II. NURSING

Ethics has received increased attention in nursing education programs; however, problems remain. This entry provides an overview of nursing ethics education in the United States and in other countries addressing both the advances made and the issues remaining.

Nursing Ethics Education in the United States

Nursing ethics has been incorporated to some degree in nursing education since the early twentieth century. In the early 1900s ethics was taught as a science necessary to the education of the competent nurse who put patient safety and welfare first (Robb). Ethics teaching, reflecting religious and military influences, focused on the character and ethics of the nurse, the virtues required of nurses (e.g., loyalty and obedience), the duties and obligations nurses owed physicians and the hospitals that employed them, and proper etiquette for nurses. Obligations that nurses have as citizens of the community to participate in public policy and political areas to achieve healthcare goals first emerged in the Code of Ethics proposed by the American Nurses' Association(2001) in 1926 and adopted in 1950, and in the nursing literature of the first half of the twentieth century (Goodrich; Densford and Everett; Fowler). These wider obligations of nurses as citizens continue to be a very minor theme in nursing ethics education.

Ethics as a distinct part of the nursing curriculum almost disappeared in the 1950s and 1960s, except in programs affiliated with religious traditions and institutions. The 1970s brought renewed attention to nursing ethics education, partly because of the resurgence of medical ethics and the appearance of bioethics in the professional and academic worlds. These were responses to challenges emerging from medical technologies, abuses in research, and changes in the healthcare environment, challenges for which no ready-made responses were available. Some nurse educators and philosophers recognized, however, that nurses faced ethical issues and challenges different from those faced by physicians, largely because of nurses' positions as employees rather than as independent professionals in healthcare organizations. The National Student Nurses' Association and the American Nurses' Association passed resolutions calling for more attention to ethics in nursing education programs.

A survey conducted to assess the status of ethics teaching in accredited baccalaureate and graduate nursing programs (Aroskar) disclosed that most schools offered limited opportunities for study of ethical aspects of nursing and that these opportunities were often integrated into other nursing courses. Only 7 percent of the programs required work in ethics or medical ethics. Codes of ethics such as the Code for Nurses (American Nurses' Association, 1976) were identified as priority content in ethics courses, followed by patients' rights and obligations. No nursing faculty had primary responsibilities for teaching ethics.

Beginning in the late 1970s and early 1980s, nursing ethics education that incorporates values clarification and a more philosophical, principled approach to ethical issues received increased attention in nursing programs. This continuing development, however, depends on administrative support, faculty priorities, interests, and expertise, and varies greatly from school to school. A few nursing programs have full-time faculty in teaching and research activities devoted to ethics in nursing. Usually these are schools with master's and doctoral programs in nursing that offer studies in ethics, bioethics, and philosophy as electives or as a minor field. Teaching resources such as textbooks and nursing journal articles on ethics have increased significantly. Since 1975, activities to enhance the teaching of ethics in nursing have been supported by the Joseph P. Kennedy, Jr., Foundation, the National Endowment for the Humanities, The Hastings Center, the Fund for the Improvement of Post Secondary Education (FIPSE), and other institutions. There are more than fifty-five academic bioethics centers in the United States offering undergraduate, graduate, or continuing education courses in bioethics. However, few have dedicated programs or joint appointments for nursing ethics education (National Reference Center for Bioethics Literature [NRCBL], 2002a).

Baccalaureate education provides the foundations for professional nursing practice that requires knowledge of ethical obligations of the profession and ethical decisionmaking skills for the practitioner. Not all baccalaureate nursing programs have required or elective courses in ethics. Ethics education is still not required for program accreditation. Where ethics is a required curriculum component, content may be offered through separate courses or modules (Payton); integrated throughout the curriculum in existing courses (Ryden et al.); or presented in some combination of separate courses and integrated into classroom and clinical experiences. New approaches focus on case discussion, writing portfolios, and web-based interaction to encourage application of core concepts to clinically encountered situations (Pinch and Graves; Sorrell et al). An overall goal is to develop morally accountable practitioners who have a clear conceptual framework and the skills for ethical decision making in practice (Cassells and Redman; Fry, 1989). Ethics education is required core content for master's education in nursing and for the preparation of advanced practice nurses (American Association of Colleges of Nursing, 1996; American Nurses' Association, 1996; Kenney).

Sara T. Fry identified four models of ethics teaching used in undergraduate and graduate nursing programs and clinical settings:

1. The moral-concepts model incorporates three general areas: historical foundations of the nursing ethic, including codes of ethics and medical versus nursing ethics; the value dimensions of nursing, such as advocacy, loyalty, and moral obligations; and the skills needed for ethical decision making.
2. The moral-issues model focuses on common moral problems in healthcare relationships, such as confidentiality and informed consent, and issues of moral concern in healthcare, such as abortion, termination of treatment, and allocation of healthcare resources. Course content includes historical and contemporary legal cases that illustrate the legal and ethical aspects of specific issues in patient care.
3. The clinical-practice model, developed by bioethicists and nurse ethicists, incorporates clinical conferences on moral issues in patient care usually specific to a clinical area, case-study presentations, and ethics rounds that focus on ethical issues pertaining to a patient's care rather than to a patient's clinical condition.
4. The ethics-inquiry model, found primarily at the graduate level, incorporates the forms of traditional philosophical inquiry such as descriptive, normative, and metaethics; explores diverse methods of ethical inquiry; and looks at the relationship of ethical inquiry to other forms of inquiry in science and nursing. Additional topics in ethics education include the role of the nurse as a moral agent; roles of gender and ethnicity in nursing ethics; major ethical theories and principles and their application in nursing practice; and the ethics of nursing research.

Since the early 1990s, caring as a foundation of nursing ethics has received a great deal of attention (Bishop and Scudder; Harbison). Curriculum change based upon theories of caring has been proposed and, in many places, implemented. However, strong critiques of theories of caring and the ethics of care persist and the success of these curricular changes has yet to be established.

The ethics of end-of-life care and pain management have also received much attention since the mid-1990s. Reviews of standard nursing texts found very little content related to pain management, end-of-life care, or the ethical issues at the end of life (Ferrell et al.). Concern over these shortcomings was mobilized into national projects to develop resources for teaching nurses the clinical skills needed for pain and symptom management as well as an understanding of the myriad ethical issues that arise in the provision of end-of-life care. The End-of-Life Nursing Education Collaboration Project (ELNEC) developed a standardized curriculum on end-of-life care and provided train-the-trainer programs for nursing school faculty, continuing education providers, and state boards of nursing across the country (American Association of Colleges of Nursing, 1996). The Toolkit for Nursing Excellence at End-of-Life Transitions (TNEEL) was provided free of charge to all nursing schools (Wells et al.). TNEEL is a computerized learning tool provided on CD-ROM that contains multimedia components such as audio, video, graphics, photographs, and animation to create an interactive program. Both of these projects contain specific ethics content as a prominent component of the suggested curricula.

Examples of specific outcome objectives for nursing ethics education include:

Identification of ethical dilemmas in the delivery of nursing care;

Identification of the components of an ethical decision-making framework;

Participation in ethical decision making in client care;

Leadership participation in ethics rounds and institutional ethics committees;

Analysis of impediments to the ethical practice of nursing;

Distinguishing the ethical elements of nursing practice from medical or technical elements; and

Analysis of nursing codes as they relate to client advocacy (NRCBL 2002b).

There are underlying tensions and ongoing debates in nursing ethics education. Argument continues over the question of whether nursing ethics does or should exist as a separate field of inquiry. Differences have arisen between those who teach ethics based on cognitive-moral-development theory and those who teach ethics based on moral philosophy and ethical theory. Evaluation of the effectiveness of ethics teaching has been a continuing challenge. Although research on ethics in nursing education has been expanding, it needs to be developed more systematically if it is to contribute to effective curriculum change (Silva and Sorrell). A shortage of adequately prepared faculty and overcrowded nursing curricula impede ethics teaching in nursing programs.

Nursing Ethics Education in Other Countries

The fact that nursing ethics education in the international arena varies so greatly reflects the state of nursing and nursing education, as well as the priority of healthcare problems and issues, in many different countries. The lack of systematic, international information about nursing ethics education creates problems in providing a general overview of the topic.

The International Council of Nursing (ICN), Geneva, in an effort to address the uneven development of nursing ethics education, has provided ethics education through publications, programs, and conferences. The ICN's code of ethics serves as the nursing code in many countries. The code was revised in 2000. Since these countries have different histories, cultures, and priorities, the question arises as to whether or not all countries have common ethical values and principles regarding nursing and nursing education. In addition, much of nursing ethics education in the United States focuses on the issues that arise from advanced medical technology, whereas the main issue in many other countries is primary healthcare. More recently, numerous countries have developed their own codes of ethics for nurses.

Since the early 1990s, ICN has scheduled a special interest group in nursing ethics at its major open international meetings. This has been very successful in identifying nurses around the world with this professional focus.

The Journal of Nursing Ethics, which began in 1994, provides an arena for information and research from an international perspective. In conjunction with the journal, the editors and editorial board members established an International Centre for Nursing Ethics at the University of Surrey, England, that provides a place for researchers and educators to visit or come for more extended work.

In the United Kingdom nursing education is well developed, and higher education has been available to nurses for many years. In some colleges or departments of nursing, ethics is either taught as a separate course or integrated into other courses. During recent decades, the Royal College of Nursing actively articulated nursing ethics. In addition, nurse educators and others have published numerous papers, research reports, and books focused on nursing ethics. A major British nursing journal includes an ethics column that deals with clinical ethical problems. The Center for Midwifery and Nursing Ethics in London publishes a newsletter, runs educational programs, and serves as a clearing-house for ethics materials. In 1990, Swansea University, Wales, sponsored the first national conference on nursing ethics and nursing ethics education. Over the past several years, Swansea has also sponsored conferences on Nursing Philosophy and since 1999 has published a journal with this title that includes ethics articles (De Raeve).

In Canada, numerous conferences have focused on nursing ethics and ethics education. An annual conference to discuss philosophy and nursing touches on many ethical themes. Several schools of nursing have invited visiting professors to teach ethics and have prepared some Canadian nursing professors to teach this subject as well. Canada has revised its own nursing code of ethics in 2002.

The ethics committee of the Swiss Nursing Association wrote a code of ethics in the 1980s and has been instrumental in increasing nurses' awareness of the need for more systematic approaches to teaching ethics in nursing programs. The association includes in its annual conference papers on ethics in curriculum content and clinical practice. For some years, one nurse educator has taught courses in Switzerland and France on ethical issues in dying and death with a special focus on suffering.

Nurse educators in Finland have offered seminars around the country on nursing ethics. One nurse educator has published a book on the topic. Several nurse educators in Finland and other Nordic countries have conducted research on ethical questions and have participated in multinational research projects examining selected ethical issues.

The board of directors of the Center for Medical Ethics at the University of Oslo, Norway, consists of people from diverse health-related professions. It continues to work with nurse educators and nurse researchers in developing educational programs and research focused on ethical issues.

Universities in both Norway and Sweden have invited nurse educators from overseas to lecture on nursing ethics. The annual, week-long seminar held in Sweden for doctoral students in nursing, which has either a primary or secondary focus on nursing ethics, has been of special interest because of its potential impact on nursing education. Extensive research on the ethics of various clinical problems with elderly patients has been undertaken at the University of Umea, Sweden. In Stockholm, two nurse educators teach and conduct research in nursing ethics.

One nurse educator in Budapest developed an ethics course for nursing students and wrote a textbook to use in this education. Another nurse educator teaches an ethics class at the Academy of Medicine in Lublin, Poland. In the Baltic States and Eastern Europe, physicians often are the major or only faculty teaching in nursing schools. For example, Estonia has a shortage of nurses prepared to teach nursing. In this context, emphasis has been placed on the medical model and little, if any, ethics has been included because the teachers have had limited exposure to ethics content. Nursing leaders in Estonia and other countries with similar problems are developing alternatives to this situation.

Throughout Latin America, Colombia has been the most active in nursing ethics education. The National Association of Nursing Schools has an ethics committee working with schools of nursing, the Ministry of Health, and the Nursing Association to increase ethical content in nursing education. The ethics committee sponsors workshops on nursing ethics and has been involved in research projects on nursing ethics. Chile has a nurse who has dealt with ethical issues working in the national nursing association. Brazil nurse educators teach nursing ethics and conduct research on ethics topics. Increasingly, nurses, and colleagues in other professions, are developing collaborative activities in teaching and research in healthcare ethics. Some of these activities involve Spain.

Australian nursing education throughout the country has supported conferences, seminars, and consultation in nursing ethics. One nurse ethicist in Melbourne has taught in a nursing program and has published several books in the field. The Center for Human Bioethics in Melbourne, established in 1980, examined the state of nursing ethics in Australia and has continued to work with nurses seeking education in ethics. In Queensland, a professor in the university nursing department served as a member of the research ethics committee at her institution. Both Australian and New Zealand nurses contribute regularly to the nursing ethics literature.

Numerous nurse educators present papers at the ongoing World Congress on Law and Ethics which recently elected a Swedish nurse to its board. In Israel, Jewish ethics has been taught throughout the nursing curricula and several educators conduct research in healthcare ethics.

The High Institute of Nursing, University of Alexandria, Egypt, held a nursing ethics conference in 1993 on ethics in education and practice. More recently, the Aga Khan University College of Nursing, Pakistan, held a conference and invited a keynote paper on nursing ethics.

In Asia, the People's Republic of China has developed eleven bachelor of science in nursing programs. The curriculum has included an ethics course that combines Confucian and Maoist ethics. The political slogan "serve the people" translates in nursing into respect for patients as persons. One Hong Kong educator conducted extensive research focused on nursing ethics in China. Korean nursing has developed an interest in ethics that manifests the influences of Christian missionary work. At Japan's national and international nursing research conferences, nurses present papers on nursing ethics from a clinical and an educational perspective. The Japanese Association of Bioethics includes nurses as speakers and participants in its conferences. The Japanese Nursing Association has an ethics committee and increasingly, the many new colleges of nursing are developing research ethics committees.

This discussion reflects great differences and many activities in nursing ethics education on the international scene. The lack of teachers and resources to teach nursing ethics remains a serious problem in many countries. However, one of the most striking developments in nursing ethics education is the amount of international research being conducted. Collaboration among Europeans and among European, Asian, and North and South American nursing colleagues has increased and provides a rich source of data for teaching.

Conclusion

The last two decades of the twentieth century have seen a significant, worldwide resurgence and expansion of nursing ethics education activities and programs. These efforts have varied greatly. Many serious challenges remain for the twenty-first century, including a lack of formal ethics teaching in many programs, inadequate resources such as prepared nursing faculty to teach ethics, and the need for evaluation of the impact of existing nursing ethics education courses and programs on nursing practice.

mila a. aroskar

anne j. davis (1995)

revised by theresa drought

anne j. davis

SEE ALSO: Bioethics; Literature and Bioethics; Narrative; Nursing Ethics; Nursing, Profession of; Nursing, Theories and Philosophy of;Sexism; Teams, Healthcare; Women as Health Professionals; and other Bioethics Education subentries

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INTERNET RESOURCES

American Nurses' Association. 2001. Code of Ethics for Nurses with Interpretive Statements. Available from <http://www.nursingworld.org/ethics/ecode.htm>.

International Centre for Nursing Ethics. 2002. Available from <http://www.freedomtocare.org/iane.htm>.

International Council of Nursing. 2000. Code of Ethics for Nurses. Available from <http://www.icn.ch/icncode.pdf>.

National Reference Center for Bioethics Literature. 2002a. "Educational Opportunities in Bioethics, Spring 2002." Available from <http://www.georgetown.edu/research/nrcbl/edopps.html#usa>.

National Reference Center for Bioethics Literature. 2002b. "Syllabus Exchange Catalogue, 2002." Available from <http://www.georgetown.edu/research/nrcbl/syllabus/sylbcat.htm>.