YNEDT-02711; No of Pages 7 Nurse Education Today xxx (2014) xxx–xxx

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Clinical Misconduct Among South Korean Nursing Students Eun-Jun Park a, Seungmi Park b,⁎, In-Sun Jang c a b c

Department of Nursing, Konkuk University, Chungju-si, Chungcheongbuk-do, Republic of Korea Department of Nursing, Hoseo University, Asan-si, Chungcheongnam-do, Republic of Korea Korean Bible University, Seoul, Republic of Korea

a r t i c l e

i n f o

Article history: Accepted 17 April 2014 Available online xxxx Keywords: academic misconduct unethical behavior nursing students nursing education research

a b s t r a c t This study examines the extent and predictors of unethical clinical behaviors among nursing students in South Korea. From survey data of 345 undergraduate nursing students, unethical clinical behaviors were examined with respect to 11 individual characteristics, frequency and perceived seriousness of classroom cheating, two factors of individual attitude, and four contextual factors. Qualitative data from two focus group interviews were analyzed to explore reasons for and contexts of unethical clinical behaviors. About sixty-six percent of the participants engaged in one or more unethical clinical behaviors over a one-semester period. The prevalence of such behaviors varied widely from 1.7% to 40.9% and was related to the type of nursing program, the number of clinical practicum semesters completed, ethical attitudes toward cheating behaviors, the frequency of cheating on assignments, the frequency of cheating on exams, the perceived prevalence of cheating by peers, and prior knowledge of academic integrity. According to the regression analysis, the last four variables explained 29.4% of the variance in the prevalence of unethical clinical behaviors. In addition, multiple reasons and possible interventions for clinical misconduct were reported during the focus group interviews. Unlike cheating in the classroom, clinical misconduct was strongly induced by clinical nurses and poor clinical practice environments. In sum, unethical clinical behaviors were widespread among the participants and need to be corrected. © 2014 Elsevier Ltd. All rights reserved.

Introduction A clinical practicum based on a paired nurse-student relationship is a key teaching method in nursing education. In South Korea (hereafter “Korea”), a single clinical practicum for two credits lasts a total of 90 h over a two-week period (9 h/day for 10 days), and nursing students are required to complete at least 1000 clinical practicum hours to graduate (Korean Accreditation Board of Nursing, 2011). During a clinical practicum, a clinical nurse serving as a preceptor is matched with one or two students and plays a major role in teaching and supervising each student. While the number of nursing schools has increased sharply in recent years, there has been a lack of clinical practicum sites. In addition, nursing faculty faces severe competition in finding nursing units with good clinical education environments. One critical indicator of the quality of clinical education is academic integrity during a clinical practicum. Academic misconduct in nursing can be defined as intentional participation in deceptive academic practices in both classroom and clinical settings (Gaberson, 1997). Learning

⁎ Corresponding author at: Department of Nursing, Hoseo University, 79-20, Hoseo-ro, Asan-si, Chungcheongnam-do, Republic of Korea. Tel.: +82 41 540 9533; fax: +82 41 540 9558. E-mail address: [email protected] (S. Park).

through practice in a clinical site may be more likely than theoretical learning in the classroom to directly influence students’ attitudes and behaviors as nurses in the future. Unethical clinical behaviors of a nursing student can bring about unsafe patient care and may even weaken his or her sense of ethical accountability as a nursing professional. Few studies have considered clinical misconduct (Hilbert, 1988; McCrink, 2010), whereas many have examined academic integrity in classroom settings (Hart and Morgan, 2010; McCabe, 2009; Tippitt et al., 2009). Little is known about unethical clinical behaviors of nursing students. Previous studies have examined individual characteristics such as students’ demographic background or attitudes (McCabe, 2001; Rennie and Rudland, 2003) and contextual factors with respect to peers and institutions (Andrews et al., 2007; Gaberson, 1997) to understand misconduct only in the classroom, often ignoring clinical misconduct. Although some types of unethical clinical behaviors of nursing students can be indirectly identified from studies of their ethical encounters during a clinical practicum (Epstein and Carlin, 2012; Pedersen and Sivonen, 2012), few studies have addressed such unethical clinical behaviors in the context of academic integrity. For reliable and effective clinical education, a clear understanding of unethical clinical behaviors of nursing students is crucial. For better insight, this study examines the extent of clinical misconduct among nursing students in Korea. More specifically, the study investigates a) how prevalent and seriously perceived unethical clinical behaviors are, b) what factors influence or

http://dx.doi.org/10.1016/j.nedt.2014.04.006 0260-6917/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Park, E.-J., et al., Clinical Misconduct Among South Korean Nursing Students, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.006

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E.-J. Park et al. / Nurse Education Today xxx (2014) xxx–xxx

predict clinical misconduct, c) what reasons drive clinical misconduct, and d) what possible measures can be implemented to prevent it.

Methods In this study, a mixed method incorporating a cross-sectional survey and focus group interviews was employed. The questionnaire was developed by the authors based on a comprehensive literature review (Diekhoff et al., 1996; Ha, 2009; Harding et al., 2004; Jackson, 2006; Kirkland, 2009; McCabe, 2001; Rabi et al., 2006; Walker, 2008). In the questionnaire, a total of 10 items for unethical clinical behaviors were adopted from Hilbert (1988) and McCrink (2010) by considering Korea’s different clinical education environment. To identify relevant variables and predictors of the prevalence of unethical clinical behaviors, 11 individual characteristics were considered, including age, gender, religion, the type of nursing program, the academic year, the number of semesters in the clinical practicum, the GPA, and prior knowledge of academic integrity. In addition, 10 variables for cheating in the classroom were included to test their relevance to clinical misconduct: both frequency and perceived seriousness of cheating on examinations or assignments, individual attitudes toward cheating, and four contextual factors (perceived prevalence of cheating by peers, the atmosphere of the institution’s academic integrity, the atmosphere of whistle-blowing, and moral support from family members and friends). Table 1 shows the number of items, the measurement scale, and Cronbach’s alpha for survey questionnaire items. Further details on these measures are discussed elsewhere (Park et al., 2013). This study was approved by the institutional review board. First, a sample size was estimated 254 persons for multiple regression analysis with 10 independent variables using a G*Power program (version 3.1.3) by entering alpha 0.05, power 0.95, and a medium effect size f of 0.10. For a nationwide sampling five nursing schools in different provinces were recruited in September 2011. All of the students who completed at least one semester of a clinical practicum in each school were invited to the study, considering a possible sampling bias that may occur if only students with a certain behavior pattern selectively participate in the study. As a result, 349 students among a total of 380 nursing students from five nursing schools anonymously answered and returned the questionnaire, and among these, a total of 345 reliable responses were included in the final analysis. Second, two focus group interviews were conducted in September 2012. Each interview included seven students in their fourth year who participated in the survey. The purpose of the interviews was to explore the reasons for or circumstances underlying unethical clinical behaviors and identify appropriate measures for preventing such behaviors. The core interview questions were a) “What kinds of unethical clinical

behaviors have you observed during your clinical practicum?” b) “Why do you think such unethical behaviors occur in clinical settings?” and c) “What do you think is necessary to prevent such behaviors?” Quantitative data were analyzed for descriptive statistics; the t-test or the F-test depending on the number of comparison groups; Pearson’s correlation coefficient; and a multiple regression analysis using SPSS (version 18.0). The significance level (α, type I error probability) of 0.05 was adopted for statistical inferences. Qualitative data from the focus group interviews were recorded, transcribed verbatim, and analyzed through a content analysis to determine answers, first independently and then comparatively by the authors. Results Third- and fourth-year students accounted for 67.0% and 24.6% of the 345 participants, respectively, and three- and four-year programs accounted for 29.6% and 70.4%, respectively. A vast majority were female (n = 308, 89.3%), and most (n = 298, 86.6%) fell into the 19-23 age group. Self-reported prevalence and perceived seriousness of unethical clinical behaviors Table 2 shows the results for self-reported prevalence and perceived seriousness for each cheating behavior. A total of 227 (65.8%) participants engaged in one or more unethical clinical behaviors out of the 10 such behaviors over a one-semester period. With the ordinal measurement scale (e.g., none, once, twice or more) converted into an interval scale (e.g., 0, 1, 2) for the application of statistics, the mean scores were 0.27 (S.D. = 0.33) on a 0–2 scale for the frequency of unethical clinical behaviors and 3.11 (S.D. = 0.93) on a 1–4 scale for perceived seriousness. The most prevalent unethical behavior was discussing patients in public places or with nonmedical personnel (#1 in Table 2, 40.9%), followed by recording or reporting inaccurate vital signs (#2, 39.2%), falsifying patient data or using inaccurate data for a case study (#3, 26.1%), and taking hospital supplies or medicines for personal use (#4, 22.3%). The least prevalent unethical behavior was recording medications as administered when they were not (#10, 1.7%), followed by recording patient responses to treatments or medications that were not assessed (#9, 5.8%). The other four unethical behaviors (#5–#8) were reported by 13%–16% of the participants. The mean scores for the perceived seriousness of unethical clinical behaviors ranged from 2.85 ± 1.02 (#4) to 3.28 ± 1.08 (#8), and many participants perceived unethical behaviors as being either not problematic or merely trivial (18.9%, #8; 33.9%, #4) depending on the

Table 1 Survey Questionnaire Items and Relationships of the Prevalence of Unethical Clinical Behaviors to Its Perceived Seriousness and Factors Related to Classroom Cheating. Characteristics Unethical clinical behaviors Frequency of unethical clinical behaviors Perceived seriousness of unethical clinical behaviors Classroom cheating Frequency of cheating on exams Frequency of cheating on assignments Perceived seriousness of cheating on exams Perceived seriousness of cheating on assignments Individual attitudes toward cheating Ethical attitudes toward cheating behaviors Neutralization behaviors Contextual factors Perceived prevalence of cheating by peers Atmosphere of the institution’s academic integrity Atmosphere of whistle-blowing Moral support from family members and friends

Number of Items

Measurement Scale: min. to max

Cronbach’s α

M (SD)

r (p)

10 10

0–2 1–4

.80 .97

0.27 (.33) 3.11 (.93)

– −.05 (.394)

11 15 11 15

0–2 0–2 1–4 1–4

.72 .75 .97 .96

0.16 (.22) 0.29 (.26) 2.99 (.96) 2.66 (.81)

.40 (b.001)⁎⁎⁎ .45 (b.001)⁎⁎⁎ −.08 (.138) −.11 (.055)

11 11

1–5 1–5

.82 .88

3.55 (.63) 2.20 (.76)

−.20 (b.001)⁎⁎⁎ −.06 (.316)

11 10 6 3

0–2 1–5 1–5 1–5

.90 .81 .87 .76

0.59 (.46) 3.26 (.65) 3.06 (.78) 3.63 (.77)

.37 (b.001)⁎⁎⁎ −.06(.293) −.10 (.069) −.05 (.388)

⁎⁎⁎ indicates statistical significance at the .001 level.

Please cite this article as: Park, E.-J., et al., Clinical Misconduct Among South Korean Nursing Students, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.006

E.-J. Park et al. / Nurse Education Today xxx (2014) xxx–xxx

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Table 2 Self-Reported Prevalence and Perceived Seriousness of Unethical Clinical Behaviors (N = 345). Unethical Clinical Behaviors

1

6

Discussing patients in public places or with nonmedical personnel Recording or reporting vital signs that are not taken or recalled accurately Using uncertain data or fabricating patient information for case reports (assignments) Taking hospital supplies or medications from the hospital for personal use Attempting to perform procedures on patients without adequate knowledge or failing to obtain guidance from instructors Recording or reporting nursing care that is not performed

7

Not reporting incidents or errors involving patients

8

Breaking sterile techniques and neither reporting it nor replacing contaminated items Recording patient responses to treatments or medications that are not assessed Recording medications as administered when they are not

2 3 4 5

9 10

Frequency in the Last Semester (n, %)

Severity of the Behavior (n, %)

None

Once

Twice or more

M(SD)

Not problematic

Trivial

Moderate

Serious

M(SD)

203 (58.8) 210 (60.9) 255 (73.9) 268 (77.7) 290 (84.1)

60 (17.4) 82 (23.8) 56 (16.2) 48 (13.9) 42 (12.2)

81 (23.5) 53 (15.4) 34 (9.9) 29 (8.4) 13 (3.8)

0.41 (0.49) 0.39 (0.49) 0.26 (0.44) 0.22 (0.42) 0.16 (0.37)

37 (11.1) 33 (9.9) 45 (13.5) 44 (13.2) 48 (14.4)

37 (11.1) 46 (13.8) 49 (14.7) 69 (20.7) 28 (8.4)

113 (33.9) 111 (33.2) 113 (33.9) 113 (33.8) 117 (35.0)

146 (43.8) 144 (43.1) 126 (37.8) 108 (32.3) 141 (42.2)

3.11 (0.99) 3.10 (0.98) 2.96 (1.03) 2.85 (1.02) 3.05 (1.04)

290 (84.1) 295 (85.5) 300 (87.0) 324 (94.2) 339 (98.3)

38 (11.0) 39 (11.3) 29 (8.4) 13 (3.8) 5 (1.4)

17 (4.9) 11 (3.2) 16 (4.6) 7 (2.0) 1 (0.3)

0.16 (0.37) 0.14 (0.35) 0.13 (0.34) 0.06 (0.23) 0.02 (0.13)

47 (14.1) 44 (13.2) 49 (14.7) 53 (15.9) 56 (16.9)

39 (11.7) 32 (9.6) 14 (4.2) 17 (5.1) 12 (3.6)

104 (31.1) 85 (25.4) 66 (19.8) 58 (17.4) 53 (16.0)

144 (43.1) 173 (51.8) 205 (61.4) 205 (61.6) 211 (63.6)

3.03 (1.06) 3.16 (1.06) 3.28 (1.08) 3.25 (1.12) 3.26 (1.13)

behavior. Breaking sterile techniques and neither reporting it nor replacing contaminated items represented the most serious unethical behavior perceived by the participants (#8, M = 3.28), followed by recording medications as administered when they were not (#10, M = 3.26) and recording patient responses to treatments or medications that were not assessed (#9, M = 3.25). On the other hand, the least serious unethical behavior was taking hospital supplies or medications for personal use (#4, M = 2.85), followed by falsifying patient data or using inaccurate data for a case study (#3, M = 2.96), which are generally not likely to directly influence patient outcomes.

Relevant factors and predictors of unethical clinical behaviors As shown in Table 3, the prevalence of unethical clinical behaviors did not vary according to individual characteristics except for the following three (α = 0.05): the type of nursing program, prior knowledge of academic integrity, and the number of clinical practicum semesters completed. Unethical behaviors were more likely for the participants in three-year programs, those with no prior knowledge of academic integrity, and those who completed three semesters of their clinical practicum than for their respective counterparts. As shown in Table 1, the prevalence of unethical clinical behaviors was examined for its relationships with the perceived seriousness of unethical clinical behaviors and 10 measures of cheating in the classroom, including the frequency and seriousness of cheating on exams or assignments, individual attitudes toward cheating, and four contextual factors. The prevalence of unethical clinical behaviors was positively related to the frequency of cheating on assignments based on the Pearson correlation coefficient (r = .45, p b .001, R2 = 20), the frequency of cheating on exams (r = .40, p b .001, R2 = 16%), and the perceived prevalence of cheating by peers (r = .37,p b .001, R2 = 14%), whereas it was negatively related to ethical attitudes toward cheating behaviors (r = −.20 (p b .001, R2 = 4%). In other words, the participants were more likely to engage in unethical clinical behaviors if they more often engaged in cheating on assignments and exams, perceived cheating by peers more prevalent, or had more lenient attitudes toward cheating. Table 4 shows the results of the stepwise multiple regression analysis using the aforementioned seven factors. The plot of residuals indicates satisfactory results for the linearity between predictors and unethical clinical behaviors, the normality of the regression model, and homoscedasticity for all values of unethical clinical behaviors

depending on the predictor. The variance inflation factor (VIF) ranged from 2.01 to 4.15, indicating that multicollinearity was not a serious concern. The four significant predictors of the prevalence of unethical clinical behaviors were the frequency of cheating on assignments (t = 5.23, p b .001, Beta = .29), the perceived prevalence of cheating by peers (t = 4.30, p b .001, Beta = .22), the frequency of cheating on exams (t = 3.40, p = .001, Beta = .19), and prior knowledge of academic integrity (t = 2.66, p = .008, Beta = .12), in that order. According to the results for this model, with other variables controlled for, every one-unit increase in the frequency of cheating on assignments produced a 0.36-unit increase in unethical clinical behaviors. The frequency of cheating on exams produced a 0.27-unit increase; the perceived prevalence of cheating by peers, a 0.16-unit increase; and prior knowledge of academic integrity, a 0.10-unit increase. The multiple regression model with these four predictors accounted for 29.4% of the variance in the prevalence of unethical clinical behaviors (F = 35.63, p b .001). Reasons for unethical clinical behaviors and measures to prevent them Based on the focus group interviews, 11 types of unethical clinical behaviors (including 8 of the 10 questionnaire items in Table 2) and relevant reasons were identified, as shown in Table 5. The reasons for unethical clinical behaviors were related mainly the nurse preceptor’s heavy workload, nurses’ undesirable practice culture, poor role models, the patient’s avoidance of students, an unclear understanding of (un) ethical behaviors, a fear of rejection by the preceptor or hospital, a fear of a negative evaluation from the preceptor, and an exaggerated expectation from a faculty member for presentations or high grades. Diverse measures for preventing clinical misconduct were found from the interview and categorized as follows: a. Educating students and nurses to build strong ethical value systems and practice ethically good care. b. Educating students to clearly understand what are ethically right or wrong behaviors based on real cases or problems. c. Providing guidelines and policies indicating what should be done in response to unethical behaviors by students themselves, peers, or nurses during a clinical practicum and regularly reminding them of those guidelines and policies before any clinical practicum. d. Redesigning assignments or tasks by considering constraints on existing clinical education environments.

Please cite this article as: Park, E.-J., et al., Clinical Misconduct Among South Korean Nursing Students, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.006

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E.-J. Park et al. / Nurse Education Today xxx (2014) xxx–xxx

e. Fostering a culture of open communication and constructive feedback for students’ errors or mistakes based on good intent. f. If necessary, administering appropriate penalties and punishments for unethical behaviors by considering pros and cons (e.g., it may discourage students from participating actively in the clinical practicum). g. Placing students with a preceptor who can be a good role model and facilitating a supportive clinical education environment.

Discussion This study examined Korean nursing students’ behaviors and attitudes toward clinical misconduct. A majority of the participants (66%) were engaged in at least 1 of 10 unethical clinical behaviors, which was higher than the proportion of cheating on exams (50%) but lower than that of cheating on assignments (78%) found in Park et al. (2013)’ study, who examined nursing students in Korea. The prevalence of clinical misconduct varied widely from 1.7% to 40.9% depending on the behavior, whereas the perceived seriousness varied little from 2.85 (SD = 1.02) to 3.26 (SD = 1.13). Based on a comparison of 8 of the 10 unethical clinical behaviors considered in this study (excluding #3 and #4 in Table 2) with the results for nursing students pursuing associate degrees in the U.S. in McCrink (2010), who found the prevalence of unethical clinical behaviors to range from 2.1% to 35.3%, a total of 6 behaviors showed higher frequency, whereas the remaining 2 (#9 and #10 in Table 2), lower frequency. The two most frequent unethical clinical behaviors were identical (#1 and #2 in Table 2), but there was a substantial difference in the prevalence of the second most frequent unethical behavior, namely recording or reporting inaccurate vital signs (13.1% in McCrink vs. 39.2% in this study), indicating much higher frequency among Korean students. In comparison to Hilbert’s (1988) study, who considered a sample of nursing students pursuing a bachelor’s degree in the U.S., the behavior of discussing patients in public places (#1 in Table 2, 40.9% vs. 79.4%) was less frequent in this study, whereas that of not reporting an incident (# 7 in Table 2, 14.5% vs.

6.3%) was more frequent. There was little difference in the prevalence of the other 5 behaviors (#4, #5, #6, #9, and #10 in Table 2) between nursing students in this study and those in Hilbert’s (1988) study, although an exact comparison was not possible. The perceived seriousness of clinical misconduct was unexpectedly low, with 18.9%–33.9% of the participants perceiving that unethical clinical behaviors were trivial or not problematic, which was much higher than the finding indicating 1.0%–3.6% (slightly or not unethical) in McCrink (2010). This suggests that Korean nursing students are more tolerant of clinical misconduct than their U.S. counterparts. Moreover, the proportion of the participants who perceived unethical behaviors as being either trivial or not problematic often exceeded that of those who were already engaged in those behaviors except for the two most frequent unethical behaviors (#1 and #2 in Table 2), suggesting a possible increase in the most unethical clinical behaviors in the future. In sum, unethical clinical behaviors were widely prevalent among the participants, and a large proportion of the participants did not consider such unethical behaviors as being ethically serious. The prevalence of clinical misconduct varied across the following seven variables: the type of nursing program, the number of clinical practicum semesters completed, ethical attitudes toward cheating behaviors, the frequency of cheating on assignments, the frequency of cheating on exams, the perceived prevalence of cheating by peers, and prior knowledge of academic integrity. According to the regression analysis, the last four variables explained 29.4% of the variance in the prevalence of unethical behaviors. The Pearson correlation coefficients for the prevalence of unethical clinical behaviors were .40 for the frequency of cheating on exams and .45 for the frequency of cheating on assignments, whereas previous studies have found them to be .26 (Hilbert, 1988) and .57 (Hilbert, 1985) with classroom cheating, respectively. Despite the differences in correlation coefficients, the results provide support for the argument that clinical misconduct and classroom cheating are positively related to each other. Therefore, it is recommended that education and interventions for academic integrity be stressed early enough during the pre-clinical years. In addition, the

Table 3 Prevalence of Unethical Clinical Behaviors According to General Characteristics (N = 345). Characteristics

N (%)

Unethical Behaviors M (SD)

Age (years) Gender Religious orientation Type of nursing program Academic year

Number of clinical practicum semesters completed Motive for choosing nursing

Bachelor’s degree in a non-nursing major Grade point average (GPA)

Competitiveness for a higher GPA Knowledge of academic integrity

19 ≤ ≤23 23 b ≤44 Male Female Yes No 3-year 4-year 2nd year 3rd year 4th year 1 semester 3 semesters Job security High salary Aptitude or preference Recommendation by others Yes No 4.0 ≤ b4.5 3.5 ≤ b4.0 3.0 ≤ b3.5 b3.0 (Very) Low (Very) High Yes No

298(86.6) 46(13.4) 37(10.7) 308(89.3) 172(49.9) 173(50.1) 102(29.6) 243(70.4) 29(8.4) 231(67.0) 85(24.6) 164(47.5) 181(52.5) 178(51.7) 17(4.9) 100(29.1) 46(13.4) 23(6.7) 321(93.3) 82(24.0) 184(53.8) 59(17.3) 17(5.0) 61(17.8) 282(82.2) 266(77.1) 79(22.9)

0.28 (0.34) 0.23 (0.32) 0.23 (0.39) 0.28 (0.33) 0.27 (0.34) 0.27 (0.33) 0.35 (0.41) 0.24 (0.29) 0.22 (0.30) 0.28 (0.35) 0.25 (0.31) 0.23 (0.28) 0.31 (0.37) 0.26 (0.32) 0.40 (0.58) 0.26 (0.30) 0.31 (0.34) 0.22 (0.30) 0.27 (0.34) 0.29 (0.35) 0.28 (0.34) 0.25 (0.29) 0.13 (0.28) 0.21 (0.21) 0.28 (0.34) 0.24 (0.31) 0.36 (0.40)

t or F value

p-value

0.79

.428

−0.84

.402

0.04

.965

2.55

.012⁎

0.56

.574

−2.18

.030⁎

1.07

.362

−0.80

.426

1.20

.309

−1.42

.156

−2.65

.009⁎

⁎ indicates significance at the .05 level.

Please cite this article as: Park, E.-J., et al., Clinical Misconduct Among South Korean Nursing Students, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.006

E.-J. Park et al. / Nurse Education Today xxx (2014) xxx–xxx

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Table 4 Results of the Multiple Regression Analysis for the Prevalence of Unethical Clinical Behaviors. Variables

Regression Coefficient b

Standard Error (SE. b)

Beta Coefficient

t

p

Constant Frequency of cheating on assignments Perceived prevalence of cheating by peers Frequency of cheating on exams Prior awareness of academic integrity (1 = never)

0.01 0.36 0.16 0.27 0.10 F = 35.63, Adjusted R2 = .294, p

.03 .07 .04 .08 .04 b .001

– .29 .22 .19 .12

0.30 5.23 4.30 3.40 2.66

.768 b.001*** b.001*** .001** .008**

** and *** indicate statistical significance at the .01 and .001 levels, respectively.

results suggest that the perceived prevalence of cheating by peers predict clinical misconduct in addition to classroom cheating studied in Park et al. (2013). The perceived prevalence of cheating by peers seems to predict various types of academic misconduct. Park et al. (2013) found that the perceived seriousness of cheating behaviors is a predictor of classroom cheating behaviors, but it had no relationship with unethical clinical behaviors in the present study. This suggests no relationship between the perception of the seriousness of unethical clinical behaviors and actual behaviors in clinical settings. The reasons for the participants’ clinical misconduct provide an explanation for the lack of this relationship. Unethical clinical behaviors were influenced mainly by clinical environments beyond individual

ethical beliefs or attitudes, and there were some problems threatening the quality of clinical education, indicating a need for better clinical education environments. In this study, the participants reported that they were not able to insist on ethical clinical behaviors because of the pressure to conform to or be accepted by clinical nurses. Given Korea’s clinical education environment, clinical nurses may lack necessary motivation in clinical education (Song and Kim, 2013) because they are not likely to be sufficiently rewarded or recognized for their contribution to nursing education by their institutions or nursing schools and are already busy with their routine workload to take on the additional burden of teaching students (Smedley et al., 2010). In addition, clinical nurses often report their lack of preparation for this teaching role regardless

Table 5 Reasons for Unethical Clinical Behaviors Based on Focus Group Interviews. Unethical Clinical Behaviors

Reasons a

• Not knowing exactly what behaviors are unethical or prohibited and sometimes forgetting that such behaviors are unethical, despite signing a consent form of confidentiality • Not having people listen to what is being talked about or being unlikely for people to learn who is being talking about Recording or reporting vital signs that are not taken or recalled accurately (#2) • Forgetting vital signs or losing notes on vital signs a or are not accurate or true • Not being able to insist on reassessing vital signs because of busy schedules of clinical nurses, fearing a damaged self-image, or an unfavorable evaluation from clinical nurses or patients • Feeling forced to record or report values that are customarily used by nurses for a normal range of vital signs. Using uncertain data or fabricating (#3)a or omitting patient information • Not being able to collect necessary patient information because of not perceiving a welcome by (diagnoses and medications) for case reports (assignments) patients and having difficulty building a rapport • Being overwhelmed by the amount and complexity of patient information • Having a heavy load of home assignments during the clinical practicum • Focusing on getting good grades in the clinical practicum Taking hospital supplies or medications from the hospital for personal use (#4) • Considering such products as inexpensive and trivial (e.g., an angiography needle) a • Using them to practice basic nursing skills by themselves after school • Seeing nurses doing the same and thus considering the behavior to be acceptable Attempting to perform procedures on patients without adequate knowledge • Perceiving clinical nurse to be extremely busy and not being able to take time to answer questions a or failing to obtain guidance from instructors (#5) • Being Expected to help clinical nurses and save their time Recording or reporting nursing care that is not performed (#6)a or is delivered • Having few opportunities to provide direct care because clinical nurses are too busy to supervise or by clinical nurse educators as the student’s own in case reports not supportive of the student’s clinical practicum • Feeling pressure to include sound and plausible nursing care in case reports even when it is not provided • Not being able to provide nursing care because patients refuse the student’s care • Perceiving tasks required for case reports (e.g., completing a nursing process) to be unrealistic because of the short length of stay or unsupportive attitudes of clinical nurse educators Not reporting incidents or errors involving patients (#7)a • Fearing clinical nurses’ negative evaluation of the student and the school • Being fearful of causing some delay in clinical nurses’ workflow • Perceiving nurses' culture of underreporting or not reporting errors and near misses Breaking sterile techniques and neither reporting it nor replacing • Fearing clinical nurses’ negative evaluation of the student and the school contaminated items (#8)a • Seeing nurses doing the same Performing nursing care as provided by clinical nurses without questioning • Not wishing to make clinical nurses to feel criticized or uncomfortable even when it is inconsistent with what is being taught at school • Desiring to improve conformity with and acceptance by nurses • Wishing to appear efficient (e.g., measuring the pulse rate for only 25 seconds instead a minute) • Wishing to be recognized as competent and skilled Being silent about peers' unethical behaviors • Perceiving relationships with peers to be important and thus not wishing to harm them as friends • Not wishing to damage the image of peers and the school • Being able to correct inappropriate behaviors by caring for one another and preserving comradeship Being silent about nurses' unethical behaviors • Not feeling it is the student’s responsibility to report nurses’ unethical behaviors • Fearing a rejection by clinical nurses (e.g., refusing the role of the clinical nurse as an educator) or the institution (e.g., refusing to provide a clinical placement) • Perceiving that unethical behaviors, although not right, are understandable and realistic because of the heavy workload and thus not wishing to “rock the boat” • Hearing very little about what should be done when finding nurses engaged in unethical behaviors Discussing patients in public places or with nonmedical personnel (#1)

a

The questionnaire item number is the same as that in Table 2 and is presented in parentheses.

Please cite this article as: Park, E.-J., et al., Clinical Misconduct Among South Korean Nursing Students, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.006

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of their professional tenure (Smedley, 2008; Song and Kim, 2013). To address these issues, a strong partnership between clinical institutions and schools and their win–win collaboration are urgently needed (Billay and Myrick, 2008). When nurse preceptors are provided with necessary support through appropriate training and recognition, they are likely to approach student activities by focusing on meeting ethical standards instead of being just an extra pair of hands (Myall et al., 2008). The participants reported some issues associated with the heavy load of home assignments and difficulties in completing case reports in an honest manner. A clinical case study applying a nursing process is commonly required in many clinical practicums in Korea. To complete a nursing process within a short practicum period (e.g., two weeks), a nursing process from a patient assignment to the evaluation of a nursing intervention must be planned early enough and be closely monitored and supervised by clinical instructors. The participants sometimes omitted patient information in their case reports because they did not clearly understand it or wished to avoid complicated cases. Although nursing students may not need some patient information and thus omit it in a case report, such a behavior should not be for fabrication and manipulation purposes. Some participants invented diagnosis, intervention, or evaluation outcomes because of practical issues such as difficulties in building a rapport with patients, few opportunities for direct care, and short length of stay. Clinical instructors should provide closer monitoring and support for nursing students because these students are often not allowed to provide direct care as a result of a high level of consumerism in health care, high patient acuity, and clinical nurses’ lack of time for student supervision. The participants stated that they disguised their unethical behaviors and avoided questioning in the clinical site for fear of their punishment or negative evaluation. It is challenging for a clinical nurse to support students’ learning without risking patients’ safety (Hallin and Danielson, 2010). However, nursing students should be encouraged to participate actively in nursing care, and their errors or mistakes should be considered part of their learning process instead of a reason for their punishment, allowing for opportunities to admit and correct their mistakes. In addition, nursing students should clearly recognize the risks associated with long-term impacts of unethical behaviors (e.g., little progress and damaged self-image as a professional) instead of emphasizing short-term outcomes such as grades. Nursing faculty is responsible for ensuring a good clinical education environment that can foster ethical behaviors. Although faculty members do not directly teach and supervise students in clinical practicum sites, they are responsible for supporting the process of teaching and learning in such settings (Luhanga et al., 2010). In this regard, faculty members should engage in continuous communication with students regarding clinical misconduct and ensure that they have a clear understanding of what is ethically expected in clinical settings (Hilbert, 1988). For this, faculty members should maintain their clinical expertise and have clear knowledge of how staff nurses practice in real clinical settings (McClure and Black, 2013). Little is known about unethical clinical behaviors of nursing students, and in this regard, this study contributes by providing important insights into their clinical misconduct. This study provides more robust results by considering multiple nursing schools across Korea and employing both quantitative and qualitative data. The qualitative data, based on interviews with students, facilitated a clearer understanding of various issues surrounding academic integrity in the clinical practicum context. However, any generalization of the results should be made with caution because the qualitative data were collected from a small number of students and therefore the results may be biased based on the underreporting of unethical behaviors. In this regard, future research should explicitly explore various issues associated with clinical misconduct arising between clinical nurses and nursing students by considering a larger sample (Epstein and Carlin, 2012). In addition, a better understanding of clinical sites as a learning

environment is needed from the perspective of students, and evidence-based interventions should be developed to foster ethical behaviors in clinical settings (Ohrling and Hallberg, 2000). Conclusions Although nursing students’ clinical misconduct has been informally recognized, to the authors’ knowledge, this study is the first to investigate this important issue in the context of Korea. From 2017, only those students graduating from accredited nursing programs will be allowed to take the national nurse licensure examination in Korea, and therefore substantial efforts have been made to improve the quality of nurse education based on the accreditation criteria set by the Korean Accreditation Board on Nursing (www.kabon.or.kr). Clinical education is one of the most crucial and challenging issues in achieving desirable outcomes. This study’s results reveal some serious constraints in the provision of quality clinical education, which threaten the realization of desirable outcomes and eventually any progress in the nursing profession in Korea. Therefore, nursing faculty and clinical nurses should work together to seriously address nursing students’ clinical misconduct and foster supportive clinical education environments for ethical behaviors. A harmonious partnership between academia and clinical institutions should be achieved to develop reliable and ethical nurses. Although the results are based on data from Korea, they may be applicable to other countries because many nursing schools worldwide are governed independently without being affiliated with clinical institutions and fewer nursing faculty members are directly involved in clinical education. Given a lack of clinical practicum sites, the school and its faculty members may not wish to create some conflicts with the clinical institution by insisting that clinical nurses train nursing students in ethically appropriate nursing behaviors. Nursing students’ vulnerability in clinical settings may render them powerless in judging ethical values and voicing their concerns even when they witness unethical nursing behaviors (Pedersen and Sivonen, 2012). As a result, they can be left without appropriate custodians in clinical education and thus receive few opportunities to learn good nursing practices. If unethical clinical behaviors of nursing students are allowed to continue, then the nursing profession may never fully achieve its academic goals based on high standards, may jeopardize patient safety, and may lose the public’s trust in the profession. Nursing schools have to initiate discussions with clinical nurses and nurse managers such that nursing students can engage in clinical practices reflecting academic integrity. Acknowledgement This research was supported by the Academic Research Fund of Hoseo University in 2012 (2012-0247). References Andrews, K.G., Smith, L.A., Henzi, D., Demps, E., 2007. Faculty and student perceptions of academic integrity at U.S. and Canadian dental schools. J. Dent. Educ. 71 (8), 1027–1039. Billay, D., Myrick, F., 2008. Preceptorship: An integrative review of the literature. Nurse Educ. Pract. 8, 258–266. Diekhoff, G.M., LaBeff, E.E., Clark, R.E., Williams, L.E., Francis, B., Haines, V.J., 1996. College cheating: Ten years later. Res. High. Educ. 37 (4), 487–502. Epstein, I., Carlin, K., 2012. Ethical concerns in the student/preceptor relationship: A need for change. Nurse Educ. Today 32 (8), 897–902. http://dx.doi.org/10.1016/j.nedt. 2012.03.009. Gaberson, K.B., 1997. Academic dishonesty among nursing students. Nurs. Forum 32 (3), 14–20. Ha, B.H., 2009. Wissenschaft der Forschung und Kommunikation und die Ausbildung der Studiumsethik. Ratio Oratio 2 (1), 7–33. Hallin, K., Danielson, E., 2010. Preceptoring nursing students: Registered nurses' perceptions of nursing students' preparation and study approaches in clinical education. Nurse Educ. Today 30, 296–302. Harding, T.S., Carpenter, D.D., Finelli, C.J., Passow, H.J., 2004. Does academic dishonesty relate to unethical behavior in professional practice? An exploratory study. Sci. Eng. Ethics 10 (2), 311–324.

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Please cite this article as: Park, E.-J., et al., Clinical Misconduct Among South Korean Nursing Students, Nurse Educ. Today (2014), http:// dx.doi.org/10.1016/j.nedt.2014.04.006

Clinical misconduct among South Korean nursing students.

This study examines the extent and predictors of unethical clinical behaviors among nursing students in South Korea. From survey data of 345 undergrad...
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