Acta Paedagogica Vilnensia ISSN 1392-5016 eISSN 1648-665X
2021, vol. 46, pp. 148–167 DOI: https://doi.org/10.15388/ActPaed.46.2021.10
Professional Ethical Aspects in the Study and Internship Environment: Research in Tallinn Health Care College
Lifelong-Learning Centre at Tallinn Health Care College, Estonia
Lifelong-Learning Centre at Tallinn Health Care College, Estonia
Tallinn Health Care College, Estonia
The importance of ethical conduct in health care was acknowledged as early as the fifth century in the Hippocratic Oath and continues to be an essential element of clinical practice. Providers are constantly faced with complex ethical dilemmas.
Students learning to be health care providers need to develop the knowledge and skills necessary to avoid or solve complex situations involving ethical conflict.
Buxton et al, 2014, 70
Abstract. 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.
Keywords: health care education, students, ethics, study environment, internship environment, support system, qualitative study
Profesiniai ir etiniai aspektai studijų ir profesinės praktikos aplinkose: tyrimas Talino sveikatos priežiūros kolegijoje
Santrauka. Sveikatos priežiūros specialistų sąlytis su (ne)etiškomis situacijomis prasideda institucijoje, kurioje studijuojama, o su pirmaisiais sunkiais atvejais susiduriama profesinės praktikos metu. Šio tyrimo tikslas yra ištirti su studentų etikos suvokimu studijų ir praktikos aplinkose susijusias problemas ir jų priežastis (neetiškomis situacijomis). Taip pat siekiama atskleisti Talino sveikatos priežiūros kolegijos studentų informuotumą apie profesinę etiką ir kaip jie naudoja esamas paramos sistemas spręsdami neetiškomis situacijomis kylančias problemas.
Rezultatai atskleidė, kad visiems respondentams svarbus etiškas bendravimas ir elgesys. Empatija, etiškas grįžtamasis ryšys ir konfidencialumas suprantami kaip svarbios etikos standartų dedamosios studijų ir praktikos aplinkose. Respondentų teigimu, problemų dėl etikos gali kilti ne tik tarp sveikatos priežiūros specialisto ir paciento, bet ir tarp sveikatos priežiūros specialisto ir gydytojo, vadovo ar dėstytojo. Visi respondentai išskyrė praktinio ir į profesinį mokymą integruoto požiūrio į etinių sprendimų priėmimą svarbą.
Pagrindiniai žodžiai: sveikatos priežiūros švietimas, studentai, etika, studijų aplinka, profesinės praktikos aplinka, paramos sistema, kokybinis tyrimas.
Received: 06/05/2021. Accepted: 10/06/2021
Copyright © Kate-Riin Kont
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:
- What are the students’ opinions of learning professional ethics?
- How important is the role of lecturers and supervisors in teaching professional ethics?
- Which kind of problems are related to professional ethics in a study and practical training environment?
- How students manage unethical problems in a study and practical training environment?
- 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 role-plays 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 unprofessional 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.
- It is a set of rules to be followed in your work
- All rules are not found in the code of ethics, unwritten rules of behaviour are considered to be acceptable in society
- Professional ethical standards
- To my mind, ethics is behaviour rather than rules…
- Responsibility at work
- The first thing to keep in mind is the confidentiality
- The confidentiality that patient data is not disseminated
- Discrimination based on race, skin colour, ethnicity and national origin is not allowed
- Ethics of teamwork: collaboration between colleagues
- Mutual respect
- Considering the opinions of others
- Treat others the way you want to be treated
- Despite any patient’s behaviour, you have to remain calm and patient-centred attitude.
- Moral cognizance
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 starts at home, but you need some more knowledge about ethics to consolidate previously acquired ethical principles
- Ethics comes from the home
- You acquire ethics at home, but some rules have to be addressed in college, too
- You have to know how to behave with your patients, clients and colleagues
- Helps to avoid conflicts or helps resolve them when they occur
- You have to know that people have different norms and limits
- There is a need for harmonizing an understanding ethical concerns
- There are certain ethical standards, but some people have not heard about them
Students emphasized the need for teaching ethics via discussions or role-playing rather than through a right-wrong opposition, and integrating ethics into other subjects. Most students emphasized the need to provide more specific techniques to understand practical situations and problem-solving skills relating to ethics.
- We addressed the topic in the 1st year, but it should be continued and integrated into other subjects
- It is not enough to go through ethics in the 1st course only
- More discussions and lessons on ethics are needed
- There are situations which need to be role-played in order to make the right decisions
- More detailed knowledge is needed on problem-solving techniques for stress management, how to put ethics into practice
- Delivering a lecture only with slides is not effective
- A base must be acquired in the first year. And it should definitely go on, integrated into the following substances. It is impossible to teach ethics as “that it is right, that it is wrong”, but ethics must grow equally understandable knowledge within us.
- Some lecturers talk about their own experiences and emphasized ethical aspects in them
- Teaching professional ethics requires high-level knowledge to provide interest in this
Based on the students’ answers to the question “Whether and how are ethical aspects treated in your professional studies?”, ethical considerations have been discussed in each subject in each speciality group and through multiple views - in addition to teaching how to treat the patient-client, and how to dress or wear makeup appropriately at work.
- Ethical theories passed at the college cannot be applied in practice. You may face different attitudes toward work ethics in practical work
- Ethical aspects have been discussed in each subject
- Attention to professional appearance has been paid (ethical appearance at work: open hair, make-up, long and coloured nail polish are not acceptable in health care)
- Ethics applies even in clothing - some people do not understand why it is not appropriate to wear a deep neckline
- All our lecturers have emphasized client-centredness
- The client’s wishes have to be accepted, not criticized.
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.
- It must be understood that experienced practitioners do not have pedagogical education, they do not have the ability to conduct lessons, the ability to express themselves. But it’s not our fault, we came to get an education
- Lecturers have to be correct and information provided by them has to be understandable
- A lecturer has to inform students about test and exam results in time
- Lecturers should provide efficient feedback
- Effective feedback should be focused on a student’s development
- Feedback for homework is mostly laconic and all students have the same comments… It should be differentiated from feedback from which something can be learned.
According to typical expectations of lecturer behaviour, the attitude towards students, and personal qualities of lecturers, students expect empathy, positive attitude, passion for the subject being taught, responsibility for their statements, polite and friendly behaviour, and equal treatment:
- Lecturers have to be very polite and friendly
- Lecturer behaviour should be a role model for students
- Lecturers should treat students well and equally
- A positive attitude and empathy and feeling welcome towards students is important
- A lecturer should be honest and responsible for their statements
- More enthusiasm from a lecturer towards their subject and teaching role is expected...
Expectations on students’ behaviour were almost as same as for lecturers – respect the lecturers and other students, be motivated to study and do not cheat (which can also be considered as an unrespectful behaviour against the classmates and lecturer):
- You have to respect your lecturers
- You have to communicate with your lecturers respectfully
- Students should provide their motivation and discipline…
- Cheating and plagiarism are not accepted
- Students should not be late or absent from the lecture. We have come here voluntarily to study and it is not kind to the teacher when there are only two people in the class
Based on the interviews, typical answers to the second question “Could you give some examples of unethical behaviour in the learning environment?” were divided into two groups: opinions on lecturers’ behaviour and opinions on students’ behaviour.
Opinions on lecturers’ behaviour include humiliation, lack of equal treatment, and unprofessional or disrespectful behaviour towards students:
- Humiliation. For many students, verbal answers are not easy. There have been situations where the teacher makes Inappropriate and offensive comments in the presence of other students… Teachers should conduct themselves better
- It is very spiteful if a lecturer’s answer to your question is “you should actually know this...”
- What I have noticed in this school that the student is not always an equal partner, the student must be silent and listen and not express any opinions
- Equal treatment of all students has not always been kept in mind
- The rules are for students, they do not apply to the lecturer
- A lecturer could not withhold her emotions back and offended a student
Opinions on students’ behaviour, concerning the hierarchical system in medicine that is incomprehensible to students, the disrespectful remarks or comments and behaviour during lectures, cheating during exams, and even smoking as unethical behaviour in health care were pointed out:
- Although we have a non-smoking school and we are not allowed to smoke on our territory, I am still disturbed that I see students smoking across the road And in the practical training environment, certain hospitals are non-smoking, but there you can still see that the employees sneaking into the yard to smoke. I think it is unethical.
- Some students behave unethically and do not respect lecturers
- There is a lot of unethical behaviour on the part of students towards teachers. Every student should be reminded that making snide remarks during the class against your teacher is not an ethical behaviour.
- The hierarchical system in medicine and the hospital exists because we need to share responsibilities. Lack of respect for teachers and emphasis on one’s position is not ethical. You have to accept that you work in this kind of structure
- Cheating is common
- Unethical communication with teachers is not accepted
- Some students interrupt lectures by talking and laughing…
Answers to the third question “What are the causes of unethical behaviour in the learning environment?” were divided into two groups: personal qualities and other causes (Rannula, 2019, 24).
Personal qualities like lack of communication and team-working skills, heavy workload, understanding of right and wrong, lack of self-confident and self-control in words and emotions as well as poor upbringing were highlighted
- A person does not know his/her limits, what is and what is not allowed to do…
- People have different norms and limits
- Poor communication skills
- You cannot control your emotional triggers, and this is a big mistake...
- Poor home education
- Straightforward persons may be misjudged as impolite…
- The student-centred attitude is emphasized in words but not in actions
- Cooperation is very important in medicine and healthcare. In a work situation or in school you have a whole team or group behind which must work for a common goal. But in fact, we have a lack of learning how to cooperate effectively
- Changes in timetables make working difficult for students and they become nervous
- A person who values himself/herself and his/her profession cannot ignore ethics…
- 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.
- Discomfort occurs as a reaction to a certain situation - e.g. a doctor treating the patient inappropriately. I have tried to resolve the situation by communicating with the patient after the unethical situation, to console the patient.
- When you witness an unpleasant attitude or behaviour, you visit the patient afterwards and say a few words, smile and it usually works.
- As a trainee, these possibilities are so limited. What can be done in such situations? Completing the internship is more important.
- I have an example of a postpartum ward we went to with a midwife. The parents had become parents for the first time and they had a lot of questions. And this midwife was very rude to them so these parents were so shocked that they no longer dared to ask anything. And I had a very uncomfortable feeling there, at that moment I didn’t say anything just I was silent and left with the midwife. Afterwards, I went back to the ward and told them to ask anything, saying that I had time to talk to them. At that moment, I thought for a moment whether the fact that I went back was ethical or rather unethical towards my supervisor.
- In certain situations, I realize that it goes a bit against my ethical considerations, but an internship is where I am more in the role of an observer. With me being there for only a month, I cannot begin to change these ethical norms or show that I am doing something different. I try to analyse and think about what would I do differently.
- Shortly, I will try to be a better medical professional in the future. There is not always much you can do, but you can and will remember this situation so that you would not behave in an unethical way.
- I think that if you see the supervisor being impolite to the client - then I, for example, talked to the child afterwards. I tried to comfort the child... I don’t know if it helped.
Secondly, health care workers’ unethical behaviour in discussing their clients’ sensitive information.
- I can share my experience. I ended up at EMO, where my mother’s classmate worked. Later I heard from the school what had been done to me there and what kind of medication I had received. I investigated the matter and found that the only person who could know these details was the mother of my classmate. I wrote to the hospital board, for which she was punished.
- A similar case where information about a patient’s diagnosis was leaked from a local family doctor’s centre. The information reached the patient through acquaintances.
- At the University of Tartu, the subject of medical ethics dealt with a case where 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.
- We have a chance that if a conflict arises in the internship base, we should first talk about it with our supervisor. If this is still not helpful, you should contact your school tutor. But I’ve heard some students turn to the school, but the attitude is such that how they dare to complain. If there is a problem, I would not dare to go to school. Rather, I will discuss these issues after the internship seminar. In some places, it is very difficult to cope as a student. You have to choose your words very well. It is very difficult to resolve these conflicts in any way.
- Well, for example, unequal treatment of students - there is nothing to say here because when you say something, you are immediately an appellant. Of course, the chair’s attention can be drawn to that, why? But usually, the chair starts to justify the lecturer. Rather, we are silent that it makes no sense.
- Rather, keep quiet
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.
- This is the moment where you want to say something terrible, but you stand and smile on. And after that, you cry on your classmate’s shoulder.
- I have picked up the phone and complained to my husband. This is my first reaction.
- The good thing is that my mother is in the same profession. She has worked in a hospital. It is a great relief to me that I can share my concerns with her because she will understand my concern.
- Since we are here at school for the second year, you can turn to classmates. Share this common problem so that you are not alone in this problem. They understand
- Another possibility is that colleagues support each other when there is a good relationship within the team.
- We have a very good group, we communicate with each other. If there is an internship period and someone experiences something negative, they write in a group chat and everyone offers advice.
- Teachers are very responsive, they often do more than they have to do to get their 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 patient, 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.
- No, I am not aware of this kind of system
- We have heard about the ethics committee…
- A study counselling system exists; the study department.
- We are aware because we were told about it in the first year. But you still turn to a teacher you trust. 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 exacerbate 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.
- The support system is good even if it is not specified exactly how it works.
- I have not seen any tutors here with my own eyes for 3 years
- We have a psychologist in the next room, go and talk. Then there is the study department as well.
- The support from the Study Department is very accessible and has been very helpful especially in the first years. You can also get feedback and solutions quickly by e-mail.
- After all, there is all information available on the school’s website to solve your problems and exactly who to contact, and you have all the e-mail addresses that you can write to if you don’t want to go personally.
- The existing support system is available if needed. We have heard something from the Ethics Committee.
- Psychological counselling. I used it in the first year. It was very difficult for me to adapt when I came straight from high school to college. I had a lot of different health problems due to the stress, I used psychological counselling and I had a lot of benefit from it.
The presence of tutors is considered necessary, especially for first-year students, but it still covers the entire learning process to the end. They support exchange students, students with disabilities to adapt to the everyday life:
- The presence of tutors is necessary for first-year students. In addition, there are people with disabilities. What I like about this school is that people in wheelchairs have the opportunity to come to learn here. But they may need to support— how to manage. I think that’s good! Tutor assistance is good as it covers the whole learning process... They support exchange students to adapt to the local climate and local life.
Students are thoroughly introduced to the support systems available at the school during the beginning of the first year. However, the results of this study showed that only a few interviewees remembered what was said at the beginning of their study years and that support systems, as well as ethics, should be discussed in a coordinated way across different subjects and throughout the curriculum.
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 professional 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 high-level 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.
Aavik, T., Keerus, K., Lõuk, K., Nõmper, A., Pevkur, A., Saarniit, L., Simm, K., Sutrop, M., Tõnissaar, M., Vaher, A. & Volt, I. (2007). Eetikakoodeksite käsiraamat [Codes of Ethics Handbook]. Tartu: Tartu Ülikool, Eetikakeskus. https://www.digar.ee/arhiiv/nlib-digar:5856
Aguilar-Rodríguez, M., Marques-Sule, E., Serra-Añó, , P. Espí-López, G. V., Dueñas-Moscardó, L. & Pérez-Alenda, S. (2019). A blended-learning programme regarding professional ethics in physiotherapy students. Nursing Ethics, 26(5), 1410–1423. https://doi.org/10.1177/0969733017748479
Baldwin, D. C., Daugherty, S. R., Eckenfels, E. J., & Baldwin, D. C., Jr. (1991). Student perceptions of mistreatment and harassment during medical school. A survey of ten United States schools. The Western Journal of Medicine, 155(2), 140–145. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002944/pdf/westjmed00096-0036.pdf
Buelow, J. R., Pamela L. Mahan, P. L. & Garrity, A. W. (2010). Ethical Dilemmas As Perceived By Healthcare Students With Teaching Implications. Journal of College Teaching & Learning, 7(2), 85-92. https://doi.org/10.19030/tlc.v7i2.92
Burgatti, J. C., Doretto Bracialli, L. A. D., & de Campos Oliveira, M. A. (2014). Ethical problems experienced in a supervised curricular internship in nursing in an integrated curriculum. Revista da Escola de Enfermagem USP, 47(4), 934-939. https://doi.org/10.1590/S0080-623420130000400023
Buxton, M., Phillippi, J. C. & Collins, M. R. (2014). Simulation: A New Approach to Teaching Ethics. Journal of Midwifery & Women’s Health, 60(1), 70-74. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jmwh.12185
Code of Ethics for Midwives. (2008). Estonian Midwives Association Website. https://www.ammaemand.org.ee/ammaemanduseetika/?highlight=eetika
Coulehan, J., & Williams, P. C. (2001). Vanquishing virtue: The impact of medical education. Academic Medicine, 76(6), 598–605. https://journals.lww.com/academicmedicine/Fulltext/2001/06000/Vanquishing_Virtue__The_Impact_of_Medical.8.aspx
Dehghani, A. (2020). Factors affecting professional ethics development in students: A qualitative study. Nursing Ethics, 27(2), 461–469. https://doi.org/10.1177/0969733019845135
Esterberg, K. G. (2002). Qualitative methods in social research. Boston, MA: McGraw-Hill.khramtsovaHammond, R., Cross, V. & Moore, A. (2016). The construction of professional identity by physiotherapists: a qualitative study. Physiotherapy, 102, 71–77. http://dx.doi.org/10.1016/j.physio.2015.04.002
Jakimets, A. (2013). Eetika põhimõtete järgimine professionaalses õenduspraktikas [Respecting of ethics principles in professional nursing practice]. Tallinn: Tallinna Tervishoiu Kõrgkool. http://dspace.ttk.ee:8080/bitstream/handle/123456789/121/AlinaJAKIMETS.pdf?sequence=3&isAllowed=y
Kaju, H. (2017). Dr Katrin Elmet: Meid on õpetatud ravima, aga mitte suhtlema! [Dr. Katrin Elmet: We have been educated to treat, but not to communicate]. Tartu Ülikooli Kliinikumi Leht. (25 September). https://www.kliinikum.ee/leht/kliinikutes-teenistustes/1259-2017-09-25-08-06-08
Keis, A. (2012). Meditsiinieetika õpetamisest Tartu Ülikooli tervishoiu instituudis. [Teaching medical ethics at the Institute of Health Care, University of Tartu]. Eesti Arst, 91(11), 629–631. https://core.ac.uk/download/pdf/288325965.pdf
Khramtsova, I., Sarrino, D.A., Gordeeva, T. & Williams. (2007). Happiness, life satisfaction and depression in college students: Relations with student behaviours and attitudes. American Journal of Psychological Research, 3(1), 8—16. https://www.mcneese.edu/wp-content/uploads/2020/08/ajpr02_07.pdf
Kotkas, E., Rannula, K., Titma, T., Puura, K., Lenk, K., Kopti, M. & Sokolova, D. (2019). Professional Ethics and its Importance in Education. International Journal of Science And Engineering, 5(2), 47-60. https://www.ephjournal.org/index.php/se/article/view/1173/680
MacFarlane, B. (2001) Justice and Lecturer Professionalism. Teaching in Higher Education, 6(2), 141-152. https://doi.org/10.1080/13562510120045159
Magnani R, Sabin K, Saidel T, Heckathorn D. (2005). Review of sampling hard-to-reach and hidden populations for HIV surveillance. AIDS, 19(2): 67– 72. http://respondentdrivensampling.org/reports/AIDS_2005.pdf
Magnusson, A., Lützėn, K. & Severinsson, E. (2002). The influence of clinical supervision on ethical issues in homecare of people with mental illness in Sweden. Journal of Nursing Management, 10, 37-45. https://doi.org/10.1046/j.0966-0429.2001.00292.x
Memarian, R., Salsali, M. & Vanaki, Z. (2007). Professional ethics as an important factor in clinical competency in nursing. Nursing Ethics, 14(2), 203–214. https://doi.org/10.1177/0969733007073715
Monteverde, S. (2014). Undergraduate healthcare ethics education, moral resilience, and the role of ethical theories. Nursing Ethics, 21(4), 385–401. https://doi.org/10.1177/0969733013505308
Ongong’a, J. J. & Akaranga, S. I. (2013). Work Ethics for Lecturers: An Example of Nairobi and Kenyatta Universities. International Journal of Arts and Commerce, 2(8), 8-22. http://hdl.handle.net/11295/80119
Project Professionalism (2001). American Board of Internal Medicine. https://medicinainternaucv.files.wordpress.com/2013/02/project-professionalism.pdf
Puusild, M. (2010). Õe eetika, professionaalsed väärtushinnangud ja eetikaprobleemid asutushooldusel eakate õenduses [Nursing ethics, professional values and ethics issues in institutional care of elderly nursing]. Tallinn : Tallinna Tervishoiu Kõrgkool. http://dspace.ttk.ee:8080/bitstream/handle/123456789/124/Puusild2010.pdf?sequence=16&isAllowed=y
Püü, R. (2015). Ämmaemanda ja üliõpilase vaheline eetika praktikakeskkonnas [Ethics between mentoring midwife and trainee during practice studies]. Tallinn : Tallinna Tervishoiu Kõrgkool. http://dspace.ttk.ee:8080/bitstream/handle/123456789/110/PuuVillemson.pdf?sequence=8&isAllowed=y
Rannula, K., Kotkas, E., Puura, K., Lenk, K. Kopti, M. & Sokolova, D. (2019). Ethical Learning Environment: Students’ Perceptions. International Journal of Science & Engineering, 5(9), 20-31. https://www.ephjournal.org/index.php/se/article/view/1559/914
Roworth, W. W. (2002). Professional Ethics, Day by Day. Academe, 88(1), 24. https://doi.org/10.2307/40252115
Sadler, G. R., Lee, H-C., Lim, R. S-H. & Fullerton, J. (2010). Research Article: Recruitment of hard-to-reach population subgroups via adaptations of the snowball sampling strategy. Nursing & Health Sciences, 12(3), 369-374. https://doi.org/10.1111/j.1442-2018.2010.00541.x
Sporrong, S. K., Arnetz, B., Hansson, M. G., Westerholm, P. & Höglund, A. T. (2007). Developing Ethical Competence in Health Care Organizations. Nursing Ethics, 14(6), 825-837. https://doi.org/10.1177/0969733007082142
Treadway, K. & Chatterjee, N. (2011). Into the Water — The Clinical Clerkships. The New England Journal of Medicine, 364(13), 1190-1193. https://anth272engl264.web.unc.edu/wp-content/uploads/sites/22020/2020/01/Into_the_Water_-_The_Clinical.pdf
Vahtramäe, A., Sikk, J., Kaldma, M., Reva, E., Koit, K., & Varendi, M. (2011). Praktika kõrgkoolis. Tallinn: Sihtasutus Archimedes. https://www.innove.ee/wp-content/uploads/2018/08/praktika-k%C3%B5rgkoolis-trykki_0.pdf
Volandes, A. (2007). Medical ethics on film: towards a reconstruction of the teaching of healthcare professionals. Journal of Medical Ethics, 33(11), 678–680. https://doi.org/10.1136/jme.2006.017665