In the 25 years I have been a bedside nurse and the 15 simultaneous years as a nursing faculty member, I have seen plenty of changes in how health care is delivered and how nursing is taught. What has not changed much is human nature—both of the nurse and the patient. Our patients’ fundamental needs, such as food, warmth, compassion, and alleviation of suffering, have remained constant. Nurses have responded to these basic needs much in the same way since the dawn of science, although the means to meet them may have changed. The foundation of the innate capacity of nurses to respond to these needs were perhaps already in them even before they entered the profession. In nursing school, this vitality is awakened through countless lectures, nursing care plans, evidence-based papers, and process recording. Nurses are “increasingly called on to perform highly skilled technical-scientific and relational work.” Therefore the motivation to cultivate virtue (compassionate practice) and virtuosity (technical skills) amongst nurses stems from the need to practice safely and accurately in less-than-optimal circumstances.1
What’s a nursing virtue?
A philosophical definition of virtue tells us it is “a force that has or can have an effect.” For example, the virtue of a medication is to cure. Essentially, a “virtue is a capacity or power and always a specific one.”2 The virtue of nursing—the power to heal the sick—is one of the critical elements of its professional value with its unique excellence in the records of the healing arts, as a distinct and effective form of treatment and wellness modality. An effective nurse is one who excels in nursing, either independently or collaboratively. In a virtuous nurse, life-saving skills and virtue converge at every patient care interface anywhere in the health care systems. Often, these virtues and values “remain unspoken, and perhaps unrecognized, but nevertheless profoundly influence what they attend to in a particular situation, the options they consider in taking action, and ultimately, what they decide” to do in response to the patient’s needs.3
A nurse is a “force” that has the power to heal or promote positive changes in the patient. And if this force is coupled with the great virtues of politeness, prudence, generosity, mercy, courage, gratitude, humility, honesty, tolerance, and gentleness, our potential for healing is unimaginable, if not already irreplaceable. The opposite is also true. The lack of these virtues in a nurse is a threat to patient safety and quality, and may lead to incivility and practice breakdown.4 The Quality and Safety Education for Nurses (QSEN) initiative proposed competencies for the new nursing graduate to “value” patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.5 Attaining safety and quality in nursing requires not only the skillful application of evidence-based knowledge, but also relies on the cultivation of values and virtue education in nursing in order to develop a competent and respected nurse.
It is beyond the scope of this article to discuss the treatise of these virtues. Often they are vaguely alluded to in the mission statements of schools and health care institutions. It is recognized that all virtues evolve over time and can be learned through experience.2 Nurses have the unique opportunity to get to know their patients over time. This allows them to “experience” their patients with greater intensity. This lasting interchange influences the formation of values in the nurse. Over time the nurse is expected to develop an ethical appreciation of the patient, not merely as a problem to be solved, but as an individual to be cared for. According to Benner, “the dominant ethic found in stories of everyday practice is one of care and responsibility.” Therefore, the development of virtuous practice is closely linked with the “development of skillful moral comportment that is derived from experience.6 Moral comportment results from reflection-on-action on the virtue of nursing during the span of a nurse’s career.3
According to Gallup’s annual survey of professions, nursing has been voted the most trusted profession in America for their honesty and ethical standards for the 11th consecutive year.7 Perhaps this reflects the collective ethical comportment that nurses manifest in practice.1 If we are to remain faithful to this public trust, nursing education must provide evidence-based clinical encounters that cultivate virtue development and growth.
The virtues already in place
Long before a student enters the nursing program, the foundations of these virtues were perhaps already laid down through their relationships with families, peers, their community, and the world at large. A study by Benner, Tanner, and Chesla showed that nurses come to clinical situations with a fundamental disposition toward what is good and right or what can be considered as virtues.8 The nursing faculty then accelerates the application of these virtues in the healing arts. It is with humility, both intellectual and experiential, that a faculty member may acknowledge the academic and clinical success of today’s graduates. This is partly the result of the richness of experiences, traditions, and cultures that students bring to the nursing program. Through carefully designed experiential learning activities, we can sustain our students’ innate and acquired virtues to be incorporated into their professional practice.
Strategies for virtue-inclusion in nursing education
Self-reflection is an essential component in value education. Benner et al. advocate for educators to “foster opportunities for students to learn how to reflect on their practice.”1 When provided with a safe climate for critical reflection, students can examine the virtues of nursing in the context of its success and practice breakdown. Integration of virtue education can easily be incorporated into classroom, simulation, and clinical activities. An essential first step would be to conduct a comprehensive curriculum review to identify gaps in moral or value education content and offer recommendations. Specific teaching strategies are offered below:
- Enrich courses by integrating dilemma-based ethics and bioethics with attention to everyday notions of good practice and relational ethics.1
- Organize small-group, student-led ethics committees and sponsor “brown-bag” discussions on similar topics.
- Integrate current events dealing with bioethics in health care, education, and politics into clinical topics as appropriate.
- Offer elective courses on ethics and value education. Collaborate with other schools within the university that may already have a course offered on the subject.
- Require reflection papers and journal entries on ethics and values, exploring their impact on quality, safety, and patient satisfaction.
- Conduct small in-class surveys or opinion pools on ethical dilemmas using interactive or online programs.
- Infuse unfolding medical-surgical case studies with ethical questions and offer guide questions for self-reflection.
- Use questioning to engage students in clinical thinking.1,9 Choose questions that allow learners to make decisions and defend their choices.10
- Sponsor informal activities, such as a movie night, for students to watch ethics-themed films, followed by a panel discussion.
- Create simulation scenarios with built-in ethical dilemmas.
- Infuse simulation exercises with inter-professional collaboration that uses the multi-disciplinary approach in dealing with ethical issues.
- Use the standardized “patient” in clinical simulation of ethical issues. Standardized patients (SP) are individuals who are trained to portray a patient with a specific condition in a realistic, standardized, and repeatable way.11 The use of SP will enhance virtue development because it allows for “nuances such as stance, touch, and orientation fused with physical presence and action” that cannot be replicated with a static manikin.6
- Encourage student to attend ethics committee meetings in the hospital, school, or community.
- Encourage students to ask a moral or ethical question during pre-and post-conferences.
- Conduct bedside rounds as an alternative to post-conference. This allows for personal interaction between the students and the patient. This will help cultivate empathy, honesty, and politeness.
This list of teaching activities is by no means exhaustive. It is important to consider that even brief but specific endeavors can be used to integrate virtue education and facilitate discussion and reflection. Ongoing faculty development activities on virtue education will also be needed in order to elevate the quality and effectiveness of these educational strategies.1
If virtue can be taught, as I believe it can be, it is not through books so much as by example.2 A student who responded to the Carnegie National Student Nurses’ Association survey said the biggest challenge in nursing education she faced was “being lectured on caring and building trust by instructors who don’t practice what they preach.” 1 As clinical faculty, we have the moral imperative to model the virtues we want our students to emulate. We provide plenty of skills practice for bed, bath, and invasive procedures, both in real-time and in simulation, but there are very limited or non-existent “skill labs” for students to practice empathy, compassion, gentleness, humor, and the highest of all virtues: love. It is time to return virtue and value education back into the nursing curriculum.
- P. Benner, M. Sutphen, V. Leonard, and L. Day, Educating Nurses: A Call for Radical Transformation.San Francisco, CA: Jossey-Bass, 2010.
- A. Compte-Sponville. A Small Treatise on the Great Virtues: The uses of philosophy in everyday life. New York: Metropolitan Books, 2001.
- C. Tanner, “Thinking like a nurse: A research-based model of clinical judgment in nursing,” Journal of Nursing Education, 45 (2006), 204-211.
- S. Luparell, “Incivility in Nursing: the connection between academia and clinical settings.” Critical Care Nurse, 31(2), (2011) 92-95.
- L. Cronenwett, G. Sherwood, J. Barnsteiner, et al, “Quality and safety education for nurses,” Nursing Outlook, 55(3), (2007) 122-131.
- P. Benner, “The role of experience, narrative, and community in skilled ethical comportment.” Advances in Nursing Science, 14(2), (1991) 1-21.
- J.M. Jones, “Nurses Top Honesty and Ethics List for 11th Year,” (2010), retrieved from http://www.gallup.com/poll/145043/nurses-top-honesty-ethics-list-11-year.aspx.
- P. Benner, C. Tanner, and C. Chesla, Expertise in Nursing Practice: Caring, clinical judgment and ethics. New York: Springer, 2010.
- F.A. Lim, “Questioning: A teaching strategy to foster clinical thinking and reasoning,” Nurse Educator, 36(2), (2011) 52-53.
- K. Bain, What the Best Teachers Do. Cambridge: Harvard University Press, 2004.
- Association of Standardized Patient Educators. Standardized patient terminology definition. ASPE Quarterly Newsletter (2010), 9(3), 9.
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