Nursing students’ ethical challenges in the clinical settings: A mixed-methods study

Abstract

Background:

Nursing students experience ethical conflicts and challenges during their clinical education. These may lead to moral distress and disturb the learning process.

Objectives:

This study aimed to explore and to evaluate the nursing students’ ethical challenges in the clinical settings in Iran.

Research design:

This was a mixed-methods study with an exploratory sequential design.

Participants and research context:

A total of 37 and 120 Iranian nursing students participated in the qualitative and quantitative phases, respectively.

Ethical considerations:

The ethical committee of Kerman University of Medical Sciences, Iran, approved the protocol of the study.

Findings:

Three main categories were extracted from qualitative data including Low attention of nurses to the patients’ preferences; Lack of authority; and Inadequate support. A total of 97% of the students had more than one ethical challenge in clinical settings and 48% of them stated that their challenges did not resolve. The total score of perceived ethical challenges was 62.03 ± 9.17, which was moderate. The highest mean score related to the “Low attention of nurses to the patients’ preferences” subscale.

Discussion:

The finding confirmed most of the existing results of other international researches about the frequency and kinds of baccalaureate nursing students’ ethical challenges.

Conclusion:

Identifying student ethical challenges helps teachers to manage their clinical learning process better. This study may provide a view for the nurses, clinical educators, and managers toward nursing students’ ethical challenges and their impact on nursing students’ clinical experiences.

Keywords

Clinical setting ethical challenge Iran mixed-methods study nursing students

Introduction

In the nursing education process, clinical education is an essential part, which provides nursing students the opportunity to increase their professional competency.¹ To be a licensed nurse, nursing students need to learn skills such as problem solving and ethical decision making in the clinical setting, but clinical settings have always been a challenging environment for them.² Indeed, nurses and nursing students face a lot of behavioral, functional, and ethical challenges, because they spend more time with the patients.^3

–6 Among these, ethical issues are one of the most critical challenges that nurses and nursing students face in the clinical setting.⁷ Although nursing students can learn the ethical standards such as advocacy, autonomy, patient rights, and collaboration with colleagues and other professional issues in the nursing schools,^7
–9 they cannot use them efficiently, because there is a lack of support and supervision in the clinical environment.¹⁰ Therefore, nursing students are more susceptible than the other health professional students to participate in undesirable and unsafe patient cares that are in contrast with their ethical values.¹¹ Thus, these challenges are more important for nursing students, because they cannot resolve them sufficiently.¹²

Different studies have assessed the ethical challenges among nursing students. The levels of ethical problems and moral distress among nursing students have been reported as mild to high in various studies.^13
–15 Lack of attention to the patient’s rights, providing insufficient information for the patients, inappropriate communication with patients, not providing confidentiality and privacy, and improper treatment of the instructors and nurses with the students were some of the frequent ethical challenges experienced by nursing students in different contexts.^{1,10,16

–21}

Regardless of the type of challenges, unresolved challenges may lead to psychological and physical problems in nursing students and may further decrease their potential to work.^18,22 The literature review indicated that the design of most studies about ethical challenges was quantitative and less qualitative and fewer studies had mixed-methods design. Also, there is a lack of research about nursing students’ ethical challenges in the clinical setting, especially in the southeast of Iran. Thus, this study aimed to explore and assess the nursing students’ ethical challenges in the clinical settings in the southeast of Iran.

Material and method

Study design and setting

We used a mixed-methods approach with an exploratory sequential design.²³ The study had three phases including qualitative, developing a questionnaire, and quantitative aspects. The survey was conducted in Kerman, Iran. Kerman has two nursing schools where more than 100 nursing students are accepted through the university entrance exam every year. Kerman has four educational hospitals. In Iran, bachelor nursing education is a 4-year-degree, and more than 50% of nursing education courses were conducted in clinical settings. Nursing students attend in the hospitals from the first academic semester and start caring for the patients under the supervision of their instructors.

Qualitative phase

In the qualitative phase, by purposive sampling, the researchers interviewed 37 nursing students using semi-structured, in-depth, face-to-face individual interviews. The data were saturated with 37 interviews. Interviews were done by a skilled female assistant professor who was an expert in in-depth interviews (PhD in Nursing). The suitable time and place for interviewing were determined for each participant based on her or his comfort (in the hospital or researcher’s office in the college). During all the interviews, the participants’ privacy was ensured and all interviews were conducted individually. The students were asked to talk about their experiences about ethical challenges that nursing students faced within the clinical settings, for example, “What are your perception of ethical challenges?” and “Please describe your experience of the ethical challenges in the hospital.” The interview was conducted using follow-up questions such as “Please tell me more about it” and “Please give me an example.” The inclusion criterion was the history of at least 3 months of clinical practice experiences. Various participants were chosen according to a different sex, age, and educational semesters to provide maximum variation. Indeed, the mean age of the participants was 22.4 ± 2.11 years. Of them, 24 were female and 13 were male. Six of them studied in the first year, eight were nursing students in the last year, and the others were nursing students in years 2 and 3. Interviews lasted 30–90 min on average. The interviews were audiotaped and then written out verbatim. The sampling continued from August 2016 to March 2017. The conventional qualitative content analysis method was used to analyze the qualitative data. The data analysis continued from August 2016 to May 2017.

Developing the questionnaire

The researchers developed a questionnaire according to qualitative data. The questionnaire consists of 21 questions with three subscales including “Low attention of nurses to the patients’ preferences” (seven items about managing patients’ different physical, mental, and spiritual needs), “Lack of authority” (seven items about nursing students’ autonomy and their positions in the healthcare team), and “Inadequate support” (seven items about the supportive roles of instructors, staff, and managers and their relationship with regard to nursing students). All items were scored on a five-point Likert-type scale (1 = never; 2 = seldom; 3 = sometimes; 4 = usually; 5 = always). Therefore, the total score ranged between 21 and 105. The higher score means facing more ethical challenges. The scores between 21 and 49, 49.1 and 77, and 77.1 and 105 mean facing with few, moderate, and lots of ethical challenges, respectively. The qualitative content validity of the questionnaire was assessed using the opinion of 11 faculty members of Razi Nursing and Midwifery School in Kerman University of Medical Sciences. A total of 20 nursing students completed the questionnaire to check the reliability. The Cronbach’s alpha was 0.85. Also, the Cronbach’s alpha for the whole sample (n = 120) was 0.8.

Quantitative phase

In the quantitative phase, with a descriptive cross-sectional design, 120 nursing students who satisfied the inclusion criterion completed the questionnaire. The response rate was 80% (120 out of 150 nursing students participated in the survey). The inclusion criterion was the same as that in the qualitative phase. Convenience sampling was used to select the samples. The sampling took place in the Razi Nursing School and lasted from May 2017 to June 2017. Data were analyzed using SPSS v. 15. The confidence interval was considered 95%. Mean and standard deviation were used to describe the ethical challenges of nursing students. Since the ethical challenge score had a normal distribution, independent t-test and analysis of variance (ANOVA) were used to compare the ethical challenge score among the demographic variable subcategories.

Ethical consideration

The Ethics Committee of Kerman University of Medical Sciences approved the study protocol (Ethics code: IR.KMU.REC.1395.380). After approval, the researchers provided some oral information to the participants including the goals and objectives of the study and the confidentiality and anonymity of the data, and the participants were free to withdraw from the study at any time. Then written consent was obtained individually.

Results

Qualitative results

According to data analysis, three main categories were extracted, which were “Low attention of nurses to the patients’ preferences,” “Lack of authority,” and “Inadequate support.”

Low attention of nurses to the patients’ preferences

One of the important challenges that nursing students faced was low attention to the patients’ preference. Almost all of the participants mentioned that they and nurses pay little attention to the patients, especially when the number of nurses is less than the number of patients. A participant reported,

We are novices; we cannot take good care of the patients. Although I am a student of the last year, I cannot insert a good venous catheter for a patient that has a bad venous vein. However, because of the nursing shortage, we have to care for patients. (P.n18)

Another participant said “In hospitals, nurses do not pay attention to the patients. Yesterday my patient wanted to have a visitor, but the head nurse said: no, no, it is forbidden” (P.n27). Some of the participants believed that patient care was not at a good level. One of the participants said, “Patient care is poor and the nurses don’t care for the patients. The patients get bedsore easily” (P.n20). Some students mentioned that low levels of care might be due to nurses’ shortage. A participant reported, “Although nurses do their best to care for the patients, the number of the nurses is few, and they get tired soon” (P.n31).

Lack of authority

The majority of the participants stated that lack of power was a challenge in the clinical settings. One of the participants said,

When we were at hospitals, we even didn’t have a room for rest. We could not teach to patients independently. Although my instructor was with us, we had to ask the nurses every work that we wanted to do for the patients (P.n13).

Some of the participants believed that medical students have more authority than nursing students. Another participant said, “A medical student has authority, but we don’t have authority. They do a lot of things for patients, but we cannot do any things” (P.n2). The participants also said that they were not allowed to do anything for the patients independently. A participant said,

I was in the surgical ward. My patient had pain at the IV site. I exchanged her IV. I did not know that she was discharged from the hospital, and then my instructor punished me by kicking me out of the patient room (P.n4).

Inadequate support

Inadequate support emerged from all interviews. The nursing students stated that their instructors, administrators of the Nursing School, nurses, physicians, and hospital managers did not support them sufficiently. Participant number 5 reported,

My instructor doesn’t support me. I need that he/she supports me. When I am supported, I can provide better care for my patients. My instructor does not respect me in front of the patients or the nurses. I feel like an orphan in the hospital.

Also, almost all participants experienced the lack of attention of the nurses to the students. Another participant said,

When I tell the nurses that my patient needs anything, they ignore me. They think that I don’t have any experience, and I am only a student, and I’m an added item in their section. I feel that I’m annoying. Thus, I try not to take care of the patients, and when my instructor sees me that I do not take care of the patient, He or she is harassing me. (P.n15)

Quantitative results

The mean age of the participants was 22.11 ± 4.3 years and 60% were female. Other demographic characteristics are shown in Table 1.

Table 1.

Demographic characteristics and ethical challenge scores of the participants.

Variable	Frequency (%)	Mean and standard deviation of ethical challenge scores	p value
Gender
Male	48 (40)	60.05 ± 6.16	0.03*
Female	72 (60)	64.01 ± 12.18	0.03*
Marital status
Yes	12 (10)	61.13 ± 7.11	0.2*
No	108 (90)	62.93 ± 11.24	0.2*
Educational year
First	30 (25)	59.21 ± 9.2	0.01**
Second	30 (25)	58.68 ± 8.77
Third	35 (29.17)	61.22 ± 6.54
Forth	25 (20.83)	69.02 ± 12.18

ANOVA: analysis of variance.

* Independent t-test.

** ANOVA.

A total of 97% of the students reported that they faced more than one ethical challenge in the clinical settings and 48% of them stated that their challenges did not resolve. The total mean score of ethical challenges was 62.03 ± 9.17. In total, 32% of participants faced with a few ethical challenges, 56% faced with moderate ethical challenges, and 12% faced with lots of ethical challenges in the clinical settings. The highest mean score was related to the “Low attention of nurses to the patients’ preferences” subscale (23.67 ± 3.16). The mean scores of the “Lack of authority” and the “Inadequate support” subscales were 19.45 ± 1.89 and 18.91 ± 4.12, respectively.

The total score of ethical challenges was 64.01 ± 12.18 for female students and 60.05 ± 6.16 for male students. The female students had significantly higher ethical challenges than the male students (p = 0.03). Also, the ethical challenge score was significantly different among students with various years of education (p = 0.01). Tukey’s post hoc test showed that the students in the final year of their training had higher scores than the students in other years (Table 1).

Discussion

Our results showed that 97% of the nursing students faced more than one ethical challenges and 68% faced with moderate to lots of ethical challenges in the clinical settings. In line with our results, baccalaureate nursing students reported moderate to frequent moral distress in clinical settings in Philippine and the Unites States.^13,14 Similar to our results, some studies in Tehran and Qom confirmed that nurses had a moderate to high level of moral distress.^24,25 In contrast with our results, Krautscheid et al.¹⁵ in their study reported the moral distress as mild to uncomfortable in nursing students. This contrast may be due to the differences among clinical settings, learning opportunities, healthcare collaborations, and health system situation in the United States and Iran.

Our results showed that the “Low attention of nurses to the patients^’ preferences” was the first important ethical challenge that nursing students faced in the clinical settings. Similar to our result, nursing students in New Zealand, Brazil, Canada, and the United States stated that the failure of the nurse’s roles as a patient advocate, disrespect to patient autonomy and dignity, not providing confidentiality and privacy, misuse of techniques, unsafe working conditions, and deficiencies in health services were their ethical challenges in clinical settings.^{10,17,18,26,27} In addition, Filipino nursing students frequently encountered with moral distressing situations such as “witnessing medical students perform painful procedures on patients solely to increase their skill,” “being required to care for patients I don’t feel qualified to care for,” and “witnessing diminished patient care quality due to poor team communication.”13 “Painful busyness” was extracted to explore nurses’ ethical challenges in a study in Norway. According to this study, nurses stated that they could not achieve their ethical values including providing individual care, advising and respecting patients to make decisions, and ensuring confidentiality in their daily practice, and this led to ethical challenges.²⁸

“Lack of authority” was the second critical ethical challenge experienced by our nursing students in the clinical settings. The lack of autonomy and authority and feeling powerless represent one of the main components causing the ethical problems in other contexts^15,29
–31 as well as in Iran. The low autonomy increases the incidence and intensity of ethical distress and may cause inappropriate communication with other medical groups.^30,31 Also, lack of independence and authority is also a barrier to evidence-based practice.³² In a systematic review, Lamiani et al.²⁷ reported that low psychological empowerment and autonomy correlated with moral distress among healthcare professionals.

“Inadequate support” was the third important ethical challenges in this study. Like our results, Brazilian, Turkish, American, Canadian, and other Iranian nursing students reported that improper treatment of the instructors and nurses with them was a source of ethical and moral distress.^{1,15,18
–20,26} The results of a systematic review also confirmed that the relationship with the mentor could lead to moral distress.²¹ In a study in Italy, one in eight baccalaureate nursing students never perceived the opportunity to discuss their ethical issues with the staff during their clinical learning experiences.³³ Support of managers, qualities of the instructor, and the instructor’s relationship are essential factors in the learning process of nursing students in clinical environments.^1,34 Inadequate support may lead to anxiety and stress in nursing students.^1,19 The results of Jamshidi et al.¹⁹ showed that stress and inferiority complex were two emotional reactions that nursing students experience in the clinical learning environment in Iran. Despite the literature that confirmed the importance of support, a study in Tehran, Iran reported no correlation between moral distress and perceived organizational support.²⁵ However, the authors concluded that this discrepancy might relate to the use of an unspecific scale to assess the perceived organizational support among the nurses.²⁵

In this study, female students had higher ethical challenges than males. Similar to our results, Jamshidi et al.¹⁹ reported that female nursing students experienced more negative emotional reactions in clinical settings than men. In contrast with our study, the results of a survey of nurses in Tehran showed that moral distress was not different between males and females.²⁵ In another study in intensive care nurses in Qom, men had higher moral distress than women.²⁴ Also, our results showed that the students in the final year of their education had more top ethical challenges than those in other years. Similar to our results, the intensive care nurses with a bachelor’s degree experienced less moral distress than nurses with a master degree.²⁴ In contrast with our results, in a study in Shiraz, students in lower semesters experienced greater negative emotional reactions than those in higher semesters.¹⁹ Another survey on American school nurses showed that moral distress was more elevated in nurses with lower education.³⁵ Also, a study of nurses in Tehran showed no correlation between moral distress and level of education.²⁵ The differences in the literature may be due to different populations and different scales for measuring ethical and moral distress. Unfortunately, we could not find any quantitative study which addressed these issues in the nursing students.

This study had some limitations. The first was the students’ confidence with the researchers. Although the researchers tried to create a comfortable atmosphere at the time of the interviews, the position of being their teachers may affect students’ responses. The second was the low sample size which may reduce the power of the quantitative study. Finally, to increase the response rate, we tried to shorten our questionnaire in the quantitative phase, so only the essential sociodemographic characteristics were assessed. Therefore, the judgment about the correlation of the sociodemographic characteristics with ethical challenges should be made with caution. Note that this study had some strengths. First, our findings are based on the context, and the results are useful for providing solutions to control and limit the ethical challenges in this context and other similar contexts. Second, we developed a new scale for measuring ethical challenges in the clinical setting which can be used in the same environments.

Conclusion

Nursing students in Iran experienced “Low attention of nurses to the patients’ preferences,” “Lack of authority,” and “Inadequate support” as the central ethical challenges in the clinical settings. The quantitative phase confirmed these ethical challenges. Therefore, as it is obvious, the nursing students in Iran like other contexts frequently experience different ethical challenges with varying intensity. This study is important because identifying students’ ethical challenges may help nursing educators and nursing administrators to manage these challenges better. Not effectively considering the ethical problems in the nursing students may lead to crescendo effects (e.g. burnout and turnover)15 or reversely may cause emotional immunization (nurses and further nursing students may cope with unresolved ethical challenges in the clinical environments, and thus their ethical sensitivity may decrease gradually).²⁸ Both of these reactions toward ethical challenges may negatively affect professional nursing values and thus the quality of patient care. Further studies are necessary to assess the long-term impacts of ethical and moral distress among nursing students in their upcoming professional life.

Footnotes

Acknowledgements

Many thanks to all nursing students who shared their valuable experiences with us. The reviewers of this study are Drs Parvin Mangolian, Behnaz Bagherian, and Seyed Hamid Seyed Bagheri.

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.

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