Ethical Issues in Clinical Teaching
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
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.
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
O’Connor (2002) identifies four ways that faculty can help students
work through the ethical dilemmas that emerge in their clinical learning.
- Students require coaching to identify the standard or the principle
- 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.
- 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.
- 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
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
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
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
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.
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
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.
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.
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,
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.