Original Manuscript
Enhancing students’ moral competence in practice: Challenges experienced by Malawian nurse teachers
Nursing Ethics 1–13 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015580811 nej.sagepub.com
Eva Merethe Solum Buskerud and Vestfold University College, Norway
Veronica Mary Maluwa Daeyang Luke Mission Hospital, Malawi
Bodil Tveit Diakonhjemmet University College, Norway
Elisabeth Severinsson Buskerud and Vestfold University College, Norway
Abstract Background: Nurses and student nurses in Malawi often encounter challenges in taking a moral course of action. Several studies have demonstrated a need for increased awareness of ethical issues in the nursing education. Objective: To explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice. Research design: A qualitative hermeneutic approach was employed to interpret the teachers’ experiences. Participants and research context: Individual interviews (N ¼ 8) and a focus group interview with teachers (N ¼ 9) from different nursing colleges were conducted. Ethical considerations: Ethical approval was granted and all participants signed their informed consent. Findings: Two overall themes emerged: (1) authoritarian learning climate, with three subthemes: (a) fear of making critical comments about clinical practice, (b) fear of disclosing mistakes and lack of knowledge and (c) lack of a culture of critical discussion and reflection that promotes moral competence; and (2) discrepancy between expectations on learning outcome from nursing college and the learning opportunities in practice comprising three subthemes: (a) gap between the theory taught in class and learning opportunities in clinical practice, (b) lack of good role models and (c) lack of resources. Discussion: Our findings indicated that showing respect was a central objective when the students were assessed in practice. A number of previous studies have enlightened the need for critical reflection in nursing education. Few studies have linked this to challenges experienced by teachers for development of moral competence in practice. This is one of the first such studies done in an African setting.
Corresponding author: Eva Merethe Solum, Centre for Women’s, Family and Child Health, Department of Nursing Science, Faculty of Health Sciences, Buskerud and Vestfold University College, P.O. Box 235, N-3603 Kongsberg, Norway. Email: [email protected]
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
2
Nursing Ethics
Conclusion: There is a clear relationship between the two themes. A less authoritarian learning climate may enhance critical reflection and discussion between students, teachers and nurses. This can narrow the gap between the theory taught in college and what is demonstrated in clinical practice. Moral competence must be enhanced in order to ensure patients’ rights and safety. Keywords Clinical practice, critical reflection, Malawi, moral competence, nurse teachers, student nurses
Introduction The ethical component of the nursing education programme is of great importance for developing moral competence in student nurses. Most of the procedures and decisions in daily nursing practice have moral dimensions.1–3 A central goal in the education of student nurses is the development of reflective, critical thinking and competence to facilitate a moral course of action.4,5 Student nurses are commonly taught ethics in theory based on the Biomedical Principles of Ethics, professional Codes of Conduct, laws and regulations.6,7 In addition, clinical supervision is essential for developing the students’ professional identity.8 Clinical teaching and supervision are intended to help students relate theory to practice and dilemmas, thus fostering critical thinking, reflective competence and attitudes that will enhance their moral decisionmaking. Jormsri et al.9 described the moral competence as a person’s ability to recognise how his or her feelings influence what is good and bad in particular situations and to reflect on them, in order to make decisions and provide the highest level of benefit for the patient. Moral competence involves ethical knowledge, skills, attitudes, motivation, behaviour and judgement capacity.10–12 Furthermore, self-reflection based on selfcomprehension is a prerequisite for the development of moral competence.13 As these qualities are typically learnt through reflection on real problems experienced in practice, a fruitful and conducive clinical learning environment is essential.3,14 This type of learning must be regarded as a process that continues throughout the entire education programme, where students gradually increase their confidence and ability to critically reflect on their own practice.14–16 Jasper17 holds that reflective practice is a strategy for learning from experience. A reflection process allows students to learn from experience and take new actions from novel perspectives. Reflection is an essential component of professional accountability and quality; thus, it should be mastered by students on completion of professional education programmes. The incorporation of critical and creative thinking enhances innovative attitudes and is necessary for professionals working in a society undergoing rapid change. In order to ensure patient safety, student nurses must understand the necessity of and assume responsibility for lifelong learning.18,19 The need for pedagogical strategies that foster moral practice and caring attitudes has been emphasised in several studies.4,11,20 Nurse teachers aim to use teaching methods that promote student nurses’ moral competence.21,22 In a review by Cannaerts et al.,12 students argued that ethics education should be grounded in actual clinical practice. Identifying nurse teachers’ experience of challenges that enhance moral competence in clinical practice may increase awareness and give rise to a discourse, thus improving practice. As in many other countries, nurses and student nurses in Malawi often encounter problems and challenges in their effort to take a moral course of action in practice. Several studies from Malawi have demonstrated a need for increased awareness of ethical issues in the nursing education.4,23–25 Since the implementation of the Charter on Patients’ and Health Service Providers’ Rights and Responsibility in Malawi,26 expectations on the quality of professional nursing care and access to health services have risen among the Malawian population.25
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
3
In a study by Solum et al.,4 Malawian student nurses revealed ethical problems in clinical practice, including the conflict between patient rights and the guardian’s presence in the hospital, violation of professional values and patient rights due to unethical behaviour on the part of healthcare professionals and, finally, moral distress caused by the conflict between moral awareness and the ideal course of action taught in nursing college. Maluwa et al.24 reported that Malawian nurses often lack ethical skills and knowledge because of the way in which ethics is taught in nursing colleges. A needs assessment conducted at Christian Health Association (CHAM) colleges in Malawi found that lack of resources and the absence of pedagogical and didactic knowledge constitute significant challenges. The assessment revealed an education programme characterised by old-fashioned teaching and learning methods.27 Teachers’ contribution seems to be related more to assessments on formal requirements such as technical procedures than to other aspects of clinical teaching, including ethical reflection. Msiska et al.23 conducted a study in Malawi that explored undergraduate student nurses’ learning environment in practice. The study revealed that the healthcare workers experience stress as a consequence of practising in healthcare settings that lack resources, including a severe staff shortage. The authors hold that the heavy workload often affects nurses in the performance of their duties, leading to burnout and loss of professional pride, which affect student nurses’ learning outcome in practice. In a study from South Africa,20 several obstacles to the facilitation of critical thinking and reflective practice for nursing students were identified. These included the educators’ lack of knowledge and negative attitudes towards new teaching and assessment methods as well as the students’ poor educational background, inadequate socialisation, in addition to cultural and instructional language incompetence. The findings indicated the need for nurse teachers to encourage critical thinking in all aspects of the nursing education. The authors recommend a paradigm shift in the nursing education from the traditional teacher-centred methods to a more learner-centred approach that can facilitate critical and reflective thinking in student nurses. All of the above-mentioned studies demonstrate the need to create strategies in which a caring attitude based on ethical reflection and critical thinking can be learned and cultivated in clinical practice. No studies have been performed in Malawi on the challenges perceived by teachers in their efforts to enhance moral competence among student nurses.
Aim The aim of this study was to explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice.
Methods A qualitative hermeneutic approach inspired by the philosophy of Gadamer28 was employed to explore and interpret the teachers’ lived experiences. Hermeneutics enables a participatory dialogue and intersubjectivity between the researcher and informants, allowing the researchers an opportunity to clarify and confirm the contextual information provided during the interviews in the light of their preconceptions. According to Gadamer,28 pre-understanding is necessary but has to be questioned in order to open up for new understanding. The researchers attempted to create an open attitude to the informants’ life world in order to develop a new understanding of the challenges involved in enhancing students’ moral competence in clinical practice.
Participants and setting A purposive sampling technique was used to recruit the study participants.29 Individual interviews with nurse teachers (N ¼ 8) took place in four different nursing colleges in north, central and south Malawi
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
4
Nursing Ethics
in spring 2009. The participants were recruited at the colleges where they were employed. Their teaching experience varied from 1 to 6 years (mean ¼ 2.5 years). A focus group interview with nurse teachers (N ¼ 9) from eight nursing colleges in north, central and south Malawi was conducted in conjunction with a workshop held in autumn 2011. The teaching experience of the focus group participants varied from 2 to 7 years (mean ¼ 3.6 years). The inclusion criteria were Malawians with at least 1 year of teaching experience. All the participants were asked to participate in the study after receiving oral and written information.
Data collection The interviews, as well as all written and oral information, were in English, the official language used in the nursing education in Malawi. In the individual interviews, a semi-structured interview guide was employed. The 45- to 60-min individual interviews (N ¼ 8) conducted at the participants’ colleges were audio taped. First, the teachers were asked to provide examples of ethical challenges experienced by students during their clinical placement. The second question concerned how the students were prepared theoretically and facilitated in clinical practice to achieve reflective and moral competence. The first two questions served as an introduction to set the agenda for the main topic, namely, the challenges they experienced in their efforts to enhance students’ moral competence.30 The interviews took the form of a dialogue, and probing questions were employed to deepen the meaning of the situation described by the teachers.30 Three interviews were conducted jointly by the first author (E.M.S.) and second author (V.M.M.), who has many years of experience as a nurse and teacher in Malawi. This enabled them to gain a shared understanding of the data collection process. V.M.M. performed two interviews independently, and the final three interviews were carried out by E.M.S., who has experience of teaching human rights, ethics and gender in several nursing colleges in Malawi. A focus group interview was conducted to obtain more information and validate the data from the individual interviews. The interaction between the focus group members contributed to a deeper understanding of the phenomenon as it clarified the participants’ views, experiences and perspectives in a way that is not possible in individual interviews.31 E.M.S. acted as moderator and the third author (B.T.) as observer. At the start of the interview, the moderator introduced the two main topics to be discussed: the ethical challenges most frequently faced by students in clinical practice and those experienced by the teachers in their efforts to enhance moral competence. The interview lasted for 75 min. B.T. took notes and ensured that all members of the group participated in the discussion and contributed with their experiences and views. The notes were discussed immediately after the interviews, all of which were transcribed verbatim.
Ethical considerations Approval was granted by the National Health Sciences Research Committee in Malawi (NHSRC2008 no. 4/36c). The participants took part voluntarily after they had received written and oral information about the purpose of the study. They signed their informed consent having been made aware of our intention to audio tape the interviews, treat data confidentially and remove their names from the transcripts, as well as of their right to withdraw at any time.
Analysis The data were analysed by means of qualitative interpretative content analysis.32 We aimed to provide a true account of the teachers’ expressed meanings about their experiences. First, the authors read the transcribed text of the individual interviews and the focus group interview on several occasions to gain a general impression of the content.28,33 During the reading, questions were posed to the text that started a back-and-forth
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
5
movement between the whole and the parts.28,34 The final step comprised structuring the textual data into main themes, subthemes and meaning units.32
Findings Two overall themes emerged from the data: (1) authoritarian learning climate and (2) discrepancy between expectations on learning outcome from nursing college and the learning opportunities in practice. Table 1. Examples of challenges experienced by nurse teachers in their efforts to enhance students’ moral competence in clinical practice. Themes
Subthemes
Example of statements
Authoritarian learning climate
Fear of making critical comments Quotation 1: A student at our college reported to the about clinical practice teacher that a certain nurse did not treat students and patients in a respectful manner. When the hospital staff was informed, the reaction was: ‘We don’t want these students; they come here to learn and not to be faultfinders’ Fear of disclosing mistakes and Quotation 2: When a nurse does something wrong, lack of knowledge e.g. administers the wrong drug and the patient dies . . . or loses both mother and baby, the other nurses and students usually cover up for her, so that she does not lose her license or her job Quotation 3: The students do not come to the Lack of a culture of critical teachers because of the social distance between discussion and reflection that them. It means that we are not empowering them promotes moral competence
Gap between the theory taught in Quotation 4: There is an ethical dimension in the Discrepancy between relationship between the student and patient when class and learning expectations on learning students try to implement the ideal/what was opportunities in clinical outcome from college taught in class. They say to the patient: because you practice and the learning are suffering from this, we are going to implement opportunities in practice 1-2-3. When the nurse says: ‘No, you can’t do that’, the students are obliged to refrain from doing something they know is right Lack of good role models Quotation 5: Ethics is about professionalism, time management, punctuality and proper documentation. I think some (not all) of the qualified nurses do not adhere to these professional principles. They are not punctual, take too long lunch breaks and are unprofessional in their encounters with patients and our students copy them Lack of resources Quotation 6: Sometimes the financial situation of the college is so bad that teachers are unable to supervise students in clinical practice. Our aim is that the students should be able to implement in practice what we teach them in class. The students imitate what they see and by the time we meet them in clinical practice it’s often too late, as they have already internalised short cuts and negative attitudes.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
6
Nursing Ethics
Theme 1: authoritarian learning climate This theme was derived from the following subthemes: (1) fear of making critical comments about clinical practice, (2) fear of admitting mistakes and lack of knowledge and (3) lack of a culture of critical discussion and reflection that promotes moral competence. Subtheme 1: fear of making critical comments about clinical practice. Many of the teachers reported that students were often afraid of being punished or expelled from nursing college. They experienced that the students were hesitant about coming forward with their own views, especially when it concerned critical remarks about how patients were treated (quotation 1 in Table 1). One informant gave an example of what can happen when a student makes critical comments about certain caring attitudes that she observes: It may create a very bad relationship with the nurse. The relationship will be unfriendly and the student will not receive assistance. The teacher will ask the nurse about her observation of the student, so the student knows that by the end of the day there will be no future for her there and she will definitely fail.
The informants provided several examples of students’ fear of being punished or expelled. The following quotation illustrates what many of the teachers considered important when assessing the students’ moral competence: We have attitude objectives. The students have to show respect for the patients, their fellow students and the staff nurse. They are evaluated according to how they show respect.
The attitude objectives given by college are guiding the students’ learning outcomes, but they are often in sharp contrast to students’ experiences of bad role models such as shouting at the patient and taking short cuts in patient care. Subtheme 2: fear of disclosing mistakes and lack of knowledge. According to the teachers, nurses sometimes cover up for each other and this practice is copied by the students. It is likely to lead to moral distress, as both nurses and students know that telling the truth is the right thing to do (quotation 2 in Table 1). The fear of admitting a lack of knowledge and making mistakes can also influence nurses’ and hence students’ willingness to care for certain patients: They (students and nurses) prefer caring for a patient who is uneducated. If they make a mistake they don’t care, because they are not going to be asked about it.
These quotations demonstrate the students’ and nurses’ fear of making a mistake. If students and nurses do not feel competent and safe in their profession, they might try to avoid situations where their knowledge and judgement can be questioned. Subtheme 3: lack of a culture of critical discussion and reflection that promotes moral competence. According to the teachers, the students were rarely willing to discuss ethical problems encountered in practice: In my experience students do not take contact with the teacher because of the relationship between them. I see that the gap between them is too wide. So if something happens to the students in clinical practice they say nothing.
The teachers assumed that the students discuss ethical problems among themselves instead with the teachers and nurses responsible for their education. In our study, the teachers reflected on how the social
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
7
distance between themselves and their students as well as the focus on procedures in practice, rules, norms and regulations might constitute a barrier to the students’ empowerment (quotation 3 in Table 1). Some of the informants stated that students were encouraged to reflect on practice when they returned to college after their clinical placement. However, others reported that reflection often focused on challenges related to practical procedures more than ethical and moral issues: We probably reflect on moral practice without realizing it. When we call our students back at the end of the week to ask about their clinical placement and what problems they encountered, we are not aware of the fact that we are also reflecting on ethics.
Furthermore, the members of the focus group stated that reflective methods were not used in their teaching neither in college nor in the practical setting. However, they were of the opinion that students learnt critical thinking through decision-making in the nursing process: Decision making gives them the chance to think critically. So I believe they have enough information to be critical thinkers.
Theme 2: discrepancy between expectations on learning outcome from college and the learning opportunities in practice This theme is based on the following subthemes: (1) gap between the theory taught in class and learning opportunities in clinical practice, (2) lack of good role models and (3) lack of resources. Subtheme 1: gap between the theory taught in class and learning opportunities in clinical practice. The teachers were concerned about how the process of learning a moral stance was handled in clinical practice. The students were told the right thing to do, but reflection on and critical thinking about moral decision-making were not emphasised in practice. The teachers took it for granted that the students were aware of the objectives to be achieved in practice: When the students go to the clinic they are given objectives, we point out to them what they should achieve. They have to judge and make moral decisions in clinical practice based on the theoretical principles we teach them in ethics.
The students may experience moral distress and difficulties in achieving objectives related to patient safety, respect and dignity when there is a conflict between what they have learnt in theory and what is common in practice, as mentioned by one teacher (quotation 4 in Table 1). Some teachers also expressed concern about nurses feeling inferior when it comes to instruction and supervision of students in clinical practice: I strongly believe that the nurses in the hospital consider themselves inferior and might say: ‘The teachers are better educated and know more about these issues, they should be the ones to tell you what to do’. Such an unfriendly relationship will affect the students.
Several informants were dissatisfied about the lack of priority given to ethical and moral aspects in both theory and practice: We emphasize just a few ethical issues, for example respect and confidentiality. But there are other ethical issues that should be taught in all courses.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
8
Nursing Ethics
This illustrates the concern that ethics is taught in one theoretical course but not followed up throughout the whole education in order to ensure that students become more experienced and ethically conscious in clinical practice. Subtheme 2: lack of good role models. Nurses are supposed to supervise and guide students to ensure moral competence and actions. They serve as important role models for the students when it comes to dealing with ethical problems that arise in a busy hospital environment. The teachers expressed concern about the way some nurses acted in their role model position (quotation 5 in Table 1). According to the teachers, students tend to copy bad practice that they observe from the nurses in the clinic: Sometimes the students just imitate the clinical staff. One example is that the patient has the right to information, but the nurse administers treatment without informing the patient.
Although students sometimes manage to practice what they learnt in theory despite the lack of good role models, some of the teachers were worried about what will happen after their graduation: When they are students, they behave like students. However, the moment they graduate they might start shouting at the patient as well.
One informant commented on the importance of supervision and reflection on moral practice in clinical training and that teachers should be available in practice for the student: It is important for teachers to demonstrate respect for the patient. You cannot only teach about attitudes. They must be learnt from good role models.
Subtheme 3: lack of resources. In both the focus group and the individual interviews, many of the teachers stressed lack of resources as a major challenge for the enhancement of reflective and moral competence. Lack of resources tends to widen the gap between what is taught in college and what is demonstrated in clinical practice: Some nurses are willing to teach, but because of the shortage of nurses there may be only one nurse on the ward and then it is difficult for this nurse to teach the students.
Quite a few teachers expressed concern about the lack of follow-up in clinical placements: The students are not followed up in practice and we don’t see how things are done. We just go to the clinical placement at a specific time to grade the students. It is really difficult and I don’t know what we are going to do about it.
Another quotation reveals that the financial situation of the college also leads to constraints in terms of how often teachers can follow up students in practice (quotation 6 in Table 1). In addition, the teachers referred to the lack of equipment that the students encounter in practice, which affects the quality of nursing care: In situations where there is a lack of equipment in the clinical area, the students may be forced to work without protective wear such as gloves and aprons. That is a problem because they are supposed to be protected.
This situation leads to ethical dilemmas, where critical thinking and moral competence have to be well developed in order to decide on a moral course of action.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
9
Discussion The aim of this study was to explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice. The results indicate a number of challenges related to an authoritarian learning climate as well as to the discrepancy between expectations on learning outcome from nursing college and learning opportunities in clinical practice. An authoritarian learning climate can lead to fear, thus constituting a barrier to critical thinking and reflection, which is crucial for the development of moral competence. The teachers reported that students can sometimes be prevented from discussing and reflecting on practice due to the social distance between them. In a recent study from Malawi, student nurses reported that teachers often interact with them in an autocratic and intimidating manner, making them uncertain and stressed in practice.35 Arries36 and Mangena and Chabeli20 hold that African students are socialised to respect authority, which means that they rarely challenge opinions or decisions. The teachers and nurses have been fostered in the same cultural tradition, which may explain why they fail to encourage students to critically reflect in and on practice. Arries36 presented several important factors perceived by student nurses to be conducive to a learning climate: Nurses and teachers should communicate respectfully, listen attentively to the students’ learning concerns, consider their viewpoints and give plausible explanations for common practice. Student nurses come to the ward for clinical practice with ‘fresh eyes’ and often detect procedures and practices that are immoral. Erdil and Korkmaz37 and Solum et al.4 claim that students recognise unsatisfactory practice and are aware of the need to improve it. According to Neville,2 students perceived several barriers to improving such practice, including fear of not being supported. In our findings, the teachers reported that the students were afraid of being negatively evaluated and considered faultfinders. On one hand, there is a risk that students will lose their self-confidence, adjust to and copy immoral practice. On the other hand, it is important that students are aware of differences in the culture and organisation of local hospital wards. They should respect existing practice, but this can only happen if they are encouraged to critically reflect on it and are invited to discuss how ethical problems can be solved in the best possible way. Ethical problems are characterised by value conflicts, leading to confusion and uncertainty about the knowledge needed for decision-making.38 Being valued as both a learner and a person is important for the empowerment of student nurses in clinical practice.39 Critical reflection is crucial because it enables the students to analyse, synthesise and evaluate their experiences.40 Students should be valued as an important resource for ensuring moral practice, patient safety and rights. Our findings indicated that showing respect was a central objective when the students were assessed in practice. Both the teachers and the nurses can use their power to prevent constructive criticism. In their review article, Epstein and Carlin41 described students’ perceptions of ethical problems in their relationships with preceptors. The students in their study experienced many unethical situations involving preceptors, to which their most common response was silence caused by fear of retribution. As students lack experience and self-confidence due to the absence of encouragement and a learning climate that enables valuable discussions, they can consider silence as the safest response. In this study, the teachers reported that the students seldom discussed ethical problems with them. If the need to show respect in practice excludes the possibility for student nurses to reflect on and express criticism of existing practice, there is a risk that it could hamper their learning of moral competence. The informants stated that the students’ learning climate is permeated by a fear of admitting mistakes in nursing practice. This is linked to the first subtheme, because the students’ fear of coming forward with their concerns also leads to a fear of admitting mistakes. Practice that covers up nurses’ mistakes is the opposite of a learning environment where staff and students can openly reflect on and learn from errors.17 This is a serious ethical problem, as it jeopardises professional conduct as well as patient rights and safety.4,37 Harrison et al.42 found that a common reason for not disclosing incidents is fear of punishment
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
10
Nursing Ethics
and unfair treatment from management. It is reasonable to assume that in a hierarchical hospital system, student nurses consider themselves even more vulnerable than nurses in terms of unfair treatment. If nurses and students lack knowledge and are afraid of the consequences of doing something wrong, they fear losing face, trust and respect.20,42 In our study, students were exposed to practice where nurses could avoid caring for educated patients to prevent their knowledge and judgement being questioned. This not only affects the care of patients with a high social and educational status but also illustrates the risk to the most vulnerable and illiterate patients.4 Rights, rules and regulations do not provide a straightforward answer to ethical questions and alone can never serve as a guarantee of moral actions.43 There is a need for nursing colleges, hospital wards and managers to ensure a supportive environment for students and nurses that encourages openness and critical reflection.42 Our findings indicate a discrepancy between expectations on learning outcome from college and the learning opportunities in practice. The teachers were aware of the gap between the theory learned in college and the ethical situations the students experienced in clinical practice. In our study, the college teachers seemed to partly relate this discrepancy to the ward nurses’ lack of knowledge and feeling of inferiority, which made them unwilling to supervise students. Many nurse facilitators on the ward lacked ethical knowledge and critical thinking skills as it was not focused on in their education.24 Taniyama et al.44 argued that some clinical educators lack confidence in terms of teaching because their educational background differs from that of the students and faculty members, who have more advanced and updated theoretical knowledge. This leads to a tendency to avoid an exchange of opinions between staff in clinical practice and nursing college teachers, thus preserving a hierarchical and suppressive learning climate. In our findings, the dialogue between the teachers highlighted the fact that nurses are important role models for students. However, everyday practice in busy hospital departments is challenging for nurses. Several studies have revealed students’ and patients’ experiences of nurses who demonstrate unprofessional attitudes and moral misconduct in student–nurse or patient–nurse encounters.3,4,23,37,45 This corresponds with our findings, indicating learning problems due to the attitude of nurses, such as shouting at patients and students, arriving late for work, leaving work early or sleeping during the night shift. It is important that teachers encourage students to critically reflect on what they experience in order to prevent them from copying the misconduct.20 The teachers reported lack of resources in practice such as qualified nurses, equipment and financial support, which are crucial for student learning. Msiska et al.23 hold that healthcare workers in Malawi encounter stressful emotions as a consequence of resource-poor healthcare settings, including a severe shortage of nurses. The increased workload frequently affects the performance of nurses, causing loss of professional pride and burnout.45 In such situations, nurses often have to give priority to patient care at the expense of student teaching. Furthermore, moral distress leads to a loss of compassion in care, affecting the learning climate for students,24,45 thus increasing the gap between the theory of ethics taught in college and learning opportunities for moral competence in practice. In our study, the teachers also stated that they were unable to teach and follow up students in practice due to lack of resources. When students experience short cuts, negative attitudes and misconduct towards the patient in practice, it can cause them moral distress as they know the difference between right and wrong from their knowledge of theory. The teachers are concerned that students will internalise the inferior practice they experience. For example, when ethical dilemmas occur due to lack of equipment and human resources on the wards, moral competence is crucial for ensuring the best possible moral course of action.20 The understanding of moral competence can be interpreted both as a structural phenomenon grounded in a context with an authoritarian learning climate and as a process phenomenon grounded in a discrepancy between learning and outcome expectations in nursing colleges and learning possibilities in clinical practice. We regard this as an expansion of the understanding of moral competence that provides a unique and contextual Malawian perspective. Our study demonstrates that an authoritarian learning climate and a discrepancy between expectations on learning outcomes from nursing colleges and learning opportunities in
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
11
practice hamper students’ development of moral competence. The two themes that emerged in this study are associated with a poor learning climate that tends to be reproduced if unchallenged.17 However, if the nurse teachers are able to challenge the existing structures ensuring a better understanding of moral competence through involving the students in critical reflection in cooperation with nurses in clinical practice, it may contribute to a better learning climate. Such cooperation may enhance the development of moral competence involving ethical knowledge, skills, behaviour, attitudes, motivation and judgement capacity.
Trustworthiness and limitations We attempted to ensure trustworthiness in all phases of the research process. The majority of the authors have personal experience of teaching at nursing colleges in Malawi and three of them have previously published an article on students’ experiences of ethical problems perceived in practice, which constituted the background for this study.4 By conducting interviews jointly with V.M.M., who has long experience as a clinical nurse, teacher and hospital matron in Malawi, we attempted to gain a mutual understanding of the data collection process and the interpretation of the data in a Malawian context. The data were analysed by means of qualitative interpretative content analysis.32 In order to establish credibility, the authors read the interview texts on several occasions. First, the authors read all the interviews several times to gain a general impression of the content. In the analysis process, we aimed to be true to the phenomenon under study and give priority to the life world of the informants.30 In order to strengthen dependability, we conducted independent analyses and ensured conformability by reaching consensus on the meaning contained in the interviews when structuring the transcribed data into meaning units, subthemes and themes.32,46,47 In order to achieve transferability, we provided a clear description of the selection of informants and the context of the study. The informants had long experience and were recruited from nursing colleges spread all over Malawi. Furthermore, similar issues and challenges occurred in both the individual interviews and the focus group interview.32 The main limitation is the number of informants, which could have been larger. The study can serve as a basis and inspiration for further systematic studies and development of moral competence in nursing education in Malawi.46
Conclusion There is a clear relationship between the two main themes. A less authoritarian attitude may enhance critical reflection and discussion between students, nursing college teachers and nurses in clinical practice, as it has the potential to reduce the gap between theory and practice. Learning moral competence must be regarded as a process that continues throughout the education programme, where students gradually increase their confidence and ability to critically reflect on their own practice. Critical reflection will lead to a better understanding of how existing nursing practice can be improved in a crowded, understaffed hospital ward. Nursing college teachers and hospital nurses should cooperate to create a learning climate that enhances critical reflection among student nurses to ensure moral competence, thus protecting patients’ rights and safety. Future research should explore the challenges faced by nurses who teach and supervise students during their clinical placement. Acknowledgements Our sincere gratitude is expressed to all the informants who took part in the study, to the support from the Centre for Women’s, Family & Child Health, Buskerud and Vestfold University College and to Monique Federsel and Gullvi Nilsson for reviewing the English language.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
12
Nursing Ethics
Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1. Benner P. Educating nurses: a call for radical transformation. San Francisco, CA: Jossey-Bass, 2010. 2. Neville L. Moral difficulties in nursing practice: reflections on the practice of a nurse teacher. Nurse Educ Pract 2004; 4: 128–134. 3. Rees CE, Monrouxe LV and McDonald LA. ‘My mentor kicked a dying woman’s bed’. Analysing UK nursing students’ ‘most memorable’ professionalism dilemmas. J Adv Nurs 2015; 71: 169–180. 4. Solum EM, Maluwa VM and Severinsson E. Ethical problems in practice as experienced by Malawian student nurses. Nurs Ethics 2012; 19: 128–138. 5. Rosser M, Mooney GP and Jasper M. Professional development, reflection and decision-making in nursing and healthcare. 2nd ed. Chichester: Wiley-Blackwell, 2013. 6. Beauchamp TL and Childress JF. Principles of biomedical ethics. Oxford: Oxford University Press, 2009. 7. Monteverde S. Undergraduate healthcare ethics education, moral resilience, and the role of ethical theories. Nurs Ethics 2013; 21: 385–401. ˚ . Evaluation of the clinical supervision and professional development of student nurses. 8. Severinsson E and Sand A J Nurs Manag 2010; 18: 669–677. 9. Jormsri P, Kunaviktikul W, Ketefian S, et al. Moral competence in nursing practice. Nurs Ethics 2005; 12: 582–594. 10. Rzymska I, Rzymski P, Wilczak M, et al. The influence of passive and active moral training on medical university on changes of students’ moral competence index – results from randomized single blinded trial. Ann Agric Environ Med 2014; 21: 161–166. 11. Lindh I-B, Severinsson E and Berg A. Exploring student nurses’ reflections on moral responsibility in practice. Reflect Pract 2008; 9: 437–948. 12. Cannaerts N, Gastmans C and de Casterle´ BD. Contribution of ethics education to the ethical competence of nursing students: educators’ and students’ perceptions. Nurs Ethics 2014; 21: 861–878. 13. Buzgova R and Sikorova L. Moral judgment competence of nursing students in the Czech Republic. Nurse Educ Today 2013; 33: 1201–1206. 14. Vanlaere L and Gastmans C. Ethics in nursing education: learning to reflect on care practices. Nurs Ethics 2007; 14: 758–766. 15. Benner P. From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley, 1984. 16. Auvinen J, Suominen T, Leino-Kilpi H, et al. The development of moral judgment during nursing education in Finland. Nurse Educ Today 2004; 24: 538–546. 17. Jasper M. Beginning reflective practice. Cheltenham: Nelson Thornes, 2003. 18. Chabeli MM. Higher order thinking skills competencies required by outcomes-based education from learners. Curationis 2006; 29: 78–86. 19. Fero LJ, Witsberger CM, Wesmiller SW, et al. Critical thinking ability of new graduate and experienced nurses. J Adv Nurs 2009; 65: 139–148. 20. Mangena A and Chabeli MM. Strategies to overcome obstacles in the facilitation of critical thinking in nursing education. Nurse Educ Today 2005; 25: 291–298.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
13
21. Berggren I and Severinsson E. The influence of clinical supervision on nurses’ moral decision making. Nurs Ethics 2000; 7: 124–133. 22. Chabeli MM. Nurse teachers’ perceptions of OSCE as a clinical evaluation method. Curationis 2001; 24: 84–92. 23. Msiska G, Smith P and Fawcett T. Emotive responses to ethical challenges in caring: a Malawian perspective. Nurs Ethics 2013; 21: 97–107. 24. Maluwa VM, Andre J, Ndebele P, et al. Moral distress in nursing practice in Malawi. Nurs Ethics 2012; 19: 196–207. 25. Muula AS. Will health rights solve Malawi’s health problems? Croat Med J 2005; 46: 853–859. 26. Ministry of Health. Charter on patients’ and health service providers’ right and responsibilities. Lilongwe: Ministry of Health, 2004. 27. Tveit B, Wasili R, Kollstrøm ML, et al. Curriculum implementation in CHAM/NMT colleges in Malawi. Lilongwe: CHAM/Improved Health Training Program, 2009. 28. Gadamer H-G. Truth and method. 2nd rev. ed. London: Continuum, 2004. 29. Dahlgren L, Emmelin M and Winkvist A. Qualitative methodology for international public health. Ume˚a: Ume˚a International School of Public Health, 2007. 30. Kvale S and Brinkmann S. Interviews: learning the craft of qualitative research interviewing. Los Angeles, CA: Sage, 2009. 31. Liamputtong P. Focus group methodology: principles and practice. London: Sage, 2011. 32. Graneheim UH and Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24: 105–112. 33. Dahlberg K, Dahlberg H and Nystro¨m M. Reflective lifeworld research. Lund: Studentlitteratur, 2008. 34. Lindh I-B. Moral responsibility in the light of nursing practice: a hermeneutic approach to inquiry. Stavanger: Department of Health Studies, Faculty of Social Sciences, University of Stavanger, 2010. 35. Msiska G, Smith P and Fawcett T. The ‘lifeworld’ of Malawian undergraduate student nurses: the challenge of learning in resource poor clinical settings. Int J Africa Nurs Sci 2014; 1: 35–42. 36. Arries EJ. Interactional justice in student-staff nurse encounters. Nurs Ethics 2009; 16: 147–160. 37. Erdil F and Korkmaz F. Ethical problems observed by student nurses. Nurs Ethics 2009; 16: 589–598. ˚ 38. Kalkas H and Sarvimaki A. Omvardnadens etiska grunder (In Swedish) [Ethical base in nursing care]. Stockholm: Almquist & Wiksell, 1987. 39. Bradbury-Jones C, Sambrook S and Irvine F. Empowerment and being valued: a phenomenological study of nursing students’ experiences of clinical practice. Nurse Educ Today 2011; 31: 368–372. 40. Morolong BG and Chabeli MM. Competence of newly qualified registered nurses from a nursing college. Curationis 2005; 28: 38–50. 41. Epstein I and Carlin K. Ethical concerns in the student/preceptor relationship: a need for change. Nurse Educ Today 2012; 32: 897–902. 42. Harrison R, Birks Y, Hall J, et al. The contribution of nurses to incident disclosure: a narrative review. Int J Nurs Stud 2014; 51: 334–345. 43. Botes A. An integrated approach to ethical decision-making in the health team. J Adv Nurs 2000; 32: 1076–1082. 44. Taniyama M, Kai I and Takahashi M. Differences and commonalities in difficulties faced by clinical nursing educators and faculty in Japan: a qualitative cross-sectional study. BMC Nurs 2012; 11: Article 21. 45. Jewkes R, Abrahams N and Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services. Soc Sci Med 1998; 47: 1781–1795. 46. Elo S, Ka¨a¨ria¨inen M, Kanste O, et al. Qualitative content analysis: a focus on trustworthiness. SAGE Open 2014; 4: 1–10. DOI: 10.1177/2158244014522633. 47. Whittemore R, Chase SK and Mandle CL. Validity in qualitative research. Qual Health Res 2001; 11: 522–537.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Enhancing students’ moral competence in practice: Challenges experienced by Malawian nurse teachers
Nursing Ethics 1–13 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015580811 nej.sagepub.com
Eva Merethe Solum Buskerud and Vestfold University College, Norway
Veronica Mary Maluwa Daeyang Luke Mission Hospital, Malawi
Bodil Tveit Diakonhjemmet University College, Norway
Elisabeth Severinsson Buskerud and Vestfold University College, Norway
Abstract Background: Nurses and student nurses in Malawi often encounter challenges in taking a moral course of action. Several studies have demonstrated a need for increased awareness of ethical issues in the nursing education. Objective: To explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice. Research design: A qualitative hermeneutic approach was employed to interpret the teachers’ experiences. Participants and research context: Individual interviews (N ¼ 8) and a focus group interview with teachers (N ¼ 9) from different nursing colleges were conducted. Ethical considerations: Ethical approval was granted and all participants signed their informed consent. Findings: Two overall themes emerged: (1) authoritarian learning climate, with three subthemes: (a) fear of making critical comments about clinical practice, (b) fear of disclosing mistakes and lack of knowledge and (c) lack of a culture of critical discussion and reflection that promotes moral competence; and (2) discrepancy between expectations on learning outcome from nursing college and the learning opportunities in practice comprising three subthemes: (a) gap between the theory taught in class and learning opportunities in clinical practice, (b) lack of good role models and (c) lack of resources. Discussion: Our findings indicated that showing respect was a central objective when the students were assessed in practice. A number of previous studies have enlightened the need for critical reflection in nursing education. Few studies have linked this to challenges experienced by teachers for development of moral competence in practice. This is one of the first such studies done in an African setting.
Corresponding author: Eva Merethe Solum, Centre for Women’s, Family and Child Health, Department of Nursing Science, Faculty of Health Sciences, Buskerud and Vestfold University College, P.O. Box 235, N-3603 Kongsberg, Norway. Email: [email protected]
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
2
Nursing Ethics
Conclusion: There is a clear relationship between the two themes. A less authoritarian learning climate may enhance critical reflection and discussion between students, teachers and nurses. This can narrow the gap between the theory taught in college and what is demonstrated in clinical practice. Moral competence must be enhanced in order to ensure patients’ rights and safety. Keywords Clinical practice, critical reflection, Malawi, moral competence, nurse teachers, student nurses
Introduction The ethical component of the nursing education programme is of great importance for developing moral competence in student nurses. Most of the procedures and decisions in daily nursing practice have moral dimensions.1–3 A central goal in the education of student nurses is the development of reflective, critical thinking and competence to facilitate a moral course of action.4,5 Student nurses are commonly taught ethics in theory based on the Biomedical Principles of Ethics, professional Codes of Conduct, laws and regulations.6,7 In addition, clinical supervision is essential for developing the students’ professional identity.8 Clinical teaching and supervision are intended to help students relate theory to practice and dilemmas, thus fostering critical thinking, reflective competence and attitudes that will enhance their moral decisionmaking. Jormsri et al.9 described the moral competence as a person’s ability to recognise how his or her feelings influence what is good and bad in particular situations and to reflect on them, in order to make decisions and provide the highest level of benefit for the patient. Moral competence involves ethical knowledge, skills, attitudes, motivation, behaviour and judgement capacity.10–12 Furthermore, self-reflection based on selfcomprehension is a prerequisite for the development of moral competence.13 As these qualities are typically learnt through reflection on real problems experienced in practice, a fruitful and conducive clinical learning environment is essential.3,14 This type of learning must be regarded as a process that continues throughout the entire education programme, where students gradually increase their confidence and ability to critically reflect on their own practice.14–16 Jasper17 holds that reflective practice is a strategy for learning from experience. A reflection process allows students to learn from experience and take new actions from novel perspectives. Reflection is an essential component of professional accountability and quality; thus, it should be mastered by students on completion of professional education programmes. The incorporation of critical and creative thinking enhances innovative attitudes and is necessary for professionals working in a society undergoing rapid change. In order to ensure patient safety, student nurses must understand the necessity of and assume responsibility for lifelong learning.18,19 The need for pedagogical strategies that foster moral practice and caring attitudes has been emphasised in several studies.4,11,20 Nurse teachers aim to use teaching methods that promote student nurses’ moral competence.21,22 In a review by Cannaerts et al.,12 students argued that ethics education should be grounded in actual clinical practice. Identifying nurse teachers’ experience of challenges that enhance moral competence in clinical practice may increase awareness and give rise to a discourse, thus improving practice. As in many other countries, nurses and student nurses in Malawi often encounter problems and challenges in their effort to take a moral course of action in practice. Several studies from Malawi have demonstrated a need for increased awareness of ethical issues in the nursing education.4,23–25 Since the implementation of the Charter on Patients’ and Health Service Providers’ Rights and Responsibility in Malawi,26 expectations on the quality of professional nursing care and access to health services have risen among the Malawian population.25
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
3
In a study by Solum et al.,4 Malawian student nurses revealed ethical problems in clinical practice, including the conflict between patient rights and the guardian’s presence in the hospital, violation of professional values and patient rights due to unethical behaviour on the part of healthcare professionals and, finally, moral distress caused by the conflict between moral awareness and the ideal course of action taught in nursing college. Maluwa et al.24 reported that Malawian nurses often lack ethical skills and knowledge because of the way in which ethics is taught in nursing colleges. A needs assessment conducted at Christian Health Association (CHAM) colleges in Malawi found that lack of resources and the absence of pedagogical and didactic knowledge constitute significant challenges. The assessment revealed an education programme characterised by old-fashioned teaching and learning methods.27 Teachers’ contribution seems to be related more to assessments on formal requirements such as technical procedures than to other aspects of clinical teaching, including ethical reflection. Msiska et al.23 conducted a study in Malawi that explored undergraduate student nurses’ learning environment in practice. The study revealed that the healthcare workers experience stress as a consequence of practising in healthcare settings that lack resources, including a severe staff shortage. The authors hold that the heavy workload often affects nurses in the performance of their duties, leading to burnout and loss of professional pride, which affect student nurses’ learning outcome in practice. In a study from South Africa,20 several obstacles to the facilitation of critical thinking and reflective practice for nursing students were identified. These included the educators’ lack of knowledge and negative attitudes towards new teaching and assessment methods as well as the students’ poor educational background, inadequate socialisation, in addition to cultural and instructional language incompetence. The findings indicated the need for nurse teachers to encourage critical thinking in all aspects of the nursing education. The authors recommend a paradigm shift in the nursing education from the traditional teacher-centred methods to a more learner-centred approach that can facilitate critical and reflective thinking in student nurses. All of the above-mentioned studies demonstrate the need to create strategies in which a caring attitude based on ethical reflection and critical thinking can be learned and cultivated in clinical practice. No studies have been performed in Malawi on the challenges perceived by teachers in their efforts to enhance moral competence among student nurses.
Aim The aim of this study was to explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice.
Methods A qualitative hermeneutic approach inspired by the philosophy of Gadamer28 was employed to explore and interpret the teachers’ lived experiences. Hermeneutics enables a participatory dialogue and intersubjectivity between the researcher and informants, allowing the researchers an opportunity to clarify and confirm the contextual information provided during the interviews in the light of their preconceptions. According to Gadamer,28 pre-understanding is necessary but has to be questioned in order to open up for new understanding. The researchers attempted to create an open attitude to the informants’ life world in order to develop a new understanding of the challenges involved in enhancing students’ moral competence in clinical practice.
Participants and setting A purposive sampling technique was used to recruit the study participants.29 Individual interviews with nurse teachers (N ¼ 8) took place in four different nursing colleges in north, central and south Malawi
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
4
Nursing Ethics
in spring 2009. The participants were recruited at the colleges where they were employed. Their teaching experience varied from 1 to 6 years (mean ¼ 2.5 years). A focus group interview with nurse teachers (N ¼ 9) from eight nursing colleges in north, central and south Malawi was conducted in conjunction with a workshop held in autumn 2011. The teaching experience of the focus group participants varied from 2 to 7 years (mean ¼ 3.6 years). The inclusion criteria were Malawians with at least 1 year of teaching experience. All the participants were asked to participate in the study after receiving oral and written information.
Data collection The interviews, as well as all written and oral information, were in English, the official language used in the nursing education in Malawi. In the individual interviews, a semi-structured interview guide was employed. The 45- to 60-min individual interviews (N ¼ 8) conducted at the participants’ colleges were audio taped. First, the teachers were asked to provide examples of ethical challenges experienced by students during their clinical placement. The second question concerned how the students were prepared theoretically and facilitated in clinical practice to achieve reflective and moral competence. The first two questions served as an introduction to set the agenda for the main topic, namely, the challenges they experienced in their efforts to enhance students’ moral competence.30 The interviews took the form of a dialogue, and probing questions were employed to deepen the meaning of the situation described by the teachers.30 Three interviews were conducted jointly by the first author (E.M.S.) and second author (V.M.M.), who has many years of experience as a nurse and teacher in Malawi. This enabled them to gain a shared understanding of the data collection process. V.M.M. performed two interviews independently, and the final three interviews were carried out by E.M.S., who has experience of teaching human rights, ethics and gender in several nursing colleges in Malawi. A focus group interview was conducted to obtain more information and validate the data from the individual interviews. The interaction between the focus group members contributed to a deeper understanding of the phenomenon as it clarified the participants’ views, experiences and perspectives in a way that is not possible in individual interviews.31 E.M.S. acted as moderator and the third author (B.T.) as observer. At the start of the interview, the moderator introduced the two main topics to be discussed: the ethical challenges most frequently faced by students in clinical practice and those experienced by the teachers in their efforts to enhance moral competence. The interview lasted for 75 min. B.T. took notes and ensured that all members of the group participated in the discussion and contributed with their experiences and views. The notes were discussed immediately after the interviews, all of which were transcribed verbatim.
Ethical considerations Approval was granted by the National Health Sciences Research Committee in Malawi (NHSRC2008 no. 4/36c). The participants took part voluntarily after they had received written and oral information about the purpose of the study. They signed their informed consent having been made aware of our intention to audio tape the interviews, treat data confidentially and remove their names from the transcripts, as well as of their right to withdraw at any time.
Analysis The data were analysed by means of qualitative interpretative content analysis.32 We aimed to provide a true account of the teachers’ expressed meanings about their experiences. First, the authors read the transcribed text of the individual interviews and the focus group interview on several occasions to gain a general impression of the content.28,33 During the reading, questions were posed to the text that started a back-and-forth
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
5
movement between the whole and the parts.28,34 The final step comprised structuring the textual data into main themes, subthemes and meaning units.32
Findings Two overall themes emerged from the data: (1) authoritarian learning climate and (2) discrepancy between expectations on learning outcome from nursing college and the learning opportunities in practice. Table 1. Examples of challenges experienced by nurse teachers in their efforts to enhance students’ moral competence in clinical practice. Themes
Subthemes
Example of statements
Authoritarian learning climate
Fear of making critical comments Quotation 1: A student at our college reported to the about clinical practice teacher that a certain nurse did not treat students and patients in a respectful manner. When the hospital staff was informed, the reaction was: ‘We don’t want these students; they come here to learn and not to be faultfinders’ Fear of disclosing mistakes and Quotation 2: When a nurse does something wrong, lack of knowledge e.g. administers the wrong drug and the patient dies . . . or loses both mother and baby, the other nurses and students usually cover up for her, so that she does not lose her license or her job Quotation 3: The students do not come to the Lack of a culture of critical teachers because of the social distance between discussion and reflection that them. It means that we are not empowering them promotes moral competence
Gap between the theory taught in Quotation 4: There is an ethical dimension in the Discrepancy between relationship between the student and patient when class and learning expectations on learning students try to implement the ideal/what was opportunities in clinical outcome from college taught in class. They say to the patient: because you practice and the learning are suffering from this, we are going to implement opportunities in practice 1-2-3. When the nurse says: ‘No, you can’t do that’, the students are obliged to refrain from doing something they know is right Lack of good role models Quotation 5: Ethics is about professionalism, time management, punctuality and proper documentation. I think some (not all) of the qualified nurses do not adhere to these professional principles. They are not punctual, take too long lunch breaks and are unprofessional in their encounters with patients and our students copy them Lack of resources Quotation 6: Sometimes the financial situation of the college is so bad that teachers are unable to supervise students in clinical practice. Our aim is that the students should be able to implement in practice what we teach them in class. The students imitate what they see and by the time we meet them in clinical practice it’s often too late, as they have already internalised short cuts and negative attitudes.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
6
Nursing Ethics
Theme 1: authoritarian learning climate This theme was derived from the following subthemes: (1) fear of making critical comments about clinical practice, (2) fear of admitting mistakes and lack of knowledge and (3) lack of a culture of critical discussion and reflection that promotes moral competence. Subtheme 1: fear of making critical comments about clinical practice. Many of the teachers reported that students were often afraid of being punished or expelled from nursing college. They experienced that the students were hesitant about coming forward with their own views, especially when it concerned critical remarks about how patients were treated (quotation 1 in Table 1). One informant gave an example of what can happen when a student makes critical comments about certain caring attitudes that she observes: It may create a very bad relationship with the nurse. The relationship will be unfriendly and the student will not receive assistance. The teacher will ask the nurse about her observation of the student, so the student knows that by the end of the day there will be no future for her there and she will definitely fail.
The informants provided several examples of students’ fear of being punished or expelled. The following quotation illustrates what many of the teachers considered important when assessing the students’ moral competence: We have attitude objectives. The students have to show respect for the patients, their fellow students and the staff nurse. They are evaluated according to how they show respect.
The attitude objectives given by college are guiding the students’ learning outcomes, but they are often in sharp contrast to students’ experiences of bad role models such as shouting at the patient and taking short cuts in patient care. Subtheme 2: fear of disclosing mistakes and lack of knowledge. According to the teachers, nurses sometimes cover up for each other and this practice is copied by the students. It is likely to lead to moral distress, as both nurses and students know that telling the truth is the right thing to do (quotation 2 in Table 1). The fear of admitting a lack of knowledge and making mistakes can also influence nurses’ and hence students’ willingness to care for certain patients: They (students and nurses) prefer caring for a patient who is uneducated. If they make a mistake they don’t care, because they are not going to be asked about it.
These quotations demonstrate the students’ and nurses’ fear of making a mistake. If students and nurses do not feel competent and safe in their profession, they might try to avoid situations where their knowledge and judgement can be questioned. Subtheme 3: lack of a culture of critical discussion and reflection that promotes moral competence. According to the teachers, the students were rarely willing to discuss ethical problems encountered in practice: In my experience students do not take contact with the teacher because of the relationship between them. I see that the gap between them is too wide. So if something happens to the students in clinical practice they say nothing.
The teachers assumed that the students discuss ethical problems among themselves instead with the teachers and nurses responsible for their education. In our study, the teachers reflected on how the social
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
7
distance between themselves and their students as well as the focus on procedures in practice, rules, norms and regulations might constitute a barrier to the students’ empowerment (quotation 3 in Table 1). Some of the informants stated that students were encouraged to reflect on practice when they returned to college after their clinical placement. However, others reported that reflection often focused on challenges related to practical procedures more than ethical and moral issues: We probably reflect on moral practice without realizing it. When we call our students back at the end of the week to ask about their clinical placement and what problems they encountered, we are not aware of the fact that we are also reflecting on ethics.
Furthermore, the members of the focus group stated that reflective methods were not used in their teaching neither in college nor in the practical setting. However, they were of the opinion that students learnt critical thinking through decision-making in the nursing process: Decision making gives them the chance to think critically. So I believe they have enough information to be critical thinkers.
Theme 2: discrepancy between expectations on learning outcome from college and the learning opportunities in practice This theme is based on the following subthemes: (1) gap between the theory taught in class and learning opportunities in clinical practice, (2) lack of good role models and (3) lack of resources. Subtheme 1: gap between the theory taught in class and learning opportunities in clinical practice. The teachers were concerned about how the process of learning a moral stance was handled in clinical practice. The students were told the right thing to do, but reflection on and critical thinking about moral decision-making were not emphasised in practice. The teachers took it for granted that the students were aware of the objectives to be achieved in practice: When the students go to the clinic they are given objectives, we point out to them what they should achieve. They have to judge and make moral decisions in clinical practice based on the theoretical principles we teach them in ethics.
The students may experience moral distress and difficulties in achieving objectives related to patient safety, respect and dignity when there is a conflict between what they have learnt in theory and what is common in practice, as mentioned by one teacher (quotation 4 in Table 1). Some teachers also expressed concern about nurses feeling inferior when it comes to instruction and supervision of students in clinical practice: I strongly believe that the nurses in the hospital consider themselves inferior and might say: ‘The teachers are better educated and know more about these issues, they should be the ones to tell you what to do’. Such an unfriendly relationship will affect the students.
Several informants were dissatisfied about the lack of priority given to ethical and moral aspects in both theory and practice: We emphasize just a few ethical issues, for example respect and confidentiality. But there are other ethical issues that should be taught in all courses.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
8
Nursing Ethics
This illustrates the concern that ethics is taught in one theoretical course but not followed up throughout the whole education in order to ensure that students become more experienced and ethically conscious in clinical practice. Subtheme 2: lack of good role models. Nurses are supposed to supervise and guide students to ensure moral competence and actions. They serve as important role models for the students when it comes to dealing with ethical problems that arise in a busy hospital environment. The teachers expressed concern about the way some nurses acted in their role model position (quotation 5 in Table 1). According to the teachers, students tend to copy bad practice that they observe from the nurses in the clinic: Sometimes the students just imitate the clinical staff. One example is that the patient has the right to information, but the nurse administers treatment without informing the patient.
Although students sometimes manage to practice what they learnt in theory despite the lack of good role models, some of the teachers were worried about what will happen after their graduation: When they are students, they behave like students. However, the moment they graduate they might start shouting at the patient as well.
One informant commented on the importance of supervision and reflection on moral practice in clinical training and that teachers should be available in practice for the student: It is important for teachers to demonstrate respect for the patient. You cannot only teach about attitudes. They must be learnt from good role models.
Subtheme 3: lack of resources. In both the focus group and the individual interviews, many of the teachers stressed lack of resources as a major challenge for the enhancement of reflective and moral competence. Lack of resources tends to widen the gap between what is taught in college and what is demonstrated in clinical practice: Some nurses are willing to teach, but because of the shortage of nurses there may be only one nurse on the ward and then it is difficult for this nurse to teach the students.
Quite a few teachers expressed concern about the lack of follow-up in clinical placements: The students are not followed up in practice and we don’t see how things are done. We just go to the clinical placement at a specific time to grade the students. It is really difficult and I don’t know what we are going to do about it.
Another quotation reveals that the financial situation of the college also leads to constraints in terms of how often teachers can follow up students in practice (quotation 6 in Table 1). In addition, the teachers referred to the lack of equipment that the students encounter in practice, which affects the quality of nursing care: In situations where there is a lack of equipment in the clinical area, the students may be forced to work without protective wear such as gloves and aprons. That is a problem because they are supposed to be protected.
This situation leads to ethical dilemmas, where critical thinking and moral competence have to be well developed in order to decide on a moral course of action.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
9
Discussion The aim of this study was to explore the challenges experienced by nurse teachers in Malawi in their efforts to enhance students’ moral competence in clinical practice. The results indicate a number of challenges related to an authoritarian learning climate as well as to the discrepancy between expectations on learning outcome from nursing college and learning opportunities in clinical practice. An authoritarian learning climate can lead to fear, thus constituting a barrier to critical thinking and reflection, which is crucial for the development of moral competence. The teachers reported that students can sometimes be prevented from discussing and reflecting on practice due to the social distance between them. In a recent study from Malawi, student nurses reported that teachers often interact with them in an autocratic and intimidating manner, making them uncertain and stressed in practice.35 Arries36 and Mangena and Chabeli20 hold that African students are socialised to respect authority, which means that they rarely challenge opinions or decisions. The teachers and nurses have been fostered in the same cultural tradition, which may explain why they fail to encourage students to critically reflect in and on practice. Arries36 presented several important factors perceived by student nurses to be conducive to a learning climate: Nurses and teachers should communicate respectfully, listen attentively to the students’ learning concerns, consider their viewpoints and give plausible explanations for common practice. Student nurses come to the ward for clinical practice with ‘fresh eyes’ and often detect procedures and practices that are immoral. Erdil and Korkmaz37 and Solum et al.4 claim that students recognise unsatisfactory practice and are aware of the need to improve it. According to Neville,2 students perceived several barriers to improving such practice, including fear of not being supported. In our findings, the teachers reported that the students were afraid of being negatively evaluated and considered faultfinders. On one hand, there is a risk that students will lose their self-confidence, adjust to and copy immoral practice. On the other hand, it is important that students are aware of differences in the culture and organisation of local hospital wards. They should respect existing practice, but this can only happen if they are encouraged to critically reflect on it and are invited to discuss how ethical problems can be solved in the best possible way. Ethical problems are characterised by value conflicts, leading to confusion and uncertainty about the knowledge needed for decision-making.38 Being valued as both a learner and a person is important for the empowerment of student nurses in clinical practice.39 Critical reflection is crucial because it enables the students to analyse, synthesise and evaluate their experiences.40 Students should be valued as an important resource for ensuring moral practice, patient safety and rights. Our findings indicated that showing respect was a central objective when the students were assessed in practice. Both the teachers and the nurses can use their power to prevent constructive criticism. In their review article, Epstein and Carlin41 described students’ perceptions of ethical problems in their relationships with preceptors. The students in their study experienced many unethical situations involving preceptors, to which their most common response was silence caused by fear of retribution. As students lack experience and self-confidence due to the absence of encouragement and a learning climate that enables valuable discussions, they can consider silence as the safest response. In this study, the teachers reported that the students seldom discussed ethical problems with them. If the need to show respect in practice excludes the possibility for student nurses to reflect on and express criticism of existing practice, there is a risk that it could hamper their learning of moral competence. The informants stated that the students’ learning climate is permeated by a fear of admitting mistakes in nursing practice. This is linked to the first subtheme, because the students’ fear of coming forward with their concerns also leads to a fear of admitting mistakes. Practice that covers up nurses’ mistakes is the opposite of a learning environment where staff and students can openly reflect on and learn from errors.17 This is a serious ethical problem, as it jeopardises professional conduct as well as patient rights and safety.4,37 Harrison et al.42 found that a common reason for not disclosing incidents is fear of punishment
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
10
Nursing Ethics
and unfair treatment from management. It is reasonable to assume that in a hierarchical hospital system, student nurses consider themselves even more vulnerable than nurses in terms of unfair treatment. If nurses and students lack knowledge and are afraid of the consequences of doing something wrong, they fear losing face, trust and respect.20,42 In our study, students were exposed to practice where nurses could avoid caring for educated patients to prevent their knowledge and judgement being questioned. This not only affects the care of patients with a high social and educational status but also illustrates the risk to the most vulnerable and illiterate patients.4 Rights, rules and regulations do not provide a straightforward answer to ethical questions and alone can never serve as a guarantee of moral actions.43 There is a need for nursing colleges, hospital wards and managers to ensure a supportive environment for students and nurses that encourages openness and critical reflection.42 Our findings indicate a discrepancy between expectations on learning outcome from college and the learning opportunities in practice. The teachers were aware of the gap between the theory learned in college and the ethical situations the students experienced in clinical practice. In our study, the college teachers seemed to partly relate this discrepancy to the ward nurses’ lack of knowledge and feeling of inferiority, which made them unwilling to supervise students. Many nurse facilitators on the ward lacked ethical knowledge and critical thinking skills as it was not focused on in their education.24 Taniyama et al.44 argued that some clinical educators lack confidence in terms of teaching because their educational background differs from that of the students and faculty members, who have more advanced and updated theoretical knowledge. This leads to a tendency to avoid an exchange of opinions between staff in clinical practice and nursing college teachers, thus preserving a hierarchical and suppressive learning climate. In our findings, the dialogue between the teachers highlighted the fact that nurses are important role models for students. However, everyday practice in busy hospital departments is challenging for nurses. Several studies have revealed students’ and patients’ experiences of nurses who demonstrate unprofessional attitudes and moral misconduct in student–nurse or patient–nurse encounters.3,4,23,37,45 This corresponds with our findings, indicating learning problems due to the attitude of nurses, such as shouting at patients and students, arriving late for work, leaving work early or sleeping during the night shift. It is important that teachers encourage students to critically reflect on what they experience in order to prevent them from copying the misconduct.20 The teachers reported lack of resources in practice such as qualified nurses, equipment and financial support, which are crucial for student learning. Msiska et al.23 hold that healthcare workers in Malawi encounter stressful emotions as a consequence of resource-poor healthcare settings, including a severe shortage of nurses. The increased workload frequently affects the performance of nurses, causing loss of professional pride and burnout.45 In such situations, nurses often have to give priority to patient care at the expense of student teaching. Furthermore, moral distress leads to a loss of compassion in care, affecting the learning climate for students,24,45 thus increasing the gap between the theory of ethics taught in college and learning opportunities for moral competence in practice. In our study, the teachers also stated that they were unable to teach and follow up students in practice due to lack of resources. When students experience short cuts, negative attitudes and misconduct towards the patient in practice, it can cause them moral distress as they know the difference between right and wrong from their knowledge of theory. The teachers are concerned that students will internalise the inferior practice they experience. For example, when ethical dilemmas occur due to lack of equipment and human resources on the wards, moral competence is crucial for ensuring the best possible moral course of action.20 The understanding of moral competence can be interpreted both as a structural phenomenon grounded in a context with an authoritarian learning climate and as a process phenomenon grounded in a discrepancy between learning and outcome expectations in nursing colleges and learning possibilities in clinical practice. We regard this as an expansion of the understanding of moral competence that provides a unique and contextual Malawian perspective. Our study demonstrates that an authoritarian learning climate and a discrepancy between expectations on learning outcomes from nursing colleges and learning opportunities in
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
11
practice hamper students’ development of moral competence. The two themes that emerged in this study are associated with a poor learning climate that tends to be reproduced if unchallenged.17 However, if the nurse teachers are able to challenge the existing structures ensuring a better understanding of moral competence through involving the students in critical reflection in cooperation with nurses in clinical practice, it may contribute to a better learning climate. Such cooperation may enhance the development of moral competence involving ethical knowledge, skills, behaviour, attitudes, motivation and judgement capacity.
Trustworthiness and limitations We attempted to ensure trustworthiness in all phases of the research process. The majority of the authors have personal experience of teaching at nursing colleges in Malawi and three of them have previously published an article on students’ experiences of ethical problems perceived in practice, which constituted the background for this study.4 By conducting interviews jointly with V.M.M., who has long experience as a clinical nurse, teacher and hospital matron in Malawi, we attempted to gain a mutual understanding of the data collection process and the interpretation of the data in a Malawian context. The data were analysed by means of qualitative interpretative content analysis.32 In order to establish credibility, the authors read the interview texts on several occasions. First, the authors read all the interviews several times to gain a general impression of the content. In the analysis process, we aimed to be true to the phenomenon under study and give priority to the life world of the informants.30 In order to strengthen dependability, we conducted independent analyses and ensured conformability by reaching consensus on the meaning contained in the interviews when structuring the transcribed data into meaning units, subthemes and themes.32,46,47 In order to achieve transferability, we provided a clear description of the selection of informants and the context of the study. The informants had long experience and were recruited from nursing colleges spread all over Malawi. Furthermore, similar issues and challenges occurred in both the individual interviews and the focus group interview.32 The main limitation is the number of informants, which could have been larger. The study can serve as a basis and inspiration for further systematic studies and development of moral competence in nursing education in Malawi.46
Conclusion There is a clear relationship between the two main themes. A less authoritarian attitude may enhance critical reflection and discussion between students, nursing college teachers and nurses in clinical practice, as it has the potential to reduce the gap between theory and practice. Learning moral competence must be regarded as a process that continues throughout the education programme, where students gradually increase their confidence and ability to critically reflect on their own practice. Critical reflection will lead to a better understanding of how existing nursing practice can be improved in a crowded, understaffed hospital ward. Nursing college teachers and hospital nurses should cooperate to create a learning climate that enhances critical reflection among student nurses to ensure moral competence, thus protecting patients’ rights and safety. Future research should explore the challenges faced by nurses who teach and supervise students during their clinical placement. Acknowledgements Our sincere gratitude is expressed to all the informants who took part in the study, to the support from the Centre for Women’s, Family & Child Health, Buskerud and Vestfold University College and to Monique Federsel and Gullvi Nilsson for reviewing the English language.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
12
Nursing Ethics
Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1. Benner P. Educating nurses: a call for radical transformation. San Francisco, CA: Jossey-Bass, 2010. 2. Neville L. Moral difficulties in nursing practice: reflections on the practice of a nurse teacher. Nurse Educ Pract 2004; 4: 128–134. 3. Rees CE, Monrouxe LV and McDonald LA. ‘My mentor kicked a dying woman’s bed’. Analysing UK nursing students’ ‘most memorable’ professionalism dilemmas. J Adv Nurs 2015; 71: 169–180. 4. Solum EM, Maluwa VM and Severinsson E. Ethical problems in practice as experienced by Malawian student nurses. Nurs Ethics 2012; 19: 128–138. 5. Rosser M, Mooney GP and Jasper M. Professional development, reflection and decision-making in nursing and healthcare. 2nd ed. Chichester: Wiley-Blackwell, 2013. 6. Beauchamp TL and Childress JF. Principles of biomedical ethics. Oxford: Oxford University Press, 2009. 7. Monteverde S. Undergraduate healthcare ethics education, moral resilience, and the role of ethical theories. Nurs Ethics 2013; 21: 385–401. ˚ . Evaluation of the clinical supervision and professional development of student nurses. 8. Severinsson E and Sand A J Nurs Manag 2010; 18: 669–677. 9. Jormsri P, Kunaviktikul W, Ketefian S, et al. Moral competence in nursing practice. Nurs Ethics 2005; 12: 582–594. 10. Rzymska I, Rzymski P, Wilczak M, et al. The influence of passive and active moral training on medical university on changes of students’ moral competence index – results from randomized single blinded trial. Ann Agric Environ Med 2014; 21: 161–166. 11. Lindh I-B, Severinsson E and Berg A. Exploring student nurses’ reflections on moral responsibility in practice. Reflect Pract 2008; 9: 437–948. 12. Cannaerts N, Gastmans C and de Casterle´ BD. Contribution of ethics education to the ethical competence of nursing students: educators’ and students’ perceptions. Nurs Ethics 2014; 21: 861–878. 13. Buzgova R and Sikorova L. Moral judgment competence of nursing students in the Czech Republic. Nurse Educ Today 2013; 33: 1201–1206. 14. Vanlaere L and Gastmans C. Ethics in nursing education: learning to reflect on care practices. Nurs Ethics 2007; 14: 758–766. 15. Benner P. From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley, 1984. 16. Auvinen J, Suominen T, Leino-Kilpi H, et al. The development of moral judgment during nursing education in Finland. Nurse Educ Today 2004; 24: 538–546. 17. Jasper M. Beginning reflective practice. Cheltenham: Nelson Thornes, 2003. 18. Chabeli MM. Higher order thinking skills competencies required by outcomes-based education from learners. Curationis 2006; 29: 78–86. 19. Fero LJ, Witsberger CM, Wesmiller SW, et al. Critical thinking ability of new graduate and experienced nurses. J Adv Nurs 2009; 65: 139–148. 20. Mangena A and Chabeli MM. Strategies to overcome obstacles in the facilitation of critical thinking in nursing education. Nurse Educ Today 2005; 25: 291–298.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
Solum et al.
13
21. Berggren I and Severinsson E. The influence of clinical supervision on nurses’ moral decision making. Nurs Ethics 2000; 7: 124–133. 22. Chabeli MM. Nurse teachers’ perceptions of OSCE as a clinical evaluation method. Curationis 2001; 24: 84–92. 23. Msiska G, Smith P and Fawcett T. Emotive responses to ethical challenges in caring: a Malawian perspective. Nurs Ethics 2013; 21: 97–107. 24. Maluwa VM, Andre J, Ndebele P, et al. Moral distress in nursing practice in Malawi. Nurs Ethics 2012; 19: 196–207. 25. Muula AS. Will health rights solve Malawi’s health problems? Croat Med J 2005; 46: 853–859. 26. Ministry of Health. Charter on patients’ and health service providers’ right and responsibilities. Lilongwe: Ministry of Health, 2004. 27. Tveit B, Wasili R, Kollstrøm ML, et al. Curriculum implementation in CHAM/NMT colleges in Malawi. Lilongwe: CHAM/Improved Health Training Program, 2009. 28. Gadamer H-G. Truth and method. 2nd rev. ed. London: Continuum, 2004. 29. Dahlgren L, Emmelin M and Winkvist A. Qualitative methodology for international public health. Ume˚a: Ume˚a International School of Public Health, 2007. 30. Kvale S and Brinkmann S. Interviews: learning the craft of qualitative research interviewing. Los Angeles, CA: Sage, 2009. 31. Liamputtong P. Focus group methodology: principles and practice. London: Sage, 2011. 32. Graneheim UH and Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24: 105–112. 33. Dahlberg K, Dahlberg H and Nystro¨m M. Reflective lifeworld research. Lund: Studentlitteratur, 2008. 34. Lindh I-B. Moral responsibility in the light of nursing practice: a hermeneutic approach to inquiry. Stavanger: Department of Health Studies, Faculty of Social Sciences, University of Stavanger, 2010. 35. Msiska G, Smith P and Fawcett T. The ‘lifeworld’ of Malawian undergraduate student nurses: the challenge of learning in resource poor clinical settings. Int J Africa Nurs Sci 2014; 1: 35–42. 36. Arries EJ. Interactional justice in student-staff nurse encounters. Nurs Ethics 2009; 16: 147–160. 37. Erdil F and Korkmaz F. Ethical problems observed by student nurses. Nurs Ethics 2009; 16: 589–598. ˚ 38. Kalkas H and Sarvimaki A. Omvardnadens etiska grunder (In Swedish) [Ethical base in nursing care]. Stockholm: Almquist & Wiksell, 1987. 39. Bradbury-Jones C, Sambrook S and Irvine F. Empowerment and being valued: a phenomenological study of nursing students’ experiences of clinical practice. Nurse Educ Today 2011; 31: 368–372. 40. Morolong BG and Chabeli MM. Competence of newly qualified registered nurses from a nursing college. Curationis 2005; 28: 38–50. 41. Epstein I and Carlin K. Ethical concerns in the student/preceptor relationship: a need for change. Nurse Educ Today 2012; 32: 897–902. 42. Harrison R, Birks Y, Hall J, et al. The contribution of nurses to incident disclosure: a narrative review. Int J Nurs Stud 2014; 51: 334–345. 43. Botes A. An integrated approach to ethical decision-making in the health team. J Adv Nurs 2000; 32: 1076–1082. 44. Taniyama M, Kai I and Takahashi M. Differences and commonalities in difficulties faced by clinical nursing educators and faculty in Japan: a qualitative cross-sectional study. BMC Nurs 2012; 11: Article 21. 45. Jewkes R, Abrahams N and Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services. Soc Sci Med 1998; 47: 1781–1795. 46. Elo S, Ka¨a¨ria¨inen M, Kanste O, et al. Qualitative content analysis: a focus on trustworthiness. SAGE Open 2014; 4: 1–10. DOI: 10.1177/2158244014522633. 47. Whittemore R, Chase SK and Mandle CL. Validity in qualitative research. Qual Health Res 2001; 11: 522–537.
Downloaded from nej.sagepub.com at UNIVERSITE LAVAL on November 18, 2015
