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Fethiye Erdil and Fatos Korkmaz

Nursing students increasingly encounter ethical problems during their clinical practice which
sometimes infringe the rights of patients. However, so far there is no study in Turkey on the
extent of problems from the perspective of nursing students, as well as how nurses are in-
volved in ethical decision making process. This study is conducted at Hacettepe University
Health Science Faculty Nursing Department with the aim of identifying the ethical problems
confronted by nursing students. Eighty-four third class and 69 senior nursing students were
volunteers to participate in this study. Their age ranged from 19 to 23 years. All participants
have taken the course entitled ‘Nursing History and Deontology’ which include 14 hours eth-
ical content. Students were asked to describe moral problems that they observed or en-
countered during their clinical practice. Ethical problems at clinical practice were reported as
physical maltreatment of patients (28%), inappropriate approaches toward patients which
cause psychological distress (24%), violation of privacy (21%), providing inadequate inform-
ation (16%) and discrimination based on the social and economical status (16%). The reasons
of these ethical problems were stated by students as the unprofessional conduct of physicians
(34%) and nurses (44%), and ineffective hospital management (9%). The most striking find-
ing of this study was that 75% of nurses were not involved in decision making process of
resolving these problems. Students suggested that nurses at clinics should be much more in-
formed about the patient rights, ethical problems, and professional conduct. Since nurses are
the role models for nursing students at practice, the results of this study demonstrate the im-
portance of an in-service education for nurses on patient rights and ethical issues. We believe
that the results of this study will contribute to the enrichment of the ethical content of nursing
Key Words: nursing students, nursing ethics, patient rights, ethical reasoning


Nursing is a profession that requires alleviating the pain and promoting the health of others.
Since the primary aim of nursing is the goodness of others, it is a value laden profession. This
specific nature of nursing requires nurses to do what is right during their practice. However,
everyday nurses encounter complex situations and conflicts which can not be resolved only
through theoretical knowledge and skills. Such situations may involve moral components that
require the skills of ethical decision making for nurses. Yet, learning the skills of ethical de-
cision making can not be enough to resolve ethical problems due to many factors including
the complex nature of a given problem.
Nurse students often come into nurse education without any professional knowledge and con-
sciousness, and socializing into the norms of nursing profession takes time. Furthermore de-
veloping an ethical sensitivity toward the moral problems in nursing practice requires addi-
tional knowledge on ethics, human and patient rights, and codes of ethics for nurses, and de-
veloping the skills of critical thinking. Even equipped with such a knowledge and skills, ethic-
al decision making still requires real life experiences and good role models. For this reason,
although ethics has been part of the nursing curriculum in many countries students lack the
professional experience and legal authority to make ethical decisions. Therefore it is likely
that they can not be able to distinguish the moral component of a problem and be involved in
the process of ethical decision making. Under these circumstances, students may experience
feelings of helpless and powerlessness and frustration when they encountered ethical prob-
In Turkey, since the establishment of the first nursing high school in 1925, there was an effort
toward higher education in nursing. In 1955, the first nursing school that offered baccalaur-
eate degree has been opened at university and by 1990 most of the nursing schools integrated
ethics into the curriculum. In 2002, a national core nursing curriculum has been prepared
which indicates that nursing education should guarantee sufficient knowledge about the nature
and ethics of profession as well as general principles governing the provision of health care1.
Today, ethics are part of all nursing programs in Turkey even though the backgrounds of
teachers, educational resources and teaching methods vary widely across the country.
However, students in nursing programs of Turkey are not exceptional from the above men-
tioned problems. Although most of the nursing students acquire the necessary knowledge and
skills on ethics during the theoretical courses, they feel incapable and stressed while ob-
serving unresolved ethical problems at their clinical practices. Probably they feel more frus-
trated than their peers at other countries because they also have to witness the inferior status
of nurses among the health care team, especially physicians. Nurses as inappropriate role
models at clinical practice who can not be involved in decision making process serve as an
important obstacle for students in transferring their theoretical knowledge into the practice.
Turkish nurses are disadvantaged in terms of their professional development because nursing
in Turkey have to struggle for its autonomy and professionalism. The main reason is that nurs-
ing is a women profession in Turkey, and women dominant professions are still regarded as
inferior due to the prevail of traditional male dominant cultural values. Therefore the point of
view of our students on the ethical problems they confronted at their clinical practice may re-
flect a cultural component on this issue. So far there is no study on what kind of ethical prob-
lems are encountered by nurse students and how they perceive the role of nurses in resolving
the problems. This study may have implications both for nurse educators in Turkey and for in-
ternational nursing education.
This descriptive study is conducted at Hacettepe University Health Science Faculty Nursing
Department with the aim of identifying the ethical problems confronted by nursing students.
Eighty-four third class and 69 senior nursing students were volunteered to participate this
study. The questionnaire was prepared by researchers according to the literature review. Ques-
tionnaire includes the moral problems which student nurses encountered during their clinical
practice. At the beginning, students were informed about the aim of the study and asked if
they want to take place in the study voluntarily. The students who voluntarily accept to take
place in the study were asked to fill the form and given back in the same lesson. It takes min-
imum 20 minutes to fill the questionnaire. The questionnaire includes 5 open ended questions.
This questions are: What are the most frequent ethical / moral problems or situations you have
encountered during your clinical practice ( you can write down one to three problems), which
of the ethical principles do you think are infringed during this problems, what are the main
factors which caused the ethical problems, Do nurses have any contribution to the solution
process of these ethical problems and what are the students suggestions about effective parti-
cipation of nurses into the solution process. The answers were classified according to the con-
tent of the problems. Students answers were analyzed by the researchers and then classified
into physical maltreatment of patients, inappropriate approaches toward patients which cause
psychological distress, violation of privacy, providing inadequate information, discrimination
based on the social and economical status and communication problems between nurse-pa-
tient, nurse-doctor, doctor-patient, student nurse-ward nurse, student nurse-doctor, student
nurse-patient. The results of the study were analzed and the findings were represented with
number and percentages.
All participant students’ age ranged from 19 to 23 years. They have taken 14 hours ethical
content in the scope of Nursing History and Deontology course.
Ethical problems at clinical practice
Ethical problems at clinical practice were reported as physical maltreatment of patients (28%),
inappropriate approaches toward patients which cause psychological distress (24%), violation
of privacy (21%), providing inadequate information (16%) and discrimination based on the
social and economical status (16%). Interestingly, students reported communication problems
between nurse-patient, nurse-doctor, doctor-patient, student nurse-clinic nurse, student nurse-
doctor, student nurse-patient as ethical problems (5%).
Frequently infringed ethical principles
Frequently overlooked ethical principles were stated as autonomy (26%), privacy (21%), non-
maleficence (18%), beneficence (18%) and justice (17%).
Factors causing ethical problems
The reasons of these ethical problems were stated by students as the unprofessional conduct
of physicians (34%) and nurses (44%) and other personnel (4%), ineffective hospital manage-
ment (9%), ineffective communication (5%) and unnecessary activities to provide experience
for nursing students (4%).
Nurses` involvement in ethical decision making process
Great amount of student nurses `reports (75%) revealed that nurses were not involved in de-
cision making process. Whereas 25% of responds acknowledged that nurses were involved in
this process.
The findings of this study which were classified into more specific topics highlighted that
most frequently encountered ethical problems by student nurses were physical maltreatment
of patients, inappropriate approaches toward patients which cause psychological distress, viol-
ation of privacy, providing inadequate information and discrimination based on the social and
economical status. The findings of the study are consistent with some of research results. In
one study Berger and friends have found that nurses are confronted ethical problems due to
the limited resources which let poor quality nursing care and unprofessional doctors` behavior
to patients2. These findings are parallel with other two studies` findings which conducted in
Korea and United States of America . In these studies mostly encountered problems were de-
scribed as; nursing staff`s unprofessional behavior that resulted in poor quality nursing care,
humiliation nursing students in front of patients and patients` families and unprofessional
physicians behaviours3-4. In the results of study called `An analysis and evaluation of student
nurses’ participation in ethical decision making` revealed similar findings such as conflict
between nurses and doctors, lieing patients about the helath status, not keeping the confiden-
tiality of patients, letting patients taking decisions without necesarry information, unethical
nursing attidue to patients5. In an other study nurses stated most difficult situations as failing
treatment procedures to relief excess pain and to make decisions instead of the patients who
are in confusion, in demance and communication problems between doctors and nurses6. Stu-
dent nurses are educated in a very complex health care system that they can observe so many
unethical situations. But the extent and the importance of the problem is beyond the results of
the studies which have done until today. In one of the study which analysed student nurses`
ethical behaviours, it is found that student nurses generally on the fourt level of Kohlberg`s
Moral Development Theory that they can make decisions according to the their professional
rules but not their personal principles7. Student nurses learn what should do or how should re-
act according to the ward nurses` attitude instead of the theoretical ethical knowledge of them.
So they should be educated with real life experiences during their clinical education .
In our study most frequently infringed ethical principles were found as autonomy and privacy.
This finding can be regarded as a consequence of paternalistic approach of healthcare staff. In
paternalistic approach health care professionals especially physicians and sometimes nurses
decide on behalf of the patients with the assumption that only they can know right decision
and patients can not decide autonomically. This problematic attitude can be seen in every
where. For example in an study which was conducted in England 23% of the nurses stated
that family members were told the diagnosis instead of the patients, the facts about the health
situations of the patients were keep secret because of the patients psychologic and mental
health situations8. Also the results of study which conducted in Netherlands showed that doc-
tors maintain the treatment procedure whether patients wants or not (%83)9. The findings of
two study also advocate the same approach, health care professionals tend to take decision
whether patients are well educated or both menatlly and physical healthy.
Nursing students reported in this study that the most striking factors causing ethical problems
were unprofessional conduct of nurses and physicians. This finding can be interpreted as al-
though nursing and medicine are professions, the members of these two professions in Turkey
sometimes dismiss professional code of ethics and they have problems in transferring ethical
knowledge into clinical practice. In the stduy of ethical problems which dutch nurses en-
countered the most problematic issues were reported also as ethical problems caused by
nurses` and doctors` unprofessional attitudes9.
When compared with other European countries the nursing profession has not gained the actu-
al power in Turkey although it is an old profession. In Turkey nurses are not aware of their
professional power in the healthcare system; their actual power comes from their caregiver
role that is why they are expected to act as patient advocates. But on the contrary, our study
displayed that nurses are not involved in any of decision making process of ethical problems
which patients encounter. This finding is also important because nursing students are gener-
ally working with these clinical nurses during their clinical practice and they observe nurses
reaction to ethical problems and internalize the same attitude towards ethical problems. The
result which can be deducted from the study whether you expand ethical course content or in-
crease credits of the course, when students graduate from the school and start working as
nurses in healthcare settings they tend to act as they learned during their clinical practice.

Conclusion and Recommendations

As today`s student but future`s registered nurses, student nurses revealed too effective clues
for nursing curriculum and nursing practice. Since students reported so many ethical problems
for which all health professionals accounted, hospital ethical procedure and policy should be
reviewed and announced to all staff, ethical violations must be regarded as a performance
evaluation criteria besides this kind of violation must be punished. Also, whenever en-
countered or taken part in an ethical problem, these situations must be recorded and should be
analyzed every six month and conclusions must be shared with whole staff.
As great amount of student nurses stated most of the nurses were not involved in decision
making process, the content of baccalaureate ethical courses must be expanded or another les-
son only including ethical issues should be in curriculum, hospital in-service education for
nurses should include ethical content and ethical decision making process. Also, nurses must
be indispensable members of the hospital ethics committees.
In conclusion, further research is needed to identify more real practical cases that contain eth-
ical dilemmas and can be used in educational programmes, and then to evaluate their effect on
ethical decision making using the personal experiences of student and clinical nurses.
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