Ethical Issues in Clinical Teaching

by Meredith Harris, MSN, RN

Many patient care issues involve both law and ethics. Law’s source is external to the individual, the rules and regulations of society; ethics derive internally, the values, beliefs, and individual interpretations. Law concerns conduct and actions while ethics concerns motives, attitudes, and culture. Laws apply uniformly to all individuals; ethical views and values may vary greatly from individual to individual. The courts have determined legal precedent for some ethical issues while others are weighed by the ethics of the profession, agency ethics committees, and individual moral values.

Nursing students must recognize the difference between legal rights and ethical views and engage in a structured ethical decision making process. With knowledge and insight of personal values, cultural norms, moral development, and ethical theory nursing students learn how to be objective when aiding patients with decision making particularly when the student’s and patient’s values differ.

Nursing programs thread legal and ethical issues throughout the nursing curriculum. The ANA Code for Nurses (http:www.nsna.org/pubs/pdf/code_of_ac.pdf) and the National Student Nurses Association Code of Academic and Clinical Conduct (http://www.nursingworld.org/ethics/chcode.htm) guide students to provide ethical care. As a clinical instructor you will want to know what theoretical introduction your students have had with ethical issues and values clarification. Some programs teach values clarification as part of teaching critical thinking. It may be helpful to read the chapter on ethical aspects of nursing care in the fundamentals of nursing textbook to learn how core ethical principles such as veracity and beneficence have been introduced.

Ethical decision-making

It will be challenging for you when students raise questions about the same ethical conflicts that you have resolved personally in your practice of nursing. You should not provide an answer from your own personal values but provide the students the opportunity to analyze the conflict.

O’Connor (2002) identifies four ways that faculty can help students work through the ethical dilemmas that emerge in their clinical learning.

    1. Students require coaching to identify the standard or the principle involved.
    2. Students need help in identifying the source of their moral discomfort since they are so focused on their own developing values that they tend not to acknowledge the legitimacy of another’s belief system. Similarly they tend to explore the first presenting issue that they encounter rather than attend to other ethical standards or principles that are involved presenting the conflict.
    3. Since they have limited knowledge and experience, students need more information to understand the ethical principles involved and the nature of the potential outcomes of alternate decisions.
    4. Students need to know that there are power, organizational policy and liability constraints on the ability of any individual to act in accordance with his or her own values.

As clinical instructor you will guide the process of student exploration of the ethical dilemmas that they encounter, or you suggest, and the possible alternatives, consequences and constraints. You will be laying or building on a foundation of ethical problem solving that will serve them throughout their education and nursing careers.

An excellent case study that identifies ethical principles and applies them to the terminal care of a developmentally disabled adult and his family can be reviewed at http://www.handinet.org/Ethics.htm

Professional boundaries

You will also need to monitor and teach nursing students to act in the best interests of their patients and to respect patient dignity in relation to professional boundaries. Students must not obtain personal gain at the patient’s expense or become involved in the patient’s personal business. In a brochure available at http://www.ncsbn.org/public/resources/res/expectnurse.pdf entitled Professional Boundaries a Nurse’s guide to the importance of appropriate professional boundaries The National Council of State Boards of Nursing, Inc defines professional boundaries

“as the spaces between a nurse’s power and the client’s vulnerability. The power comes from the professional position and the access to private knowledge about the client. Establishing boundaries allows the nurse to control this power differential and allows a safe connection to meet the client’s needs.”

The brochure offers clarification about the continuum of professional behavior ranging from under involved (distancing, disinterest, and neglect) through the zone of helpfulness to over involved (boundary crossing, boundary violation, and professional sexual misconduct). This continuum will assist your students in establishing and maintaining student patient relationships.

Ethical responsibilities of the clinical instructor

Nursing students like patients are vulnerable in relation to the power of the nursing faculty; they are unique individuals deserving respect. As clinical instructor you hold tremendous power and control over your students; it is unethical to abuse this power and control. O’Connor (2002) lists inappropriate behaviors: “sarcasm and belittling; threatening; criticizing the student in front of others; acting in a superior fashion; showing favoritism to one student over another; refusing to answer legitimate questions; rudeness, and authoritarianism.”

When I reflect back on my initial nursing education, I can remember most of these behaviors frequently directed at my classmates and myself. To me it is interesting to ponder whether the “eating of your young” by staff nurses is the legacy of past inappropriate conduct of nursing educators. Your students will thrive when they are not afraid or humiliated.

Role confusion

Being respectful and approachable does not promote the mistaken belief in students that you want to be their friend. You might have the experience of knowing or being related to students in the nursing program; you may well have encouraged them to enroll in nursing school! To avoid unclear boundaries, bias, and role confusion let the course coordinator know of your prior relationship with these individuals and request that they be assigned to another clinical group. When reassignment is not possible, it is wise to clarify to the individuals that during the clinical rotation you will remain impartial in selecting learning experiences and in evaluating clinical performance. Knowing more about one individual than your other students is awkward and stressful for the faculty to not compromise either your instruction or the student’s learning.

When possible it is also helpful to avoid clinical instruction on the same unit that you work as a staff member. Again there will be role confusion for the patients, family, nurses and other staff. They will expect you to provide care or information about patients that you cared for in your staff role that will take you away from your responsibilities to your students. One clinical instructor who worked on the same unit where he instructed students found wearing scrubs the same color as the students helped remind the staff when he was in the instructor role. While it may be tempting to check your work email or follow up with committee work while you are at the agency, you are under contract to the college to be with students and should not do so.

As in the nurse patient relationship, the power and authority inequity in the faculty student relationship precludes any intimate relationship with a student. Colleges have policies and procedures related to sexual misconduct between faculty and students.

Confidentiality

According to the Family Education Rights and Privacy Act of 1974 (FERPA) disclosure of student information to others without the permission of the student is protected under federal law. Grades are part of the restricted information; therefore you must be particularly cautious that when you provide evaluative information to students that it is done privately. During post conference do not reference any student error as a learning opportunity for the others in the group. Even if the student shares with the group his/her clinical difficulty, do not contribute to the discussion in any way that reveals your judgment about the student’s performance.

With such close proximity to each other nursing students often become very involved in each other’s lives. Students will ask you questions such as, is Mary sick today or did John quit school? Refer them back to the person in question with a statement like I’m sure Mary/John welcomes your concern perhaps you could contact him after clinical. In some instances you may need to clarify that you protect Mary/John’s privacy as you would protect their own and that you have no information to share. I make a practice when I’m speaking with students who are absent or leaving the program to inform them that I will only share information about their status with the course leader and suggest that if the student desires to have students know, that he/she should notify them. You might want to discuss this practice with the information that you provide at your group’s orientation to clinical.

In all discussions about patients and on all written assignments regarding patient care be sure that patient confidentiality is protected. You must keep both student and patient information secure.

Academic dishonesty

The college will have an academic dishonesty policy. When you suspect that students are plagiarizing the work of others, you will need to consult the course leader or program director for the consequence of misrepresenting assignments as one’s own. Do not tolerate any falsifying of the patient record. Also be sure students can correct documentation errors in the patient record according to agency policy.

References

Students from your clinical groups will request that you provide references for them to obtain employment, scholarships, or transfers to other programs. You have valuable opinions on their nursing practice. When you provide a reference for a graduate you are making the endorsement of a colleague. Some schools have standardized reference forms for faculty to use.

There are legal and ethical considerations when you cannot provide a positive recommendation.

“From a legal perspective, faculty who state in writing information that he student perceives to cast him in a negative light run the risk of a lawsuit by the student for defamation of character. From an ethical perspective, faculty who withhold negative information that relates to the position applied for quite possibly violates ethical principles related to beneficence (e.g. do no harm, as in patient welfare).” (Henshaw and Scheetz, 2000)

It is advisable to have the student put their request for a reference in writing designating who is to receive the reference and to tell the student immediately when you cannot make a favorable recommendation. Usually the student will withdraw his/her request when they learn the reference will not promote their goal.

“Courts have ruled that letters of recommendation, written for students by faculty, for the specific purpose for which they were intended, do not meet the legal standard of defamation of character. If your letter of recommendation meets the following conditions, it is unlikely that the student will prevail in a defamation lawsuit:

    • Written at the written request of the student
    • Directed only to the individual specified by the student
    • Written for the purpose specified by the student (e.g. recommendation for employment or graduate school)
    • Presents a fair and honest appraisal of the student’s ability. performance, and potential
    • Includes an accurate representation of the facts

To avoid allegations of breach of privacy, require that the student submit to you a detailed written request for a letter of reference. Keep the student’s request on file.” (Henshaw and Scheetz, 2000)

Other responsibilities

You have the obligation to be available to students to supervise their care. Many faculty wear pagers that are compatible with the electronic requirements of the agency; mark the assignment sheet or let the unit clerk know when you are off the unit and when you will return. You have a responsibility to return assignments in a timely manner so students may benefit from your review and comments while there is still an opportunity to make corrections or remediate care. You have a responsibility to keep your nursing license and required immunizations current.

In summary you will broaden your knowledge of the legal and ethical issues in nursing practice as you transition from nursing clinician to nursing educator. You will identify many parallels between the nurse patient relationship and the faculty student relationship. Seek guidance from experienced educators as you extend your responsibility and accountability to meet the high standards in your new role.