A Pragmatic Approach to the Application of the Code of Ethics in Nursing Education

A Pragmatic Approach to the Application of the Code of Ethics in Nursing Education

Elizabeth Tinnon, PhD, RN, CNE & Kathleen Masters, DNS, RN & Janie Butts, PhD, RN

The code of ethics for nurses was written for nurses in all settings. However, the language focuses primarily on the nurse in context of the patient relationship, which may make it difficult for nurse educators to internalize the code to inform practice. The purpose of this article is to explore the code of ethics, establish that it can be used to guide nurse educators’ practice, and provide a pragmatic approach to application of the provisions.

Keywords: code of ethics for nurses; ethics; ethical environment; nurse educators

The American Nurses Association designated 2015as the year of ethics. This was in conjunction withthe publication of the newest revision of The Code of Ethics for Nurses With Interpretive Statements (The Code).1 The language used in some provisions within The Code focuses on the nurse in the context of the patient relationships, but it also includes nurses interacting with other professionals and the public. With the use of the terms patient, other professionals, and the public, nurse educators may find some difficulty in internalizing The Code to inform their practice.

Rosenkoetter and Milstead2,3 proposed and later revised a separate code of ethics for nurse educators. This code provided 17 guiding statements but no interpretive analysis. The National League for Nursing (NLN)4 proposed guide- lines intended for all members of nursing education based on the core values of caring, integrity, diversity, and excellence. The NLN ethical principles for nursing education elaborate and provide broad statements reflecting principles applicable to nursing education. The authors of both of these documents indicate that they are not intended to replace The Code but to broaden it, making it clear that nurse educators should incorporate The Code, the foundational document that guides the practice of all nurses in all settings, into their practice.1

Although including the ethical guidelines specifically developed for nursing education enhances the educational

environment, the question that remains is, ‘‘Can the code of ethics for nurses be used effectively within nursing education?’’ The purpose of this article is to explore the code of ethics for nurses and make the case that it can be used to guide nurse educators in their practice and provide a pragmatic approach to application of the provisions.

In a search of the literature using ethics and nursing education, most articles were related to teaching ethics within the curriculum, but there were a limited number of articles related to ethical concerns within the sphere of nursing education. Fowler and Davis5 also found this phenomenon to be true, reporting less than 10% of the 2600 articles reviewed for their study related to ethical issues in nursing education and the remainder concerned with teaching ethics within the curriculum. They found a dispro- portionate number of articles related to issues of authorship and student cheating. Other ethical issues found in nursing education included incivility, lateral and horizontal violence, breaches in confidentiality,3 global migration, racism and prejudice, and mobbing and bullying.5 Ethical concerns exist in the academic environment, and as such, nurse educators need an awareness of the applicability of The Code and its use in their practice.

The Code ‘‘establishes the ethical standard for the profession and provides a guide for nurses to use in ethical analysis and decision-making.’’1 The Code consists of 9 provisions that guide nurses in their practice. The focus of the first 3 provisions are nurse-patient relationship; the second 3 provisions are focused on the accountability of practice toward others, oneself, and the work environment; and the final 3 provisions focus on duty to the profession, collaboration, and social justice.1

In exploring The Code,1 one of the first issues to examine is the language. The term ‘‘patient’’ is used specifically only in provisions 2 and 3. Terms such as ‘‘promote health and safety’’ and ‘‘provide optimal care’’ are found throughout the pro- visions and in the interpretative statements. How can nursing

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Author Affiliations: Assistant Professor (Dr Tinnon) and Professor (Drs Masters and Butts), College of Nursing, University of Southern Mississippi, Hattiesburg. The authors declare no conflicts of interest. Correspondence: Dr Tinnon, College of Nursing, University of Southern Mississippi, 3215 Montague Blvd, Hattiesburg, MS 39401 (elizabeth.tinnon@usm.edu). Accepted for publication: May 10, 2017 Published ahead of print: June 28, 2017 DOI: 10.1097/NNE.0000000000000407

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faculty apply The Code with this specific language? Perhaps the place to begin is with the purpose of The Code. As stated earlier, The Code establishes the standards for the profession to guide nurses’ actions. People directly or indirectly are the recipient of those actions. In other words, The Code tells us how we ought to treat others. Does it matter if the recipient is a student instead of a patient and the provider is a nurse educator?

The case could be made that differences exist in the nurse-patient relationship as opposed to the faculty-student relationship. We agree that the student-faculty relationship is not identical to that of the nurse-patient relationship; however, both the student and patient need knowledge, support, and guidance to meet their individual goals. An argument could be made that the patient is more vulnerable with differing power status than the student. We would counter that students are vulnerable to the actions of faculty in terms of grades and ultimately progression through the program.6,7 Just as the patient is dependent on the nurse to act in an ethical manner, the student is dependent on the ethical behavior of the faculty. The underlying values and spirit on which The Code was founded and ought to be used, one could, where it is logical to do so, substitute the focus from patient to student.

Faculty-Student Relationship (Provisions 1 to 3) The first 3 provisions focus on the nurse-patient relationship, but in this article, we approach these provisions from the perspective of the nurse educator–student relationship. Provision 1 suggests that nurses ought to treat all individuals who they encounter with compassion, respect, dignity, and worth. Respect is not the absence of disrespect; rather, respect is an active behavior of faculty conveying acknowl- edgement of the value and worth of the individual. Respect for autonomy serves as the basis for any nursing relation- ship, whether the relationship is with a student or a patient. Concepts related to this foundational principle of respect include respect for autonomy and civility. Incivility is a term interwoven in provisions 1, 5, and 6 of The Code. In this article, we focus the discussion of civility in provisions 1 and 6 because they are the provisions with a significant focus on respect and civility. In what ways do faculty exhibit respect for students?

Altimiller8 found that students felt disrespected or ‘‘put down’’ when faculty did not answer their questions. Faculty should demonstrate respect in and out of the classroom and in every exchange with students. Respect can be exhibited both verbally and nonverbally with tone, word choice, body language, and active listening to students. In a phenom- enological study of prelicensure students’ experience with bullying from faculty, the participants cited being listened to and taking their opinion into consideration as respectful behavior.6 Tangible ways to give a voice to students is for them to complete formative course evaluations during the semester, and then the faculty act on those evaluations. One practical way to convey respect is to recognize that students learn and retain information in unique ways. Incorporating various teaching methods within each class period demon- strates faculty understanding of each student’s individuality. Another way to maintain self-respect and convey respect

for others is to manage uncivil behaviors in student or student-to-teacher interactions. Failure to do so sets a pre- cedent, and students perceive poorly managed classrooms as disrespectful.9

One significant faculty concern is the role of advising because it lays the groundwork for students’ education. What needs to be preserved in the advisor-advisee re- lationship is student self-determination. However, before students make informed decisions about their courses, they must have the appropriate information and an un- derstanding of the implications for each decision. Advis- ing is a high-stakes endeavor that can affect students’ admission to and progression through the program. If a faculty member fails to provide or withholds accurate and current information about courses, course sequencing, admission, progression policies, and deadlines, students may make uninformed decisions that could prevent them from reaching their goals. There are times when students make choices with which faculty disagree, however, if students are given the correct information and understand the implications, it is their right to do so. Faculty should create an environment of support and show respect for students’ autonomous decisions.

Provision 2 focuses on the primacy of commitment to the recipient of care, such as the nursing educator shows to the student. The Code gives us guidance that our primary and overriding commitment is to the student. A faculty mem- ber has an ethical obligation of fidelity or, in other words loyalty,10 to the student, which supersedes other relation- ships. Loyalty to the student also involves being a student advocate. As faculty, we have the moral obligation to serve as an advocate for students when we believe that policies, procedures, and curriculum changes are not sound and justified. It is our duty, after proper investigation, to confront faculty who treat students in an unethical manner. Just as trustworthiness is a virtue central to the nurse-patient relation- ship,10 it is also essential in the faculty-student relationship. Trustworthiness must be established early in the faculty- student relationship; examples include faculty adherence to the syllabus and demonstration of faculty keeping their word. Individual encounters where the faculty member demon- strates trustworthiness include keeping appointments, time- liness in response to e-mails, and appropriate follow-through on faculty commitments.

Students indicate that it is the faculty-student rela- tionship that most influences learning and student suc- cess,9 but this can be a delicate balance because part of the faculty role is evaluation of the student. Evaluation translates to assigning student grades. Students may have unrealistic expectations or may blame faculty when they are unsuccessful, which can strain the relationship.

The faculty-student relationship is a professional rela- tionship and not a personal relationship. Inherent in a pro- fessional relationship is power inequality. It is important that educators maintain professional boundaries with students, because this will model the professional relationship. The Code is explicit about professional boundaries. Just as in the nurse-patient relationship, friendship relationships that tend to be more personal in nature between educators and students are inappropriate and will likely trespass the professional boundary line.

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Nurse educators should be aware of the policies affecting their use of social media.11,12 Some programs allow faculty to ‘‘friend’’ students and others expressively forbid the practice. Researchers13,14 found that students may be unprofessional in their use of social media and may have difficulty separating their professional from their personal lives about what they post on social media. The use of social media by students must be addressed within the curriculum especially because it relates to ethical conduct in clinical settings. Students should be aware of the professional nurse role that they will assume and the appropriate use of social media, which means professional nurses must show respect for others’ moral spaces and maintain etiquette in all uses of social media.15

Provision 3 centers around advocating and protecting the rights of the individual. Just as the nurse-patient re- lationship is protected by privacy and confidentiality, so should the faculty-student relationship. Mingled within the ethical discussion of privacy and confidentiality is the legal implications of the Family Educational Rights and Privacy Act (FERPA),16 which requires faculty to keep ac- ademic records private with very limited exceptions, once a student is 18 years or enrolled in higher education. It is not a matter of simply making sure that confidential in- formation is not left where others can see. For example, one of the biggest concerns of students during meetings with faculty is related to what others who are outside the faculty office might hear about their grades or performance. Faculty may also become privy to student information that is not covered by FERPA but which should be held in confidence. Examples of this would include personal family information, romantic relationships, and financial stressors.

There are times when student information cannot remain confidential, and faculty need to break confidentiality such as when the faculty member has a strong and reasonable belief that the student may be a harm to themselves or others; this would be consistent with the Tarasoff versus Regents University of California (1976)17 ruling. Most universities have anonymous alert systems for at-risk students, which when implemented reach out to offer support to students who are experiencing life stressors but not to the degree of harming themselves or others. There may be times when sharing information with other faculty is in the best interest of the student, such as conveying academic difficulties to the successive faculty so that they are aware and can intervene; however, faculty must be judicious in disclosing information about students.

Just as nurses have a responsibility to ensure that the patients who participate in research do so willingly and give an informed consent, faculty members have an obligation to protect and advocate for students in the same manner. There has been a call for increasing evidence-based practice within nursing education18,19 that requires research to be conducted in the educational setting. Students are particularly vulnerable with regard to participating in faculty research. They may fear reprisal if they do not participate, but even if they do, they may experience negative emotions when their performance pro- vokes a fear of letting down the faculty member. Faculty must consider whether the intervention compromises the partici- pants’ learning experience or negatively affects the student’s grade and ultimate progression in the program. Using the bio-

ethical principles of respect for autonomy, nonmaleficence, beneficence, justice, and veracity help faculty to decrease the potential for violating self-determination of the student within the research study.20,21

Provision 3 specifically calls for nurse educators to ‘‘ensure that basic competence and commitment to profes- sional standards exist prior to entry into practice.’’4 Faculty members need to convey the most current information to students and ensure through program policy that students who progress through the program of study are prepared to progress and eventually graduate. As indicated by The Code, the ways that faculty can help maintain the profession’s integrity is through stringent admission criteria into the nursing program, followed by a demanding curriculum, which ensures competent nurses on graduation.

Duty to Self and Ethical Obligations to Others (Provisions 4 to 6) The next group of provisions addresses the role of the nurse and duty to self and obligations to others beginning with provision 4 that focuses on authority, accountability, and responsibility of the nurse educator. Faculty members are responsible for their actions related to teaching, research, and service.22 Nurse educators are involved in many aspects of academe and are accountable for de- cisions made about the curriculum, course design, indi- vidual assignments, evaluative processes, advising, policies, and procedures and to the larger university as a whole. In addition to following the policies and procedures of the university, they are responsible to follow laws that govern the educational process at the national and state level. The educator follows a code of conduct including ethical principles and adherence to standards set forth by the profession such as those found in scope of practice for the academic nurse educator and the nurse educator competencies.4,23

Nurse educators are also responsible for those to whom they delegate tasks, such as graduate assistants and precep- tors. There is a duty to monitor performance and evaluate performance in terms of learning outcomes. In the clinical setting, faculty share responsibility for patient care with their students. One particular area for responsibility and account- ability specifically addressed in the interpretive statements is that faculty must ensure that the student’s level of knowl- edge and skills is appropriate for the safe care of the as- signed patient.22

The focus of provision 5 is on nurse educators owing the same duties to themselves as they do to their students. The duty to self translates to respect for one’s own uniqueness and worth. Nurse educators need to demonstrate self-respect by caring for their physical, psychological, and spiritual well- being, especially balancing their work, family, and leisure.

Similar to a conflict of interest that may exist between the expectation of the facility and the needs of the patient, a nurse educator may experience a conflict between or- ganizational expectations of the school of nursing and the needs of a student or group of students. Nurse educators are employees and, as such, owe a duty to their employer. For example, some educators may feel pressured to lower the admission standards to meet the retention goals, be asked to alter grades to meet graduation goals, be asked by a

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colleague to ignore an ethics violation, or interact with students without regard for justice or fairness. If a faculty member is asked to commit an act that would violate The Code or their own morality, they have a duty to consciously object and speak out.

Another way to demonstrate respect for oneself is to maintain competence within the profession. With the rapid changing health care system and accompanying technolog- ical advances in health care and education, nurse educators need to keep up-to-date in the latest development in their area of expertise and teaching responsibilities. Nurse educators, both personally and professionally, must engage in lifelong learning.

The focus of provision 6 is on the nurse educator as a moral agent working to create and maintain an ethical environment. What would an ethical environment look like in nursing education? The Code indicates that a moral milieu supports ethical action. ‘‘Environments constructed for the equitable, fair, and just treatment of all reflect the values of the profession and nurture excellent nursing practice.’’1 If nurses are to be moral agents, they must do good toward others (beneficence), avoid harming others (nonmaleficence), respect the autonomy of others, and treat each person encountered with respect and dignity.

Uncivil faculty behaviors include rude condescending remarks to students, loss of patience, incompetence, poor communication, showing disinterest in students, and chal- lenging other educators’ knowledge and credibility.8,24,25

Incivility can also be directed at faculty. Clark and Springer26

and Clark27,28 found that faculty perceived the following student behaviors as uncivil: disturbing others by talking in class, making disrespectful remarks about the faculty, dis- crediting the faculty, arriving late or leaving early from class, using cell phones, sleeping during class, and engaging in academic dishonesty. An ethical imperative exists within the context of the relationship of not only faculty to student but also faculty to faculty. Clark29 identified multiple uncivil faculty-to-faculty behaviors, all of which violate the princi- ples of beneficence, nonmaleficence, and respect for autonomy. While we speak of incivility, the real issue is an unethical environment. The faculty is responsible for the moral teaching and learning climate. An initial step toward establishing an ethical environment is to explain the academic integrity policies on the first day of class. When the faculty indicates that honesty is an expectation and there is zero tolerance for any form of dishonesty, most students will understand the difference between right and wrong behaviors.

Duty to the Profession, Global Health, and Social Justice (Provisions 7 to 9) The final 3 provisions focus on ethical obligations of nurse educators beyond their immediate surroundings to the global community. Provision 7 illustrates moral obligations to further the profession through scholarly endeavors and maintaining professional standards. Faculty members in higher education have an expectation of research and schol- arship, as well as teaching and service, usually tied to their continued employment or tenure at the university. Other faculty may find their primary focus as teaching; however, all faculty members have responsibility related to the scholar-

ship of teaching by virtue of their role. Oermann30 identifies the scholarship of teaching as inquiry about learning and teaching, asking questions about what works best, and seek- ing answers. Although The Code does not explicitly mandate that all nurse educators conduct research, it calls for faculty to apply research within nursing education and remain current in their area of practice.5

The focus of provision 8 is the collaboration needed to improve the conditions of those locally and around the world. Health as a universal right is the foundational belief underlying provision 8.1 While nurse educators are indi- vidually responsible to seek out ways to collaborate to improve the health of society, they also need to ensure that the curriculum has incorporated collaboration. Corbridge and Tiffen31 indicated that there is still a lack of interpro- fessional offerings in many schools.

How do students learn to collaborate with others? Nursing education should provide students with the basic foundation and understanding of interprofessional and collaborative practice.32 Students need opportunities to interact with students from other health profession pro- grams.33 If students are to learn how to collaborate to solve problems, they must first experience this within the nursing curriculum. While the focus of provision 8 is col- laboration, the purpose of the collaboration is to uphold human rights and improve the health of others and lessen health disparities.1

Nurse educators have a moral obligation to raise students’ awareness of health disparities, locally, nation- ally, and globally. The nurse’s role in decreasing health disparities should be included in the curriculum. Incor- porating service learning into the curriculum is a way for students to acquire nursing values. With service learning, students can develop ‘‘moral judgment, civic responsibil- ity, cultural competence, and global awareness.’’34

Provision 9 focuses on articulating nursing values through professional organizations and integrating princi- ples of social justice into the profession and health policy. In the interpretative statement about integrating social justice, The Code specifically challenges the nurse educa- tors to ensure that the students understand that they must address social justice issues. How can The Code guide a nurse educator’s teaching? Following The Code’s pro- visions on the equal, just, and fair treatment of human beings would support and complement teaching students about poverty, economic inequality, health disparities, and global concerns. Another way for The Code to guide teaching practice is introducing students to social justice issues and providing opportunities to engage with vul- nerable populations. Exposing students to these issues helps to transform The Code to real-life examples.

An area that is new to The Code is the inclusion of environmental stewardship in terms of social justice and health policy. This concept of The Code can guide faculty in assisting students to think outside of their geographical area to achieve global awareness. Integral to physical health and improved socioeconomic status is environmental health. It is not enough for environmental stewardship to be taught through the narrow lens of community nursing; rather, this concept should be threaded through other nurs- ing courses.

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Summary An examination of The Code revealed that it can and should guide the practice of nurse educators. Although other doc- uments can also be used, it is The Code that remains nonne- gotiable for nurses in all settings. The authors presented pragmatic ways in which The Code could be applied to nurse educators’ practice. Conscious attention to The Code by nurse educators is essential to creating and maintaining an ethical faculty-student relationship and environment in which to practice as a nurse educator.

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5. Fowler M, Davis A. Ethical issues occurring within nursing education. Nurs Ethics. 2013;20(2):126-141.

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11. Schmitt TL, Sims-Giddens SS, Booth RG. Social media use in nursing education. Online J Issues Nurs. 2012;17(3):2.

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20. Ridley R. Assuring ethical treatment of students as research participants. J Nurs Educ. 2009;48(10):537-541.

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24. Robertson JE. Can’t we all just get along? A primer on student incivility in nursing education. Nurs Educ Perspect. 2012;33(1):21-26.

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26. Clark CM, Springer P. Academic nurse leaders’ role in fostering a cul- ture of civility in nursing education. J Nurs Educ. 2010;49(6):319-325.

27. Clark CM. Pursuing a culture of civility: an intervention study in one program of nursing. Nurse Educ. 2011;36(3):98-102.

28. Clark CM. Creating and Sustaining Civility in Nursing Education. Indianapolis, IN: Sigma Theta Tau; 2013.

29. Clark CM. National study on faculty to faculty incivility: strategies to foster collegiality and civility. Nurse Educ. 2013;38(3):98-102.

30. Oermann M. Defining and assessing the scholarship of teaching in nursing. J Prof Nurs. 2014;30(5):370-375.

31. Corbridge S, Tiffen J. Implementation of an interprofessional educational model. Nurse Educ. 2013;38(6):261-264.

32. Gordon MA, Lasater K, Brunett P, Dieckmann NF. Interprofessional education: finding a place to start. Nurs Educ. 2015;40(5):249-253.

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34. Mueller C. Service learning: developing values, cultural compe- tence, social responsibility, and global awareness In: Billings D, Halstead J. eds. Teaching in Nursing: A guide for Faculty. 5th ed. St. Louis, MO: Saunders; 2016:197-210.

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