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Ethical Problems Observed

by Student Nurses
Fethiye Erdil and Fatoş Korkmaz
Key words: clinical education; ethics; nursing; nursing education; nursing ethics; nursing
students

This descriptive study was conducted to determine nursing students’ observation of ethical
problems encountered in their clinical practice. Data were collected through a questionnaire
from 153 volunteer nursing students at a university-based nursing school in Ankara,
Turkey. The students reported that some patients are either physically or psychologically
mistreated by doctors and nurses; they were not given appropriate information; they were
subjected to discrimination according to their socio-economic situation; and their privacy
was ignored. The findings reveal that nurses’ own unethical behaviors contribute to a rise
in ethical problems. It is argued that nurses should internalize their professional and ethical
roles in order to provide safe and ethical care and be good role models for students.

Introduction
Nurses frequently encounter ethical challenges, for example, in relation to the care of
individuals with do not resuscitate orders,1–3 the treatment of dying patients,4–9 dealing
with issues of abortion, euthanasia10,11 and physical or chemical restraint.12–14 A review
of earlier studies in Turkey demonstrated that nurses tend to experience dilemmas in
terms of passive euthanasia, abortion,10 terminal phase patient care, do not resuscitate
orders,14 and decisions about whether to terminate the life of children with neural tube
defects.15
Nurses are required to make ethical decisions and to advocate for the rights of their
patients. Numerous socio-economic, political and cultural factors in health care and
nursing practice may contribute to the rise of ethical problems. Inequalities in access
to health care, inadequate allocation of resources and understaffing can be the main
factors contributing to ethical problems. Sometimes ethical dilemmas arise because of
the unethical attitudes and behaviors of practicing nurses and physicians. Individual
variables such as personal character traits and values, lack of knowledge and sensitivity
about ethics and patients’ rights, limited autonomy and unsatisfactory working con-
ditions may negatively influence the decisions and acts of nurse practitioners.

Address for correspondence: Fatoş Korkmaz Hacettepe University Faculty of Health Sciences,
Nursing Department, Samanpazari, Ankara, Turkey. Tel: +90 3123051580; Fax: +90 3123127085;
E-mail: erdil@hacettepe.edu.tr

Nursing Ethics 2009 16 (5) © The Author(s), 2009. 10.1177/0969733009106651


Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav
590 F Erdil and F Korkmaz

Nurses are obliged to provide safe, competent and ethical care, but how they respond
to ethical dilemmas and/or problems varies depending on the situational context and
individual, organizational and cultural factors. Ethical problems are complicated and
are frequently difficult to resolve. The hierarchical and often inflexible structure of the
hospital or organization8–10,16–19 restricts nurses’ involvement in decision making. Dis-
agreements and conflict among health care teams can make it difficult to solve these
problems.16 This situation can result in dilemmas, desperation, stress and exhaustion
for nurses.8,16,20–22
Romyn23 states that nurses are guided by professional codes of ethics for the solution
of ethical problems but argues that codes fail to provide sufficient ethical guidance
because they are too general and abstract. For this reason, nurses usually follow their
own methods of reasoning20,24 and thus prefer solutions that are best for patients,22 by
taking into account moral and spiritual values25 or obtaining support from colleagues
on whom they rely.21
Professional decisions and qualified nurses’ practice influence not only the quality
of patient care and ethical problem solving, but also the learning experience and
professional development of nursing students. Clinical practice is an essential part
of nursing education and students require effective clinical placements to integrate
theoretical knowledge into practice. Students have a limited knowledge base, a lack
of confidence and restricted authority during their clinical practice. For this reason
they can participate in nursing practice and decisions about patient care only under
the guidance and supervision of either practicing nurses or the faculty members who
co-ordinate their practical education. Nurses therefore serve as role models for nursing
students in the course of clinical practice.
Few studies have addressed students’ experiences with ethical dilemmas during
their clinical placements but Han and Ahn26 found that the most frequently experi-
enced dilemmas were not telling the truth to patients, and families giving up on
relatives who could not be cured. Nolan and Markert27 found that students anticipated
euthanasia, confidentiality, withdrawal of treatment, resuscitation, and patients’ rights
versus professional autonomy as major ethical issues. Cameron et al.28 demonstrated
that nursing students do not experience ethical problems in the same way as graduate
nurses. She reports that, as their status is lower, they feel more powerless to resolve
conflicts. The development of students’ moral judgment also varies according to their
academic years. Kim et al.6 found that moral development scores were higher in fourth
year than in first year students. Lemonidou et al.29 investigated ethical development in
Greek student nurses during clinical practice at the beginning of their studies. They
identified the process of developing an awareness of personal values through empath-
izing with patients as a core theme. Their study also indicates how the students were
affected by unethical practices. Those who witnessed either violation of patients’ rights
or non-adherence to codes of ethics described these situations as very grave. Some of
the students experienced a variety of negative feelings such as a sense of failure, des-
pair, disappointment, turmoil, agitation, nervousness, embarrassment, shame, anger
or depression.
Although studies have been conducted on ethical dilemmas confronted by nurses
in Turkey, no previous research has identified ethical problems from the perspectives
of students during their clinical practice. It was considered that research on this issue
would be beneficial to organizing the clinical experience of students in such a way as to
contribute to their ethical decision-making capacity. Our primary aim was to identify

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Ethical problems observed by student nurses 591

the ethical problems observed or witnessed by students during their clinical practice.
Our secondary aim was to explore students’ observations about the involvement of
nurses in ethical problems and the ethical decision-making process. Nurse education in
Turkey is predominantly conducted at university level and ethics was integrated into
the curriculum in the 1990s;30 however, most nurses are still subordinate to physicians
and they do not take part in ethical decision-making processes. Nursing has evolved
over time and we presumed that nurses assume their roles as independent professionals
in their approach towards ethical problems.

Purpose
The purpose of this study was to determine student nurses’ observations of ethical
problems encountered during clinical practice and the approaches used by nurses to
resolve these problems. The study was conducted in order to answer the following
questions:

• What ethical problems do nursing students observe during their clinical training?
• How are clinical nurses involved in resolving ethical problems?
• What are students’ suggestions regarding how nurses can actively participate in
ethical decision making?

Method
The study was conducted at a university-based nursing school in Ankara, Turkey. This
school has no institutional research ethics committee, thus written permission to carry
out this study was granted by the director of the school.
Students at this university receive a total of 14 hours’ ethics education as part of the
‘Nursing History and Deontology’ course, which is scheduled in their third academic
year. Purposive sampling included third and fourth year student nurses who received
this ethics training and who volunteered to participate. Eighty-four of 115 third grade
students (73%) and 69 of 120 fourth grade students (57.5%) participated in the study,
giving a sample size of 153.
All of the students were informed verbally by the researchers that their participation
was voluntary and that refusing to take part would not influence their academic per-
formance or grades. They were informed that the aim of the study was to explore
ethical problems experienced, witnessed or observed by themselves during their
clinical placements and how clinical nurses contribute to the ethical decision-making
process. The students were requested not to write their names on the survey sheet and
to describe only one of the most striking ethical problems they had encountered during
their clinical practice. They were asked to abstain from using patients’, nurses’ and
physicians’ names or any identifying information about the clinical setting.
The data were collected by questionnaire, which included an explanatory statement
at the beginning of the form stressing the aim of the study and that participation was
voluntary. The questionnaires consisted of five open-ended questions:

1) Did you observe any situation during your clinical practice that you regarded as a
moral issue? If yes, please describe the situation.

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592 F Erdil and F Korkmaz

2) In your opinion, were any ethical principles violated during this ethical problem or
situation? If yes, which principle(s)?
3) What were the factors that resulted in this ethical problem or situation?
4) What was the decision or contribution of nurses in the resolution of the problem or
situation that you observed?
5) What are your suggestions for the active participation of nurses in solutions to
ethical problems encountered in your clinical work?

Questionnaires were distributed at the end of a class session to those who agreed to
participate. Student representatives from each class gathered the forms and returned
them to the researcher within a week.

Data analysis
As the data were collected by open-ended questions, each response was read through
by the researchers. After interpretation of the data, common themes emerged from the
responses to questions 1 and 2.

Findings
The third and fourth grade students who participated in the study were aged between
19 and 23 years. All participants stated that they had observed some kind of ethical
problems during their clinical practice. Most of the information received was about
unethical and improper behavior of nurses and physicians. The situations that students
most frequently expressed as ethical problems were categorized under six main themes:
physical maltreatment of patients (10%); psychological maltreatment of patients
(34%); ignoring patients’ privacy (24%); not giving patients sufficient and appropriate
information (25%); discriminating against patients according to their socio-economic
or educational status (5%); and relationships between patients and nurses, nurses and
doctors, student nurses and clinical nurses, student nurses and doctors, and student
nurses and patients (2%) (Table 1). The most important factors in the occurrence of
ethical problems were identified as unprofessional behavior on the part of doctors and
nurses. The responses to question 3 were, therefore, related to questions 1 and 2.

Table 1 Ethical problems observed by nursing students


during clinical training (n = 153)

Ethical problem No. %


Physical maltreatment 16 10.0
Psychological maltreatment 52 34.0
Ignoring patient privacy 37 24.0
Inappropriate information 38 25.0
Discrimination 7 5.0
Relationships 3 2.0

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Ethical problems observed by student nurses 593

Some of the students’ observations categorized under three of the above mentioned
topics included the statements below.

Physical maltreatment of patients:

Some patients were lying on wet sheets and nurses did not care.

A doctor shouted and slapped a pregnant woman while she was screaming during labor
pain.

A doctor performed frequent and unnecessary vaginal examinations to improve his


practice skills.

Health personnel were scolding and deliberately pushing a patient in a psychiatric clinic.

Psychological maltreatment of patients:

A nurse in a psychiatric clinic humiliated the patient while shouting in his face that he is
already mad.

Doctors and nurses despised and abused patients verbally.

A woman who was undergoing an abortion was humiliated by the doctor.

A nurse scolded a patient angrily because she had fecal incontinence.

A nurse and a care assistant made fun of the reasons why a patient attended an emergency
clinic.

A patient who refused to sign the consent form was threatened by the intern doctor with
being discharged from hospital.

Violation of privacy:

Patients were forced to undress in front of many medical students.

A female doctor came into the patients’ room where 6–8 women were lying on their beds
and said ‘please all of you get undressed for vaginal examination’.

A nurse did not close the curtain in the emergency unit while giving patients physical
care.

Patients in the intensive care unit were left undressed and exposed.

Nurses did not consider the physical privacy of patients while giving an enema.

Patient records in clinics are available for everyone to see.

Private medical information about certain patients was shared among the staff.

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594 F Erdil and F Korkmaz

The students also stated that patients were not provided with sufficient information
about their diagnosis, treatments and prognosis, and that they were forced to sign the
consent forms without being informed clearly.

Frequently violated ethical principles


The participants said that the ethical principles violated during clinical practice were:
respect for an individual’s autonomy (30.0%); respect for an individual’s privacy and
intimacy (22.0%); and the principles of doing no harm (16.0%), beneficence (17.%) and
justice (15.0%).

Factors contributing to ethical problems


The students stated that a number of factors contributed to the occurrence of ethical
problems. These included unprofessional behavior among doctors (38.0%), nurses
(34.0%) and other health personnel (20.0%), in addition to problems stemming from
hospital management (6.0%) and inefficient communication (2.0%).

Nurses’ participation in the ethical decision-making process


A majority of participating students (77%) said that nurses did not take part in the
process of resolving the ethical problems they encountered.

Discussion
The students participating in the present study noted that the ethical problems they
most frequently experienced were physical and psychological maltreatment of patients
and disrespect for patients’ privacy. The results of the present study are similar to those
of previous studies on ethical problems and their causes as encountered by nurses
and by nursing students during their clinical training.26,28,31,32 This indicates that the
quality of service provided by health care professionals is affected by many factors.
The most important of these are: health personnel shortages; high patient-to-nurse
ratios; inadequate institutional understanding of the importance of health care services
and their quality; and insufficient resources and their unjust distribution.8,9,17,18 These
factors cannot be overcome only by health care personnel because such problems re-
quire more comprehensive national policies and institutional regulations, apart from
individual endeavors. Hence, professionals working in health care services experience
intense levels of stress, which are increased by the burden of not being able to find
solutions to these problems and their causes. Individuals experiencing stress can no
longer analyze events from different perspectives and they fear they will become more
pessimistic and fulfill only their own responsibilities. This intense anxiety may result
in either physical or psychological maltreatment of patients by doctors and nurses.
Many previous studies have supported the view that ethics education plays an im-
portant role in gaining skills for coping with ethical problems, taking an active part
in the decision-making process, and gaining a professional identity.33–39 However, the

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Ethical problems observed by student nurses 595

expected positive impact of ethics education may occur only if this knowledge is in-
ternalized by members of the profession and integrated with their experiences. The
findings of the study suggest that doctors and nurses have not yet internalized the
ethical knowledge they gained during their ethics education, and that they have not
been able to exhibit this knowledge in their professional practice and relationships.
Ethics education may not be sufficient if it is not supported by professional experience,
personal characteristics and institutional policies and/or regulations. Nurses who
received ethics education during their training and had long experience gained from
working in health care contexts were observed to have better ethical decision-making
skills the longer their professional experience.39
The students participating in the present study stated that principles of respect for
individuals’ autonomy, privacy and intimacy were violated in most ethical problems.
Previous studies on the same subject reported similar results with regard to violation
of the principle of respect for autonomy.32,40 Generally, doctors, and sometimes nurses,
think that they are best placed to make the most appropriate choices on behalf of their
patients and therefore behave accordingly. Patients take up a passive stance with
doctors and nurses when they are admitted to hospital, thus accepting all of the treat-
ment that they recommend. This process is also supported by the fact that patients are
not aware of their rights. Violation of the principles of patients’ autonomy is further
facilitated by doctors and nurses who make unilateral decisions on behalf of patients,
rather than taking the time to discuss thoroughly the range of options available and to
incorporate patient preferences into their treatment.
It is obvious that many health care institutions in Turkey lack conditions that enable
physical privacy for patients. This principle is widely regarded by students as being
violated because wards typically include rooms for five or six patients in which there are
no curtains or screens (or else these do not function correctly) between patients, which
are important for ensuring privacy and dignity. Doctors and health care personnel
are, this study suggests, insensitive to the privacy of patients. There are no adequate
databases in Turkey for reliably recording details of patients in health care institutions.
Data are registered in many institutions with the help of filing systems, and records are
retained for access by individuals other than health teams, such as students, assistant
health personnel and patients’ relatives. Even in institutions where patient records are
held on electronic databases, these lack security precautions that prevent access and
use of the records by unauthorized persons.
The most striking finding stated by the students participating in the study is that
only a few nurses take part in ethical decision-making processes, with 77% of them not
taking part at all. Nursing is one of the professional groups that works with patients
for the longest period of time in the health care system. However, because of high
patient-to-nurse ratios, insufficient funding and inadequate use of resources, nurses
become focused on functions that necessitate technical skills and therefore cannot
assume the patient advocacy role. Hence, some of the nurses become contributors to
ethical problems and patients’ rights violations rather than enablers in resolving them.
This striking result is significant because it highlights the awareness of nursing stu-
dents in contrast to the stance displayed by qualified nurses. It is thought that there are
not sufficient role models to guide students to internalize the ethical knowledge they
receive during their training by implementing this knowledge during patient care on
the basis of real cases.

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596 F Erdil and F Korkmaz

Conclusion and recommendations


The results of this study indicate that health care personnel, in particular physicians
and nurses, who are obligated to provide safe, respectful and ethical care, are contribut-
ing to the increasing numbers of ethical problems. In spite of legal regulations about
patients’ rights and patient safety procedures in health care institutions, it seems that
unethical behaviors persist, leading to the violation of patient rights. Another striking
finding of this study is that the students stated that nurses do not take an active part
in ethical decision-making processes. The findings suggest that nurses should internal-
ize their professional and ethical roles in order to make effective ethical decisions. The
students’ suggestion about the need to facilitate ethical discussion within in-service
training programs for nurses, and the formation of units that deal with resolving ethical
problems, should be taken into consideration.
The results of this study should be taken into account by nurse educators, hospital
nursing service administrators, ethics committees and nurse researchers. In addition,
it is clinical nurse educators’ and researchers’ responsibility to maintain supportive
communication and encourage students to develop the capacity for ethical judgment,
to engage in a sustained and independent search for truth and to promote ethical
practice.

Limitations of the study


Several limitations of this study need to be stated. First, the aim was to explore ethical
problems that student nurses observe during their clinical practice and the approaches
taken by nurses to these ethical dilemmas. The results presented here should be
interpreted cautiously because they reflect only the observations and perspectives of
students. The students’ responses may have been influenced by their personal feelings,
perceptions and attitudes towards clinical practitioners, including physicians and
nurses, during their clinical experiences. Students’ perspectives may have the potential
for bias, which limits the external validity of this study. Identifying real ethical problems
in clinical practice requires a more detailed, objective and solid research process.
Second, this is a small scale study that included only third and fourth year students
of one nursing school amongst more than 80 such schools in Turkey, and the students’
observations were from only a few practice areas. The results cannot, therefore, be
generalized.
Third, the use of questionnaires with five open-ended questions to collect such im-
portant information limits the reliability of the findings. Structured interviews would
have served to amplify the investigation.
Fourth, although the students were informed that their participation was voluntary
and that refusing to participate would not influence their academic performance or
grades, they may have felt compelled to take part because the researchers were also
their instructors.
The results of this study should, therefore, be further supported by new studies.

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Ethical problems observed by student nurses 597

Acknowledgements
The authors would like to thank the third and fourth year students from Hacettepe
University Faculty of Health Sciences Nursing Department who volunteered to parti-
cipate in this research. We also thank Associate Professor Leyla Dinç for her support
throughout the study and the anonymous reviewers.

Conflict of interest statement


The authors declare that there is no conflict of interest.

Fethiye Erdil and Fatoş Korkmaz, Hacettepe University, Ankara, Turkey.

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