Professional Ethical Aspects in the Study and Internship Environment: Research in Tallinn Health Care College

The exposure of healthcare professionals to (un)ethical situations starts in the educational institution, and the first serious cases occur during internships. The aim of the current study is to investigate the problems and causes (concerning unethical situations) related to students’ perception of ethics in the study and practice environment and to describe the awareness of Tallinn Health Care College’s students of professional ethics and the use of existing support systems in solving unethical problems. The findings indicated the importance of ethical communication and behaviour by all respondents. Empathy, ethical feedback, and confidentiality were perceived to be an integral part of ethical standards within the study and training environment. Respondents pointed out that ethical issues may occur not only between a health care professional and a patient, but also between a health care professional and doctor, supervisor, or teacher. A practical approach to ethical decision-making integrated into professional training has been assessed by all respondents.


Introduction
Ethics is related to all aspects of human behaviour and decision-making, so it consists of several different subdivisions. Ethics implies continuous human development, the ability to learn new things, to feel one's own moral beliefs, and to strive for the improvement of oneself and one's surroundings in a way which meets the standards of the existing environment and are unambiguous values (Code of Ethics for Midwives, 2008).
Professional ethics is based more on rules in professional practice and less on the law and becomes clear to the person through recommendations based on learning, experience, example, and living environments at home (Aavik et al., 2007, p. 10). Professional ethics is a rational thinking process that aims to understand what values should be maintained and disseminated in an organization. In other words, professional ethics is a moral and conscientiousness commitment in any kind of work, duty, and responsibility (Memarian et al, 2007, 212).
Ethics is increasingly being included in the training curriculum for health-care professionals because new graduates need the abilities and skills necessary to effectively manage their careers, as well as to care for others. Educators and curriculum managers have the responsibility to prepare competent healthcare professionals by offering learning experiences that allow students to understand and integrate multiple perspectives among healthcare team members (Buelow et al., 2010, p. 85). The interpersonal role and function of teachers could develop professional ethics in students (Dehghani, 2020, 468).
Medical ethics, as an academic study, has been taught in Estonia since 1997 as part of the degree programs for future doctors, and later it has been added to all curricula that prepare health care professionals (Keis, 2012).
The problem is that health care professionals often lack necessary support as well as systematic training in dealing with ethical dilemmas in practice (Sporrong et al., 2007, 825). This is a skill to be learned. Communication training should be a compulsory part of medical training and the volume of instruction should be significantly higher. Good teamwork should also be given special attention (Elmet, 2017).
A good healthcare professional must be able to communicate in a professional manner in difficult situations. Are students ready to face these situations and analyse them later as professionals? Is the support system, both in the practice and study environment, strong enough to encourage and guide students to handle such situations? All these questions led to applied research among the students of Tallinn Health Care College.
Research questions were raised as follows: (1) What are the students' opinions of learning professional ethics?
(2) How important is the role of lecturers and supervisors in teaching professional ethics? (3) Which kind of problems are related to professional ethics in a study and practical training environment? (4) How students manage unethical problems in a study and practical training environment? (5) Are the students' aware and eager to use of the existing support system? There have been a few final theses based on literature sources, about midwifery ethics, defended in Tallinn Healthcare College, Ethics between mentoring midwife and trainee during practice studies (Püü, 2015) and in nursing ethics Respecting of ethics principles in professional nursing practice (Jakimets, 2013) and Nursing ethics, professional values and ethics issues in institutional care of elderly nursing (Puusild, 2010). In Estonia, the ethics education of health care students and their readiness to face unethical situations in the study and practical training environment has not been studied before.
The aim of the current study is to widen this gap and provide a unique data in the context of Estonian health care education.

Why is it necessary to teach professional ethics and how to teach ethics in a way that would be useful in real life?
The training of professional ethics and ethical aspects during professional studies is very important -it aims at developing students' analytical skills, critical thinking, decision-making and ethical awareness, whereas motivation becomes a necessary condition to facilitate learning (Aguilar-Rodríguez et al. 2019, 1411. Professionalism in health care includes altruism, excellence, duty, honour and integrity, and respect for others. These characteristics of health care and medical professionals have been taken as a basis to develop and provide professional ethics training (Project Professionalism, 2001, 6). More difficult is the development of attitudes guided by ethics. During professional education, attitudes can be taught through reflective practice (Burgatti et al., 2014, 935). A growing amount of literature has dealt with the content, goals, format, and methods of evaluating student learning in medical and health care ethics education. In general, healthcare ethics educators agree that the goal of ethics education is highly practical: to promote ethics in practice and positively influence the moral behaviour of future practitioners (Monteverde, 2014, 386). Lawlor (2007) claims that moral theories are complex and take quite a long time to understand. When teaching ethics to future professionals, time is often limited, as a large part of the teaching activity is practical training. Students are presented with a large amount of information on a theoretical basis that they cannot receive, or students are presented with a simplified theory that has very little value (Lawlor, 2007, 371).
As stated by Hammond et al. (2017), a "rule-based education of professional ethics may perpetuate a conventional mode of thinking; individuals obediently following the rules. This potentially limits reflection and reflexivity in practitioners' thinking about their values and beliefs." (Hammond et al., 2017, 75). It is very important to use right methods to teach ethics in a way that would be useful in communication with colleagues, patients and doctors, in the training environment. Students often feel a lack of roleplays as a tool for teaching ethics and introducing students to real cases and offer rich and textured details of cases, including the patient's perspective and the clinical reality (Volandes, 2006, 678). Different approaches can be used to teach the different cases of ethical issues in real life for students. Research in ethics education provides mixed outcomes on various educational methods for providing ethics content. Ethics education incorporates similar goals, such as the ability to recognize moral conflicts, knowledge of ethical foundations and decision-making models (Gorgulu & Kinc, 2007). Volandes (2006) introduces the method called "clinical vignettes" which uses more ethical discussions and more real patient cases in teaching medical students and focuses less on teaching rules or norms. Details essential for ethical analysis are often lost in the written or oral description provided to students. Visualization can bring a clinical vignette to life. For this reason, film as an ethnography may be relevant in discussions of medical ethics (Volandes, 2007, 678). Simulation as the other method has been shown to be an effective learning environment for students to learn and practice complex skills sets (Buxton et al, 2015). Ethical simulation can help students develop their knowledge, skills and behaviour within a safe environment. This increases self-confidence and allows you to explore communication techniques. Using simulation to teach and learn ethics enriches students' understanding of ethical concepts and promotes ethical behaviour in practice (Bensfield et al, 2012;Buxton et al, 2015).
From this it follows that (1) teaching ethics to health care students is important, it must begin in the first study year and continue throughout the curriculum, as moral theories are complex and take quite a long time to understand, and (2) the right teaching methods can contribute to the formation and further development of ethical beliefs.

The lecturer's and clinical supervisor's role and responsibility in ensuring an ethical learning in study and practical training environment
Lecturers have a significant responsibility in educating students about justice and ethics. Nevertheless, although most andragogy programs concentrate on teaching techniques, not much attention is paid to the ethical dilemmas that higher education teachers face every day (MacFarlane, 2010, 141). Roworth (2002) claimed that most lecturers do not give much attention to professional ethics. Also, students' mistreatment by lecturers or practical training supervisors has been investigated. Although the exact definition of student mistreatment is elusive, it is generally characterised as disrespectful and unpro-fessional behaviour towards students (Ellis et al, 2019, 143). Lecturers are professionals who should behave politely, respectfully and equally with their students. Students, in turn, must trust their teachers and show respect and courtesy to them. This mutual understanding is important because ethical acts and choices are expected to be acceptable and reasonable from all relevant points of view. Surveys have indicated that medical students' mistreatment with a concurrent feeling of "lack of emotional support from faculty", leads to humiliation in a practical training environment, and being threatened with unfair grades have been common (Coulehan & Williams, 2001;Baldwin, 1991). Both lecturers and students should know their limits and refrain from unethical behaviours, which may eventually disturb academic work or performance (Ongong'a & Akaranga, 2013, 14). Ongong'a and Akaranga (2013) highlight that: Lecturers do not only encourage their students to pursue education, but also represent the best academic and ethical standards in their disciplines. They are expected to demonstrate respect for students, conduct and ensure fair evaluation of students without the discriminatory treatment, exploitation and harassment (Ongong'a & Akaranga, 2013, 8).
However, attitude towards lecturers refers to thinking highly of lecturers' professional level and showing them respect but also getting to class on time (Khramtsova, Saarnio, Gordeeva & Williams, 2007). Magnusson et al. (2002) highlight that healthcare professionals who received supervisory support in clinical training felt that they were more confident in their decision-making and in their relationship with the patient had gained a deeper insight into the importance of both the patient and patient safety care than those who did not. The results emphasize the need for clinical supervision as it leads to greater self-confidence (Magnussonet al., 2002, 37).
One of the primary important environments for the development of the values related to the trainee's professional ethics is the internship institution, where experience is gained from moral dilemmas and choices. (Vahtramäe et al. 2011, 29). The medical and health care learning and practical training environments differ from that of other higher education programs in the challenges of the clinical teaching setting. Treadway and Chatterjee stated that "the rules governing the responses to these experiences are unclear… so [medical and health care] students take their cues from the behaviours they observe" (Treadway & Chatterjee, 2011, 1191. These cues are commonly referred to as the hidden curriculum. The hidden curriculum consists of cultural mores that are transmitted, but not openly acknowledged, through formal and informal education. Students' observations of lecturers and supervisors' behaviours have been claimed to affect students' learning more than formal teaching (Treadway & Chatterjee, 2011). Unforeseen situations can cause problems in both the learning environment and in practice (Jamshidi et al., 2016, 1). The mentor at the internship institution has an important role in the development and explanation of ethical attitudes (Vahtramäe et al. 2011, 29).
In summary, (1) the role and personal example of a teacher cannot be underestimated, with their behaviour and respectful attitude towards students, the lecturer can shape the ethical foundations of future health care professionals, and (2) when a student goes on an internship, a good mentor can help shape the ethical beliefs of a future healthcare professional in a new environment, where the student has to deal with doctors, nurses, patients and experienced colleagues.

Method, data collection and analysis
A qualitative approach and semi-structured interview methodology was used to conduct the study. Seven focus groups interviews with students from all higher education curricula of the college were conducted and recorded.
Two forms of sampling were used to identify participants: (a) purposeful sampling and (b) snowball sampling. Taylor et al. (1997) pointed out that when key players are interviewed, they may lead the researcher to other respondents. Magnani et al., (2005) argue that snowball sampling is associated with inviting difficult-to-reach communities to join health-care intervention projects or research studies. (Magnani et al., 2005, 571). Sadler et al., (2010) are convinced that: Snowball technique is often less expensive and less time-consuming than using traditional recruitment strategies to gather participants in proportion to the focus community (Sadler et al., 2010, 370) The researchers took into account people's privacy, and the anonymity and confidentiality of the data were guaranteed.
The focus group was led by a moderator whose task was to keep the discussion within the specified topic and create an environment free of social pressure. The duration of an interview varied from 1,5-2 hours, and the working language was Estonian (Rannula et al, 2019, 23;Kotkas, et al., 2019, 49). The interviews were conducted on a voluntary basis, with anonymity and the protection of personal data, ensuring confidentiality. Interviewees were also asked for permission to record the interview on a voice recorder. The interviews lasted approximately 50 minutes at the premises of Tallinn Health Care College. All interviews were recorded as accurately as possible. The interviewers were the study team.
After the interviews were conducted, transcribing audio recordings was the first step toward analysing qualitative data. Researchers created a complete written copy, or transcript, of the recording by playing it back and typing each spoken word. To ensure anonymity, the interviewees were not indicated which syllabus the student's answer comes from.
For the categorisation of specific themes, the texts were heard repeatedly by the research team. Simplified expressions were highlighted in the text and keywords were assigned to the text units, which were grouped based on similarities and differences. Finally, it was possible to begin to see some commonalities across categories or themes. The audio files of the interviews were deleted after transcription, the data from the interviews, including the quoted excerpts, are not associated with individuals or with the students' curricula.
Thematic Content Analysis (TCA) was used to describe and categorize qualitative data -relevant topics were chosen from the interviews and horizontal analysis employed.
As it often occurred, the answers of the respondents within the interview were not full sentences but sometimes emotional short exclamations adding to the previous answer of the group member, the researcher's interpretation of the answer includes the logical thought sequence. (Rannula et al., 2019, 21)

Students' opinions on learning professional ethics
The following section will focus on presenting information on the first research task, which was to investigate and describe the students' opinions on learning professional ethics. Three questions were asked to gain insight into the topic: What is the meaning of professional ethics? If and why is it necessary to teach professional ethics? Whether and how are ethical aspects treated in your professional studies?
When answering the question "What is the meaning of professional ethics?", expressions like "set of (unwritten) rules, standards or norms", "specialist's rights", "responsibility" "confidentiality", "respect others and their opinions", "morality" and "human rights" were mentioned by students most frequently. Also, a patient-centred attitude with mutual respect for both patients and colleagues to be important in professional ethics, and a sense of morality in professional ethics were highlighted.
• Based on the interviews, it can be concluded that most students find learning ethics to be very useful when answering the question "If and why is it necessary to learn professional ethics?".
Some students found that the basic understanding of ethics starts from home, but it is possible to gain more specific knowledge during the study years as well. Learning ethics provides students with knowledge that is useful for ethical behaving with their patients and solving conflicts. Different understanding of professional ethics and the necessity to harmonize the definition was highlighted. It was considered that not all aspects of ethics are equally understood; therefore, more knowledge about ethics is needed.
• It can be highlighted that ethics are almost universally taught during the early years of training, when students are unfamiliar with the clinical reality in which ethical issues arise. Although some students believe that ethical behaviour and attitudes start at home, they agree that some things can be learned at school. Students of the Tallinn Health Care College have an opinion that ethical aspects of health care should be discussed in each subject, not only in the 1st year, but within the entire curriculum, and the teaching ethics should include not only slide presentations about ethical rules, norms and standards and right vs wrong behaviour confrontation. What students expect is more simulations and role-plays based on the example of the lecturer's own experience of real-life work situations, and discussions.

The problems related to professional ethics in a study environment
The next section focuses on the second research task, which was to investigate and describe students' opinions about the learning environment. Three questions were asked to get an overview of the topic: How do you visualise an ethical learning environment? Could you give some examples of unethical behaviour in the learning environment? What are the causes of unethical behaviour in a learning environment?
Based on the interviews, the answers to the question "How do you perceive an ethical learning environment?" were divided into two main groups in order to bring out the students' opinions on lecturers' and students' behaviour separately (Rannula et al., 2019, 23). Health care students feel that although their lecturers are highly valued professionals, they are not educated as teachers, and sometimes have a lack of knowledge on how to transfer their experience and skills to students. Interviewees emphasized that they expect more accurate and clear information transmission, adequate and quick feedback, which helps improve the professional development of students.
• • Apathy and no motivation It is obvious from the section above that medicine and health care schools have some specific ethical issues but also issues that are common in every educational institution. Students expect from lecturers quick and effective feedback, adequate information transmission, better pedagogical skills, respectful and equal treatment, more empathy, a student-centred attitude and the need to feel valued by lecturers. They want to see that lecturers are motivated to teach them. But also they understand that there have to be some rules because it is necessary for their future internship or work in a hospital. Students are also very critical of other students' unethical behave in school. They do not accept smoking in medicine and health care area and disturbing lecturers and/or other students during the course, being late or absent from the lecture, cheating and plagiarism. They understand how important is cooperation as a group in College or as a team in a hospital and they expect to gain more skills in this area in their subjects.

The management of unethical problems in a study and practical training environment
The current section of the article will focus on presenting information on the third research task, which was to describe and analyse the management of unethical problems in a theoretical and practical training environment. Two questions were asked to gain insight into the topic: How have you behaved in an unethical situation or whether you have noticed it? To whom have you approached to resolve any unethical situation?
When answering the question "How have you behaved in an unethical situation or if you have noticed it?", most often the interviewees emphasized the feeling of discomfort, which emerged when witnessing an unethical situation during the internship. Students attempted to solve the uncomfortable situation by talking to the patient later, which in turn raised questions about whether talking to the patient or client without a supervisor present is ethical or not. Interviewees have tried to stop the nurses chattering in front of patients with severe conditions e.g. putting a finger to mouth-body language. The topic is instead addressed on an individual basis, and the students contemplated the situations relevant to one's future professional identity and behaviour.
• medical staff discussed patients' cases on the bus. It seems that medical professionals do not think it could harm anyone, rather they need to chat and talk after a hard day's work and share experiences or daily events. Students also consider certain agreements with pharmaceutical companies unethical, e.g., if some kind of medicine is recommended to patients more often than not, you would get gifts, etc. Also advertising of some medicines or food supplements which promise fast results but which effect is not proven scientifically. Vitamins for children in a form of gummy bears were also mentioned. Students feel it creates conflicts at the level of ethical issues if they have to make suggestions that are based on marketing goals and not on customer well-being • • We have some agreements with various pharmaceutical companies that if you sell our products more, you will receive gifts and then we should also push them more, although we might recommend something else. • • For example, we have a certain medicine which are not out in the hall for the client. And if the customer doesn't see it on the shelf, he doesn't dare ask for it, and he leaves. That's not okay either. • • But some drug and dietary supplements promotions are also a bit unethical. They promise some miracle effects or that they are 100% safe and suitable for everyone. There is no ethical or scientific research on dietary supplements. There may be attractive descriptions on the packaging, but the fact is that it doesn't work. How interviewees answered the question "To whom have you approached to resolve an unethical situation?" In several practical training bases, it has been clearly stated that the beforementioned activity is unethical.
• • When it comes to an internship tutor, it is not appropriate to say anything. Not even that you're afraid of this tutorial feedback, but it still does not feel appropriate... it may seem like you are saying you're smarter than your tutor, it's even unethical, as they said here. The next step in trying to solve a conflict is to contact the college supervisor. It was emphasized, that the support system exists, but it is approached with caution. In a practical training environment and or college-based learning environment, it is feared that addressing the concerning issues would result in retribution. Nevertheless, in resorting to this solution, students express their concern that leaving the student with an unfavourable impression in the eyes of the practical training institution. It was stated that it is wiser not to verbalize one's hesitations and to leave the discussions of any problems to the practical training final seminar. Students noted that their role in a practical training base is rather complex and difficult, one must choose their words extremely carefully. Also, solving any of these problems is rather difficult.
• Students claimed than when faced with an unethical situation at the college or a practical training institution, they prefer to discuss the matter with their families, fellow students, colleagues or in some cases with a lecturer they tryst. In case of concern with one of the subjects, firstly the lecturer is always addressed.
• pay. If there has been a problem, they still ask after that a solution was found and so on. In conclusion, this section emphasized that unethical situations were seldom witnessed in practical training situations, e.g. doctors' impolite behaviour towards the pa-tient, midwives' impolite behaviour with new parents, therapists' behaviour with children. Examples of unethical behaviour were diagnoses leaking out of the family doctor's centre and health care workers discussing patients while on a bus. As an excuse for this kind of behaviour, it was found that medical professionals are unlikely to think that this could harm anyone, but rather that it is a matter of feminine chatter and storytelling and sharing experiences. Lessons are learned from watching unethical situations during the traineeship in order to avoid such behaviour in the future as a professional healthcare worker.
It was emphasized that in case of a conflict at a practical training institution, the suggestion has always been to first discuss it with the supervisor. At the same time, the feedback from the practical training base supervisor is dreaded, because pointing out shortcomings might lead to an impression of believing oneself smarter than the supervisor or the head of the department/organisation. Students understand the rules and that the hierarchical system in hospitals and other health care institutions is necessary, because of the amount of responsibility being coordinated.
In the case of witnessing an unethical situation at the college or a practical training institution, students would rather discuss the matter with their families or coursemates.

The awareness and usage of the existing support system.
This part of the article will focus on presenting information on the fourth research task, which was to map the awareness and usage of the existing support system. During the focus group interviews, two questions were asked to gain insight into the topic. Are you aware of the existence of a support system in high school? Whether and how has the existing support system been available to you?
The answers to the question "Are you aware of the existence of a support system in high school?" were scant. Most students are not aware of the existence of the support system at all or have less information on its content.
• If there is a concern with a certain subject, always contact the relevant lecturer. • • I have been here for three years now and only now finally found out that there is an ethics committee, it took a long time. The students' answers to the question, "Whether and how the existing support system has been available to you?" highlighted that they relate the support system less to ethical problems, and more to psychological and educational problems. However, the knowledge that the support system exists and will be available if necessary, is very important. Counselling with a psychologist is considered necessary, because problems can also arise outside of school, while a long queue in the psychologist's availability may ex-acerbate the problem. It was also pointed out that this side of the psychological support system has remained blurred, and it is not clear exactly what could be addressed. It was found that there must be a place to go and talk about your concerns. Support for study counselling was also stressed. If there is a moment where one can't cope with school, they will receive support from classmates and teachers. •

Conclusions and Discussion
Being a healthcare professional means continuous learning and self-improvement. Based on the literature review, it can be said that teaching ethics to future healthcare professionals is very important -it helps to develop analytical thinking skills, respectful attitude towards lecturers, classmates, colleagues, teamwork skills and the ability to make pro-fessional decisions in a real work environment. Ethics has a different meaning for each student. Many responses interpreted ethics as a set of rules (both formal and informal) and norms. According to the students' more detailed comments, learning ethics provides them with the knowledge that is useful for ethical behaving with their patients and solving conflicts. One student emphasized that teaching professional ethics requires highlevel knowledge and skills from the lecturer. Moreover, it was found that teaching ethics only in the first year and as a separate subject is not enough -ethics should be integrated into different disciplines. Ethics instruction is now integrated into all subjects in each speciality group in Tallinn Health Care College. Integrating ethics into different subjects is one possible solution for improving the ethical behaviour of healthcare professionals. Experiential learning then allows these skills to be put into practice.
How and by what methods to teach ethics in a way that benefits students from the knowledge gained? The literature reviewed recommends different approaches, like the use of a method called "clinical vignettes" -visual media and filming the sample situations as a to teach and learn ethics as well as ethics simulation method, role-plays etc. There is strong evidence from the current study that students do not expect traditional theoretical lectures. They reinforced the need to provide more practical situations and problem-solving skills related to ethics in the instruction and internship environment. Traditional pedagogical methods do not necessarily produce enduring results or the translation of knowledge to future practice. Opportunities for students to enter into the experiences of patients should be explored further to determine if reported effects are enduring and impact future professional ethics in practice.
When talking about teaching ethics, there is no way to ignore ethics teachers, their personal example and respectful attitude towards students which refelcts also the studnts' attitudes to ethical behaviour towards teh colleages and patients in the practical training environment.
Different support systems need more promotion inside the College. Most respondents possess information on the existence of a support system in the college, but the awareness of different services available varies. The current support system has been available to all students who have needed it. Students have heard about psychological counselling, but it is not quite clear what kind of problems they should pursue it for. Students know about the Study Department services, tutor system, but they are convinced that tutors are mostly for first-year students or foreign exchange students. Upon witnessing unethical behaviour, students are not ready to share this experience with an internship or school supervisor. Rather, it is preferable for them to discuss and analyse the situations that happened with family members or with fellow students afterwards.
The study had the limit -the interviews were conducted by different members of the Ethical Committee in different study groups. This led to very thorough answers to some questions in some groups, including some additional questions, while other issues were addressed in less detail and, in some cases, very superficially. Therefore, interviews were not conducted at a uniform level.
Many new questions arose for the Ethical Committee which can be investigated in future. For example: • • What students expect of the school support system and tutor system, and what inputs and outputs are expected from teaching ethics in college in order to prepare students for internships and future working life. • • What students should know about hierarchy in hospitals and health care institutions -whether and why it is necessary. • • What do students and lecturers think is a hidden curriculum, and does it also exist in Estonia. This research was conducted in Tallinn Health Care College, and can be considered as a pilot project that can be successfully extended to all medical and health care curricula in other Estonian higher education institutions and universities. The authors hope that the results of the current study will encourage other health care institutions to investigate students' opinions and experiences in dealing with ethical issues and to analyze whether the educational institution has done its best to turn students into professionals who can successfully deal with ethical issues in their everyday working life.