Abstract: When a clinical instructor must weigh the duty to educate against urgent patient care needs.
Clinical nursing instructors have two primary ethical responsibilities: to ensure a competent nursing workforce by educating students in the physical and psychosocial skills that constitute good nursing care, and to ensure that patients who allow students to care for them receive safe, quality nursing care. Both obligations can usually be met without undue compromise. However, when unit resources are insufficient and can't easily meet patient needs, the responsibility to educate students may conflict with the unit's more immediate patient care priorities.
Nursing care is the practical application of scientific knowledge to clinical decision making; it is also the application of technical and relational skills for the benefit of people with real and potential health problems. Therefore, educating competent nurses requires several approaches. Some aspects of nursing, such as acid–base balance or the pathophysiology of schizophrenia, can be learned in the classroom. Other aspects, such as performing a physical examination, can be experienced and improved through the use of simulated situations. But true mastery of nursing practice can only be acquired through giving care, with expert guidance, to real patients in all their physical and psychosocial diversity. As nursing theorist Patricia Benner puts it, “At the heart of good clinical judgment and clinical wisdom lies experiential learning from particular cases.”1 Aside from the dual obligations of educating students and ensuring safe, quality patient care, nurse educators in a clinical setting (as well as their students) should operate with acknowledged gratitude to the patients who altruistically agree to be cared for by a novice, and to the host institution and its staff. The host institution's first responsibility is to its patients—and the education of students, while important, is secondary; in addition, hosting students generally involves some institutional expenditure of limited resources.When the nurse instructors’ obligation to educate students and to ensure that they provide high quality care to patients doesn't align with the unit's patient care priorities, instructors may find themselves struggling to balance the learning needs of students, the care needs of patients, and the needs of the host institution.
Consider the following hypothetical case:Jane Merritt, a clinical instructor for eight medical–surgical students, steps into the nurses’ station and immediately senses the atmosphere of urgency that's often indicative of short staffing. Barbara Stuart, the charge nurse, says, “Jane, I'm so glad it's your clinical day. We need you and the students to help us out. It would be great if the students can get the vitals, answer the lights, and help with routine ADLs and ambulating. Today, it's all hands on deck—I'm sure you understand.”Earlier that morning, Ms. Merritt had reviewed the unit census and identified one patient with congestive heart failure, hypertension, and possible depression who needed to learn blood pressure self-monitoring, and another with uncontrolled type 2 diabetes and poststroke hemiplegia whose caregivers needed support. She had planned to supervise several students in assessing and caring for these patients. She considers this experience essential for the students to meet the course goals and progress to the next level. The activities Ms. Stuart suggests, while essential aspects of nursing care, involve skills the students had mastered earlier in the program. Ms. Merritt's plan for exposing the maximum number of students to these patients with her guidance cannot happen if she accepts the charge nurse's plan for her students to help out.Ms. Merritt may feel uncomfortable, but she doesn't immediately recognize the situation as an ethical problem. If we examine the source of her discomfort, we can see that basic professional values are in conflict; this is an ethical dilemma that can be addressed using the tools of ethical analysis.
The two nurses can work together toward a resolution of the conflict and the formulation of a plan of action by first identifying the values involved and how they conflict. Then the discomfort arising from circumstances in which not all of the values in play can be fully enacted can be examined, explicitly and transparently.After determining the values in conflict, the nurses can identify those aspects of the situation that determine the moral justification for the different possible actions—that is, the variables ethically relevant to the circumstances. In addition, they will need to identify applicable and relevant legalities and practice standards. Having done so, they will be ready to assess the relative merits of the ethically relevant variables and plan action that agrees with their values, to the greatest degree possible in the circumstances, and complies with ethical, legal, and practice standards.
IDENTIFYING CONFLICTING VALUES
A practical way to identify the values in a given situation is to consider the factors used to judge better outcomes. In weighing the options related to teaching the students versus making the students available to help the staff, both the clinical instructor and the charge nurse are concerned with balancing the consequences of their choices as they affect two areas: * student learning, which may influence the care of future patients * the quality of care given to today's patientsThe outcome of this situation will be judged by the degree of student learning and the quality of patient care. Therefore, the values at stake and in conflict are learning and patient care. In addition, Ms. Merritt, the clinical instructor, is concerned about acting in a way that's consistent with gratitude to the staff for hosting the students.Naturally, the two nurses would prefer to fully honor the values of both student learning and patient care. While this is possible on most days, it is not today. While they would like to support the enactment of both of these values, we can expect the clinical instructor to advocate first for educating the students and the charge nurse for providing the best patient care.While important values are in conflict here, there's no need to assume that a resolution must put all available resources solely in support of one or the other. In actual practice, compromise is more likely, and a situation like this is likely to involve a negotiation between the instructor and the charge nurse to reach a plan of action that involves some teaching and some helping. If, when values are in conflict, the parties involved jump too quickly to adversarial positions, the opportunity for creative resolutions can be passed over. Still, after due consideration of creative solutions and compromises, the nurses in this example may well find that the plan of action should emphasize either teaching or helping.
IDENTIFYING ETHICALLY RELEVANT VARIABLES
Identifying ethically relevant variables can be helpful when deciding where to place the emphasis in a resolution. Ethically relevant variables, nicely described by Chis Gastmans in a 2002 article in Nursing Ethics, are those aspects of a situation that, if changed, alter the potential satisfaction of the values at stake.2 As variables, each represents a continuum of possibilities rather than either/or alternatives. Where the specific facts of a case occur on that continuum can be understood as supporting an emphasis on one of the relevant values.3 Examples from the current case include the following: * The good that would come from teaching and the likelihood of this good. The greater the potential future patient benefit from the students’ learning, the stronger the rationale for emphasizing teaching instead of helping out. (The greater likelihood of the students achieving competency from the clinical instructor's planned lessons than by taking part in patient care activities in which they are already competent supports the argument for more emphasis on teaching.) * The good that would come from helping out and the likelihood of this good. Patient need and the potential for alleviation of suffering contribute to the rationale for greater emphasis on helping over teaching. In addition, by having the students help out where needed on the unit, the instructor is achieving some degree of good by honoring the debt of gratitude to the staff. (The likelihood of achieving good from helping out on the unit would support this value if the student and instructor's assistance in unit nursing care actually improve patient care or reduce risk.) * The harm that could come from not teaching and its likelihood. The more the clinical instructor believes that future patients could be harmed if the students lack competency in the areas she had planned to teach, the stronger the rationale for emphasizing teaching over helping out. In addition, the teaching enterprise could be harmed if the unit began to expect higher levels of student help. * The harm that could come from not helping. The perceived level of urgency of patient need for care on the unit is likely to affect the strength of support for the rationale to help out. * The effect on relationships. Emphasis on either helping out or teaching will affect the relationship between the instructor and the staff and institution differently. These relationships could suffer from the perception that the instructor and students are not appreciative of the staff's support of their education. This might not mean emphasizing helping over teaching, but it does argue for the instructor giving real attention to meeting the staff's needs.One difficulty in weighing these parameters is that the good consequences of helping the staff are short term and visible, and with patients in the present, while the good of teaching is hypothetical competence in the future. Ethical justification for a plan of action in this situation calls for the parties involved to explicitly state the values at stake and then weigh the case-specific facts in relation to the ethically relevant parameters. This must then also be reconciled with the applicable legalities of the nurse–patient relationship.
STANDARDS AND LEGALITIES
In negotiating a plan of action, both the clinical instructor and the charge nurse need to consider their legal relationship to the patients. A nurse–patient relationship exists as soon as the student represents her- or himself to the patient as giving nursing care. The student, the instructor, and the responsible staff nurse all have legal liability within this relationship. Therefore, student assignments need to be carefully made so they fall within the students’ current capabilities and allow for sufficient guidance from the instructor and staff to ensure quality of care. This consideration will need to remain a priority in the students’ assignments even if the decision in this case is to favor helping out over student instruction.Under ordinary circumstances, the students would not have a legal obligation to care for patients not assigned by the instructor for educational purposes. Still, if the instructor and students witness patients suffering from lack of nursing care, this creates a moral disposition to assist. Further, under extreme circumstances—such as during a natural disaster, or if life and limb were at risk, or severe suffering could be alleviated by helping out—there would be a moral and, if extreme enough, a legal obligation to contribute care.
OPPORTUNITY FOR SYSTEMIC CHANGE
When problematic situations arise frequently enough, they point to an opportunity for systemic change. Emerging innovative models of academic–clinical partnerships, such as dedicated educational units (DEUs), may help limit the occurrence of the type of problem encountered by the two nurses in this hypothetical case. In the DEU, staff are trained and integrated as mentors and instructors of students, with faculty serving in a coaching, guidance role.4 DEUs reduce the chance of situations like the one described here by increasing the amount and quality of engaged, recurring communication in the service of achieving shared objectives; encouraging “problem solving to maintain valued relationships”; and “working together toward mutual outcomes.”5 DEUs achieve these goals by arranging resources in advance and training staff to support educational goals by making this part of their job expectation—with the time a staff member needs to spend with the student and the help given by the student included in the individual and unit workload allocation calculation.
HARD DECISIONS REQUIRE WORKING TOGETHER
Because new situations arise all the time, and every situation varies in its ethically relevant aspects, rigid rules often cannot guide ethical action. Instead, analytic skills and transparent negotiation are crucial for resolving conflicts between values as they arise in day-to-day interaction—and for supporting the solutions we choose.
1. Benner P. Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education Bull Sci Technol Sci. 2004;24(3):188–99
2. Gastmans C. A fundamental ethical approach to nursing: some proposals for ethics education Nurs Ethics. 2002;9(5):494–507
3. National Ethics Committee of the Veterans Health Administration. Ethical considerations that arise when a home care patient on long term oxygen therapy continues to smoke. Washington, DC: Department of Veterans Affairs, Veterans Health Administration, National Center for Ethics in Health Care; 2010 Mar. http://www.ethics.va.gov/docs/necrpts/NEC_Report_20100301_Smoking_while_on_LTOT.pdf.
4. Murray TA, et al. Building bridges: an innovative academic-service partnership Nurs Outlook. 2010;58(5):252–60
5. Mulready-Shick J, Flanagan K. Building the evidence for dedicated education unit sustainability and partnership success Nurs Educ Perspect. 2014;35(5):287–93
By Olsen, Douglas P. PhD, RN; Palmer, Lisa M. MSN, RN; Poindexter, Kathleen PhD, RN, CNE
Douglas P. Olsen is an associate professor, Lisa M. Palmer is an instructor, and Kathleen Poindexter is an assistant professor at the Michigan State University College of Nursing in East Lansing. Olsen is also a contributing editor of AJN. Contact author: Douglas P. Olsen, firstname.lastname@example.org. The authors have disclosed no potential conflicts of interest, financial or otherwise.
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