Reflective based learning for nursing ethical competency during clinical practices

Abstract

Background

A combination of theoretical and practical approaches is required to learn and acquire ethical competencies in caring. Occasionally, reflection on practical action differs from theoretical learning. In the context of reflective learning, issues such as ethical values can be discussed since they evoke conflict among nursing students.

Aim

To identify ethical conflicts encountered by nursing students during clinical placements and to determine their cooperation strategies.

Research design

Qualitative study with a content analysis according to Elo and Kinglas framework.

Participants and research context

Students enrolled in a nursing program at a Spanish university aged between 22 and 35, mainly women.

Methodology

The study includes 134 ethical reflections from nursing students in the last year of the nursing program, written during their clinical practices in a variety of learning environments. The research team analyzed the reflections using an inductive content analysis method.

Ethical considerations

Ethical permission was obtained by the management center according to Law 3/2028, and all the participants accepted to participate through the informed consent form.

Findings

Three main categories emerged from the analysis of the ethical reflections: (1) evaluation of professional performance and patient care; (2) the student as the protagonist of the dilemma; (3) student coping. Student dilemmas and concerns are related to ignorance, student-patient communication, mistakes made and self-confidence. Some situations conflict with the autonomy of patients and their rights, and can contribute to stressful situations for patients. Stress factors include hospital routines, which the patient cannot modify, and asymmetric relationships with staff, which encourage passivity.

Conclusion

All ethical problems detected by the students begin with the professional-patient relationship, including issues related to bad news, errors or malpractice. Reflection on the ethical values of nursing, both in the classroom and in clinical practices, allows students to develop a greater ethical awareness of care, enhancing their decision-making skills in ethical dilemmas.

Keywords

Ethical competence nursing students hospital care reflection based learning qualitative research

Introduction

Nursing is characterized by a holistic view of the individual, which implies respect, as well as maintaining dignity.¹ Nurses are in continuous contact with people, accompanying them in their health-disease process. They are expected to behave ethically, seeking the benefit of others and defending the needs of their patients.^2,3 In this sense, ethical nursing care is considered to be any action taken to meet the needs of individuals, in accordance with the goals and perspectives of the nursing profession.⁴ Current healthcare environments are changing and becoming more complex as a result of technological challenges and of an ageing population, leading to high-complexity situations, such as nurses feeling to harm the patient and prolonging his or her life unnecessarily.¹ These situations favour the presence of conflicts and ethical concerns among professionals.^1,5 The way in which professionals cope with and manage these conflicts can affect the quality of life of their patients and of nurses themselves by protecting or enhancing burnout.⁶ Nurse ethical awareness implies some skills competence to identify the ethical nature of nursing, as soon as willingness. That ability will lead the professionals to ethical sensitivity and subsequent moral agency and moral action.⁷ Ethical sensitivity can be defined as that which allows professionals to properly recognize, interpret and respond to the concerns of those who receive professional services.

The central characteristic of ethical sensitivity is decision-making within the uncertainty of professional practice.⁸ Ethics is an element of care that explains the satisfaction of professionals in their work environment. It focuses on the use of principles and values that facilitate appropriate decision-making and is linked to professional competence and job satisfaction.⁹

Nursing professional values such as ethics, commitment and professional mastery are acquired throughout the years of study at university,¹⁰ with ethical values being the most highly valued by nursing professionals and students,¹¹ including patient advocacy, privacy, confidentiality and respect.¹²

Different studies have demonstrated the importance of developing ethics learning in undergraduate education not only in the classroom but also through group and individual reflection in simulation environments or within real clinical settings.^13,14 Students benefit from being trained in reflection by avoiding moral distress.¹⁵ Conversely, inadequate education in this area is associated with an increased risk of professional malpractice.¹³

There is often a gap between what students learn in the classroom and what is actually done in different health institutions, and they face stressful situations related, for example, to the degree of responsibility to carry out some specific tasks delegated by nurses or doctors who accompany the students in their practices.¹⁶ There are mainly three reasons for concern when students are the protagonists of the conflict: ‘harming the patient’, ‘making a mistake with medication’ and ‘hurting themselves’.^17,18

In clinical placements, students are exposed to a variety of ethical dilemmas. Reflection and critical thinking about daily practice facilitate the acquisition of ethical competence in professionals and students.¹⁹ Writing these reflections on their experiences enables them to reflect on practice. We understand that reflection on practice, on lived experience, enables the improvement of action and competencies, as part of a cycle, namely, experience-reflection-action.^20,21

Reflecting on clinical experiences leads to the development of critical thinking skills, promotes self-understanding, facilitates coping and leads to an improvement in clinical practice, facilitating a more objective view of the situation, and of the interaction with others.²² The aim of this study is to identify the ethical issues faced by nursing students during their clinical placements and their coping strategies through reflections.

Methodology

Design

Based on Gibbs’ reflective cycle, the study uses a qualitative research approach.²³ This design pursues a holistic understanding of the phenomenon under study²⁴ as well as exploring, describing and understanding students’ concerns about the ethical dilemmas they face during clinical practice and their coping.²⁵

Context

According to the Bologna framework, students pursuing a nursing degree in Spain must complete at least 2300 h of clinical practice in different care settings. These hours are unevenly distributed over the 4 years, with the most clinical hours in the third and fourth years.

Students carry out their clinical practice in different healthcare institutions: primary care centres, hospitals, social healthcare centres and mental health centres; every student carries out a rotation in almost all healthcare settings during their studies. During the data collection period, the students were doing their clinical practice in different hospitals in the region.

In each subject of clinical practices, the coordinators and associate professors of the university are the ones who manage the tasks and work to be carried out during the specific period of practices. Also, every student is assigned a clinical nurse tutor when they begin their practices. Tutors are responsible for guiding students and they are professionals who assist them in their clinical development and learning.²⁶

Participants

In 2018-2019, 73 students from a university in Catalonia, Spain were invited to participate in the study, while doing their clinical practices. The coordinators added the objectives and information of the study in the online platform of the subject, and students agreed to participate, or not, through a specific check box. In the A total of 68 students aged 21–35 (91.7%) agreed to participate. There were 61 females (89.7%) and 7 males (10.3%), which corresponds to the gender difference in the classroom. The participation rates of third-year students (n = 37; 55.2%) and fourth-year students (n = 31; 44.7%) were similar.

Data collection

Data was collected between December 2018 and March 2019 through students’ written reflections during their third and fourth clinical placements, which are part of the placement portfolio, an activity included in their assessment.^27,28

Each student submitted two ethical reflections (136). Following a first reading, the research team eliminated some because they did not address ethical issues or were incomplete, resulting in 114 Gibbs cycles for analysis. Despite having eliminated some reflections, all participating students contributed at least one as a single unit of analysis. Students’ narratives were submitted and were available on the virtual campus platform after the end of their clinical placements.

Self-reflections writings about their practices and experiences, made at home and thinking deeply about them, offer benefits, including that the interviewer does not influence the possible responses, for example.²⁹ They are free to write about any topic that concerns them, following the only premise that implies the ethics of care. These reflections are scripted using the Gibbs’ cycle structure (Figure 1), where in addition to posing a situation, the student explores their feelings and emotions and discusses possible actions if they were faced with similar situations in the future, all creating a cycle experience-reflection-action.

Figure 1.

Gibbs’ reflective cycle: Adaptation from Gibbs, 1988.

Data analysis

Data were analyzed using the content analysis framework proposed by Elo and Kinglas:³⁰

One of the researchers was responsible for downloading the documents from the platform, who assigned a number to anonymize the contributions. Once all the documents were recollected, the researcher team proceeded to a first reading. The researcher team was composed of four professors with extensive experience in tutoring student clinical practices, as well as with experience in qualitative research methods.

As part of the preparation phase, each student’s reflections were considered as a single unit of analysis. After reading all of the students’ reflections in depth independently, each researcher took notes on the key points in each reflection, which served as the basis for the organization phase. In a second phase, the researchers met to contrast and shared their notes. After this first meeting, the students’ reflections were reread again independently. Once the organization phase was completed, a second meeting was held to discuss the themes and categories and the codes that exemplified the content of the categories that were worked on. Finally, the results were written up by consensus among the researchers.

Validity, reliability and rigour

The analysis was carried out independently by the researchers and meetings were held to discuss and reach a consensus on the different topics. A high level of consensus was reached during the meetings. The analyzed themes were returned to the data to ensure rigour, which allowed cross-checking of the data, and the final categories presented in the results.³¹

Ethical considerations

This study was approved by the centre’s management and complied with current regulations on data confidentiality, outlined in Law 3/2018. An informed consent form explained the objectives of the study and ensured the anoymity of the participants and the confidenciality of the data used to present and disseminate the results, before the submission of the documents in the university platform. Participants were free to withdraw from the study at any time without prejudice.

Results

For each theme, there were three categories identified. Table 1 summarizes these results. They are described in more detail below.

Table 1.

Category table.

Theme	Category
1. Evaluation of professional performance and patient care	Learning in nursing care
	Nursing values observed in patient care
	Vulnerability at the end of life
2. The student as the protagonist of the dilemma	Not knowing
	Making mistakes
	Student-patient communication
3. Student coping	Self-confidence
	I am a student; how do I act?
	Future approaches to problems

Evaluation of professional performance and patient care

It shows how students value the care and attention provided by health professionals, including their nurse mentors and other team members, and how this impacts their education.

Learning in nursing care

In this course, students examine how clinical tutors or other health professionals provide care or relate to patients and their families. Reflections reveal ambivalent situations in which some express concern that the patient or family member does not receive adequate care:

‘It is unacceptable not to pay attention to a person in pain. It is necessary to empathize with a vulnerable person with discomfort and pain’ (S22).

Some students, however, express admiration for the good work of professionals.

‘Both the doctor and the nurse transmit professionalism and tranquillity that is necessary and worthy of imitation’ (S13).

Students show frustration and helplessness when faced with situations where professionals have committed ‘wrongdoings’, resulting in a bad deal to patients or their families.

‘I felt sorry for the patient and ashamed of the nurse’s lack of professionalism’ (S25).

On these occasions, nursing students compare the practice of nursing care with the theory they have learned at university. It is noteworthy that a high number of the reflections show concern for care situations incongruency with the ethics learned in the classroom.

Among them are situations involving errors in practice:

‘As a result of what happened, I realized that often the theory is easier to apply than the practical application’ (S22).

Moreover, students highlight situations of conflict in assessment and communication with the patient or family;

‘On my first day with my new tutor, I observed that she was someone who listened and supported the patient regardless of her workload. At the university, we are taught that this is what should be done, but whenever I did an internship, the nurse prioritized other things’ (S12).

Whenever students show admiration for a professional performance, they notice how the team acts in a coordinated manner in different situations, such as an emergency, and how they know what each other needs to do.

‘Seeing all the professionals work together non-stop to save that man’s life was the best thing about the situation’ (S39).

They take these professionals as an example of performance and their own future projection:

‘I wish I could be like my nurse, a person capable of diminishing “I wish you were here”’ (S10).

Students are also impressed by nurses’ ability to make quick and accurate evaluations of their patients, which allows them to anticipate potential problems.

‘Nursing observation and the clinical eye are essential in detecting potential risks to patients’ (S15).

In addition, emotional support is provided to the patient and family. These observations are directed both at nurses and to other professionals, such as doctors.

‘…the professionalism and tranquillity transmitted by both the doctor and the nurse are essential and worthy of imitation’ (S29).

Nursing values observed in patient care

Nursing values include all aspects which pertain to patient care, including responsibility, respect, dignity and protection when a patient decides on their own health.

Six of the cycles analyzed refer to respecting the patient’s wishes. They describe situations in which a patient refuses to receive treatment or to choose the professional he/she wishes to be treated by. The students face an ethical dilemma when the patient refuses to be treated by them, indicating a lack of trust. Several students express understanding and respect for the patient’s position, while others view it as a devaluation of themselves.

‘I felt very vulnerable and kind of unprotected since my nurse did not say anything at all. In general, I felt judged and devalued’ (S7).

‘I understand it was an intimate moment for the patient, and I wanted her to be among the smallest number of people. She was uncomfortable with the presence of students’ (S3).

Although the situations begin in the same manner, they develop in different ways. In the first case, the nurse forces the situation so the student can perform the catheterization procedure while in the second case, the patient’s decision is prioritized over the students. Nurse-tutors have two options in these situations: either to respect the patient’s wishes or to protect the student’s right to practice.

‘A nurse commented, “This is a university hospital, so patients should keep that in mind”’ (S56).

‘The patient did not want me to catheterize her. In the end, my nurse convinced her to let me do it’ (S20).

Intimacy and privacy, which include the dignity of the individual, appear frequently and relate to situations where communication is poor with the patient, causing psychological harming situations, or situations that violate dignity and identity. These scenarios involve speaking impersonally or recriminating past events that have already occurred, but are out of the patient’s control:

‘The doctor justified herself, expressing: “If she was not so fat it would be a simpler procedure.” I felt sad, it was an unpleasant situation for everyone’ (S63).

As in previous situations, students feel discomfort when witnessing unethical practices.

‘It hurt me so much to hear the assistants talking badly in front of the patient himself’ (S6).

This category also includes the lack of privacy for patients, who are constantly watched by professionals who enter the room without warning. In addition, they refer to the vulnerability of privacy and confidentiality when professionals make comments about patients in front of others.

‘Patient privacy is very important, so it is inappropriate to talk about one patient in front of another’ (S46).

‘There were many people there including family members, while the patient was lying in his toilet and examining his bladder to make sure it wasn’t inflamed. All I could think was what he must be feeling’ (S26).

Students are concerned about the way in which information is provided to the patient and family; they understand the importance of good information so that the patient can make decisions.

‘I believe that the patient was not aware of what was being explained to her, nor of the diagnosis, nor of the surgical intervention that was going to be performed on her’ (S32).

‘The doctor had been very cold and direct in giving the news. I was filled with compassion and sadness’ (S43).

Vulnerability at the end of life

At the end of life, vulnerability is directly related to the conspiracy of silence that appears in three cycles and the lack of empowerment the individual has.

Students perceive the conspiracy of silence, in which information is denied to the patient himself, as a lack of respect for the autonomy of the individual and an annulment of his decision-making capacity. Although students are critical of these situations and grasp the meaning they may have for the person and family, they also perceive them as situations over which they have little power to decide and/or act from their role as a student.

‘His wife glances at me looking for complicity in me. Obviously, it is none of my business to communicate anything, but my heart shrinks knowing that R has so few days left and he is unable to decide what to do’ (S1).

Additionally, students discuss the lack of respect for patients’ autonomy at the end of life.

‘She is an autonomous person who can make her own decisions about her health. Although she has always expressed her wishes, professionals have never respected them’ (S31).

The student playing a central role in the dilemma

Near 42 of the reflections presented, students perceive themselves as protagonists of ethical dilemmas, playing a central role in the different situations experienced. It seems that they become aware in their reflections that they have an active role in many situations, and by identifying their role, they have the opportunity to incorporate changes and improvements in their actions. Among the categories that emerge from the analysis in order of frequency are not knowing, student-patient communication, errors and self-confidence. Generally, their reflections do not appear to be directly linked with ethical values, although an uneasiness may appear when they are unable to act or perform a technique.

In presenting their reflections to their teachers, they show uneasiness:

‘Choosing a specific time or situation to perform a Gibs Cycle is a difficult task because in our profession every day we find a moment that encourages us to reflect or excites us either by anger, sadness or joy’ (S1).

Unknowing

Most of them attribute not knowing to the lack of experience in situations that they have never experienced before or when the situation has impacted them emotionally, such as death or the verbalization of suicidal ideas.

‘Every time I went to see Mercedes, I saw that she had little desire to live. One day she even told us that she wanted to rest forever… that she didn’t want to live that way. After listening to these words right there, a cold sweat ran down me and, although we tried to cheer her up with all our might, her face reflected us that she wanted to rest, to let go of that tragic way’ (S14).

The dilemmas and concerns students raise revolve around whether they should have known how to act or not, or the discomfort, helplessness and insecurity caused by not having the necessary knowledge. Some of the reflections contain messages such as ‘I should have known’ or ‘I don’t have enough experience’, which implies a high level of commitment and personal demand around what is expected of them as professionals.

‘At that time, I didn’t know how to react, I didn’t know what to do to help, and when I felt useless and uncomfortable in that situation because I was just watching… so I left’ (S33).

‘…I was paralyzed with fear, although I was willing to do what I could according to my knowledge (…) I felt very powerless in the face of the situation since I did not know how to act’ (S45).

However, in the reflections analyzed there is no direct relationship with any ethical principle or value explicitly. A large number of student concerns are collected under this subcategory. This is closely related to another subcategory, student coping, in that their lack of initiative or their inability to act can be justified by the fact that, as students, they cannot act according to their values.

‘From my position as a nursing student I think I couldn’t do anything else and I think I acted correctly…’ (S64).

‘I did not master nor have the appropriate treatment for this type of situation, perhaps due to my short career in this profession, which caused me insecurity’ (S68).

Making mistakes

Some students explain mistakes made in a procedure or in the administration of medication and how they have tried to solve them when they realize them.

‘Although I was scared, everything was in an incident, nothing happened to the patient and I learned a lot from the situation. It is important to pay attention to the medication and ask about the medication to be administered’ (S65).

‘I consider that forgetfulness is useful to realize that it is very easy to make a mistake, forget a step in the procedure or lose sterility during the technique can pose a risk of infection for the patient’ (S46).

Students are concerned about this situation, which they alleviate by explaining that they are still students and that despite all they know and how much they study, there will always be a first time, which prevents appropriate action or effectiveness. They even associate their mistakes with those that an experienced nurse could make.

‘Thinking coldly was not such a serious mistake, although at the time it seemed like a serious forgetfulness’ (S33).

‘…Failure exists but does not mean falling (…) so that does not mean it made me a worse nurse’ (S42).

‘That’s why it’s normal that before we do something right we make a mistake and we have to practice it many times. What’s more, we’re all human, and even those who have worked as nurses for years are wrong’ (S49).

‘I recognize that my performance has not been correct. I have felt vulnerable to the situation and have chosen to disregard myself. My emotions and feelings have been out of control, which has made me feel bad and question my abilities’ (S23).

Student-patient communication

Many of the situations analyzed found that communication with patients was not as easy as they had imagined. The possibility of making mistakes makes them view it similarly to any other technique. Thus, they become aware of what a well-said word can cause or, on the other hand, what an inappropriate word can do.

‘…knowing how to listen and correctly interpret non-verbal communication, gives us the key to reach the person and offer a relationship of authentic help (…) So I put aside the technical part a bit and started to go with her’ (S60).

‘I liked that the lady explained to me what she felt and that I could accompany her’

‘After what happened, I stayed to listen and talk with the patient. And it seems that this helped her calm down from it. I think active listening is very important’ (S57).

Student coping

Self-confidence

These situations in which they have made mistakes, or have had difficulties in communication cause discomfort in students and can lead to situations of lack of self-esteem that reduces their ability to make decisions.

‘As a nursing student, I did what I could’ (S43).

In contrast, they experience satisfaction and increased confidence when they are able to act in situations they have never faced before. They feel more confident in themselves and even put themselves to the test to show that they can do things that they feel prepared to do.

‘I realized I had the necessary resources, so I got ahead myself’ (S52).

In these situations, they appreciate those nurse-tutors who help, support and correct their mistakes without showing contempt or scolding in front of patients or other colleagues.

‘The patient seemed uncomfortable with the cure I was performing. My nurse explained that I was doing it correctly, which gave me confidence’ (S59).

‘When the situation occurred, I was very nervous. My tutor approached me and hugged me, apologized for asking me so many questions, and congratulated me for having done a good job as a team. It made me so happy’ (S65).

I am a student; how do I act?

In these situations, students face internal debates between doing or saying what they think is right, or staying silent or doing nothing, either because it contradicts their nurse’s attitude, or because they don’t feel they are able to maintain their reasoning with patients or professionals, or because they don’t feel sufficiently prepared.

‘I felt helpless at not being able to say what I really thought. I did not tell him, nor will I tell him while he is in practice’ (S8).

‘But where should I leave my feelings? Is there a corner in the soul to hide the “what I would do”?’ (S23).

‘I do not understand why at that time I did not say anything. I think I was shy. I have the feeling that I was complicit in having violated the dignity of that person’ (S9).

Sometimes students feel like a burden. They are afraid of making mistakes even though they want to act more autonomously.

‘I had doubts so I asked them. Sometimes I had to ask more than once to get an answer, making me feel as if I was a burden. But I was afraid of not asking and doing something wrong’ (S5).

Future approaches to problems

During Gibbs’ reflection cycles, students provide solutions to situations that concern them, such as a plan for the future if the same situation occurs again (Table 2). Among them is the importance of knowing the patient before performing procedures, either through the medical history or the interview. Apologizing and acknowledging mistakes is part of good nurse-patient communication.

‘In the future, I would like to know how to accompany and support the patient during such a difficult process. Also, I would like to know how to react differently from what my tutor nurse has done’ (S50).

‘Part of the problem was my inexperience. I didn’t like the feeling of feeling like an obstacle and the only way to fight it was with more training and experience’.

‘In order to give an answer, it is important to assess and empathize with the individual, so that the nurse’s comfort in the application of the technique does not prevail’ (S68).

Table 2.

Students’ solutions to professional malpractices.

Care improvement proposals
Assess the patient’s perceptions
Detect possible risk factors knowing the medical history
Spend more time with people
Apologize and admit mistakes
Meet the patient before entering the room
Get to know the patient’s history
Ensure that the well-being of individuals is promoted by insisting on the measures that are appropriate for them (insist on the treatment pattern)
Regarding the information
Provide clear information and allow questions
Talk to doctors so that they speak correctly to patients
Ensure that the rights of the patient are protected and that harmful comments are not made about them
Promote interprofessional communication to maintain evolutionary information
Health team coordination
Provide information in a more tactful manner
Points to consider to improve as future professionals
Learn more
Learn to take action
Become more assertive
Be able to manage your emotions
Learn from experiences

Discussion

The aim of the study was to identify those situations of ethical conflict that nursing students face during their periods of clinical practice and the coping strategies they use.

It has been found that the main dilemmas and concerns of students have to do with the performance of professionals and their own role as students.

Nursing students are concerned about the values of nursing in patient care, mainly responsibility, respect, dignity and protection, especially at the end of life, and how these values may be reflected in actions that endanger patient safety, including medication and assessment errors and gaps in communication with patients and their families.³² Student dilemmas and concerns are related to ignorance, student-patient communication, mistakes made and self-confidence.

Nursing students are concerned about the rights and safety of patients. They understand all patients must receive care based on nursing values such as respect, dignity, responsibility and honesty;¹² they describe professional actions that they do not like as well as actions carried out by themselves that they value as aspects to improve.

Observing their coping strategies through the Gibbs cycles has allowed us to visualize the solutions they provide, which could improve clinical practice. Among their proposals, we find ideas such as spending more time getting to know patients and their circumstances, acknowledging mistakes and apologizing, improving communication with patients, as well as within the multidisciplinary team. After completing their studies, they can prepare to be better nurses by learning and improving their communication skills and managing their emotions.³²

The results have also allowed us to know the emotions of students and show how dealing with ethical dilemmas can cause emotions of discomfort and helplessness in students.³³

Performance evaluation of other professionals

Based on our sample, participants reflect on the actions taken by other professionals. Among the inadequate ones, the students value the importance of professional-patient communication, and the importance in the most delicate situations for the patient, such as in the stages at the end of life, which is in line with the literature³⁴ as well as the importance of having developed communication skill, such as the author³⁵ points out in his article.

In these situations, students show empathy towards the situation the patient is experiencing and understand that the patient may be suffering from it. To establish a nurse-patient relationship, it is important to put yourself in the patient’s shoes, acknowledge their individuality and show respect, which helps to build trust.³⁶ Research based on patient interviews has concluded that patients expect close treatment and empathy from professionals, along with accurate information on their terms.^37,38

These responses show an understanding of how the values impact patient care and workplace culture,³⁹ as well as a commitment to providing compassionate, person-centred care.³³

Even though students value this action as ‘unacceptable’ and consider how they would react in another situation, they rarely defend the patient. Students value the fact that their role as students prevents them from expressing themselves openly.⁴⁰ The findings are consistent with the review by Albert et al. which showed that students wanted ethical care, but lacked the ability to decide for themselves, and were torn between silence and denunciation.⁴¹ In their reflections, the students acknowledge their inaction, and intention to improve in the future. They explain what they should have done in this situation, how they should act in similar future situations, how to deal with professionals while they are ‘only’ students, how with respect and humility they can confront professionals for their wrongdoings, and how these situations affect the patient, their emotions and their safety.^42,43 Though some cannot take action at this point, reflection on certain situations allows them to consider proactive measures and actions to be taken in the future.⁴⁴

In situations that students consider unfair or wrong, they experience moral emotions,⁴⁵ and moral distress,⁴⁶ causing discomfort among them.⁴⁷

Inexperience, lack of knowledge

Students reflect on their inexperience and lack of knowledge, which can leave them out of the situation and without participating in the care. They are concerned about practices, afraid, above all, of making mistakes in their performance and causing harm to patients.

The World Health Organization defines patient safety as ‘the prevention of errors and adverse effects for patients associated with medical care’. Safety is compromised by human errors such as carelessness, inadvertent omissions, as well as lack of technical skills.⁴⁸ For nursing students and recent graduates, procedures and programs are necessary to guide their care, which facilitates safe practices.^49,50 It is not described in the reflections of the students in this study whether errors are communicated or if they remain unreported and totally unknown to the tutor nurse.

These situations of error, forgetfulness or lack of experience cause feelings of discomfort in students. Additionally, they worry about ‘what their peers and the nurses who tutor them will think’.⁵¹ According to Pedersen’s research, positive reinforcement from professionals reinforces learning, safety and ethical development among nurses.⁴³ These situations are stressful for students¹⁷ and they need support and guidance from their tutors-nurses to reinforce a practice positively.⁵²

In these reflections, the students reinforce their status as interns to alleviate the discomfort they have experienced. Nevertheless, none of them mention the possible repercussions their actions may have had for the patient: infection risk, need to repeat puncture, emphasizing their own feelings over the potential injury.⁴³

Relationship with the patient

The nurse-tutors are presented as guarantors of originating clinical training opportunities for students. It presents itself as an ethical controversy, where care professionals’ interests are considered to be more important than the wishes of patients. However, in Spain, patient autonomy is defined by the law 41/2002, which establishes the patient’s right to decide and how their decision must be respected.

These situations conflict with the autonomy of patients and their right to define how they should be taken care of. All these situations contribute to stressful situations for patients. Stress factors include hospital routines, which the patient cannot modify, and asymmetric relationships with staff, which encourage passivity in the patient.⁵³ As explained in Howe and Anderson,⁵⁴ previous bad experiences can influence the patient’s refusal to allow students to attend, and how the student’s request for permission improves participation.

Limitations

This study is limited by the fact that these reflections are derived from a compulsory one, which implies writing directed at teachers, which can sometimes lead to the concealment of some actions, usually their own. To mitigate this limitation, students were asked for their consent to participate in the study after the delivery of the reflective cycles, in such a way that we minimized the fact that students wrote for their benefit, although Genua⁵⁵ shows a positive correlation between the reflective diaries and the honesty of the students.

This study was conducted in hospitals, so its results cannot be generalized to primary care environments. Although the reflections of the students from the different care settings provide a great deal of thematic richness, the experiences in the different situations can differ considerably, if we compare a mental health hospital ward with an emergency room. We believe, however, that it is interesting to analyze the reflections based on their experiences, rather than on the speciality in which they practice.

In addition, we want to mention the context covid-free in which the reflections were made. Probably, the topics of concern that students would refer to during their clinical practices in the midst of a pandemic would be some of them different from those referred to in our study, although we think that many of them would remain.

Conclusions

It is common for students to express concern for patients when they are not being treated correctly, even though they do not feel able to defend them because they are students.

When their patients are ill, students report being afraid to make mistakes and unsure of how to act, hiding behind their student status in order to minimize these situations. Nurses are sometimes more inclined to defend the professional future of students, violating the rights of patients to free choice of professional. Professional values influence decision-making in patient care.

These must be approached from the classroom theory, so that students can recognize them in their clinical practice. Reflection on the ethical values of nursing, both in the classroom and in clinical practices, allows students to develop a greater ethical awareness of care, enhancing their decision-making skills in ethical dilemmas. Assessing and reflecting on the care response of other professionals allows the student to project themselves as a professional responsible for these decisions, understanding which situations they can imitate and which ones they can improve.

Footnotes

Author contributions

IFJ, LOS and MAG, participated in the conception, design of the survey and data collection. IFJ, LOS, MAG and MJH contributed to the analysis and interpretation of the data. IFJ, JLPG, PGS, MJH, LOS and MAG participated in the writing of the manuscript. All authors have read and accepted the final version of the manuscript.

Declaration of conflicting interests

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.

ORCID iD

Laura Ortega Sanz

References

Haahr

Norlyk

Martinsen

, et al. Nurses experiences of ethical dilemmas: a review. Nurs Ethics 2020; 27: 258–272.

Poorchangizi

Borhani

Abbaszadeh

, et al. Professional values of nurses and nursing students: a comparative study. BMC Med Educ 2019; 19: 438.

Jiménez-López

Roales-Nieto

Seco

, et al. Values in nursing students and professionals. Nurs Ethics 2016; 23: 79–91.

International Council of Nurses . The ICN code of ethics for nurses, https://www.icn.ch/system/files/2021-10/ICN_Code-of-Ethics_EN_Web_0.pdf (2021, accessed 16 November 2022).

Rassin

Tzevlin

Malul

, et al. Retrospective study of emerging themes in the decision-making process of patients considering amputation. J Vasc Nurs 2012; 30: 54–60.

Stolt

Leino-Kilpi

Ruokonen

, et al. Ethics interventions for healthcare professionals and students: a systematic review. Nurs Ethics 2018; 25: 133–152.

Milliken

Grace

. Nurse ethical awareness: understanding the nature of everyday practice. Nurs Ethics 2017; 24: 517–524.

Weaver

Morse

Mitcham

. Ethical sensitivity in professional practice: concept analysis. J Adv Nurs 2008; 62: 607–618.

Victor

Cullen

. The organizational bases of ethical work climates. Adm Sci Q 1988; 33: 101.

10.

Bijani

Tehranineshat

Torabizadeh

. Nurses’, nursing students’, and nursing instructors’ perceptions of professional values: a comparative study. Nurs Ethics 2019; 26: 870–883.

11.

Fernández‐Feito

Basurto‐Hoyuelos

Palmeiro‐Longo

, et al. Differences in professional values between nurses and nursing students: a gender perspective. Int Nurs Rev 2019; 66: 577–589.

12.

Iacobucci

Daly

Lindell

, et al. Professional values, self-esteem, and ethical confidence of baccalaureate nursing students. Nurs Ethics 2013; 20: 479–490.

13.

Monteverde

. Caring for tomorrow’s workforce. Nurs Ethics 2016; 23: 104–116.

14.

Robinson

Lee

Zollfrank

, et al. Enhancing moral agency: clinical ethics residency for nurses. Hastings Cent Rep 2014; 44: 12–20.

15.

Sasso

Bagnasco

Bianchi

, et al. Moral distress in undergraduate nursing students. Nurs Ethics 2016; 23: 523–534.

16.

McCarthy

Trace

, et al. Addressing ethical concerns arising in nursing and midwifery students’ reflective assignments. Nurs Ethics 2018; 25: 773–785.

17.

Rodriguez-Santamaria

Alatorre-Esquivel

Sosa-Briones

, et al. Factores generadores de estrés en estudiantes de enfermería durante la práctica clínica. Desarro Cientif Enferm 2011; 19.

18.

López-Medina

Sánchez-Criado

. Percepción del estrés en estudiantes de enfermería en las prácticas clínicas. Enfermería Clínica 2005; 15: 307–313.

19.

Lechasseur

Caux

Dollé

, et al. Ethical competence: an integrative review. Nurs Ethics 2018; 25: 694–706.

20.

Patel

Metersky

. Reflective practice in nursing: a concept analysis. Int J Nurs Knowl 2021; 33. DOI: 10.1111/2047-3095.12350. Epub ahead of print 9 October 2021.

21.

Jasper

. Beginning reflective practice. London, UK: Foundations in Nursing and Health Care, 2003.

22.

Naber

Markley

. A guide to nursing students’ written reflections for students and educators. Nurse Educ Pract 2017; 25: 1–4.

23.

Gibbs

. Learning by doing, a guide to teaching and learning methods. Oxford: Oxford Brookes University, 1998.

24.

Polit

Beck

. Nursing research: Generating and assessing evidence for nursing practice. Philadelphia USA: Lippincott Williams & Wilkins, 2017.

25.

Van Manen

. Phenomenology in its original sense. Qual Health Res 2017; 27: 810–825.

26.

Ó Lúanaigh

. Becoming a professional: what is the influence of registered nurses on nursing students’ learning in the clinical environment? Nurse Educ Pract 2015; 15: 450–456.

27.

Hill

. The portfolio as a summative assessment for the nursing student. Teach Learn Nurs 2012; 7: 140–145.

28.

Ben

DMF

Davis

Harden

, et al. Portfolios as a method of student assessment. Med Teach 2001; 23: 535–551.

29.

Morrell-Scott

. Using diaries to collect data in phenomenological research. Nurse Res 2018; 25: 26–29.

30.

Elo

Kaariainen

Kanste

, et al. Qualitative content analysis. SAGE Open 2014; 4: 215824401452263.

31.

Elo

Kyngäs

. The qualitative content analysis process. J Adv Nurs 2008; 62: 107–115.

32.

Chen

Liu

, et al. The relationship between moral sensitivity and professional values and ethical decision-making in nursing students. Nurse Educ Today 2021; 105: 105056.

33.

Joyce-McCoach

Smith

. A teaching model for health professionals learning reflective practice. Proced - Soc Behav Sci 2016; 228: 265–271.

34.

Kato

Tamura

. Family members’ experience of discussions on end-of-life care in nursing homes in Japan. J Hosp Palliat Nurs 2020; 22: 401–406.

35.

Gutiérrez-Puertas

Márquez-Hernández

Gutiérrez-Puertas

, et al. Educational interventions for nursing students to develop communication skills with patients: a systematic review. Int J Environ Res Public Health 2020; 17: 2241.

36.

Whitney

White

AEC

Rosenberg

, et al. Trust and shared decision‐making among individuals with multiple myeloma: a qualitative study. Cancer Med 2021; 10: 8040–8057.

37.

Sjödahl

Gard

Jarnlo

G-B

. Transfemoral amputees’ experiences of the first meeting and subsequent interactions with hospital staff. Disabil Rehabil 2008; 30: 1192–1203.

38.

Lippe

Farya

Jennifer

, et al. Communicating oncologic prognosis with empathy: a pilot study of a novel communication guide. Am J Hosp Palliat Med 2020; 37: 1029–1036.

39.

Lyneham

Levett-Jones

. Insights into registered nurses’ professional values through the eyes of graduating students. Nurse Educ Pract 2016; 17: 86–90.

40.

Fagan

Lea

Parker

. Student nurses’ strategies when speaking up for patient safety: a qualitative study. Nurs Health Sci 2021; 23: 447–455.

41.

Albert

Younas

Sana

. Nursing students’ ethical dilemmas regarding patient care: an integrative review. Nurse Educ Today 2020; 88: 104389.

42.

Katayama

Muramatsu

Aoki

, et al. Psychometric evaluation of the ethical caring competency scale in nursing. BMC Nurs 2022; 21: 103.

43.

Pedersen

Sivonen

. The impact of clinical encounters on student nurses’ ethical caring. Nurs Ethics 2012; 19: 838–848.

44.

Andersson

Svensson

Frank

, et al. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics 2022; 23: 29.

45.

Haidt

. Elevation and the positive psychology of morality. In: Flourishing: positive psychology and the life well-lived. 2003, Washington, USA: American Psychological Association, pp. 275–289.

46.

Chin

Hsu

. Moral distress model reconstructed using grounded theory. J Nurs Res 2018; 26: 18–26.

47.

Epstein

Delgado

. Understanding and addressing moral distress. OJIN Online J Issues Nurs 2010; 15. DOI: 10.3912/OJIN.Vol15No03Man01. Epub ahead of print 30 September 2010.

48.

Murray

Sundin

Cope

. New graduate registered nurses’ knowledge of patient safety and practice: a literature review. J Clin Nurs 2018; 27: 31–47.

49.

Fernandez

TenHam‐Baloyi

Mathew

, et al. Predicting behavioural intentions towards medication safety among student and new graduate nurses across four countries. J Clin Nurs 2022; 00: 1. DOI: 10.1111/jocn.16330. Epub ahead of print 26 April 2022.

50.

Stolic

Southern

, et al. Medication errors by nursing students on clinical practice: an integrative review. Nurse Educ Today 2022; 112: 105325.

51.

Bäck

Karlström

. Developing confidence during midwifery training: the experience of Swedish final year students. Sex Reprod Healthc 2020; 25: 100535.

52.

Nesbit

Jensen

Delany

. The active engagement model of applied ethics as a structure for ethical reflection in the context of course-based service learning. Physiother Theor Pract 2018; 34: 1–12.

53.

Molina-Mula

Gallo-Estrada

. Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. Int J Environ Res Public Health 2020; 17: 835.

54.

Howe

Anderson

. Involving patients in medical education. BMJ 2003; 327: 326–328.

55.

Genua

. The relationship between the grading of reflective journals and student honesty in reflective journal writing. Nurs Educ Perspect 2021; 42(4): 227–331. DOI: 10.1097/01.NEP.0000000000000826. Epub ahead of print 26 May 2021.