Ethics in Nursing
Introduction
The specificity of ethics in nursing stems from the fact that nursing, alongside medicine as an applied science, emerged in a much later historical period. The present state was preceded by a development whose beginning was marked by the emergence of nursing as an independent profession. Respect for general as well as specific moral norms has always been part of good professional performance. The ethics of both professions is derived from the overall level of morality in society. Health workers carry out professional procedures and are observed by the public. Whether their conduct is judged as good depends primarily on the patient's perception of care. In accordance with current tendencies in modern society, the determining criteria are the right to self-determination and the preservation of human dignity. (Haškovcová, 2002).
In the care of the sick, mutual relationships arise and develop among the people participating in this process, especially the relationship between the helper and the one who receives help. One of the goals of ethics is to cultivate this relationship. An elementary part of the profession is the nursing procedure. Everything a nurse does while caring for a patient has its own moral accompaniment; ethics influences the nurse's behavior in carrying out her activities. "It can be stated that morality in nursing is what concerns good and benefit, or harm and injury to the patient or client, because all nursing acts always have a moral impact." (Fišerová, 1998, p. 8).
The concept of nursing underwent changes in historical periods, but its essence remained help. Because helping another person can be interpreted as doing good, ethics becomes an elementary part of professional performance. The first historical figure who described the ethical aspects of nursing in her professional publication was Florence Nightingale. She perceived service to the sick as a spiritual mission and approached it with all her Christian virtues.
Future health workers in the Czech Republic are prepared for the profession of general nurse at three levels of the educational system. Secondary medical schools prepare students in the field of Health Assistant. At higher medical schools, students are educated in the field of Qualified General Nurse. University preparation of health professionals takes place in the bachelor's and follow-up master's degree program Nursing, field of study General Nurse. The core field of all the stated study programs is Nursing.
The graduate profile - health assistant - from an ethical perspective is formed during the course of study by leading students to observe the moral principles of nursing care and requirements for protecting privacy. The graduate is able to help and lead patients to responsibility for their own health. In relation to oneself, he or she has mastered the skills of self-regulation, self-evaluation, and strengthening one's own health in order to face demanding professional and life situations. After completing professional preparation, the health assistant is competent in terms of knowledge of his or her human rights and respect for the rights and cultural differences of other people. Knowledge and skills related to the ethics of nursing care and patients' rights form part of general vocational content. The student acquires the necessary professional competencies for the relationship with patients and other workers, as well as competencies important from the perspective of work performance. Specifically vocational content brings students theory and practice of health care and nursing of individual categories of patients.
Nursing leads students to acquire theoretical knowledge and practical skills necessary for caring for the sick. The basis of teaching consists of the theory of the nursing process as a prerequisite for providing holistic and individualized care. In addition to procedures and principles of caring for patients, the student learns to respect patients' rights, to assume personal responsibility for providing care, and to work in interaction with other members of the health care team. Teaching is conceived in groups, with the teacher's explanation alternating with exercises intended to prepare students for entering practice in a real hospital environment and contact with the patient. In the thematic area Development of Nursing and Education of Health Workers, the student becomes acquainted with the ethical code of health professions. Patients' rights are one component of the content of the thematic area Organization of Work of the Health Care Team, nursing process. In the areas Patient and Hospital Environment, Hygienic Care of Children and Adults, Care of the Patient with Pain, Monitoring of Physiological Functions, Ward Round, and Collection of Biological Material, students learn proper ways of dealing with the hospitalized patient, especially with respect for his or her natural modesty and sociocultural specificity.
Research Objective
The aim of our research was to determine the relationship between the content of instruction and teaching methods in vocational subjects and success in forming students' professional attitudes, ways of behavior, and conduct.
Method
To process our work, we used the questionnaire method. The first research sample consisted of 14 teachers with predominantly more than twenty years of experience. Six members of the teaching staff had 21 or more years of practice, 5 teachers had 11 to 20 years of practice, 2 out of the total number had taught for 6 to 10 years, and 1 teacher had gained pedagogical experience for less than 5 years. Twelve teachers taught in the 2nd year, 10 out of the total number in the 4th year, 9 teachers taught students in the 3rd year, and 6 teachers worked in the 1st year, while most of them participated in teaching in multiple years simultaneously. The second research sample consisted of students. Of these, there were 41 women and 3 men, who were in the teaching process at the secondary school level.
Results of the Survey among Teachers
Half of the total number of respondents held the opinion that it is not appropriate to teach ethics at a secondary medical school as an optional subject. We consider this the most significant finding of the entire preliminary research in view of the fact that ethics is the most important part of performing a helping profession. Interesting and at the same time paradoxical is the fact that all the teachers who answered the question are health workers by original profession. From the perspective of the effectiveness of ethical preparation, this is very significant, because they gained experience from situations of helping the sick. They share the ethical principles of the nursing profession, participated in solving demanding decision-making situations, and took part in the general discussion of health workers on dilemma topics.
From the perspective of the didactics of theoretical and practical health subjects, it is important that teachers acquaint students with the expected learning outcomes. Students thus study individual areas from the perspective of educational goals. They know what they are supposed to learn and what they are supposed to understand. They apply knowledge and moral attitudes in practice. In this way, the subject matter becomes meaningful to them and they perceive it as practically usable.
We consider another important element of the teaching process to be that teachers, in most cases, address the question of what expectations students connect with the whole process of ethical preparation. The assumption that teachers are oriented in the expectations of students with certain practical goals is confirmed by the finding that they adapt the content of instruction to the needs of students. By asking about student preferences in relation to ethical topics, the assumption was confirmed that increased interest in this sense is expressed by students. An even more convincing finding shows that teachers accept this in two ways. On the one hand, they create space for solving current problematic situations from nursing practice, and on the other hand, they include topics beyond the requirements of the school educational program. All teachers discuss ambiguous topics with their students, and although the result of the survey was in this case partly devalued by an error in formulating the question, I can conclude that the discussions concern especially abortion, euthanasia, organ donation, and providing information to patients. By finding out students' moral attitudes toward themselves in lessons, teachers also create space for their self-reflection.
There is also general discussion among teachers about the content, methods, and forms of ethical preparation of students at school. In the area of the methodological approach, where respondents were invited to indicate the spectrum of used methods, discussion, explanation, solving model situations, work with text, and group teaching prevailed. Less than half of the teachers use role-play teaching, project teaching, and brainstorming to activate students. The order of teaching methods according to the degree of popularity among students, as compiled by teachers, approximately correlates with the previous scale. A clear majority of teachers mentioned discussion and solving model situations. For deeper study, they recommend additional literature on ethical topics to students. Given that ethics is addressed to varying degrees by 3 theoretical and 1 theoretical-practical subject, students draw on recommendations of ethical literature in all related subjects, thereby highlighting interdisciplinary relationships.
In the area of determining achieved study results, we found that teachers in half of the cases out of the total number of respondents verify understanding of ethical subject matter using knowledge tests. More than half examine orally, and approximately one third of teachers use model situations to verify acquired knowledge and skills. The most frequent topics of essays with ethical themes are euthanasia and abortion. However, the subject of the inquiry was not whether teachers assign the topic or whether the choice is left to students, which is a substantial difference from the perspective of determining students' interest.
A clear agreement at the highest or almost highest possible number of responses occurred in four questions. In these cases, it turned out that teachers inform students in advance about educational goals, adapt the content of instruction to the subjective educational needs of students, and give them the opportunity to deal in theory lessons with solving problems from hospital practice. It is also now clear that all teachers, with only one exception, teach the contents of patients' and health workers' ethical codes in their subjects. This creates intensive interdisciplinary relationships and multiplies the effect of instruction in social science, general vocational, and specifically vocational subjects.
Results of the Survey among Students
In the area of motivation for choosing a health profession, it turned out that in most cases the choice of a helping profession was probably rather random than that the student had deliberately headed toward this very important moment. Related to this is the finding that again most students continue to think about the correctness of their decision. It is likely that students who were not strongly motivated to choose the profession before beginning their studies are subjecting their decision to critical evaluation before entering professional life. From this we infer that some of the total number of respondents are those who will not perform the profession for which they are now preparing in the future.
From the perspective of the expected shift between developmental stages of moral development, it is important to us that most students use the content of ethical preparation in their private lives. What strongly interested us and has high importance from the perspective of the process of forming professional attitudes is the personal experience of most students with the role of hospitalized patient. According to the current age of the respondents, we assume that in several cases they were pediatric patients and that they have experience with nursing-relevant phenomena such as loss of certainty, anxiety, fear, and pain.
From the perspective of the effectiveness of teaching methods and forms, it is a satisfactory finding that respondents perceive the mutual connections of ethical knowledge and skills acquired in general education and vocational subjects. This implies that students predominantly follow interdisciplinary relationships and the effects of different areas of instruction thus reinforce one another from their perspective. Most students expect from teaching guidance for practical situations of decision-making and action. It was not investigated whether these are generally to be effective instructions or advice for solving demanding situations, or instructions for ordinary ethical conduct with the sick. Some students probably realize that in the real conditions of care provision there are situations in which it is not possible to apply unequivocal guidelines for conduct. In response to the question whether patient cases are the subject of discussions, students in most cases answered that they return to them together with teachers, which probably correlates with the possibility of solving situations from practice in theoretical lessons, as reported by the teachers.
We tried to clarify preparedness for ethical conduct through questions determining to what extent students are confident in relation to the patient, how deeply they have internalized and observe the moral principles of the nursing profession, whether they subject their verbal and nonverbal expression to conscious control in contact with the patient, and whether they feel responsible in relation to him or her. In the most important phase from the perspective of the functionality of the relationship between the helping health worker and the patient, most students feel confident. This means that, from their point of view, they are prepared to establish contact and conduct initial interviews with patients. However, there is also a significant group of students who do not feel confident at the initial meeting with the patient. We further consider it a very significant result that students split into two completely equal groups in assessing the level of their confidence in behavior toward the sick. It was not specified in relation to which nursing situations the students should express confidence in behavior. They may have had in mind a broad spectrum of situations, from those demanding in terms of choosing the way of dealing with a patient in serious health condition to ways of behavior toward specific groups of patients such as children or elderly patients, patients with sensory or mobility limitations. We consider it an important verification of the validity of the survey of students' subjective confidence to supplement the survey by asking their teachers. We assess the adoption of moral norms by the fact that students predominantly follow their own principles in their approach to patients. From the stated finding, it can be inferred that they cultivate the morality of the performance of their future profession, which is very important for them and for their patients. Since students are led during theoretical and practical instruction to the responsible provision of care, the expected result is that they feel personal responsibility for the patient.
Another area of questions focused on the rules of proper communication with the sick. Reflection on the clarity of the health worker's own message as a basic prerequisite for successful communication between the helper and the patient illustrates that most students probably receive feedback on whether, for example, an instruction or explanation was clear to the patient. From the perspective of helping the patient cope with the adverse effect of fear, it is significant that about half of the questioned students state that they do not know how to communicate and act, for example, with a child or adult who is afraid. What students specifically imagine under the term fear has significance here, whether they associate it with ordinary or serious situations.
In the area of questions related to patients' rights, we made some very interesting and surprising findings. One of them is the result indicating that most students assess the consideration of patients' right to privacy in hospital as insufficient. Given the fact that 4th-year students have significant experience with relatively independent observation of hospital care, we consider this statement relevant and serious from the perspective of their perception of the work of health workers, which is supposed to serve a model function. Related to this is the question of how students themselves fulfill patients' right to privacy. It is interesting that only half of the total number of respondents answered. They variously formulated important measures to ensure physical privacy, especially in the sense of how to protect the patient's nudity from the eyes of others and respect their modesty. In contrast, students with the opinion that the patient's right to privacy in terms of the protection of sensitive data is adequately taken into account have a clear majority. This probably results from the practice of applying the legal standard on the protection of personal data, setting up security mechanisms of information technologies in the medical facility, and principles of working with medical records. The phenomenon of informed consent of the patient in the case of non-physician health workers relates to nursing procedures or they participate in informing the patient about a medical procedure. A quarter of the students who answered negatively probably had in mind the presumed consent of the patient to ordinary nursing procedures. Communicating the truth was addressed through two related questions. In almost all cases, students are convinced that by telling the truth about a serious health condition, the patient may be harmed. Although this does not follow from the wording of the question, the students probably have in mind information given by a doctor, because this type of communication is not the responsibility of a non-physician worker. It would be interesting to find out whether they also mean distinguishing between ways of communicating the information. At the same time, a larger group of students knows and takes into account the patient's right to truthful information.
In the area of questioning about the moral qualities of the health worker, students assigned a degree of importance to individual qualities. One of the most interesting findings of the entire survey among students is the resulting scale of the importance of qualities, where professionalism dominates. It is followed by empathy, affection, and patience, between which there are no longer marked differences in evaluation. This illustrates that students consider the moral qualities of the health worker less important than the professional aspect in the sense of the correctness of performing nursing activities.
The concept of dignity was attempted to be captured by the same group of students who stated ways of protecting the patient's physical privacy. Through their formulations, students express connections between the concept of dignity and dying, respect for the human being and the deceased, respect for the human right to privacy, relationship to one's own person, and responsible fulfillment of a person's duties in relation to other people.
In the area of moral attitudes, we tried to determine students' relationship to themselves by means of a question asking whether they continually care for their own health. Although the result of the survey was partly devalued by the wording programmatic care, it can be expressed in the sense that approximately half of the students apply a healthy lifestyle. To the question of an engaged moral attitude toward euthanasia, a number of students far exceeding half did not answer. A clear majority of the remaining answers expresses a positive attitude under certain conditions, which students variously defined. These are most often unbearable and long-term pain, irreversible reduction in quality of life, the patient's wish, incurable disease, and the irreversible necessity of connecting the patient to devices ensuring vital functions. Five students unconditionally reject euthanasia and at the same time justify their position. One respondent answered that he or she is undecided.
Experience with nursing care in the terminal stage of human life, which is the most difficult from the standpoint of the moral demands of the profession, was had by half of the total number of respondents. This fact undoubtedly has a major influence on the formation of students' professional moral attitudes. There is probably a relationship here between personal experience of this kind and the expressed moral attitudes of students toward euthanasia.
Table 1 Qualities important for a health worker in order according to students
Conclusion
The results of our research survey in both research samples complement each other and demonstrate that there is no defined specific space for working with students in the area of forming professional attitudes toward people in demanding life situations and in the area of addressing serious moral phenomena in medicine and nursing. An opportunity for improvement in teaching at the secondary medical school is the application of teaching methods focused on active learning of attitudes as a basic component of ethical preparation. The teaching subject Ethics in Nursing is decisive in terms of the quality of preparation for the performance of the profession of general nurses.
Authors: PhDr. Lada Cetlová, PhD., PhDr. Marcela Babická List of bibliographic references [1] FIŠEROVÁ, J. Ethics in nursing. Auxiliary textbook. 1st edition. Brno: IDVPZ Brno, 1998. 60 p. ISBN not listed. [2] HAŠKOVCOVÁ, H. Medical ethics. Prague: Galén, 2002. 272 p. ISBN 80-7262-132-7.