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Volume 17, Issue 53 (2024)
JMED 2024, 17(53): 34-44 |
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Ethics code: IR.ABZUMS.RES.1400.094
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Hosseini S H, Tayebi Z, Poormoosa Poostin Saraee Y. Nursing students' perception of nurses' professional misconduct: A descriptive qualitative study. JMED 2024; 17 (53) :34-44
URL: http://edujournal.zums.ac.ir/article-1-1711-en.html
URL: http://edujournal.zums.ac.ir/article-1-1711-en.html
1- Department of Healthcare Services Management, School of Health, Alborz University of Medical Sciences, Karaj, Iran.
2- Department of Nursing, School of Nursing, Alborz University of Medical Sciences, Karaj, Iran. & Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran. ,tayebi2010@hotmail.com
3- Department of Healthcare Services Management, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran.
2- Department of Nursing, School of Nursing, Alborz University of Medical Sciences, Karaj, Iran. & Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran. ,
3- Department of Healthcare Services Management, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran.
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Table 3. Process of extracting the "conscious omission" category
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Abstract
Background & Objective: It is essential to identify and find solutions to reduce professional misconduct among nurses that affect the satisfaction of patients and nurses, improve the work environment, and guide educational programs. Explaining the experiences of nursing students would also help in future studies of the issue. Therefore, this study was conducted to explain the perception of nursing students towards " professional misconduct " in interaction with nurses.
Materials & Methods: This qualitative study was conducted with the conventional content analysis design from April to November 2022 at Alborz University of Medical Sciences, Alborz, Iran. The data were collected through semi-structured interviews with 15 senior nursing students who were selected by purposive sampling method. The gathered data were analyzed in MAXQDA20 software using the Elo and Kyngas inductive approach.
Results: Data analysis led to the formation of 83 open codes, 12 sub-categories, and 4 categories (themes), namely "conscious omission", "unsympathetic atmosphere", "unfavorable environment", and "ineffective training". Recording unrealistic reports, neglecting patients and their training, and care discrimination belonged to the “conscious omission” category. Enslavement, disrespect, discrimination, lack of organizational trust, and poor interaction with the patient and family formed the subclasses of an "unsympathetic atmosphere". The "unfavorable environment" category was constituted of two subcategories of overcrowded wards and lack of facilities and equipment, and two subcategories of insufficient academic education and lack of role models were the constituents of the "ineffective training" category.
Conclusion: Nursing students are facing professional misconduct at the bedside. Failure to perform professional duties efficiently was the most prominent example of perceived unprofessional behavior. Despite the importance of the influence of the environment and resources in development of unprofessional behavior, the absence of ethical role models in the clinical environment was considered an extremely serious factor in the emergence and incidence of professional misconduct. The findings revealed that creating a favorable environment and continuous training in the principles of professional ethics were effective in reducing the occurrence of professional misconduct.
Professionalism is a set of features, behaviors, and actions that are beneficial for the individual and the surrounding community (1). Possessing the common characteristics of dedication and selflessness, love and compassion, respect for others (patients, colleagues, and personnel), establishing proper communication with patients and colleagues, accepting mistakes, commitment and responsibility, trustworthiness, and honesty are among the examples of professionalism (5). In contrast to professional behaviors that deal with the positive and affirmative aspects of values and behaviors, non-professional behaviors are defined as negative behaviors that in providing health services to individual, environmental, and managerial aspects (6) has in many cases endangered the safety and health of the patient, distorted the relationship between the medical staff and the patient, reduced the patient's satisfaction, and eventually, caused the personal interests of the health team members to be prioritized over those of the patient (5, 7).
Nurses make up one of the major and abundant components of the health team. Due to the nature of the healthcare, this group spends a lot of time with patients and maintains a close relationship with them. Care, as a fundamental concept in nursing, involves ethical and human relationships, and ethical considerations are inherent in providing care to clients in all dimensions, making nursing and ethics inseparable (8, 9). Although ethical and professional behavior is necessary in all professions, since nursing is focused on serving others, the provision of ethical care is expected in this profession (10). The evidence shows that the spiritual care provided by nurses plays an effective role in the recovery of patients' health (11). Therefore, avoiding professional misconduct is more sensitive and crucial in nursing practice than in other professions (12). It is necessary to play an active role in reducing professional misconduct in the workplace, creating and maintaining positive environments, and supporting safe and quality care (10).
The role of nursing students will be highly important in care decisions related to medical treatments and health interventions in the future. The training of professional nurses who are able to act effectively in decisions and professional and ethical challenges starts from studentship; regarding this, it is more reasonable to first identify their views and experiences and then provide the necessary training (13). It is worth considering that the personal and professional values of nursing students continuously change under the influence of several factors (14, 15). To elaborate, the trend of professional behaviors from theoretical and basic nursing education to internships and also after the start of work experiences (16) has decreased, especially in students who have had a history of professional misconduct (17). Therefore, to explain the nature and factors that cause unprofessional behavior and to promote professional behavior, evaluation and educational intervention have been emphasized from the early years of education, especially in the hospital and at the patient's bedside (18), which can lead to the development of relevant curriculum and educational content (15).
Most of the existing studies investigated this issue from the point of view of nurses (6, 10, 12, 19, 20), and very limited studies have been carried out to explain second-hand experiences from the nursing students’ point of view (20); So the current study was conducted to investigate the nursing students' perception of professional misconduct in interaction with nurses.
Materials & Methods
Design and setting(s)
This qualitative study was conducted with the conventional content analysis design from April to November 2022 at Alborz University of Medical Sciences, Alborz, Iran.
Participants and sampling
The statistical population of the study consisted of the senior undergraduate nursing students of Alborz University of Medical Sciences, Alborz Province, Iran. A total of 15 students were selected through purposive sampling method. The inclusion criteria were being a senior student, having passed at least one semester of internship in the hospital, and being willing to participate in the study.
Data collection methods
Data were collected through individual semi-structured interviews by a trained researcher. To properly guide the interviews, an interview guide was developed. The initial questions of the interview guide were extracted from related literature. Before conducting the interview, the objectives of the study were explained to the participants and informed consent was obtained. The time and place of the interview were chosen by the participants in either the meeting hall of the School of Nursing or the hospital where the student was performing their internship.
The interviews mainly started with general questions: "Can you describe the experience of one of your internship shifts? What experiences did you have during your internship that were different from what you read and expected in theory lessons? What behaviors did you see from the personnel that were questionable for you?” The interview continued with probing questions, such as "why do you think so?" This question was asked following the participant's answer with the theme of lack of proper conditions to provide proper and ethical care.
To avoid probable problems, the interview was recorded by an electronic device, and the important points during the interview, including non-verbal reactions, were also noted by the interviewer. Field notes were used as effective reminders during data analysis. For instance, relatively long pauses or silences or surprised facial expressions were among the things that were taken into account as field notes in the analysis. The average duration of the interviews was 45 min. In cases where there was ambiguity after the transcription and initial reading of the interview text, the interviewee was contacted again and new data was added to the interview text (in 4 of the interviews, the students were contacted again, the ambiguous points were investigated, and additional explanations were added). Data gathering continued until data saturation.
Data analysis
Immediately on the same day of the interview, the transcription of the recorded content was done. Data analysis was performed using the inductive approach of Elo and Kyngas. In the first stage, meaningful words and sentences were labeled as open codes in line with the objectives of the study. Following that, open codes were organized based on semantic affinity, and using the reduction pattern, categories and subcategories were developed based on semantic similarities and differences (21). To facilitate the coding process, MAXQDA software (version 2020) was employed. As a comprehensive work desk, this software accelerates the analysis process.
Rigor
In this study, the trustworthiness of the data was ensured by utilizing credibility, confirmability, and transferability criteria (22). The credibility of the data was confirmed using semi-structured interviews, field notes, and long involvement with the research topic. In addition to this, the categories were reviewed by the participants and the research team, while the data review and analysis process were done by the research team and peer review. In the current research, to increase the confirmability of the data, interviews were conducted in a certain and non-interval time frame with a full focus on the subject. The process of data analysis and code categorization was carefully examined by experts with experience in inductive content analysis. To achieve this criterion, all the stages of performing the research, especially the stages of data analysis, were recorded in detail along the procedure. To facilitate the transferability of the findings, a clear description of the context, the selection method, the characteristics of the participants, the data collection procedure, and the data analysis process was provided. By explaining the obstacles and limitations, readers were given the conditions for using the findings in other contexts (23).
Results
A total of 15 undergraduate nursing students (10 females and 5 males), whose average age was 22.2 years, were included in the study as participants (Table 1).
Background & Objective: It is essential to identify and find solutions to reduce professional misconduct among nurses that affect the satisfaction of patients and nurses, improve the work environment, and guide educational programs. Explaining the experiences of nursing students would also help in future studies of the issue. Therefore, this study was conducted to explain the perception of nursing students towards " professional misconduct " in interaction with nurses.
Materials & Methods: This qualitative study was conducted with the conventional content analysis design from April to November 2022 at Alborz University of Medical Sciences, Alborz, Iran. The data were collected through semi-structured interviews with 15 senior nursing students who were selected by purposive sampling method. The gathered data were analyzed in MAXQDA20 software using the Elo and Kyngas inductive approach.
Results: Data analysis led to the formation of 83 open codes, 12 sub-categories, and 4 categories (themes), namely "conscious omission", "unsympathetic atmosphere", "unfavorable environment", and "ineffective training". Recording unrealistic reports, neglecting patients and their training, and care discrimination belonged to the “conscious omission” category. Enslavement, disrespect, discrimination, lack of organizational trust, and poor interaction with the patient and family formed the subclasses of an "unsympathetic atmosphere". The "unfavorable environment" category was constituted of two subcategories of overcrowded wards and lack of facilities and equipment, and two subcategories of insufficient academic education and lack of role models were the constituents of the "ineffective training" category.
Conclusion: Nursing students are facing professional misconduct at the bedside. Failure to perform professional duties efficiently was the most prominent example of perceived unprofessional behavior. Despite the importance of the influence of the environment and resources in development of unprofessional behavior, the absence of ethical role models in the clinical environment was considered an extremely serious factor in the emergence and incidence of professional misconduct. The findings revealed that creating a favorable environment and continuous training in the principles of professional ethics were effective in reducing the occurrence of professional misconduct.
Introduction
During the last three decades, professionalism has been considered one of the main and basic issues in most of the curricula prepared for medical students (1, 2); therefore, it has found its place in the curriculum (3). In Iran, during the last two decades, special attention has been paid to this issue in clinical education curricula (4).Professionalism is a set of features, behaviors, and actions that are beneficial for the individual and the surrounding community (1). Possessing the common characteristics of dedication and selflessness, love and compassion, respect for others (patients, colleagues, and personnel), establishing proper communication with patients and colleagues, accepting mistakes, commitment and responsibility, trustworthiness, and honesty are among the examples of professionalism (5). In contrast to professional behaviors that deal with the positive and affirmative aspects of values and behaviors, non-professional behaviors are defined as negative behaviors that in providing health services to individual, environmental, and managerial aspects (6) has in many cases endangered the safety and health of the patient, distorted the relationship between the medical staff and the patient, reduced the patient's satisfaction, and eventually, caused the personal interests of the health team members to be prioritized over those of the patient (5, 7).
Nurses make up one of the major and abundant components of the health team. Due to the nature of the healthcare, this group spends a lot of time with patients and maintains a close relationship with them. Care, as a fundamental concept in nursing, involves ethical and human relationships, and ethical considerations are inherent in providing care to clients in all dimensions, making nursing and ethics inseparable (8, 9). Although ethical and professional behavior is necessary in all professions, since nursing is focused on serving others, the provision of ethical care is expected in this profession (10). The evidence shows that the spiritual care provided by nurses plays an effective role in the recovery of patients' health (11). Therefore, avoiding professional misconduct is more sensitive and crucial in nursing practice than in other professions (12). It is necessary to play an active role in reducing professional misconduct in the workplace, creating and maintaining positive environments, and supporting safe and quality care (10).
The role of nursing students will be highly important in care decisions related to medical treatments and health interventions in the future. The training of professional nurses who are able to act effectively in decisions and professional and ethical challenges starts from studentship; regarding this, it is more reasonable to first identify their views and experiences and then provide the necessary training (13). It is worth considering that the personal and professional values of nursing students continuously change under the influence of several factors (14, 15). To elaborate, the trend of professional behaviors from theoretical and basic nursing education to internships and also after the start of work experiences (16) has decreased, especially in students who have had a history of professional misconduct (17). Therefore, to explain the nature and factors that cause unprofessional behavior and to promote professional behavior, evaluation and educational intervention have been emphasized from the early years of education, especially in the hospital and at the patient's bedside (18), which can lead to the development of relevant curriculum and educational content (15).
Most of the existing studies investigated this issue from the point of view of nurses (6, 10, 12, 19, 20), and very limited studies have been carried out to explain second-hand experiences from the nursing students’ point of view (20); So the current study was conducted to investigate the nursing students' perception of professional misconduct in interaction with nurses.
Materials & Methods
Design and setting(s)
This qualitative study was conducted with the conventional content analysis design from April to November 2022 at Alborz University of Medical Sciences, Alborz, Iran.
Participants and sampling
The statistical population of the study consisted of the senior undergraduate nursing students of Alborz University of Medical Sciences, Alborz Province, Iran. A total of 15 students were selected through purposive sampling method. The inclusion criteria were being a senior student, having passed at least one semester of internship in the hospital, and being willing to participate in the study.
Data collection methods
Data were collected through individual semi-structured interviews by a trained researcher. To properly guide the interviews, an interview guide was developed. The initial questions of the interview guide were extracted from related literature. Before conducting the interview, the objectives of the study were explained to the participants and informed consent was obtained. The time and place of the interview were chosen by the participants in either the meeting hall of the School of Nursing or the hospital where the student was performing their internship.
The interviews mainly started with general questions: "Can you describe the experience of one of your internship shifts? What experiences did you have during your internship that were different from what you read and expected in theory lessons? What behaviors did you see from the personnel that were questionable for you?” The interview continued with probing questions, such as "why do you think so?" This question was asked following the participant's answer with the theme of lack of proper conditions to provide proper and ethical care.
To avoid probable problems, the interview was recorded by an electronic device, and the important points during the interview, including non-verbal reactions, were also noted by the interviewer. Field notes were used as effective reminders during data analysis. For instance, relatively long pauses or silences or surprised facial expressions were among the things that were taken into account as field notes in the analysis. The average duration of the interviews was 45 min. In cases where there was ambiguity after the transcription and initial reading of the interview text, the interviewee was contacted again and new data was added to the interview text (in 4 of the interviews, the students were contacted again, the ambiguous points were investigated, and additional explanations were added). Data gathering continued until data saturation.
Data analysis
Immediately on the same day of the interview, the transcription of the recorded content was done. Data analysis was performed using the inductive approach of Elo and Kyngas. In the first stage, meaningful words and sentences were labeled as open codes in line with the objectives of the study. Following that, open codes were organized based on semantic affinity, and using the reduction pattern, categories and subcategories were developed based on semantic similarities and differences (21). To facilitate the coding process, MAXQDA software (version 2020) was employed. As a comprehensive work desk, this software accelerates the analysis process.
Rigor
In this study, the trustworthiness of the data was ensured by utilizing credibility, confirmability, and transferability criteria (22). The credibility of the data was confirmed using semi-structured interviews, field notes, and long involvement with the research topic. In addition to this, the categories were reviewed by the participants and the research team, while the data review and analysis process were done by the research team and peer review. In the current research, to increase the confirmability of the data, interviews were conducted in a certain and non-interval time frame with a full focus on the subject. The process of data analysis and code categorization was carefully examined by experts with experience in inductive content analysis. To achieve this criterion, all the stages of performing the research, especially the stages of data analysis, were recorded in detail along the procedure. To facilitate the transferability of the findings, a clear description of the context, the selection method, the characteristics of the participants, the data collection procedure, and the data analysis process was provided. By explaining the obstacles and limitations, readers were given the conditions for using the findings in other contexts (23).
Results
A total of 15 undergraduate nursing students (10 females and 5 males), whose average age was 22.2 years, were included in the study as participants (Table 1).
Table 1. Characteristics of participants
| No. | Gender | Age (year) | Academic semester | Interview location |
| 1 | Male | 22 | Semester 8 | Nursing school |
| 2 | female | 23 | Semester 8 | Nursing school |
| 3 | Male | 21 | Semester 7 | Nursing school |
| 4 | female | 22 | Semester 8 | Teaching hospital |
| 5 | female | 21 | Semester 8 | Teaching hospital |
| 6 | Male | 22 | Semester 8 | Teaching hospital |
| 7 | female | 23 | Semester 7 | Nursing school |
| 8 | female | 22 | Semester 8 | Teaching hospital |
| 9 | female | 22 | Semester 8 | Teaching hospital |
| 10 | Male | 22 | Semester 7 | Nursing school |
| 11 | Male | 23 | Semester 7 | Teaching hospital |
| 12 | female | 23 | Semester 7 | Teaching hospital |
| 13 | female | 22 | Semester 8 | Teaching hospital |
| 14 | female | 21 | Semester 7 | Nursing school |
| 15 | female | 24 | Semester 8 | Nursing school |
After holding the interviews (7 interviews in the School of Nursing and 8 interviews in teaching hospitals) and analyzing the data, 83 open codes were extracted and then integrated to code more accurately and facilitate the research process, which led to the formation of 12 subcategories and 4 categories or themes. Table 2 presents an example of the method of induction from the participants' statements to the relevant category. The developed categories included "conscious omission", "unsympathetic atmosphere", "unfavorable environment", and "ineffective training", which will be described later (Table 3).
Table 2. Process of extracting the "conscious omission" category
| Category | Sub-category | open codes | Quotations |
| Conscious omission | Recording unreal reports | Signed by an unrelated person Failure to perform necessary tasks for patients, but recorded in reports |
“Things that are mentioned in the patient's file but are not done in practice; for example, training was not given to the patient accurately, but the related reports were signed by the nurse herself" (Participant No. 4). “Some nurses don’t do some of the necessary tasks for patients due to fatigue, but they write in the report that they have done them" (Participant No. 7). |
Table 3. Process of extracting the "conscious omission" category
| Category | Subcategory | Example of codes |
| Conscious omission | Recording unreal reports | Failure to perform the necessary tasks of the patients, but recording them in the report files |
| Neglecting to train the patient and their family | Reports signed by an unrelated person | |
| Neglecting the patient | Failure to provide training to patients and their companions | |
| Care discrimination | Ignoring the request of the patient and their companion | |
| Unsympathetic atmosphere | Enslavement | Bullying of experienced personnel to other personnel Threatening students by some personnel |
| Disrespect and discrimination | Inappropriate behavior of staff with students Disrespect in the final evaluation of students Discrimination among nursing and medical students |
|
| Lack of organizational trust | An atmosphere of lack of trust between nurses Attention to rumors Conspiracy between nurses Gossiping between nurses |
|
| Poor interaction with the patient and their family | Improper treatment with the patient and their companion Lack of understanding of the patient's condition Failure to talk courteously with patients Yelling at the patient's companion instead of responding appropriately Swearing the patient's mother because of her sensitivity |
|
| Unfavorable environment | Overcrowding of the ward | Need for more human forces to reduce work pressure Inappropriate behavior due to work pressure Inappropriate behavior due to a crowded and noisy environment |
| Lack of equipment and facilities | Inadequate quality of hospitalization and verbal conflict in this regard Lack of timely care due to lack of warning system |
|
| Ineffective training | Insufficient academic training | Gap between theoretical education in the university and ethical issues Need to increase the number of units related to professional and ethical behaviors and issues Expression of the experiences of professors about behavioral and moral matters as an effective measure |
| Absence of role model | Importance of the way professors and staff behave during studies and its impact on students' behavior Effect of how professor deals with students in institutionalizing ethics |
1. Conscious omission: One of the categories extracted from the data, which seemed to be more prominent than the rest of the concepts, was failure to perform the job duties consciously and correctly. One of the most important dimensions of professional behavior in any field is the quality of the tasks related to that field of work, and naturally, failure to fulfill this task is a clear example of unprofessional behavior. This category was formed from the subcategories of neglecting the patient, recording unreal reports, care discrimination, and neglecting to train the patient and their family.
Unreal records and baseless reports about the care that was not done, including the vital signs that were not checked, the medicine that was not prescribed, and the care that was not given, were among the issues that were frequently heard in the statements of the study participants. Participant No. 11, who was a nursing student in the 8th semester and had an internship experience in the general department of a hospital, mentioned the things that had surprised him as follows: "…Some nurses, perhaps due to fatigue or lack of time, don't do some of the necessary tasks for the patients, but they write in their report that they have done it".
This issue was not limited to nurse's notes; there were even other documents that were completed formally. Participant No. 12, who was a 7th-semester nursing student, mentioned this issue as well and expressed concern about the contradiction between what is done and what is recorded: "…Somethings are recorded in the patient's record that are not done in practice; for example, the patient was not taught, but the documents were signed by the nurse and it was recorded in the nurse's note that patient education was done". Participants also narrated observations of not providing some essential care. A student described her own experience of observing the intentional omission of some frequencies of medications as follows: "…One of the nurses dropped the albumin container and broke it and did not inject the albumin to the patient without informing anyone" (Participant No. 12).
Neglecting the patient was one of the other concepts that ultimately led to professional misconduct. A final-year nursing student mentioned the cases of neglect that he had encountered during the internship: "…I used to think that nurses neglect patients because of their high workload, but during the internship, I realized that they had enough time, but they didn't seem to want to take care of the patient; somehow, they had become indifferent and when the patient or their family asked for something, they didn't pay attention; this really made me very upset" (Participant No. 6).
The participants mentioned the care discrimination among patients because of their race or nationality, which was completely contrary to the professional ethical codes in nursing. In addition, care discrimination for certain patients was also something to concern about for students.
"… Nurses treat some patients with special conditions, such as HIV, very badly. I was wondering why they behaved like this; she is just a patient and it's our duty to take care of her, but sometimes no one even went to take a blood sample from the HIV patient" (Participant No. 10).
2. Unsympathetic atmosphere: The second category was the unsympathetic atmosphere. Naturally, the existence of empathy and solidarity among members can be effective in strengthening the professional atmosphere, while unprofessional behavior is expected to occur in a disjointed atmosphere. An unsympathetic atmosphere was developed from the subcategories of poor interaction with patients and their families, enslavement, disrespect and discrimination, and lack of organizational trust. In an environment where positive interactions and relationships are supposed to be ongoing by default, poor interactions and sometimes discriminatory and disrespectful behaviors are observed at all levels of communication. The communication pattern of enslavement between experienced and less experienced nurses and even between the nurses and nursing students contributed to the lack of positive interaction. Students mentioned the moments when they were insulted, disrespected, and ignored by staff, or were clearly mistreated compared to medical students and did not receive adequate organizational support. In addition, the relations between the nurses at different levels were accompanied by problems, such as attention to rumors, conspiracy, and gossip, which indicated weak organizational trust and made the atmosphere of the department unsympathetic.
A student who had just completed his internship in the surgery ward described his experience of the inappropriate treatment of the staff as follows: "…The first days when I went to do my internship, some of the staff treated me very badly, as if I were their subordinate. I did all the work at the ward; despite this, I wasn't even allowed to sit in the nursing station. If I wasn't busy, I had to stand up " (Participant No. 5).
Another student described the experience of inappropriate communication in the pediatrics internship as follows: "…In the pediatric ward of the hospital...I was doing my internship. I was very organized and behaved well, but in the final evaluation, I was very disrespected; I was very disappointed. And I really think I can't survive in nursing with these conditions" (Participant No. 9).
Participant No. 13 believed that the inappropriate interactions of personnel were not ineffective in the occurrence of unprofessional behaviors. she stated: "…There are a lot of rumors and gossiping among the nurses, they also pull the rug from under their coworkers, and it is natural that you can't work well and behave ethically in these conditions".
In addition to the communication problems between the treatment staff, the lack of effective interaction of the staff with the patients, especially their families, caused tension in the atmosphere and created an inappropriate atmosphere. The absence of sympathy and empathy expected from the staff was questionable and disappointing for the students to the extent that the thought of becoming such people in their future careers was terrifying for them. Participant No. 4 narrated the incident she witnessed in the pediatric ward as follows: "…In the pediatric ward, one of the staff tried several times to find a vein to draw blood but could not find the child's vein, so the child's mother was upset. The nurse complained and started yelling. She was swearing at the child's mother, the whole ward was messed up, it was a very bad situation, everyone was nervous". This type of behavior was sometimes observed toward the patient's families. Some students mentioned their experiences with the argument of the staff with the patient's family, even in special departments, that led to the disruption of the empathetic atmosphere.
3. Unfavorable environment: The third category was dedicated to environmental factors that caused unprofessional behaviors. This category consisted of two subcategories of overcrowding of the ward and the lack of equipment and facilities. The provision of a suitable work environment and the availability of sufficient equipment and supplies are effective in improving the quality of work life and basically prevent the occurrence of related dissatisfaction; otherwise, it is not surprising to observe professional misconduct that are rooted in environmental factors. At present, the per capita ratio of nurses to patients is inappropriate in most general departments; besides that, the significant volume of traffic in the departments, especially in educational and medical centers, makes it difficult to manage these conditions and focus on providing care.
Participant No. 4 mentioned the importance of sufficient staff to provide quality care and considered increased workload a determining factor of unprofessionalism. In addition to this issue, the lack of equipment and facilities is added to the cause of professional misconduct. One of the students in the 8th semester described this relationship as follows: "…The nurses said in their own words that if there were an alarm system, they could have provided timely care, by which they meant the central monitors, which if they had, maybe they could detect abnormal cases more easily and earlier" (Participant No. 14).
4. Ineffective training: This category, which is related to education, mainly focused on the importance of education from the perspective of participants. Despite the current emphasis on ethics-related curricula in nursing, as well as separate workshops in this field, the participants believed that more training could be effective in reducing professional misconduct some extent. The lack of academic education and the absence of a role model formed the subclasses of this category. The participants of this study highly recommended paying more attention to the academic training of professional ethics. The gap between theory and practice, which has been noticed for years in various fields, manifested itself in the utterances of the participants: "…What is taught in the university is very different in practice. Professional ethics is very tasteful and is practiced differently in different cities and different hospitals" (Participant No. 13).
The need to simultaneously pay attention to the quantity and quality of training was also pointed out: "…faculty members can have a great impact on students by teaching ethics correctly, the number of ethics units in nursing should be increased" (Participant No. 7). In addition to academic training, the necessity of holding continuous conferences and workshops with topics related to professional ethics for personnel was emphasized by the participants, and in general, continuity in training and repetition of concepts and issues related to ethics was recommended.
Apparently, the presence of positive role models in this field, in the position of either academic staff or department personnel, is highly effective. Despite the importance of this issue, it does not seem that what is desired and expected is realized. Participant No. 15 pointed as follows: "…The behavior of professors and personnel during course training can have a significant impact on students' behavior and it is better to consider these issues continuously". Participant No. 2, who was a 8th-semester nursing student, believed that teacher-student interaction has a particular importance: "…The way a professor deals with students is very important, and the way of dealing with them has a great impact on the institutionalization of ethics in students".
Discussion
This study was conducted to explain the experiences of senior nursing students regarding professional misconduct and possible solutions. The findings of this research indicated that conscious omission and an unsympathetic atmosphere were the most important examples of unprofessional behavior from the point of view of nursing students at the bedside. It was also found that unfavorable environmental conditions, such as the lack of equipment and overcrowding of the ward, ineffective training as insufficient academic education, and the lack of role models were the most important factors in the emergence of these unethical behaviors.
In line with the findings of the present study, those of a study by Sadeghi and Ashktorab (24), entitled "Ethical problems observed by nursing students", demonstrated mistreatment with patients, the absence of proper and empathetic communication, and the lack of providing sufficient information.
Recording unreal reports was among the observed cases that could lead to serious harm to the health of the patient and the quality of service. Authentic and principled recording of nursing reports is one of the most important functions and professional responsibilities in nursing, and the efficiency of nurses’ performance in this regard should be emphasized by nursing management (25, 26).
Care discrimination was determined as one of the examples of unprofessional behavior in this study. The findings of a study by Zolfegharzade et al. (27) also showed that there were discriminatory measures towards AIDS patients in hospitals, while removing such measures is necessary to improve the quality of care for these patients.
The lack of nurses’ empathy with the patients and companions was also mentioned abundantly by the students. In a study by Popovicova and Belovicova (28), the findings demonstrated that unsympathetic communication led to patients' refusal to cooperate and feelings of anxiety, fear, mistrust, and aggression. Furthermore, discriminatory behavior between experienced and less experienced nursing personnel as well as between nurses and students creates an unsympathetic atmosphere, while the observance of ethics in nursing management depends on the proper interpersonal relationship between supervisors and nursing staff (29). In a study by Heydari Gorji et al. (30), nurses in special departments stated that 6% of nurses showed violent behavior towards their colleagues at least once a month. In another research conducted by Filipova (31), bullying in the workplace was considered a serious problem and 12% of nurses identified themselves as victims of this problem.
The results of a study by Nikbakht Nasrabadi et al. (32) revealed that the occurrence of offensive and impolite behaviors could affect the quality of services provided by nurses, which emphasizes the necessity of managing these behaviors. On the other hand, appropriate behavior of patients with nursing staff has been reported as one of the facilitating factors of professional ethics in nursing (29). The lack of trust, and attention to rumors, conspiracy, and gossip among colleagues were also reported, which showed the lack of organizational trust among nurses. Strengthening organizational trust should be given special attention by educational and hospital officials as it has a positive and significant relationship with boosting the professional ethics of nurses and their self-efficacy (33).
Among other results and effects of unprofessional behavior related to conscious omission and an unsympathetic atmosphere is jeopardizing patient safety. The results of studies demonstrate that one of the issues that plays a significant role in the degree of compliance with patient safety and attention to maintaining it is professionalism (5, 34). In their study, Parizad et al. concluded that the management's active attention to reducing professional misconduct and creating a positive professional environment would improve patient safety and service quality (35). Westbrook et al. (36) also stated in their study that professional misconduct was common among hospital employees and these behaviors could endanger the lives of employees and the safety of patients. In his study, Bostani has also emphasized the importance of nursing ethics education programs at the undergraduate level because of their prominent role in increasing the quality of patient care (37).
The findings indicated that such factors as a disproportion between the number of nurses and patients and lack of equipment and facilities, absence of organizational support, weak communication in the hierarchy, and the lack of necessary unity and coordination among the personnel of inpatient departments created an unfavorable environment, which consequently decreased the concentration of nurses in caring for patients. The findings of a study by Azarabad et al. (38) revealed that from the students' point of view, the heavy workload of nurses, the huge number of patients and their unstable condition, and the inappropriate work environment played a role in the emergence of unethical behaviors and mistakes. Taqhavi Larijani et al. (39) also pointed out that the lack of nurses led to several problems, one of the most important of which was the weakening of moral behavior.
From the students’ point of view, the inadequacy of university education was effective in the occurrence and spread of unprofessional behaviors, and to promote ethical behaviors, professional and ethical behaviors should be taught more. Holding continuous conferences and workshops with topics related to professional ethics is also effective in institutionalizing professional behavior. It is also recommended to provide nursing ethics courses with an integrated approach, interprofessional education, and professional ethics education at the patient's bedside, which was emphasized in a study performed by Jafari et al. (40). In another study by Ashipala and Shaluwawa (41), it was also pointed out that teaching ethics and professional behavior would lead to positive effects in providing services to patients and increase the efficiency of nurses.
In addition to the above, the students believed that the existence of useful role models, both in the position of academic staff members and inpatient department staff and colleagues, would be highly influential. Raso et al. (42) stated in their study that the behavior of working nurses was monitored by students and deeply affected their professional growth. In another study, the impact of the lack of support and weak cooperation of experienced personnel were reported on the increase of unethical behaviors (38). Therefore, working nurses should be justified in this regard and the necessary training is required to be provided to them. Razavipoor et al. (43) also introduced clinical professors as suitable role models for the professional role of learners.
Conclusion
It is obvious that, in most cases, the principles of professional ethics are followed by nurses despite the organizational deficiencies, especially the lack of staff, so this study only reflects the students' experiences of limited cases of professional misconduct with the aim of removing obstacles to the implementation of professionalism.
The findings of this study demonstrated that conscious omission and an unsympathetic atmosphere were among the most important examples of professional misconduct among nurses from the perspective of students as spectators at the bedside. An unfavorable environment and ineffective training were mentioned as other factors underlying the occurrence of unprofessional behaviors. Trying to create favorable job conditions along with providing continuous professional ethics training with novel teaching and learning approaches can be a positive step in promoting professionalism in nursing. However, improving professional behaviors and trying to reduce the incidence of professional misconduct is highly complicated and requires extensive and detailed studies as well as structural modification.
According to the results, it is suggested to include more units to teach professionalism and professional ethics in nursing courses with novel teaching methods. Identifying figures who are outstanding in professionalism and have behaved well with patients, patients' family, colleagues, and others in the schools and hospitals and using them as professors' assistants, especially during internships of students, can be highly effective. It is also recommended to hold multiple and consecutive case-based meetings for nursing students and staff. One of major limitations of this study, was the reluctance of students to participate in the study due to the fear of disseminating unpleasant experiences related to clinical environment. To alleviate this problem, at the beginning of all the interviews, the students were assured that their answers would remain confidential, and by explaining the objectives and necessity of the study and the possible results, their cooperation was obtained to conduct the interview; despite this, some students did not agree to cooperate. Moreover, due to the conditions of the COVID-19 epidemic, students' theory classes were not held on-site. As a result, access to the students was made possible after repeated coordination, and the interviews were conducted by observing health-related regulations.
Ethical considerations
This article was extracted from a research project approved by the Ethics Committee of Alborz University of Medical Sciences (IR.ABZUMS.RES.1400.094) and was completed with the financial support of the mentioned university. The participation of the students in this study was completely voluntary; therefore, their verbal and written consent was obtained to participate in the study and they were assured of the confidentiality of their personal information.
Acknowledgments
The authors would like to express their gratitude to the officials of the research assistant for issuing the letter of introduction and also to the Dean of the School of Nursing for their assistance in coordinating with the students.
Disclosure
The authors did not have any conflict of interest at any stage of the research.
Author contributions
SHH and ZT formulated the research idea. SHH and YPPS collected data. SHH and ZT performed the analysis and interpreted the data. All authors wrote the manuscript and approved the final manuscript.
Unreal records and baseless reports about the care that was not done, including the vital signs that were not checked, the medicine that was not prescribed, and the care that was not given, were among the issues that were frequently heard in the statements of the study participants. Participant No. 11, who was a nursing student in the 8th semester and had an internship experience in the general department of a hospital, mentioned the things that had surprised him as follows: "…Some nurses, perhaps due to fatigue or lack of time, don't do some of the necessary tasks for the patients, but they write in their report that they have done it".
This issue was not limited to nurse's notes; there were even other documents that were completed formally. Participant No. 12, who was a 7th-semester nursing student, mentioned this issue as well and expressed concern about the contradiction between what is done and what is recorded: "…Somethings are recorded in the patient's record that are not done in practice; for example, the patient was not taught, but the documents were signed by the nurse and it was recorded in the nurse's note that patient education was done". Participants also narrated observations of not providing some essential care. A student described her own experience of observing the intentional omission of some frequencies of medications as follows: "…One of the nurses dropped the albumin container and broke it and did not inject the albumin to the patient without informing anyone" (Participant No. 12).
Neglecting the patient was one of the other concepts that ultimately led to professional misconduct. A final-year nursing student mentioned the cases of neglect that he had encountered during the internship: "…I used to think that nurses neglect patients because of their high workload, but during the internship, I realized that they had enough time, but they didn't seem to want to take care of the patient; somehow, they had become indifferent and when the patient or their family asked for something, they didn't pay attention; this really made me very upset" (Participant No. 6).
The participants mentioned the care discrimination among patients because of their race or nationality, which was completely contrary to the professional ethical codes in nursing. In addition, care discrimination for certain patients was also something to concern about for students.
"… Nurses treat some patients with special conditions, such as HIV, very badly. I was wondering why they behaved like this; she is just a patient and it's our duty to take care of her, but sometimes no one even went to take a blood sample from the HIV patient" (Participant No. 10).
2. Unsympathetic atmosphere: The second category was the unsympathetic atmosphere. Naturally, the existence of empathy and solidarity among members can be effective in strengthening the professional atmosphere, while unprofessional behavior is expected to occur in a disjointed atmosphere. An unsympathetic atmosphere was developed from the subcategories of poor interaction with patients and their families, enslavement, disrespect and discrimination, and lack of organizational trust. In an environment where positive interactions and relationships are supposed to be ongoing by default, poor interactions and sometimes discriminatory and disrespectful behaviors are observed at all levels of communication. The communication pattern of enslavement between experienced and less experienced nurses and even between the nurses and nursing students contributed to the lack of positive interaction. Students mentioned the moments when they were insulted, disrespected, and ignored by staff, or were clearly mistreated compared to medical students and did not receive adequate organizational support. In addition, the relations between the nurses at different levels were accompanied by problems, such as attention to rumors, conspiracy, and gossip, which indicated weak organizational trust and made the atmosphere of the department unsympathetic.
A student who had just completed his internship in the surgery ward described his experience of the inappropriate treatment of the staff as follows: "…The first days when I went to do my internship, some of the staff treated me very badly, as if I were their subordinate. I did all the work at the ward; despite this, I wasn't even allowed to sit in the nursing station. If I wasn't busy, I had to stand up " (Participant No. 5).
Another student described the experience of inappropriate communication in the pediatrics internship as follows: "…In the pediatric ward of the hospital...I was doing my internship. I was very organized and behaved well, but in the final evaluation, I was very disrespected; I was very disappointed. And I really think I can't survive in nursing with these conditions" (Participant No. 9).
Participant No. 13 believed that the inappropriate interactions of personnel were not ineffective in the occurrence of unprofessional behaviors. she stated: "…There are a lot of rumors and gossiping among the nurses, they also pull the rug from under their coworkers, and it is natural that you can't work well and behave ethically in these conditions".
In addition to the communication problems between the treatment staff, the lack of effective interaction of the staff with the patients, especially their families, caused tension in the atmosphere and created an inappropriate atmosphere. The absence of sympathy and empathy expected from the staff was questionable and disappointing for the students to the extent that the thought of becoming such people in their future careers was terrifying for them. Participant No. 4 narrated the incident she witnessed in the pediatric ward as follows: "…In the pediatric ward, one of the staff tried several times to find a vein to draw blood but could not find the child's vein, so the child's mother was upset. The nurse complained and started yelling. She was swearing at the child's mother, the whole ward was messed up, it was a very bad situation, everyone was nervous". This type of behavior was sometimes observed toward the patient's families. Some students mentioned their experiences with the argument of the staff with the patient's family, even in special departments, that led to the disruption of the empathetic atmosphere.
3. Unfavorable environment: The third category was dedicated to environmental factors that caused unprofessional behaviors. This category consisted of two subcategories of overcrowding of the ward and the lack of equipment and facilities. The provision of a suitable work environment and the availability of sufficient equipment and supplies are effective in improving the quality of work life and basically prevent the occurrence of related dissatisfaction; otherwise, it is not surprising to observe professional misconduct that are rooted in environmental factors. At present, the per capita ratio of nurses to patients is inappropriate in most general departments; besides that, the significant volume of traffic in the departments, especially in educational and medical centers, makes it difficult to manage these conditions and focus on providing care.
Participant No. 4 mentioned the importance of sufficient staff to provide quality care and considered increased workload a determining factor of unprofessionalism. In addition to this issue, the lack of equipment and facilities is added to the cause of professional misconduct. One of the students in the 8th semester described this relationship as follows: "…The nurses said in their own words that if there were an alarm system, they could have provided timely care, by which they meant the central monitors, which if they had, maybe they could detect abnormal cases more easily and earlier" (Participant No. 14).
4. Ineffective training: This category, which is related to education, mainly focused on the importance of education from the perspective of participants. Despite the current emphasis on ethics-related curricula in nursing, as well as separate workshops in this field, the participants believed that more training could be effective in reducing professional misconduct some extent. The lack of academic education and the absence of a role model formed the subclasses of this category. The participants of this study highly recommended paying more attention to the academic training of professional ethics. The gap between theory and practice, which has been noticed for years in various fields, manifested itself in the utterances of the participants: "…What is taught in the university is very different in practice. Professional ethics is very tasteful and is practiced differently in different cities and different hospitals" (Participant No. 13).
The need to simultaneously pay attention to the quantity and quality of training was also pointed out: "…faculty members can have a great impact on students by teaching ethics correctly, the number of ethics units in nursing should be increased" (Participant No. 7). In addition to academic training, the necessity of holding continuous conferences and workshops with topics related to professional ethics for personnel was emphasized by the participants, and in general, continuity in training and repetition of concepts and issues related to ethics was recommended.
Apparently, the presence of positive role models in this field, in the position of either academic staff or department personnel, is highly effective. Despite the importance of this issue, it does not seem that what is desired and expected is realized. Participant No. 15 pointed as follows: "…The behavior of professors and personnel during course training can have a significant impact on students' behavior and it is better to consider these issues continuously". Participant No. 2, who was a 8th-semester nursing student, believed that teacher-student interaction has a particular importance: "…The way a professor deals with students is very important, and the way of dealing with them has a great impact on the institutionalization of ethics in students".
Discussion
This study was conducted to explain the experiences of senior nursing students regarding professional misconduct and possible solutions. The findings of this research indicated that conscious omission and an unsympathetic atmosphere were the most important examples of unprofessional behavior from the point of view of nursing students at the bedside. It was also found that unfavorable environmental conditions, such as the lack of equipment and overcrowding of the ward, ineffective training as insufficient academic education, and the lack of role models were the most important factors in the emergence of these unethical behaviors.
In line with the findings of the present study, those of a study by Sadeghi and Ashktorab (24), entitled "Ethical problems observed by nursing students", demonstrated mistreatment with patients, the absence of proper and empathetic communication, and the lack of providing sufficient information.
Recording unreal reports was among the observed cases that could lead to serious harm to the health of the patient and the quality of service. Authentic and principled recording of nursing reports is one of the most important functions and professional responsibilities in nursing, and the efficiency of nurses’ performance in this regard should be emphasized by nursing management (25, 26).
Care discrimination was determined as one of the examples of unprofessional behavior in this study. The findings of a study by Zolfegharzade et al. (27) also showed that there were discriminatory measures towards AIDS patients in hospitals, while removing such measures is necessary to improve the quality of care for these patients.
The lack of nurses’ empathy with the patients and companions was also mentioned abundantly by the students. In a study by Popovicova and Belovicova (28), the findings demonstrated that unsympathetic communication led to patients' refusal to cooperate and feelings of anxiety, fear, mistrust, and aggression. Furthermore, discriminatory behavior between experienced and less experienced nursing personnel as well as between nurses and students creates an unsympathetic atmosphere, while the observance of ethics in nursing management depends on the proper interpersonal relationship between supervisors and nursing staff (29). In a study by Heydari Gorji et al. (30), nurses in special departments stated that 6% of nurses showed violent behavior towards their colleagues at least once a month. In another research conducted by Filipova (31), bullying in the workplace was considered a serious problem and 12% of nurses identified themselves as victims of this problem.
The results of a study by Nikbakht Nasrabadi et al. (32) revealed that the occurrence of offensive and impolite behaviors could affect the quality of services provided by nurses, which emphasizes the necessity of managing these behaviors. On the other hand, appropriate behavior of patients with nursing staff has been reported as one of the facilitating factors of professional ethics in nursing (29). The lack of trust, and attention to rumors, conspiracy, and gossip among colleagues were also reported, which showed the lack of organizational trust among nurses. Strengthening organizational trust should be given special attention by educational and hospital officials as it has a positive and significant relationship with boosting the professional ethics of nurses and their self-efficacy (33).
Among other results and effects of unprofessional behavior related to conscious omission and an unsympathetic atmosphere is jeopardizing patient safety. The results of studies demonstrate that one of the issues that plays a significant role in the degree of compliance with patient safety and attention to maintaining it is professionalism (5, 34). In their study, Parizad et al. concluded that the management's active attention to reducing professional misconduct and creating a positive professional environment would improve patient safety and service quality (35). Westbrook et al. (36) also stated in their study that professional misconduct was common among hospital employees and these behaviors could endanger the lives of employees and the safety of patients. In his study, Bostani has also emphasized the importance of nursing ethics education programs at the undergraduate level because of their prominent role in increasing the quality of patient care (37).
The findings indicated that such factors as a disproportion between the number of nurses and patients and lack of equipment and facilities, absence of organizational support, weak communication in the hierarchy, and the lack of necessary unity and coordination among the personnel of inpatient departments created an unfavorable environment, which consequently decreased the concentration of nurses in caring for patients. The findings of a study by Azarabad et al. (38) revealed that from the students' point of view, the heavy workload of nurses, the huge number of patients and their unstable condition, and the inappropriate work environment played a role in the emergence of unethical behaviors and mistakes. Taqhavi Larijani et al. (39) also pointed out that the lack of nurses led to several problems, one of the most important of which was the weakening of moral behavior.
From the students’ point of view, the inadequacy of university education was effective in the occurrence and spread of unprofessional behaviors, and to promote ethical behaviors, professional and ethical behaviors should be taught more. Holding continuous conferences and workshops with topics related to professional ethics is also effective in institutionalizing professional behavior. It is also recommended to provide nursing ethics courses with an integrated approach, interprofessional education, and professional ethics education at the patient's bedside, which was emphasized in a study performed by Jafari et al. (40). In another study by Ashipala and Shaluwawa (41), it was also pointed out that teaching ethics and professional behavior would lead to positive effects in providing services to patients and increase the efficiency of nurses.
In addition to the above, the students believed that the existence of useful role models, both in the position of academic staff members and inpatient department staff and colleagues, would be highly influential. Raso et al. (42) stated in their study that the behavior of working nurses was monitored by students and deeply affected their professional growth. In another study, the impact of the lack of support and weak cooperation of experienced personnel were reported on the increase of unethical behaviors (38). Therefore, working nurses should be justified in this regard and the necessary training is required to be provided to them. Razavipoor et al. (43) also introduced clinical professors as suitable role models for the professional role of learners.
Conclusion
It is obvious that, in most cases, the principles of professional ethics are followed by nurses despite the organizational deficiencies, especially the lack of staff, so this study only reflects the students' experiences of limited cases of professional misconduct with the aim of removing obstacles to the implementation of professionalism.
The findings of this study demonstrated that conscious omission and an unsympathetic atmosphere were among the most important examples of professional misconduct among nurses from the perspective of students as spectators at the bedside. An unfavorable environment and ineffective training were mentioned as other factors underlying the occurrence of unprofessional behaviors. Trying to create favorable job conditions along with providing continuous professional ethics training with novel teaching and learning approaches can be a positive step in promoting professionalism in nursing. However, improving professional behaviors and trying to reduce the incidence of professional misconduct is highly complicated and requires extensive and detailed studies as well as structural modification.
According to the results, it is suggested to include more units to teach professionalism and professional ethics in nursing courses with novel teaching methods. Identifying figures who are outstanding in professionalism and have behaved well with patients, patients' family, colleagues, and others in the schools and hospitals and using them as professors' assistants, especially during internships of students, can be highly effective. It is also recommended to hold multiple and consecutive case-based meetings for nursing students and staff. One of major limitations of this study, was the reluctance of students to participate in the study due to the fear of disseminating unpleasant experiences related to clinical environment. To alleviate this problem, at the beginning of all the interviews, the students were assured that their answers would remain confidential, and by explaining the objectives and necessity of the study and the possible results, their cooperation was obtained to conduct the interview; despite this, some students did not agree to cooperate. Moreover, due to the conditions of the COVID-19 epidemic, students' theory classes were not held on-site. As a result, access to the students was made possible after repeated coordination, and the interviews were conducted by observing health-related regulations.
Ethical considerations
This article was extracted from a research project approved by the Ethics Committee of Alborz University of Medical Sciences (IR.ABZUMS.RES.1400.094) and was completed with the financial support of the mentioned university. The participation of the students in this study was completely voluntary; therefore, their verbal and written consent was obtained to participate in the study and they were assured of the confidentiality of their personal information.
Acknowledgments
The authors would like to express their gratitude to the officials of the research assistant for issuing the letter of introduction and also to the Dean of the School of Nursing for their assistance in coordinating with the students.
Disclosure
The authors did not have any conflict of interest at any stage of the research.
Author contributions
SHH and ZT formulated the research idea. SHH and YPPS collected data. SHH and ZT performed the analysis and interpreted the data. All authors wrote the manuscript and approved the final manuscript.
Article Type : Orginal Research |
Subject:
Medical Education
Received: 2022/09/18 | Accepted: 2023/08/16 | Published: 2024/04/16
Received: 2022/09/18 | Accepted: 2023/08/16 | Published: 2024/04/16
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