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Nursing Ethics
20(2) 126141
The Author(s) 2013
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Marsha D Fowler
Azusa Pacific University, USA
Anne J Davis
University of California, San Francisco, USA
Abstract
The large body of literature labeled ethics in nursing education is entirely devoted to curricular matters of
ethics education in nursing schools, that is, to what ought to be the ethics content that is taught and what
theory or issues ought to be included in all nursing curricula. Where the nursing literature actually focuses
on particular ethical issues, it addresses only single topics. Absent from the literature, however, is any
systematic analysis and explication of ethical issues or dilemmas that occur within the context of nursing
education. The objective of this article is to identify the spectrum of ethical issues in nursing education
to the end of prompting a systematic and thorough study of such issues, and to lay the groundwork for
research by identifying and provisionally typologizing the ethical issues that occur within the context of
academic nursing.
Keywords
Ethical issues, ethics, nursing education
Introduction
The modern nursing ethics literature in the United States is almost a century and a half long, reaching back
to a series of journal articles published in 1873. At that time, the first true nursing journal in the United
States, The Trained Nurse and Hospital Review, published a series of six articles on ethics in nursing.1
Although the literature hints at earlier books, Isabel Robbs book Nursing Ethics: For Hospital and Private
Use,2 published in 1900, is generally regarded as the first nursing ethics book in the United States. From
those days to the present, the nursing ethics literature has been broad, deep, and extensive, at times selfreflective and courageous. With the rise of bioethics in the 1960s, the already extensive nursing ethics literature burgeoned, growing to include 20 years of a dedicated journal, Nursing Ethics. Thus, given the
extent of the literature, we might ask whether there are any new frontiers for nursing ethics, any new ground
to be turned? Except for as yet unimagined advances in nursing and biosciences, it would seem unlikely. But
issues new to the nursing ethics literature do surface now and again. Witness, for example, Yilderim et al. s3
2007 article on mobbing of nursing faculty, an article that went where none had gone before. Freda and
Kearneys4 article also raises a new issue, that of ethical issues faced by nursing editors, and Freda, Broome
and others raise ethical issues encountered by nursing reviewers.5,6 The global nursing community and the
Corresponding author: Marsha D Fowler, 901 E. Alosta Ave, WCAM 219, P.O. Box 7000, Azusa, CA 91702-7000, USA.
Email: marsharaven@gmail.com
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issue of nurse migration is another emergent moral issue.7 Another domain in which new ground may be
turned is that of ethical issues in nursing education. The nursing literature does contain articles on specific
ethical issues that arise within the context of nursing education. However, there is nothing in the nursing
ethics literature in English that comprehensively or systematically addresses ethical issues arising within
the context of nursing education; here is a point at which new ground is ready to be plowed.8
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issue of nurse migration is another emergent moral issue.7 Another domain in which new ground may be
turned is that of ethical issues in nursing education. The nursing literature does contain articles on specific
ethical issues that arise within the context of nursing education. However, there is nothing in the nursing
ethics literature in English that comprehensively or systematically addresses ethical issues arising within
the context of nursing education; here is a point at which new ground is ready to be plowed.8
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particularly with respect to student incivility. Another 5.8% of the articles dealt with bullying, mobbing,
respect/disrespect, and uncivil or abusive communicationanother area of subsequent growth in the literature. Only 4.7% of the articles addressed the academic freedom of faculty. Another 4.7% of the articles
focused on the changing educational environment including global collaboration, distance education, software piracy, cultural barriers to progress, technological innovation, and the nursing shortage; this too is an
area of growth in the most recent literature. Only 1%2.1% of the remaining articles dealt with the remaining categories. These categories included the profession and society, including cross-cultural education, political involvement of nursing, and the knowledge economy. Issues in evaluation, including
topics of incompetent students, performance criteria for faculty, grading students, merit pay for faculty, and
post-tenure evaluationa small category indeed, and covering both student and faculty evaluation
received minor attention. Additional categories included faculty conflicts-of-interest and facultystudent
interaction. A scant 1% of the remaining articles addressed issues of faculty misconduct generally, sexual
misconduct specifically (i.e. student sexual involvement with patients), and developing a code of ethics for
nursing educators.
Many of the ethical issues that arise in nursing education are not addressed in the nursing literature,
though those same issues may be addressed in reference to nursing practice. For example, there are many
hundreds of articles devoted to the topic of the impaired nurse, that is, the nurse who is practicing clinically under the influence of drugs or alcohol. These articles also touch upon diversion programs for the
impaired nurse, so that the nurse might be rehabilitated to return to practice rather than being prosecuted
within the criminal justice system. The impaired nurse educator is never mentioned nor is the impaired student addressed.
In addition, some ethical issues that are amply addressed in the general higher education literature are not
touched upon in the nursing education literature. For example, considerable attention is given to the topic of
faculty sexual misconduct in the higher education literature (i.e. facultystudent sexual involvement). This
topic is not addressed in the nursing literature though there are a small number of articles that enjoin faculty
to be aware of the potential for student sexual involvement with patients.
It is of interest that the same relative weight of attention vis-a`-vis specific issues has persisted across the
two literature reviews. There has been a persistence of concern, still disproportionate, for issues of designating authorship, particularly for research-based journal articles. Student cheating also remains in the foreground. It is of some concern that a major continuing focus of the literature on ethics in nursing education
remains heavily weighted toward authorship concerns, and student cheating; not only are there ethical
issues that deserve greater attention than they have received, but there are also significant issues that are
not addressed at all.
The follow-up review of the approximately 1800 articles keyed as ethics and nursing education showed,
as noted above, that there has been some growth and some shift in the nursing literature in English. Those
articles still remain focused on what to teach in the nursing ethics curriculum. However, with regard to ethical issues actually occurring within the context of nursing education, the areas where the nursing literature
has grown have been in relation to (a) student incivility, including disengaged, disinterested, disrespectful,
disruptive, defiant, and disturbed behaviors;9 (b) concerns with regard to cheating, plagiarism, fabrication
of data, and facilitating cheating have received greater attention particularly in the form of technocheating or cyber cheating; (c) the implications of global migration or immigration of students and
poaching faculty from other nations; (d) racism, bigotry, prejudice, intolerance, and injustice in academics;
and (e) mobbing, bullying, and violence in the academic setting. Clearly, globalization has had an impact on
the nursing academic arena particularly in the domain of intercultural sensitivity and hospitality.
There are domains of ethical concern that continue to be taboo in the nursing ethics literature. One example is that of the impaired nurse educator, whether by virtue of substance abuse, mental illness, or perhaps
more frequently because of decline with aging. We can be reluctant to retire older faculty, particularly
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beloved older faculty, in the same ways that we are often reluctant to constrain the freedom of a declining
parent. A second example of a taboo is that of sexual relationships/misconduct between faculty, junior
faculty, and students. More specifically, there is nothing in the nursing ethics literature that addresses multigenerational lesbian sexual misconduct within schools of nursing. This issue is not addressed in the nursing
literature nor is it addressed in the higher education literature. A third example is the failure of the literature
to address the academically successful student who has no fit with the profession. Such issues arise when
economic recession and job loss cause persons in unrelated fields, so-called second-career students, to enter
nursing to secure employment. Some of these students fail ever to identify with nursing values and in some
cases, actively dislike the profession yet succeed in the classroom. The presence of a nursing shortage compounds such cases. These three issues may themselves be taboo, but perhaps they hint at a broader concernthat the entire domain of ethics in nursing education is, itself, taboo. Pursuing this line of inquiry
is certainly a painful self-reflection, disclosure, and exposure; it is, however, a necessary part of moral
self-regulation.
The concern herein is not to evaluate the literature in terms of the issues it raises or does not raise, or even
to evaluate the quality of the extant literature or specific studies. Rather, the concern here is to survey the
landscape of ethical issues that occur in nursing education to two ends. First, we hope to prompt a systematic
and thorough study of such issues that will expand the moral reflection and discourse upon such issues. Second, it is hoped that comprehensive study of these issues could ultimately eventuate in formalized moral
standards for nursing education and for the development and adoption of broad policies and procedures for
dealing with specific issues. The first step in this endeavor is to lay the groundwork for research by identifying the nature, extent, and prevalence of issues and to typologize provisionally the ethical issues that occur
within the context of nursing education.
The weakness of the nursing ethics literature in this domain requires that we provisionally amplify the
literature with our own knowledge and experience. In doing so, we go beyond the literature to include issues
with which we are familiar, either directly or indirectly. Here, we draw upon a combined 80 plus years as
nursing educators. Many of these issues have been brought to us for consultation, others we have observed,
and yet others have been brought to our attention by faculty colleagues both within and outside the United
States. All of the issues named below do fall within our experience, even if infrequently. We have chosen
specifically to exclude issues of which we have only hearsay documentation as well as those that we deem
one-off occurrences tied to a specific person or context. This list does not include system-based ethical
issues (such as unjust salaries/wages for faculty, the glass-ceiling for nursing faculty advancement in
universities, prejudicial barriers to nursing education, nontraditional clinical settings/web-based nursing
education, cyber-space research, etc.). These issues remain to be explored separately and are not
addressed here.
A proposed typology
Our current typology includes six categories:
Faculty
Students
Facultystudent roles and interaction
Academic and scientific integrity
Nursing educational administration
Profession, society, and global relations.
In each category, the issues are listed in subcategories. An attempt has been made to be as inclusive as
possible, recognizing that this is a preliminary typology.
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4. Student violence
5. Racism, bigotry, and intolerance among students
6. Privacy and confidentiality: background checks on studentsdata pooling, data surveillance,
and drug testing
7. Exchange student experiences: international experiences
B. Clinical education in the practice setting
1. Moral objection to participation
2. Clinical risk
3. Bullying of students in clinical facilities
4. Racism, bigotry, and intolerance in clinical facilities
5. Use of students for service
C. Student evaluation
1. Fair warning and due process
2. Grievances
3. Good grades and nursing misfit
4. Cheating, plagiarism, facilitation of dishonesty, and academic dishonesty
5. Unsafe students
6. Student academic freedom
III. Facultystudent roles and interaction
A. Role boundaries
1. Friendship versus mentorship
2. Student advising
3. Therapy or education
B. Faculty power and authority
1. Students as status individuals (vulnerable)
2. Undue influence and coercion
3. Student labor: using students for faculty ends
4. Faculty research on nursing students
5. Sexual misconduct
C. Respect for persons
1. Respect and civility
2. Racism, bigotry, and intolerance
IV. Academic and Scientific Integrity
A. Dishonesty
1. Faculty plagiarism
2. Falsification or fabrication of research findings
3. Research fraud
4. Grant misconduct
5. Academic records: falsification of/tampering with
6. Reports: fraud and misrepresentation
B. Integrity
1. Openness, self-policing, and peer review
2. Whistle-blowing
V. Nursing Educational Administration
A. Governance
1. Shared faculty governance
2. Evenhandedness and cronyism
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3. Oligarchic despotism
4. Intrafaculty ethos and relationships
B. Faculty recruitment
1. Process and participation
2. Stealing faculty
3. Employing registered students as faculty
4. Employing ones own graduates as faculty
C. Administrator relationships
1. Respect and civility
2. Bullying, coercion, and mobbing
D. Administrative role
1. Interference with teaching or grading
2. Violations of procedure, process, policy, and bylaws
3. Violations of academic standards
4. Misrepresentation, fraud, and illegal acts
E. Use of resources
1. Misappropriation or misuse of funds and resources
2. Conflicts of interest
VI. Profession, Society, and Global Relations (related to nursing education)
A. Educational standards and accreditation
B. Professional standards and ethics
C. Educating for reality and educating for the ideal
D. Socialization versus indoctrination
E. Prejudice, discrimination, and injustice in academic nursing
1. Community outreach and programs
2. Admissions policies
3. Scholarships and financial aid
F. Cultural conformity versus social activism
G. The changing educational environment
H. Transnational nursing education, educational imperialism, and neocolonialism
I. Stealing faculty internationally
The sixth category differs in that it represents social ethical concerns that arise within nursing education
within particular schools but function at a macrolevel. Failure of schools to oversee adherence to national
standards for education and practice, reinforcing empire in distance or global education, schools engaging in robbing the poor to staff the schools in rich countries with faculty (as when wealthy nations
refuse to develop national workforce sustainability), and prioritizing business values over nursing values are
local issues with profound effect upon the global nursing community.
Of approximately 100 person-based ethical issues in nursing education, 70% are not moral dilemmas at
all, that is, there is no conflict of norms or values. They represent, instead, moral failure. In these instances,
there is no question as to what is right or good; rather, these issues reflect a failure to adhere to what is commonly understood and affirmed as right or good. These ethical issues thus represent a failure of moral character, that is, a failure of virtue. Early US nursing ethics (from the 1870s through the 1950s) emphasized
virtue over duty, particularly in the moral formation of nurses.10 The shift from a virtue ethics toward a
duty-based ethics within American culture, nursing, and education is well documented.11,12 In addition, the
educational environment in the United States is changing as institutions increasingly seek funding from corporate foundation sources resulting in the importation of business priorities and values into nursing and
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university education.13,14 These values can be inimical to nursing values. These two factors combine to
mitigate against nursings traditional concern for virtue and nursing values and can set the stage for a continuation of or rise in the neglect or failure of virtue in nursing educational settings.
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