Gallagher, A

Snelling, P

Nursing Ethics

Brunel University Research Archive

Is nursing ethics education in disarray?’Paul Snelling and Ann Gallagher We write this editorial soon after receiving Marsha Fowler’s book on the history of Nursing Ethics.1 In the first chapter, Marsha quotes extensively from the Standardised and Mandated National League for Nursing Education Ethics Requirements for Nursing Education 1915-1919. These include: customary morality; personal or reflective morality; ethical ideals and standards; moral judgement; conduct and character; the place of ‘the self’ in the moral life; the social virtues; ethical principles as applied to community life; principles of ethics applied to one’s work or professional life; and principles of ethics as applied to one’s personal life. The detail given for each of the ten classes is extensive. A century later, Pam Grace suggests that ‘ethics education in nursing is in disarray’.2 She argues that there is no consensus about what should be taught and how, nor any detailed knowledge about how ethics is taught (or learned) internationally. There is, Pam suggests, a growing body of evidence that suggests that many nurses do not feel that their ethics education prepares then for professional life. All of us have an individual responsibility to work, as well as we are able, to prepare our students for ethical practice. However, this cannot be done by individuals working in isolation. Regulators and professional bodies must provide the necessary professional leadership. In the United Kingdom at least, they have failed to do this.  In the United Kingdom, there is no explicitly stated curriculum for pre-registration nursing. The Nursing and Midwifery Council (NMC) publishes Standards of Proficiency for Registered Nurses,3 a document which specifies the knowledge and skills needed by registered nurses. Universities must demonstrate that their courses prepare their students to meet these standards. The word ‘ethics’ and its cognates appear just twice in the document: once, specifically, in relation to research ethics and once more generally as follows: …the registered nurse will be able to (p. 8)3 understand and apply relevant legal, regulatory and governance requirements, policies, and ethical frameworks, including any mandatory reporting duties, to all Copyright © The Author(s) 2024. Snelling, P. and Gallagher, A. (2024) 'Is nursing ethics education in disarray?', Nursing Ethics, 31 (2-3), pp. 129 - 131. DOI: 10.1177/09697330241256992. (see: https://uk.sagepub.com/en-gb/eur/journal-author-archiving-policies-and-re-use).areas of practice, differentiating where appropriate between the devolved legislatures of the United Kingdom.  There is no further detail. Generic standards can also be found in Standards and frameworks of other professions and jurisdictions, for example, medicine in the United Kingdom4 and nursing in the United States5 which both give more detail. In addition, they provide further suggestions and learning resources provided by the Institute of Medical Ethics in the United Kingdom6 and by the American Association of Colleges of Nursing in the United States.7,8  A recent integrative review on ethics education to support ethical competence in healthcare9 located 40 studies, four from the United Kingdom. Only one study, on immersive simulation, was in nursing.10 A further review, on factors contributing to moral competence in nursing located 29 studies, included no articles from the United Kingdom.11  A further way in which ethical practice can be supported is by guidelines for practice. In UK Medical practice, detailed guidance on ethical, legal and professional issues are provided by both the regulator (General Medical Council, via guidance12 and an ethical hub13) and the professional body (British Medical Association, via ethical guidance14 and an ethics committee15). In the United Kingdom, the NMC removed guidance when the last iteration of its Code was released,16 and while the professional body (Royal College of Nursing – RCN) does provide a little guidance, this is not always easy to locate amongst general work-related advice. As an example, there is limited guidance from the NMC or the RCN on the important ethical (and professional and legal) issue of confidentiality, and what circumstances justify or require disclosure.17 In contrast, in the United States, the professional body – The American Nurses Association (ANA) – Code of Ethics18 includes guidance, and there is an ANA Centre for Ethics and Human Rights.19  The conclusion from this brief analysis is that preparation for ethical practice for nurses and midwives in the United Kingdom, understood as both required educational preparation and professional guidance, is insufficient. If Pamela Grace is correct, this situation is far from unique.  An initial step to addressing this shortfall is to undertake research, not solely on educational interventions but also on curricula requirements. Starting with regulatory surveys, this research would need to include details of how universities interpret and apply the often non-specific statements about ethical and professional practice, requiring collaboration between universities who are in important ways competitors in an apparently shrinking pool of prospective students.20  But it needs more than this. Nurses need not only education but guidance. In this respect, ethical and legal issues are little different from evidence-based guidance that forms a foundation of practice in professional healthcare. And yet, this is conspicuously absent in some jurisdictions, including the United Kingdom. We practitioners, researchers, and educators, readers of Nursing Ethics, cannot plug this omission, but we can hold the regulatory and professional organisations to account for what is, in some areas, a significant failure of ethical leadership.  Whilst there is, then, an increasing body of scholarship and research in nursing ethics generally – and in this journal, in particular – it is clear that there are gaps which could be filled by regulators and professional bodies. The example of explanatory and detailed guidance from some international regulators can be learnt from and emulated. Returning to Pam Grace’s claim that nursing ethics education is in disarray, progress has been made over the last three decades. However, reflection and research need to continue on curriculum content and methods. However, the primary deficits regarding nursing ethics relate to guidance in important ethics-related content. There is an opportunity here for regulators to engage with nurse ethicists to fill this gap.   References  1. Fowler M. Nursing Ethics, 1880s to the present: An archaeology of lost Wisdom and identity. London: Routledge, 2024.  2. Grace P (2022) No Moral compass. A critique of the goals ad methods of contemporary nursing ethics education. In Lipscomb M (Ed) Complexity and Values in Nurse Education. Routledge: London, Chapter 4, pp. 72-87.  3. Nursing and Midwifery Council. Future nurse: standards of proficiency for registered nurses, https://www.nmc.org.uk/globalassets/sitedocuments/standards-of-proficiency/nurses/future-nurse-proficiencies.pdf (2018).  4. General Medical Council. Outcomes for graduates, https://www.gmc-uk.org/-/media/documents/outcomes-for-graduates-2020_pdf-84622587.pdf (2018).  5. American Association of Colleges of Nursing. The essentials: core competencies for professional nursing education, https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf (2021).  6. Institute of Medical Ethics. Core curriculum for undergraduate medical ethics and law, https://ime-uk.org/wp-content/uploads/2020/10/IME_revised_ethics_and_law__curriculum_Learning_outcomes_2019.pdf (2019).  7. American Association of Colleges of Nursing. Concept across domains: ethics, https://www.aacnnursing.org/Portals/0/pdfs/essentials/database/Ethics-Concept-Across-Essentials-Domains.docx (2021b).  8. Robichaux C, Grace P, Bartlett J, et al. Ethics education for nurses: foundations for an integrated curriculum. J Nurs Educ 2022; 61(3): 123–130.  9. Andersson H, Svensson A, Frank C, et al. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics 2022; 23(1): 1–26.  10. Gallagher A, Peacock M, Zasada M, et al. Care-givers’ reflections on an ethics education immersive simulation care experience: a series of epiphanous events. Nurs Inq 2017; 24(3): e12174.  11. Wiisak J, Stolt M, Igoumenidis M, et al. Factors contributing to the promotion of moral competence in nursing. Nurs Ethics 2024: 09697330241235305.  12. General medical Council (nd) professional standards for doctors https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors  13. General Medical Council (n. d.). Ethical Hub, https://www.gmc-uk.org/professional-standards/ethical-hub.  14. British Medical Association (2023) Ethics https://www.bma.org.uk/advice-and-support/ethics#approaching-an-ethical-question  15. British Medical Association. Medical ethics committee overview, https://www.bma.org.uk/what-we-do/committees/medical-ethics-committee/medical-ethics-committee-overview (2023).  16. Snelling PC. Can the revised UK code direct practice? Nurs Ethics 2017; 24(4): 392–407. 17. Snelling P, Quick O. Confidentiality and public interest disclosure: a framework to evaluate UK healthcare professional regulatory guidance. Med Law Int 2022; 22(1): 3–32.  18. American Nurses Association. Code of ethics for nurses, https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/ (2015).  19. American nurses association (nd) ethics and human Rights https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/  20. Church E (2024) Nursing UCAS applications fall for third year running. Nursing Times, 15th February 2024. https://www.nursingtimes.net/news/workforce/nursing-ucas-applications-fall-for-third-year-running-15-02-2024/ 

Is nursing ethics education in disarray?

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Is nursing ethics education in disarray?

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