Yusrita Zolkefli
PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam BE1410, Brunei Darussalam
Corresponding Author’s Email: yusrita.zolkefli@ubd.edu.bn
ABSTRACT
In mid-December 2019, an ethics colloquium on moral courage was conducted, which prompted considerable interest among the clinical nurses in Suri Seri Begawan Hospital, the second-largest hospital in Brunei. The question and answer session reflected the sense of vulnerability that nurses might encounter in their daily practice. To be morally courageous, it appears that one has to be ready to accept the possible price of speaking up or raising concern about questionable and poor practices within the workplace settings. Overall, the session ensued in a meaningful and intriguing discussion, particularly when courage was regarded through a narrow and sceptical lens. As educators, there is a striking need for greater clarity on the role of nursing education in teaching moral courage and the long-standing challenges involved in ensuring that future nurses hold this value in realising good ethical practices.
Dear Editor,
In mid-December 2019, an ethics colloquium on moral courage was conducted, which prompted considerable interest among the clinical nurses in Suri Seri Begawan Hospital, the second-largest hospital in Brunei. The question and answer session reflected the sense of vulnerability that nurses might encounter in their daily practice. To be morally courageous, it appears that one has to be ready to accept the possible price of speaking up or raising concern about questionable and poor practices within the workplace settings. Overall, the session ensued in a meaningful and intriguing discussion, particularly when courage was regarded through a narrow and sceptical lens. As educators, there is a striking need for greater clarity on the role of nursing education in teaching moral courage and the long-standing challenges involved in ensuring that future nurses hold this value in realising good ethical practices.
We recognise that students invest half of their learning in a clinical setting. They are more likely to experience or be expected to engage in circumstances below the standard. For example, the unequal power relations between nurses and students have been popular themes in the literature whenever they want to act courageously. In other words, the students' reduced ability to act with moral courage is epitomised when they repeatedly restrict their role and identity as merely being a student in clinical placements (Bradbury-Jones et al., 2011). Such an image becomes problematic when considering their status as the lowermost in the professional hierarchy (Grealish & Trevitt, 2005).
Furthermore, the need for acceptance was so strong that they reported being hesitant to risk upsetting the nurse (Levett-Jones & Lathlean, 2009). If such narratives persist, we must be particularly concerned. We certainly would not want students to be at risk of feeling or becoming desensitised to poor practices. Likewise, we do not wish that the students enter the workplace, believing that the theories and codes of ethics taught at university are hypothetical and inconsistent with reality.
Moreover, there are also concerns that students who do not have the moral courage to challenge unethical conduct may suffer some degree of moral distress after the incident (O'Mara et al., 2014). Not only students reported feeling guilty, but they also blamed themselves for any adverse results or trauma experienced by the patient, even though they were only observers of the situation (Rees et al., 2014). Unfortunately, this moral discomfort affected many students physically and emotionally (O'Mara et al., 2014). These responses were particularly evident every time I evaluated nursing students' written reflections on their clinical experiences.
As nursing educators, the fundamental question is how we can best prepare our students for moral courage (Fitzpatrick, 2018). We can also motivate students to act courageously and develop a degree of moral resilience. Looking back on past teaching observations, I often discovered the frustration, anger and reflections of nursing students who struggle with unethical issues that they feel are counterproductive and harmful to nurses and other health professionals. In many instances, it is most likely that the students perceive silence as a way forward. Thus, it is perhaps time to extract valuable lessons from the students' reflective feelings and experiences, for example, by incorporating them into our teaching as nursing case studies or scenarios. It would also help incorporate practical ethical dilemmas into clinical teaching that offer debriefing on ethical practices, methods of conflict management, and advocacy.
Meanwhile, integrating ethical values in all nursing courses is also significantly desirable rather than as a standalone option. Similarly, students must fully realise that it is by no means startling that they will “bump into” moral issues throughout their professional lives regardless of context and clinical setting. Simultaneously, it is salient that nurse educators and practising nurses, in general, be more assertive and take the time to consider, reflect, and deliberate how we can aspire them to be ethically competent nurses in the future. To do so, we must strongly reject outdated notions that students are powerless. In essence, strong commitment and proactive engagement from both education and practice will help contour morally courageous future nurses who do not trade-off on good and ethical care and are able to recognise and appropriately respond to ethical concerns.
Note: No hospital data were collected in the writing of the paper, which is entirely based on the author’s teaching reflections on the subject.
REFERENCES
Bradbury-Jones, C., Sambrook, S., & Irvine, F. (2007). The meaning of empowerment for nursing students: a critical incident study. Journal of advanced nursing, 59(4), 342–351. https://doi.org/10.1111/j.1365-2648.2007.04331.x
Bradbury-Jones, C., Sambrook, S., & Irvine, F. (2011). Empowerment and being valued: a phenomenological study of nursing students' experiences of clinical practice. Nurse Education Today, 31(4), 368–372. https://doi.org/10.1016/j.nedt.2010.07.008
Fitzpatrick J. J. (2018). Teaching Moral Courage: Obligation and Challenge. Nursing Education Perspectives, 39(4), 200. https://doi.org/10.1097/01.NEP.0000000000000372
Grealish, L., & Trevitt, C. (2005). Developing a professional identity: student nurses in the workplace. Contemporary Nurse, 19(1-2), 137–150. https://doi.org/10.5172/conu.19.1-2.137
Levett-Jones, T., & Lathlean, J. (2009). 'Don't rock the boat': Nursing students' experiences of conformity and compliance. Nurse education today, 29(3), 342–349. https://doi.org/10.1016/j.nedt.2008.10.009
O'Mara, L., McDonald, J., Gillespie, M., Brown, H., & Miles, L. (2014). Challenging clinical learning environments: experiences of undergraduate nursing students. Nurse Education in Practice, 14(2), 208–213. https://doi.org/10.1016/j.nepr.2013.08.012
Rees, C. E., Monrouxe, L. V., & McDonald, L. A. (2015). 'My mentor kicked a dying woman's bed…' analysing UK nursing students' 'most memorable' professionalism dilemmas. Journal of Advanced Nursing, 71(1), 169–180. https://doi.org/10.1111/jan.12457