Ethical dilemmas

E Mary Chiarella

IWORK

in curriculum planning

This paper delivers a discussion regarding the ethical dilemmas currently facing curriculum planners when designing nurse training programmes. The paper acknowledges the ideal of curriculum planning in nurse education and sets against it the worsening picture of nurse staffing levels facing many hospitals at present. It attempts to consider the esteem needs of the students and the legal requirements for care in relation to this dilemma. Whilst appearing to take a rather pessimistic view, the paper reflects the realities of the staffring problems currently being faced by

some Liverpool hospitals.

Ethical dilemmas, which are receiving so much current publicity, are faced not only by nurses in the clinical situation, but also by nurses in education, especially when preparing those early and influential days in the student nurses’ programme.

The ethical dilemma which is faced is basi- cally this - for whom is the introductory part of a nursing programme planned ~ for the student, for the service or for the patient? The obvious response to this question is ‘for all of them, of course’, but the point must be clari- fied by saying ‘Yes, but from whose viewpoint and for whose benefit’?

In an ideal student-centred environment, as all tutors learn when away on their tutors’ courses, the curriculum should be student- centred, it should allow for self-discovery, it

should promote inquiry amongst the learners, and should have a thematic, ‘building-block’ approach. The concept of a health-illness con- tinuum, community based nursing education programme is the dream of many within the profession, as was indicated by the response to the UKCC paper ‘Project 2000’ (UKCC 1987).

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E Mary Chiarella RGN SCM (NSW) RNT DipNEd,

Lecturer, Department of Nursing, University of Liverpool, 1 Abercromby Square, PO Box 147, Liverpool L69 3BX Manuscript accepted July 1987

Notwithstanding Project 2000, most general nurse training programmes are currently hos- pital based with a small community input; and despite the Government’s protestations to the contrary, many wards are having staffing pro- blems; and it is common knowledge that nurs- ing is currently having a recruitment crisis. Thus allocations officers await the intakes of students anxiously, to see whether they can spread them adequately. As for the wards to which the learners are going, every unit hopes for a good intake of learners, because although this means extra work initially for the trained staff when they have more ‘freshers’ to orientate to the ward environment, by the end

96

NURSE EDUCATION TODAY 97

of their ward allocation they will have at least

a relatively reliable workforce with reasonable

stalling numbers to give satisfactory patient

care. These observations are made with no

intended criticism; the reality of the situation is

that these learners are part of the workforce,

and whilst they remain so, the ward sister

needs them to be competent, as do the

patients.

Indeed, not only do the patients need them

to be competent, they have a legal right to

expect them to be competent. A point of law

raised in the case of Nettleship v. Weston

( 197 I) was that where a learner driver was

driving a car, he owed the same duty to the

general public as an experienced driver, or at

least a driver who has passed his driving test.

Finch (1980) points out that:

‘by the same token, a student nurse can be

expected to occupy a similar position. That

is, an error or omission which would in a

more senior nursing colleague, amount to a

breach of duty and thus actionable negli-

gence, will not be excused merely because

it was a learner who made it’. (Finch 1980,

P 23)

Not only do the ward staff and the patients

require the learners at least to be competent in

the skills required to work on their particular

ward, the learners themselves feel the need to

be useful members of the ward team. There

can be no doubt that most nurse tutors have

sat in an evaluation following, for example, a

first medical ward allocation (where perhaps

the students had been taught skills related to

nursing patients with respiratory and cardio-

vascular disorders) and the learners have said:

‘I wish you had taught us how to do Clinistix/

insulin injection/care of patient undergoing

lumbar puncture, many of the patients on my

ward were diabetic/neurological patients’.

Many nurse tutors have explained to the

learners that they are only learners, that they

cannot be expected to do everything at once,

that they attempt to develop the curriculum in

an intellectually meaningIu1 and educationally

viable manner to meet the educational require-

ments; but it does not resolve this ethical

dilemma, and the next time one sits down to

prepare an introductory course programme or

a modular programme the question lurks -

‘How can one best prepare the learner not only

for her long term future as a registered nurse;

but also for 6-7 weeks hence, when she goes on

to her ward, so that her self-esteem can be

preserved, and so that she will not become

another drop out’?

When looking at the work of West &

Rushton (1986), it is interesting to note that

one of the most troublesome issues related to

worry for learners is about the novelty of

situations and attempts to master new skills.

Nurse tutors are aware of the anxiety of their

learners, and the decision as to how many skills

to pack into their overcrowded teaching time is

ever present. This creates cognitive dissonance

within the professional, as such concepts as

patient-centred care are part of the educational

philosophy, and thus the attempt to design the

programme to incorporate skills into a coherent

patient-centred picture, which in itself limits

the skills which can or should be fitted in.

However, the reality is that while patient allo-

cation is attempted in most areas, its imple-

mentation can create difficulties, particularly

where a small number of trained staff are

supplemented mainly by auxiliary support, in

order to boost staffing levels when student

intakes are low. The ward sister is being told

by nurse educators on the one hand to imple-

ment patient allocation, and on the other hand

she must question the wisdom of allowing a

mainly untrained workforce to accept such

responsibilities on both practical and legal

grounds. Often for her the safest option is to

delegate tasks to her auxiliaries, and it thus

becomes difficult to implement patient allo-

cation for the learners, particularly when the

workforce, for a morning shift, may consist of

one trained member of staff, one learner, and

two or three auxiliaries.

These staffing situations often place un-

bearable pressures on the learners too. If the

only two people able to use the title nurse are

herself and the trained member of staff; and

98 NURSE EDUCATION TODAY

the nursing requirements are greater than that

of her training, then who should carry them

out - the trained member of staff, who may be

involved in ward management anyway, the

learner, who would be exceeding her level of

competence so to do, or the auxiliary who has

not received any nursing education at all?

It could be argued that these are the times

when nurse tutors should get on to the wards,

and use these opportunities to update their

clinical skills and ease the staffing crisis by

providing support for the learners. But intakes,

albeit small, keep on coming in schools of

nursing to maintain service requirements and

devolved examinations do need marking, and

it would seem that some tutors genuinely

do find it difficult to get to the wards, however

much they would wish to be there. Thus the

dilemma persists - how does one prepare the

learners for this environment; should that odd

extra procedure just be squeezed in, perhaps

at the expense of say, the discussion on ethics?

There is no doubt that supernumerary status

should ease this dilemma for curriculum

planners, although a caveat must be placed

on the ‘20% service contribution’ described in

Project Paper 9 (UKCC 1987).

Likewise, the introduction of the helper

grade and the reduction in the student work-

force may increase the pressures on the imple-

mentation of patient allocation, unless there is

a compensatory increase in trained staff.

In the short term, however, the well-

described theory and practice gap widens in

proportion to stalling problems, and continues

to create ethical dilemmas in curriculum

planning.

References

Nettleship v. Weston 1971 CA 2 QB691 Finch J When are you liable for negligence? Nursing

Mirror 4 September 1980; 22-24 West M, Rushton R 1986 The drop-out factor. Nursing

Times 31 December: 29-31 UKCC 1987 Project Paper 9, Project 2000, The Final

Proposals, United Kingdom Central Council, London, Paper 7