lack of opportunity to be engaged in discussion, students can lose ethical competences and increase the risk of moral distress. 11
The perceived opportunity to discuss ethical issues of participant students was mildly affected by the nursing programme and the hospital units attended and in both a low cluster effect was reported. The majority of predictors have emerged at the clinical environment level: students who perceived greater clinical learning opportunities have reported an increased perception of discussing ethical issues with nurses. Also, the perception of having gained more competences during their clinical experience was positively associated with ethical discussions, confirming that students considered the acquisition of competences as a whole, in which technical and ethical competences are interrelated. 18 In addition, students who perceived themselves to be independent in the learning processes, by identifying learning needs and strategies and self-evaluating their progress, have reported they were more likely to discuss ethical issues. Self-directed learning can also increase effectiveness in acquiring ethical competence and students can perceive themselves more confident in being engaged in ethical discussion with their clinical nurses. 2
The perception of being immersed in a context in which patient safety and nursing care quality is higher has promoted the discussion of ethical issues. In those clinical environments where safety and nursing care quality are threatened, there is an increased need to discuss ethical implications. However, in these situations often determined by understaffing, nurses are focused on completing their tasks and lack the time to discuss students’ ethical issues. 27 Unsafe working conditions have been reported as causing the most moral distress among nursing students: 10,14,16,28 time pressure can also negatively impact students’ patient care and their professional development. Therefore, faculties should not assign students to those settings with higher nurse-to-patient ratios or with negative habits regarding the safety and the quality of nursing care.
The quality of the tutorial strategies adopted as well as the tutorial model offered during the clinical learning experience have both emerged as factors that positively affect the likelihood of discussing ethical issues. Clinical nurses have the responsibility to address students’ moral distress and make them feel supported in developing critical thinking and the ability to make moral decisions. 29 –31 They act as role models exemplifying professional values that students wish to emulate; 32 moreover, students consider being ethical an essential professional value that they scrutinise among nurses encountered during their clinical experiences. 32 Therefore, training clinical nurses to increase their competence in mentoring students can also increase the opportunity to discuss ethical issues in daily practice; nurse managers should also support clinical nurses to engage students in discussing ethical problems aimed at developing their autonomous moral thinking.
On the other hand, students have reported that when they were supervised directly by the nurse teacher as the faculty member in the clinical environment, they perceived less likelihood of discussing ethical issues. Sometimes nurse teachers are considered by students to be evaluators, and this could have threatened the freedom to report and discuss ethical issues. Moreover, they might not be directly involved in the care of patients due to their teaching and researcher role, thus limiting an in-depth discussion on issues that emerged in the clinical practice. Instead, students who were supervised by clinical nurses reported being more likely to discuss ethical issues, possibly because trained clinical nurses stimulated students to voice their ethical concerns, arrange discussions and receive creative feedback, as reported in the literature. 23,33
A few factors emerged at the individual level: male students were less likely to be engaged in ethical discussions compared to their female peers. Men have been reported to have a different sensitivity compared to women, possibly because they are more focused on acquiring technical skills rather than speculative knowledge such as ethical decision-making. However, previous qualitative studies 14,32 highlighted ethical dilemmas and professional values in the nursing profession according to the perception of both male and female students, although the former was less represented than the latter. In addition, students with parental responsibilities reported having more opportunities to discuss ethical issues, and this can be interpreted under different lines: they can be older, attending the final years of nursing education, thus more prepared in being engaged in ethical discussion; or because they are more used to identifying ethical issues since they are exposed daily to making choices for their child’s benefit and avoiding harm, which are fundamental ethical principles.
Limitations
Our study has several limitations. The sample size was not calculated a priori given the intent to involve all students attending their education in the existing nursing programmes. In addition, data were collected with a questionnaire, by having students self-report their perceptions. No data were collected regarding the ethical content of the theoretical courses attended (which may be variable across Italy) or students’ cultural and religious beliefs that may influence the perception of ethical issues. Moreover, aiming at measuring the quality of the CLE, the CLEQI 21,24 was used instead of other instruments well established at the international levels. 4 Furthermore, although there is a national curriculum, local variations could have affected the findings (e.g. different clinical learning objectives).
The cross-sectional design used suggests the need of being cautious in considering the associated factors as determinants of the increased likelihood to discuss ethical issues as perceived by students. Causative factors require different study designs (e.g. intervention studies), which may be addressed in the future. In addition, the concept of ‘discussing ethical issues’ 9 was briefly defined in the questionnaire and participants may have attributed different meanings; 34 moreover, we have used a single question without exploring more in depth, for example, the quality of such discussion.
According to the limited amount of explained variance emerged in the multivariate analysis, further research is recommended to capture all the factors affecting ethical discussions in the clinical practice. It would also be interesting to inquiry students with regard to the barriers and difficulties they perceived in the practice as well as to complement their perceptions by collecting that among clinical nurses. Finally, analysing the stress (ethical or moral distress) suffered by students in relation to the opportunity perceived to discuss ethical issues is strongly recommended.
Conclusion
One out of eight nursing students never experienced the opportunity to discuss ethical issues during their clinical learning experience; while around one-third perceived ‘enough’ opportunities.
The pedagogical atmosphere characterised by the quality of tutorial strategies, the tutorial models adopted, the learning opportunities offered, the quality of the learning environment, the safety and nursing care quality delivered, and the self-directed learning opportunities – in addition to gender and clinical competence learned during the clinical training – were identified as factors associated with the perceived opportunity to discuss ethical issues. Nursing faculties should assess these prerequisites in clinical settings before deciding on their accreditation as a context in which nursing students should attend their clinical experience. Moreover, the nursing faculty and nurse managers should also enhance their competence to discuss ethical issues with students among the clinical nurses by identifying factors that threaten this learning opportunity in daily practice.
Footnotes
Acknowledgements
The authors would like to thank all participating students, as well as the SVIAT network, who have supported the project.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.