Jottmal of Advanced Nurstng, 1992,17,10-15
Professional ethics as perceived by American nursing undergraduates Bnghid Kelly RNC PhD Assoaate Professor, College of Nurstng and Health, Wtlltam Cooper Procter Hall, Medical Center, Untverstty of Ctnannah, Ctnannah, Ohio, 45221-0038, USA
Accepted for pubhcahon 10 May 1991
KELLY B (1992) Journal of Advanced Nursmg
17,10-15
Professional ethics as perceived by American nursing undergraduates The purpose of the study was to explore the perceptions of Amencan nursing undergraduates about professional ethics The method was quabtative, specifically, a grounded theory approach was used The sample compnsed li senior baccalaureate nursing students, from a possible population of 120, who were m their final clinical rotation pnor to graduation Infonnants were volunteers who gave informed consent having been bnefed on the purposes of the study and how their confidentiahty would be protected Data were collected through audio-taped mterviews and dmical logs Analysis was conducted through the constant comparative method Findmgs revealed two concepts central to their view of good nursmg These were (a) respect, and (b) canng Respect was descnbed as respect for patients and families, respect for self, colleagues and the profession Canng was associated with showing 'concern and love', providing psychological support, getting mvolved, being 'cheerful and fnendly' and 'taking the time' to do a good job They did not evidence an ambiguous professional role They espoused values consistent with the professional code of ethics They perceived that respect for others was basic to good nursmg They believed that good nurses cared about their patients and how nursmg was done They appeared to lmk professionalism with good nursmg
INTRODUCTION What emergmg graduate nurses believe about their ethical role directs their prachce Meleis (1975) says that role-modellmg, role repehhon and mterachon with professional reference group is necessary for professional role-danfication Yet, there is much disagreement between nursmg service and nursmg educahon on nursmg's professional role What efiFect such dissension has on the ethical role conception of emergmg graduate nurses, we do not know But we know that new graduate nurses are confused between what they leam m schools of nursmg and what is expected of them m hospital nursmg prachce Role conflict and role ambiguity are common sources of stress among this group (Bnef rf«/ 1979, Kramer 1985, Dailey 1990) 10
There is mounhng evidence that disillusionment with nursmg has its roots m the formal socialization process (Kramer 1985, Dobbs 1988) Professional soaabzahon studies have foimd that nursmg students receive conflictmg messages from their dmical mstructors (Olesen & Whittaker 1968, Simpson 1978, Cohen 1981, Buckenham & McGrath 1983, Meba 1988) Incongruihes noted were the dassroom emphasis on an mdnnduabshc, hobshc, canng approach m contrast to task-onented, techmcally profiaent messages of the dimcal leammg expenence Buckenham & McGrath (1983) assert that 'student nurses are groomed for subordmahon' They condude from their research that nursing students are socialized to obedience, resped for authonty and loyalty to the team, and that both their acceptance mto, and contmued
Professional ethtcs membersbp of the health team depends upon their manifest recogmtion of their subordinate role Cohen (1981) says, 'The requirement for a subservient, dependent demeanor must be reconciled with the demand for {jerfeetion and the fear of killtng a pahent' The result, aeeordmg to Cohen, ts an atmosphere where students feel eonstneted and spted upon and where the very students who would make the best professtonals are dnven out of nursmg beeause they are too asserttve Other sourees of distllustonment are the mtstreatment nurstng students reeetve from thetr 'role models'
Unethical teaching acts In a reeent study, laek of respeet for students eonshtuted the largest number of unetbeal teaehtng aets by nurstng faculty (Thets 1988) Pumttve mstruettonal styles undermtne students' self-esteem and depnve them of selfeonfidenee (Flagler et al 1988, Pagana 1988, Windsor 1987) Do eontradtehons sueh as these adversely affeet the soetaltzatton proeess m nurstng? The purpose of tbs paper ts to explore the p)ereephons of Amenean nurstng undergraduates regardmg professional ethics Ethieal nursmg happens when a good nurse does the nght thmg The nght thmg for Amenean nurses ts outbned m the Code for Nurses Wtth Interpretative Statements (Ameneem Nurses' Assoeiation 1985) Yet, we have bttle information about how hospital nurses evidence adherenee to these pnneiples tn nurstng praehee Informal surveys show that many nurses bebeve thetr professtonal standards are bgher than those of other nurses (Nursmg Etbes Probe 1974) Studies have found that while nurses know what eonstitutes nght eonduet in nursmg praettee, they bebeve that the typteal nurse wtll not do tt (Buekenham & MeGrath 1983, Ketefian I98I) Felton & Parsons (1987) found a postttve relahonsbp between level of nursmg edueatton and level of moral reasonmg But, knowledge of moral reasonmg ts not betng h-anslated tnto pradtce (Cox 1986, Felton 1984, Gaul 1987, Nokes 1985) It ts bghly posstble that semor nursmg students have already leamed to solve etbcal questtons favourmg the bureaucratic mstttuhon mstead of the patient (Swider et al 1985) Any eondustons about the etbeal deaston-makmg of nurses m general would be premature based on current findmgs It does appear, however, that nurses sometimes disregard what thetr eonsaenees dtetate (Beardshaw 1981) Is tbs discrepant role a eonsequenee of ambiguous professional soaalizahon? If nursmg students are eonfused about what is nght one might expeet tbat sueh ambiguity would be refleded m tbeir pere^hons of gcK)d nursing, that is nursing as it ought be done
The researeh queshon explored m t b s paper is How do Amenean nursmg undergraduates desenbe thetr pereephon of good nurstng?
METHOD The method was quabtattve, spectfically, a grounded theory approach was used The setttng was a large metropobtan tmtverstty m mtdwestem United States The sample eompnsed 23 semor baeealaureate nursmg students who volunteered for the study and gave informed eonsent, havmg been given details of the purpose of the study and how their eonfidentiality would be protected
Methodologieal issues Glaser & Strauss (1967) defmed grounded theory as dtseovery of theory from data Grounded theory dtreets that a strategy of eonstant eompanson be done throughout data eolleetton and analysts Emergmg data provide dtreehon for further questiomng, whieh is ealled theoretieal samplmg Whether theoretieal samplmg requires one to sample outside the group under study depends on the foeus of the study (Glaser & Strauss 1967) In thts ease, the foeus was the ethteal values of undergraduate nurses Informants The tnfoimants were m thetr fourth and final year of study The majonty were between the ages of 22 and 25, tbee were tn thetr late twenties, one was in her early tbrhes and two were in their forties Two were men and two were Afro-Amenean The sample, albeit voluntary, was an exeellent demograpbe representahon of the semor elass All had a requtred eourse m nurstng etbes that foeused on gutded analysts of frequently eneountered etbeal and moral dtlemmas m praehee settmgs Thetr final dmteal eourse, destgned to mtntmtze the effeets of 'reabty shoek', took place tn hospttal setttngs A course asstgnment was a dtmeal log tn whteh students expressed thetr eoneems, fiiistrahons, joys and aeeompbsbnents Data collection
Colledton of data oeeurred tbough (a) audiotaped mdepth interviews, and (b) ebmeal logs A semi-struetured mterview began with queshons about nursmg's professtorwl values and thetrs m partteular In ease mformants were influeneed to provide a 'dassroom answer' the word etbes was not used m the early part of the mtervtew The bulk of data presented m thts paper was m response to the followmg statement 11
B Kelfy I want you to think of nursing as you have expenoKed it and then tell me what you bebeve good nursing is I also want to know what you beheve bad nursing is. In other wcn-ds what, m your exf)enences, are examples of nursmg as you bebeve nursmg ought to be done and likewise examples of nursmg as it ought not be done? Respondents received an opportumty to validate data throughout tbe mterviews In addihon, they reviewed the findmgs and found tbem credible Guba (1981) refers to tbis strategy as 'memt)er diecks' Analysis Data were reviewed for pattems Examples of codmg categones emergmg from tbs study were 'takmg time' and 'bstenmg' Classificahon of tbese mitial pattems preceded
bgher-order clustermg of categones Atwood & Hmds (1986) suggest a vabdity check to test bow weU data bits, le informant's words, fit tbe categones Two experts reviewed and compared raw data and findmgs for category 'fit' and were also in agreement witb tbe mvestigator on core vanables
THE FINDINGS The findmgs revealed respect and canng as central to good nursmg Resped was descnbed as tbe message conveyed to the other m mihal mteradion, l e recogmhon of the person Canng was assoaated witb sbowmg 'concem and love', providmg psydiological support, gettmg mvolved, bemg 'cheerful and fiiendly' and 'taking tbe time' to do a good job
Respect Havmg respect for pahents and families, self, coUeagues and tbe profession was considered basic to good nursing Resped for pahents was wbat tbe 'ideal' nurse would do TTie first nurse was ideal she bstened to whatever the pahent had to say to her If she didn't understand, she'd say, 1 didn't understand that please speak slower ' She was candid on the phone with the family She gave her respect by pullmg curtams when some procedure had to be done She always explainedfrombeginning to end What comes to mmd IS my preceptor She has been a good role model just the way she would talk to the patients S3ie would treat them like human beings and encourage them, esp>eaally m labour are! dehvery where Hiey need a lot of encouragranent It was not just what she said it was the way sbe said it 12
Providmg a cbmate for pahent seif-determmation was considered a very important part of resped for pahents I really value as a nurse supporhng the independence of pah^its as much as possible and bending over badcward to let them do for themselves what they can do, which is hard to do a lot of times m the mstituhonal setting, because it means giving up a certcun amount of conhol a feeling of power not bemg ngid at>out adhering to hospital routmes, where there is no medical reason to do so can the patient put on street dothes, can the pahent have a snack other than the prescnbed snack tune But these informants were more conscious of the need for respect when observing its absence The first thmg that comes to mind that really makes me angry, IS nurses that don't bsten to the patients They go m the room and they want to hear a certain tbng and no matter what the patient says that is the way they come out They (dodors] don't treat the patient with dignity Tliey overlook them as persons They just treat them like machines that are not fundionmg and they have to fix them I had a female pahent and she had cancer They just talked over her 1 tbnk she has cancer', and the lady is sittmg there sa)nng, 1 have cancerT and nobody ever told her They scheduled tbngs and they didn't even tell her why Another concem identified was tbe manner m wbch pahents were addressed Instead of callmg the patient by their name, they — a lot of nurses — call the pahents by their first name or they call them 'honey' I work with a lot of older patients and I don't hke that behtthng I think we should show resped I wouldn't call my grandmother 'honey'' I wouldn't call anyone older than me "honey' I hate it when people do it to me But tbe area tbat most concemed tbese nursing students, by far, was tbe way pahents were 'talked about' If the patient asks for something that the nurse has not thought of providmg, then that pahent was termed 'maiupulahve' and discussed m the conference room as such One patient said that he wanted to have a footboard because he was very uncomfortable lying m bed It seemed like a reasonable request but it brought on all these diarges of being manipulahve As the night shift came on, the talk turned to tbs man His night nurse found him m the bathroom (not such an unusual event, considenng that he is allowed to be up and about) 'What's witti 29, he's running around the hospital?' 'He's probably confused' I contnbuted tbat I luufai't found bm (X)nfiised
Professional ethics
at all 'You know, they get more confused at mght I dcm't think there's a full moon' I went down to cheek. He was merely using the bathroom On a unit that handles sueh a high proportion of genatne patients, I would expeet less prejudiee Respeet for self, eoUeagues and profession was desenbed m terms of self-respeet as a professtonal, respeet for eoUeagues and professiottalism tn general They desenbed self-respeet as asserttveness, eontmutng one's edueahon and promotmg the nghts of the nurse They bebeved nurses deserved more respeet I also bebeve there is sueh a thing as a nurse's nght — and not just dealing with a patient I have seen nurses abused Nurses need to realize their own nghts their nght to organize themselves, their nght to present themselves m a pobtieal way Their nght not to be abused whether it is by a physieian or by a pahent 'I am here, this is what I am domg for you You should have some respeet for me' Keeping up with your profession is a very valuable thing to keep in mmd because it ehanges so quickly, you know, if you don't keep up through your organizations or contact with your fellow workers, RNs, lnservices and things bke that I think that also makes you a professional Your behaviour, your dress how you make contact with that person I think that's real important The mformants desenbed respeet for coUeagues tn terms of eoUaborattve, professtonal eommumeahons Collaboration is a big thing It is eommumeation with others, with the staff and with patients I have seen instructors and other preceptors mteraet with people in a professional way and I want to refleet myself m that way I want to leam to speak and aet professionally 'Baekbitmg' and laek of professional umty were examples provtded of how nurses did not show respeet for eaeh other Tbs was a souree of eonstderable dtstress One satd, I don't think nurses are half as kmd to eaeh other as they are to the patient there is a httle lackmg there that I wish were untrue but I see a lot of baekbiting of one another whieh is very distressing Promotmg nursmg as a profession, subscnbing to tbe Code and beeommg tnvolved tn the professtonal orgamzahon were aU examples of respeet for the professton Keeping standards b g h was viewed as a professional obligation and they evidenced an awareness of the need for vigtlance m tbs area
there IS pressure to conform to existmg standards there IS room to grow and to ehange thmgs but you have to be a very strong nurse to do it Get it done that is the hospital policy Cuthng comers, get it done quickly — not necessanly the best way Time is the one constramt for me — peer pressure would not bother me as mueh as hme Considenng the above, it seems redundant to say tbat mformants personified eanng wbeb they identified as the other aspeet of good nursmg
Canng Carmg was dosely abgned with respect m revelations, but was differentiated beeause of eoneeptual quality The eoneept of eanng is exemplified as all 'the bttle thmgs' It's the bttle thmgs that are important to the patient This man I had — he eouldn't walk — he had been bedndden for a month — he eouldn't even stand up and use his unnal He needed help to walk and the nurses didn't have time to do it Yet, there are nurses at the nurses' station just sittmg their yakkmg Nurses need to have tune to take care of pahents The exceptional nurses did those things, holding hands, talkmg to them, tellmg them what was gomg on Beingrealopen and honest with the fanubes Giving them psychological kmd of support along with the physical Canng quabties eonsidered essential to good nursing were eited as foUows cheerful and fnendly I am a very canng person Patients tell me they know I eare about them It makes a difference when you walk into a person's rcx)m and say 'good momingi' You might be eheekmg an IV but you are startmg his day the profession should show concem and love to other people When the canng aspeet is left out, nursing mtervenhons become ntualistic and are perceived as tasks that must be completed at a certam time a good nurse is one who treats each of her pahents as if they were a dose family member She is aware of their psychosocial and spintual needs a nurse who is a finend to the patient who makes the hospital seem less stressful and fnghtemng The example of eanng role models was particularly stgnifieant iTiere has been one partieular nurse — she is a faeulty member — this was a nurse that sang to her pahent when I went to dry dress him not only was this therapeutie for Ae 13
B Kelly
pahent, it was very therapeutic for me She gets to know the patient They ask, When are you coming back?' you could see the pnde she takes m her work she showed how to do trach care, checking the children's nedcs where the rubber goes mto the neck. She noticed the nurses leavmg cotton sticking aroimd there or they were dirty or just wasn't done nght She is willmg to stay, if it takes a half hour longer to get the job done nght
been published at the time of these mterviews Yet they appeared to be saymg that, for a nurse, canng is nght The relahonship between respect and carmg is complex Based on this study, respect is the mihal athtude m the nurse-dient relationship, followed by canng A more thorough analysis of these concepts and emergmg theorehcal relahonships can be found elsewhere (Kelly 1990) Implications
Uncaring
The implications for nursing seem clear Assuming that Conversely, uncanng was viewed m terms of 'not taking these emergmg professionals do mdeed value what they time', being 'sloppy' and 'passmg the buck' Informants profess, they must be acutely aware that they are out of perceived that some nurses did not assume accountability, step with the real world of hospital nursmg One wonders how they cope with such a discrepancy Indeed, if the for example, seemg nursmg 'as a job' not a career ethical values of the profession are most evident m rhetonc, what does it imply for the professionalization of nursing? Some of the negatives nurses that don't give themselves Nelson (1986) discusses the concept of authenticity as credit for what they know They are always passmg the buck, 'Well, ask your doctor about that' They are not willmg to the fabnc of ethical pradice She says the authentic nurse is wiUing to take the nsk of being an mdividual who makes commit themselves or be accountable responsible deasions and is willmg to answer for them When I see nurses who don't assume their responsibility, try Nursmg students emulate their faculty role models Data to shirk their duty, and try to pass it off on to somebody else from this study show the importance of role models, Instead of takmg that little extra time to seek the answer to students descnbmg the faculty achvities they considered the problem, they try to pass it on to someone else and, more respectful and carmg Nursing educators have an ethical often than not, it seems they [the pahents] never get the obhgahon to respect and care for their students It is answer or are left, kmd of hangmg, trymg to figure out what is through this af&liahon that students leam what the nursegomg on patient relationship ought to be The transferabihty of the findings to similar contexts remains to be seen So far, a study of English nursing underDISCUSSION graduates reveals analogous values and concems about hospital nursmg (Kelly I99I) Evidently, these problems The aim of the study was to determine how semor nursmg are intemahonal m scope and are most likely related to the undergraduates perceived professional ethics It was condispanty that exists between the ideals of nursmg and the duded that they did not evidence an ambiguous professional role, they espoused values consistent with the everyday struggle to get through the workload that takes professionai code of ethics, they perceived that respect for place m the real world of hospital nursmg pradice Howothers was basic to good nursmg, they believed that good ever, there is need for corroborahon of findmgs It would nurses cared about their patients and how nursing was also be mterestmg to examme how good nursmg is done, they appeared to hnk professionalism with good descnbed and defmed by practismg nurses nursing That respect emerged as pnmary m this study should Acknowledgements not be surpnsmg Moral philosophers Dowme & Telfer This study was founded by two grants. Beta Iota Chapter, (1970) say that 'not only is it the paramount moral athtude Sigma Theta Tau, and a research award from Brodic but all other moral pnnaples are to be explamed in terms of Foundation, Umversity of Cmannati if To paraphrase Kant (1964), we give resped to all human bemgs, not because they deserve it, but because of their humanity However, the fact that canng was identified as References an ethic was unexpected They had read excerpts from Watson (1979) and Leimnger (1977) but the bterahu-e makmg a cormechon between canng and ethics had not 14
Amencan Nurses' Assoaahon (1985) Cade for Nurses With Interprdedtve ^temerOs Amencan Nurses' Assoaahon, Kansas Gty, Missoun
Professional ethics
Atwood J & Hinds P (1986) Heuristic heresy apphcahon for Kelly B (1990) Resjject and canng etbcs and essfflice of nursing rehabdity and vahdity cntena to produds of grounded theory In Ethtcal and Moral Dimenstons of Care (Lemmger M ed), Westem Joumal of Nurstng Research 8(2), 135-154 Wayne State University Press, Detroit, Midugan, pp 67-79 Beardshaw V (1981) Consaenhous Objectors at Work Mental Kelly B (1991) The professional values of Enghsh nursmg underHospttal Workers A Case Study Social Audit, London graduates Joumal of Advanced Nurstng 16,867—872 Bnef A , Aldag R, Van Sell M & Melone N (1979) Anticipatory Ketefian S (1981) Moral reasoning and moral behavior Nursing soaalization and role stress among registered nurses Joumal of Research 30(3), 171-175 Health and Soctal Behavtor 20,161-166 Kramer M (1985) Why does reality shock continue? In Current BuckenhamJ & McGrath G (1983) The Soaal Realtty of Nurstng Issues in Nursing (McCloskey J & Grace J eds), Blackwell Health Saence Press, Sydney, Austraha, pp 104 Saentific Publications, Boston, pp 891-902 Cohen H (1981) The Nurse's Quest for a Professional Identity Leininger M (1977) Canng the essence and central focus of Addison-Wesley, Menlo Park, California, pp 140 nursing Amencan Nurses' Foundatton Nurstng Research Reports Cox J (1986) Ethical deasion-makmg by hospital nurses Dtsser12,1-7 tahon Attracts Intemattonal 44,131b Meha K (1988) Leamtng and Worktng The Occupahonal SoaalDailey R (1990) Role perceptions and job tension as predictors tzatton of Nurses Tavistock Pubhcahons, London of nursmg tumover Nursing Connechons 3(2), 33-41 Meleis A (1975) Role insufficiency and role supplementation a Dobbs K (1988) The senior preceptorships as a method for concephial framework. Nursmg Research 24, 264-271 antiapatory soaalizahon of baccalaureate nursing students Nelson M (1986) Authentiaty fabnc of ethical practice In Bhtcal bsues tn Nurstng (Chmn P ed), Aspen Pubhcahons, Joumal of Nursing Educahon 24(4), 167-171 Rockville, Maryland Dowme R &TelferE (1970) Respect for Persons Schoken Books, Nokes K (1985) TTie relahonship between reasoning, the relahonNew York. ship dimension of the soaal chmate of the work environment, Felton G (1984) Attnbution of responsibihty, ethical/moral and percephon of reakstic moral behavior in registered proreasomng and the ability of undergraduate and graduate fessional nurses Dissertation Abstracts Memattonal 46,119B students to resolve ethical/moral dilemmas Dissertation Nursing etbcs probe (1974) Nursing '74 4,34-^4 Abstracts Intemahonal 46,474B Felton G & Parsons M-A (1987) The impact of nursing edu- Olesen V & Wbttaker E (1968) The Silent Dialogue Jossey Bass, San Francisco cation on ethical/moral deasion-making Joumal of Nursing P ^ a n a K (1988) Stresses and threats reported by baccalaureate Education 26(11) nursmg shidents in relahon to an initial chnical expenence Flagler S, Loper-Powers S & Spitzer A (1988) Chnical teaching Joumal of Nursmg Educahon 27(9), 418--424 IS more than evaluation alone' Joumal of Nursing Education Simpson I (1976) From Student to Nurse Cambndge Umversity 27(8), 342-348 Press, Cambndge, Massachusetts Gaul A (1987) The effed of a course in nursmg etbcs on the relahonship between ethical choice and etbccil adion in Swider S, McEbnurry B & Yarlmg R. (1985) Etbcal deasionbaccalaureate nursing students Joumal of Nurstng Educahon makmg m a bureaucrahc context by semor nursmg students 26(3), 113-116 Nursmg Research 34(2), 108-112 Glaser B & Strauss A (1967) The Discovery of Grounded Theory Theis C (1988) Nursmg students' perspedives of unetbcal Aldine, Chicago teacbng behaviors Joumal of Nursing Education 27(3), Guba E (1981) Cntena for assessmg the trustworthmess of 102-105 naturahshc mquines Edticahon, Communication and Technology Watson J (1979) Nursing The Philosophy artd Saence of Canng Joumal 29(2), 75-91 Little, Brown, Boston Kant I (1964) The Doctnne of Vtrhie (McGregor I transl), Harper Windsor A (1987) Nursing students' percephons of chnical and Row, New York. expenence Joumal of Nurstng Educatton 26(4), 150-154
15
Professional ethics as perceived by American nursing undergraduates Bnghid Kelly RNC PhD Assoaate Professor, College of Nurstng and Health, Wtlltam Cooper Procter Hall, Medical Center, Untverstty of Ctnannah, Ctnannah, Ohio, 45221-0038, USA
Accepted for pubhcahon 10 May 1991
KELLY B (1992) Journal of Advanced Nursmg
17,10-15
Professional ethics as perceived by American nursing undergraduates The purpose of the study was to explore the perceptions of Amencan nursing undergraduates about professional ethics The method was quabtative, specifically, a grounded theory approach was used The sample compnsed li senior baccalaureate nursing students, from a possible population of 120, who were m their final clinical rotation pnor to graduation Infonnants were volunteers who gave informed consent having been bnefed on the purposes of the study and how their confidentiahty would be protected Data were collected through audio-taped mterviews and dmical logs Analysis was conducted through the constant comparative method Findmgs revealed two concepts central to their view of good nursmg These were (a) respect, and (b) canng Respect was descnbed as respect for patients and families, respect for self, colleagues and the profession Canng was associated with showing 'concern and love', providing psychological support, getting mvolved, being 'cheerful and fnendly' and 'taking the time' to do a good job They did not evidence an ambiguous professional role They espoused values consistent with the professional code of ethics They perceived that respect for others was basic to good nursmg They believed that good nurses cared about their patients and how nursmg was done They appeared to lmk professionalism with good nursmg
INTRODUCTION What emergmg graduate nurses believe about their ethical role directs their prachce Meleis (1975) says that role-modellmg, role repehhon and mterachon with professional reference group is necessary for professional role-danfication Yet, there is much disagreement between nursmg service and nursmg educahon on nursmg's professional role What efiFect such dissension has on the ethical role conception of emergmg graduate nurses, we do not know But we know that new graduate nurses are confused between what they leam m schools of nursmg and what is expected of them m hospital nursmg prachce Role conflict and role ambiguity are common sources of stress among this group (Bnef rf«/ 1979, Kramer 1985, Dailey 1990) 10
There is mounhng evidence that disillusionment with nursmg has its roots m the formal socialization process (Kramer 1985, Dobbs 1988) Professional soaabzahon studies have foimd that nursmg students receive conflictmg messages from their dmical mstructors (Olesen & Whittaker 1968, Simpson 1978, Cohen 1981, Buckenham & McGrath 1983, Meba 1988) Incongruihes noted were the dassroom emphasis on an mdnnduabshc, hobshc, canng approach m contrast to task-onented, techmcally profiaent messages of the dimcal leammg expenence Buckenham & McGrath (1983) assert that 'student nurses are groomed for subordmahon' They condude from their research that nursing students are socialized to obedience, resped for authonty and loyalty to the team, and that both their acceptance mto, and contmued
Professional ethtcs membersbp of the health team depends upon their manifest recogmtion of their subordinate role Cohen (1981) says, 'The requirement for a subservient, dependent demeanor must be reconciled with the demand for {jerfeetion and the fear of killtng a pahent' The result, aeeordmg to Cohen, ts an atmosphere where students feel eonstneted and spted upon and where the very students who would make the best professtonals are dnven out of nursmg beeause they are too asserttve Other sourees of distllustonment are the mtstreatment nurstng students reeetve from thetr 'role models'
Unethical teaching acts In a reeent study, laek of respeet for students eonshtuted the largest number of unetbeal teaehtng aets by nurstng faculty (Thets 1988) Pumttve mstruettonal styles undermtne students' self-esteem and depnve them of selfeonfidenee (Flagler et al 1988, Pagana 1988, Windsor 1987) Do eontradtehons sueh as these adversely affeet the soetaltzatton proeess m nurstng? The purpose of tbs paper ts to explore the p)ereephons of Amenean nurstng undergraduates regardmg professional ethics Ethieal nursmg happens when a good nurse does the nght thmg The nght thmg for Amenean nurses ts outbned m the Code for Nurses Wtth Interpretative Statements (Ameneem Nurses' Assoeiation 1985) Yet, we have bttle information about how hospital nurses evidence adherenee to these pnneiples tn nurstng praehee Informal surveys show that many nurses bebeve thetr professtonal standards are bgher than those of other nurses (Nursmg Etbes Probe 1974) Studies have found that while nurses know what eonstitutes nght eonduet in nursmg praettee, they bebeve that the typteal nurse wtll not do tt (Buekenham & MeGrath 1983, Ketefian I98I) Felton & Parsons (1987) found a postttve relahonsbp between level of nursmg edueatton and level of moral reasonmg But, knowledge of moral reasonmg ts not betng h-anslated tnto pradtce (Cox 1986, Felton 1984, Gaul 1987, Nokes 1985) It ts bghly posstble that semor nursmg students have already leamed to solve etbcal questtons favourmg the bureaucratic mstttuhon mstead of the patient (Swider et al 1985) Any eondustons about the etbeal deaston-makmg of nurses m general would be premature based on current findmgs It does appear, however, that nurses sometimes disregard what thetr eonsaenees dtetate (Beardshaw 1981) Is tbs discrepant role a eonsequenee of ambiguous professional soaalizahon? If nursmg students are eonfused about what is nght one might expeet tbat sueh ambiguity would be refleded m tbeir pere^hons of gcK)d nursing, that is nursing as it ought be done
The researeh queshon explored m t b s paper is How do Amenean nursmg undergraduates desenbe thetr pereephon of good nurstng?
METHOD The method was quabtattve, spectfically, a grounded theory approach was used The setttng was a large metropobtan tmtverstty m mtdwestem United States The sample eompnsed 23 semor baeealaureate nursmg students who volunteered for the study and gave informed eonsent, havmg been given details of the purpose of the study and how their eonfidentiality would be protected
Methodologieal issues Glaser & Strauss (1967) defmed grounded theory as dtseovery of theory from data Grounded theory dtreets that a strategy of eonstant eompanson be done throughout data eolleetton and analysts Emergmg data provide dtreehon for further questiomng, whieh is ealled theoretieal samplmg Whether theoretieal samplmg requires one to sample outside the group under study depends on the foeus of the study (Glaser & Strauss 1967) In thts ease, the foeus was the ethteal values of undergraduate nurses Informants The tnfoimants were m thetr fourth and final year of study The majonty were between the ages of 22 and 25, tbee were tn thetr late twenties, one was in her early tbrhes and two were in their forties Two were men and two were Afro-Amenean The sample, albeit voluntary, was an exeellent demograpbe representahon of the semor elass All had a requtred eourse m nurstng etbes that foeused on gutded analysts of frequently eneountered etbeal and moral dtlemmas m praehee settmgs Thetr final dmteal eourse, destgned to mtntmtze the effeets of 'reabty shoek', took place tn hospttal setttngs A course asstgnment was a dtmeal log tn whteh students expressed thetr eoneems, fiiistrahons, joys and aeeompbsbnents Data collection
Colledton of data oeeurred tbough (a) audiotaped mdepth interviews, and (b) ebmeal logs A semi-struetured mterview began with queshons about nursmg's professtorwl values and thetrs m partteular In ease mformants were influeneed to provide a 'dassroom answer' the word etbes was not used m the early part of the mtervtew The bulk of data presented m thts paper was m response to the followmg statement 11
B Kelfy I want you to think of nursing as you have expenoKed it and then tell me what you bebeve good nursing is I also want to know what you beheve bad nursing is. In other wcn-ds what, m your exf)enences, are examples of nursmg as you bebeve nursmg ought to be done and likewise examples of nursmg as it ought not be done? Respondents received an opportumty to validate data throughout tbe mterviews In addihon, they reviewed the findmgs and found tbem credible Guba (1981) refers to tbis strategy as 'memt)er diecks' Analysis Data were reviewed for pattems Examples of codmg categones emergmg from tbs study were 'takmg time' and 'bstenmg' Classificahon of tbese mitial pattems preceded
bgher-order clustermg of categones Atwood & Hmds (1986) suggest a vabdity check to test bow weU data bits, le informant's words, fit tbe categones Two experts reviewed and compared raw data and findmgs for category 'fit' and were also in agreement witb tbe mvestigator on core vanables
THE FINDINGS The findmgs revealed respect and canng as central to good nursmg Resped was descnbed as tbe message conveyed to the other m mihal mteradion, l e recogmhon of the person Canng was assoaated witb sbowmg 'concem and love', providmg psydiological support, gettmg mvolved, bemg 'cheerful and fiiendly' and 'taking tbe time' to do a good job
Respect Havmg respect for pahents and families, self, coUeagues and tbe profession was considered basic to good nursing Resped for pahents was wbat tbe 'ideal' nurse would do TTie first nurse was ideal she bstened to whatever the pahent had to say to her If she didn't understand, she'd say, 1 didn't understand that please speak slower ' She was candid on the phone with the family She gave her respect by pullmg curtams when some procedure had to be done She always explainedfrombeginning to end What comes to mmd IS my preceptor She has been a good role model just the way she would talk to the patients S3ie would treat them like human beings and encourage them, esp>eaally m labour are! dehvery where Hiey need a lot of encouragranent It was not just what she said it was the way sbe said it 12
Providmg a cbmate for pahent seif-determmation was considered a very important part of resped for pahents I really value as a nurse supporhng the independence of pah^its as much as possible and bending over badcward to let them do for themselves what they can do, which is hard to do a lot of times m the mstituhonal setting, because it means giving up a certcun amount of conhol a feeling of power not bemg ngid at>out adhering to hospital routmes, where there is no medical reason to do so can the patient put on street dothes, can the pahent have a snack other than the prescnbed snack tune But these informants were more conscious of the need for respect when observing its absence The first thmg that comes to mind that really makes me angry, IS nurses that don't bsten to the patients They go m the room and they want to hear a certain tbng and no matter what the patient says that is the way they come out They (dodors] don't treat the patient with dignity Tliey overlook them as persons They just treat them like machines that are not fundionmg and they have to fix them I had a female pahent and she had cancer They just talked over her 1 tbnk she has cancer', and the lady is sittmg there sa)nng, 1 have cancerT and nobody ever told her They scheduled tbngs and they didn't even tell her why Another concem identified was tbe manner m wbch pahents were addressed Instead of callmg the patient by their name, they — a lot of nurses — call the pahents by their first name or they call them 'honey' I work with a lot of older patients and I don't hke that behtthng I think we should show resped I wouldn't call my grandmother 'honey'' I wouldn't call anyone older than me "honey' I hate it when people do it to me But tbe area tbat most concemed tbese nursing students, by far, was tbe way pahents were 'talked about' If the patient asks for something that the nurse has not thought of providmg, then that pahent was termed 'maiupulahve' and discussed m the conference room as such One patient said that he wanted to have a footboard because he was very uncomfortable lying m bed It seemed like a reasonable request but it brought on all these diarges of being manipulahve As the night shift came on, the talk turned to tbs man His night nurse found him m the bathroom (not such an unusual event, considenng that he is allowed to be up and about) 'What's witti 29, he's running around the hospital?' 'He's probably confused' I contnbuted tbat I luufai't found bm (X)nfiised
Professional ethics
at all 'You know, they get more confused at mght I dcm't think there's a full moon' I went down to cheek. He was merely using the bathroom On a unit that handles sueh a high proportion of genatne patients, I would expeet less prejudiee Respeet for self, eoUeagues and profession was desenbed m terms of self-respeet as a professtonal, respeet for eoUeagues and professiottalism tn general They desenbed self-respeet as asserttveness, eontmutng one's edueahon and promotmg the nghts of the nurse They bebeved nurses deserved more respeet I also bebeve there is sueh a thing as a nurse's nght — and not just dealing with a patient I have seen nurses abused Nurses need to realize their own nghts their nght to organize themselves, their nght to present themselves m a pobtieal way Their nght not to be abused whether it is by a physieian or by a pahent 'I am here, this is what I am domg for you You should have some respeet for me' Keeping up with your profession is a very valuable thing to keep in mmd because it ehanges so quickly, you know, if you don't keep up through your organizations or contact with your fellow workers, RNs, lnservices and things bke that I think that also makes you a professional Your behaviour, your dress how you make contact with that person I think that's real important The mformants desenbed respeet for coUeagues tn terms of eoUaborattve, professtonal eommumeahons Collaboration is a big thing It is eommumeation with others, with the staff and with patients I have seen instructors and other preceptors mteraet with people in a professional way and I want to refleet myself m that way I want to leam to speak and aet professionally 'Baekbitmg' and laek of professional umty were examples provtded of how nurses did not show respeet for eaeh other Tbs was a souree of eonstderable dtstress One satd, I don't think nurses are half as kmd to eaeh other as they are to the patient there is a httle lackmg there that I wish were untrue but I see a lot of baekbiting of one another whieh is very distressing Promotmg nursmg as a profession, subscnbing to tbe Code and beeommg tnvolved tn the professtonal orgamzahon were aU examples of respeet for the professton Keeping standards b g h was viewed as a professional obligation and they evidenced an awareness of the need for vigtlance m tbs area
there IS pressure to conform to existmg standards there IS room to grow and to ehange thmgs but you have to be a very strong nurse to do it Get it done that is the hospital policy Cuthng comers, get it done quickly — not necessanly the best way Time is the one constramt for me — peer pressure would not bother me as mueh as hme Considenng the above, it seems redundant to say tbat mformants personified eanng wbeb they identified as the other aspeet of good nursmg
Canng Carmg was dosely abgned with respect m revelations, but was differentiated beeause of eoneeptual quality The eoneept of eanng is exemplified as all 'the bttle thmgs' It's the bttle thmgs that are important to the patient This man I had — he eouldn't walk — he had been bedndden for a month — he eouldn't even stand up and use his unnal He needed help to walk and the nurses didn't have time to do it Yet, there are nurses at the nurses' station just sittmg their yakkmg Nurses need to have tune to take care of pahents The exceptional nurses did those things, holding hands, talkmg to them, tellmg them what was gomg on Beingrealopen and honest with the fanubes Giving them psychological kmd of support along with the physical Canng quabties eonsidered essential to good nursing were eited as foUows cheerful and fnendly I am a very canng person Patients tell me they know I eare about them It makes a difference when you walk into a person's rcx)m and say 'good momingi' You might be eheekmg an IV but you are startmg his day the profession should show concem and love to other people When the canng aspeet is left out, nursing mtervenhons become ntualistic and are perceived as tasks that must be completed at a certam time a good nurse is one who treats each of her pahents as if they were a dose family member She is aware of their psychosocial and spintual needs a nurse who is a finend to the patient who makes the hospital seem less stressful and fnghtemng The example of eanng role models was particularly stgnifieant iTiere has been one partieular nurse — she is a faeulty member — this was a nurse that sang to her pahent when I went to dry dress him not only was this therapeutie for Ae 13
B Kelly
pahent, it was very therapeutic for me She gets to know the patient They ask, When are you coming back?' you could see the pnde she takes m her work she showed how to do trach care, checking the children's nedcs where the rubber goes mto the neck. She noticed the nurses leavmg cotton sticking aroimd there or they were dirty or just wasn't done nght She is willmg to stay, if it takes a half hour longer to get the job done nght
been published at the time of these mterviews Yet they appeared to be saymg that, for a nurse, canng is nght The relahonship between respect and carmg is complex Based on this study, respect is the mihal athtude m the nurse-dient relationship, followed by canng A more thorough analysis of these concepts and emergmg theorehcal relahonships can be found elsewhere (Kelly 1990) Implications
Uncaring
The implications for nursing seem clear Assuming that Conversely, uncanng was viewed m terms of 'not taking these emergmg professionals do mdeed value what they time', being 'sloppy' and 'passmg the buck' Informants profess, they must be acutely aware that they are out of perceived that some nurses did not assume accountability, step with the real world of hospital nursmg One wonders how they cope with such a discrepancy Indeed, if the for example, seemg nursmg 'as a job' not a career ethical values of the profession are most evident m rhetonc, what does it imply for the professionalization of nursing? Some of the negatives nurses that don't give themselves Nelson (1986) discusses the concept of authenticity as credit for what they know They are always passmg the buck, 'Well, ask your doctor about that' They are not willmg to the fabnc of ethical pradice She says the authentic nurse is wiUing to take the nsk of being an mdividual who makes commit themselves or be accountable responsible deasions and is willmg to answer for them When I see nurses who don't assume their responsibility, try Nursmg students emulate their faculty role models Data to shirk their duty, and try to pass it off on to somebody else from this study show the importance of role models, Instead of takmg that little extra time to seek the answer to students descnbmg the faculty achvities they considered the problem, they try to pass it on to someone else and, more respectful and carmg Nursing educators have an ethical often than not, it seems they [the pahents] never get the obhgahon to respect and care for their students It is answer or are left, kmd of hangmg, trymg to figure out what is through this af&liahon that students leam what the nursegomg on patient relationship ought to be The transferabihty of the findings to similar contexts remains to be seen So far, a study of English nursing underDISCUSSION graduates reveals analogous values and concems about hospital nursmg (Kelly I99I) Evidently, these problems The aim of the study was to determine how semor nursmg are intemahonal m scope and are most likely related to the undergraduates perceived professional ethics It was condispanty that exists between the ideals of nursmg and the duded that they did not evidence an ambiguous professional role, they espoused values consistent with the everyday struggle to get through the workload that takes professionai code of ethics, they perceived that respect for place m the real world of hospital nursmg pradice Howothers was basic to good nursmg, they believed that good ever, there is need for corroborahon of findmgs It would nurses cared about their patients and how nursing was also be mterestmg to examme how good nursmg is done, they appeared to hnk professionalism with good descnbed and defmed by practismg nurses nursing That respect emerged as pnmary m this study should Acknowledgements not be surpnsmg Moral philosophers Dowme & Telfer This study was founded by two grants. Beta Iota Chapter, (1970) say that 'not only is it the paramount moral athtude Sigma Theta Tau, and a research award from Brodic but all other moral pnnaples are to be explamed in terms of Foundation, Umversity of Cmannati if To paraphrase Kant (1964), we give resped to all human bemgs, not because they deserve it, but because of their humanity However, the fact that canng was identified as References an ethic was unexpected They had read excerpts from Watson (1979) and Leimnger (1977) but the bterahu-e makmg a cormechon between canng and ethics had not 14
Amencan Nurses' Assoaahon (1985) Cade for Nurses With Interprdedtve ^temerOs Amencan Nurses' Assoaahon, Kansas Gty, Missoun
Professional ethics
Atwood J & Hinds P (1986) Heuristic heresy apphcahon for Kelly B (1990) Resjject and canng etbcs and essfflice of nursing rehabdity and vahdity cntena to produds of grounded theory In Ethtcal and Moral Dimenstons of Care (Lemmger M ed), Westem Joumal of Nurstng Research 8(2), 135-154 Wayne State University Press, Detroit, Midugan, pp 67-79 Beardshaw V (1981) Consaenhous Objectors at Work Mental Kelly B (1991) The professional values of Enghsh nursmg underHospttal Workers A Case Study Social Audit, London graduates Joumal of Advanced Nurstng 16,867—872 Bnef A , Aldag R, Van Sell M & Melone N (1979) Anticipatory Ketefian S (1981) Moral reasoning and moral behavior Nursing soaalization and role stress among registered nurses Joumal of Research 30(3), 171-175 Health and Soctal Behavtor 20,161-166 Kramer M (1985) Why does reality shock continue? In Current BuckenhamJ & McGrath G (1983) The Soaal Realtty of Nurstng Issues in Nursing (McCloskey J & Grace J eds), Blackwell Health Saence Press, Sydney, Austraha, pp 104 Saentific Publications, Boston, pp 891-902 Cohen H (1981) The Nurse's Quest for a Professional Identity Leininger M (1977) Canng the essence and central focus of Addison-Wesley, Menlo Park, California, pp 140 nursing Amencan Nurses' Foundatton Nurstng Research Reports Cox J (1986) Ethical deasion-makmg by hospital nurses Dtsser12,1-7 tahon Attracts Intemattonal 44,131b Meha K (1988) Leamtng and Worktng The Occupahonal SoaalDailey R (1990) Role perceptions and job tension as predictors tzatton of Nurses Tavistock Pubhcahons, London of nursmg tumover Nursing Connechons 3(2), 33-41 Meleis A (1975) Role insufficiency and role supplementation a Dobbs K (1988) The senior preceptorships as a method for concephial framework. Nursmg Research 24, 264-271 antiapatory soaalizahon of baccalaureate nursing students Nelson M (1986) Authentiaty fabnc of ethical practice In Bhtcal bsues tn Nurstng (Chmn P ed), Aspen Pubhcahons, Joumal of Nursing Educahon 24(4), 167-171 Rockville, Maryland Dowme R &TelferE (1970) Respect for Persons Schoken Books, Nokes K (1985) TTie relahonship between reasoning, the relahonNew York. ship dimension of the soaal chmate of the work environment, Felton G (1984) Attnbution of responsibihty, ethical/moral and percephon of reakstic moral behavior in registered proreasomng and the ability of undergraduate and graduate fessional nurses Dissertation Abstracts Memattonal 46,119B students to resolve ethical/moral dilemmas Dissertation Nursing etbcs probe (1974) Nursing '74 4,34-^4 Abstracts Intemahonal 46,474B Felton G & Parsons M-A (1987) The impact of nursing edu- Olesen V & Wbttaker E (1968) The Silent Dialogue Jossey Bass, San Francisco cation on ethical/moral deasion-making Joumal of Nursing P ^ a n a K (1988) Stresses and threats reported by baccalaureate Education 26(11) nursmg shidents in relahon to an initial chnical expenence Flagler S, Loper-Powers S & Spitzer A (1988) Chnical teaching Joumal of Nursmg Educahon 27(9), 418--424 IS more than evaluation alone' Joumal of Nursing Education Simpson I (1976) From Student to Nurse Cambndge Umversity 27(8), 342-348 Press, Cambndge, Massachusetts Gaul A (1987) The effed of a course in nursmg etbcs on the relahonship between ethical choice and etbccil adion in Swider S, McEbnurry B & Yarlmg R. (1985) Etbcal deasionbaccalaureate nursing students Joumal of Nurstng Educahon makmg m a bureaucrahc context by semor nursmg students 26(3), 113-116 Nursmg Research 34(2), 108-112 Glaser B & Strauss A (1967) The Discovery of Grounded Theory Theis C (1988) Nursmg students' perspedives of unetbcal Aldine, Chicago teacbng behaviors Joumal of Nursing Education 27(3), Guba E (1981) Cntena for assessmg the trustworthmess of 102-105 naturahshc mquines Edticahon, Communication and Technology Watson J (1979) Nursing The Philosophy artd Saence of Canng Joumal 29(2), 75-91 Little, Brown, Boston Kant I (1964) The Doctnne of Vtrhie (McGregor I transl), Harper Windsor A (1987) Nursing students' percephons of chnical and Row, New York. expenence Joumal of Nurstng Educatton 26(4), 150-154
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