Analysis of graduating nursing students' moral courage in six European countries

Nurses' justifications for morally courageous acts in ethical conflicts: A narrative inquiry

Background: Moral courage is defined as the courage to act in ethical conflicts based on individual or professional values despite the personal risks involved. Nurses justify their decisions to act morally courageously as part of their ethical decision-making.Objective: To describe registered nurses' justifications for acting morally courageously, or not, in ethical conflicts where they needed moral courage.Research design: A narrative inquiry with a holistic content approach was used. Individual, in-depth interviews were conducted in January-February 2023. The data were analysed using holistic content analysis.Participants and research context: Fourteen registered nurses with experience in situations where they needed moral courage participated. The nurses came from the somatic, palliative, mental health, and substance abuse care fields in Finland.Ethical considerations: Good scientific practice was followed. Ethical approval was obtained before data collection from the university's ethics committee.Findings: The nurses needed moral courage in ethical conflicts with patients present and between professionals. Individual responsibility, professional ethics, and emotions were identified as bases of nurses' justifications for morally courageous acts. The justifications for acting morally courageously, or not, had individual, contextual, and organisational perspectives. Morally courageous acts included starting a discussion about the conflict with other professionals and reporting the situation in writing within one's organisation.Discussion and conclusions: The identified bases and perspectives of justifications illustrate the complexity of nurses' decision-making in ethical conflicts, either leading to morally courageous acts or not. These results can inform nursing practice and research in developing processes to strengthen nurses' moral courage and examining relationships between moral courage and other concepts, such as moral resilience.

Exploring the foundations and influences of nurses'moral courage: a scoping review

INTRODUCTION

In the realm of healthcare, nurses frequently encounter complex ethical issues that demand moral courage. Nurses'moral courage is defined as the ability to act in alignment with their moral beliefs, even when faced with difficulties and dangers during ethical challenges. This study aims to explore the role of moral courage in nursing practice, highlighting its importance in maintaining patient care standards and fostering ethical decision-making.

METHODS

This scoping review on nurses' moral courage was conducted following Arksey and O'Malley's five-step approach. Relevant literature was sourced from databases such as Embase, PubMed, ScienceDirect, Web of Science, PsycINFO, Scopus, and CINAHL, spanning the years 2000-2024. A total of 40 studies were selected, focusing specifically on the foundations and influences of nurses' moral courage, with data extraction and synthesis for reporting.

RESULTS

The study highlights moral courage as crucial in nursing for ethical decision-making and patient care. Global variations in moral courage are influenced by cultural, contextual, and organizational factors. Tools for measurement show score discrepancies. Nursing education shapes moral courage, necessitating tailored programs. Research explores personal and organizational influences on ethical behavior, with factors like age, work experience, and ethics training impacting moral courage. Morning shift nurses and those with official employment exhibit higher moral courage. Gender's impact remains inconclusive, requiring further study. Training in nursing ethics enhances moral courage, emphasizing its role in care quality.

CONCLUSION

In conclusion, understanding the diverse factors shaping moral courage in nursing is vital for navigating ethical challenges and improving patient care quality. Tailored educational strategies are essential to foster moral courage among nursing professionals globally, emphasizing the need for ongoing research and interventions to enhance ethical practice and patient outcomes.

Relationship between Moral Sensitivity and Moral Reasoning with Moral Courage in Nursing Students

Background

Nursing students required to be prepared to face ethical problems in their future workplace. Solving moral dilemmas requires the implementation of moral decisions, which necessitates significant moral courage. Moral sensitivity and moral reasoning can play a key role in the emergence of morally courageous behavior. The aim of this study was to investigate the relationship between moral sensitivity and moral reasoning with moral courage in nursing students.

Materials and Methods

This was a cross-sectional study. The participants consisted of 296 nursing students of Isfahan University of Medical Sciences, Iran, in 2021, which selected through the census method. Data were collected using the Persian versions of the Moral Sensitivity and Sekerka's Moral Courage questionnaires and Nursing Dilemma Test. Data were analyzed by SPSS software (v. 25.0) using descriptive and analytical statistical methods (t-test, ANOVA, Pearson correlation, and regression analysis).

Results

A total of 296 nursing students participated in this study. The results showed no significant correlation between moral sensitivity and moral courage (r = 0.04, p = 0.41); however, a significant positive correlation was observed between moral reasoning and moral courage (r = 0.19, p < 0.05). The results of multiple regression analysis showed that moral reasoning was the only predictor of moral courage in nursing students (p < 0.05).

Conclusions

oral reasoning ability played a more significant role in developing moral courage than moral sensitivity. Tracking the sensitivity, reasoning, and moral courage status during education can reveal valuable information on the process of moral practice formation in nurses.

Ethical issues in palliative care: nursing and quality of life

BACKGROUND

Nurses occupy a pivotal role in the provision of palliative care, acting as frontline providers who address the physical, emotional, social, and spiritual needs of patients. The complexities inherent in palliative care frequently give rise to ethical dilemmas that significantly impact nurses' decision-making and patient interactions. It is therefore essential to gain an understanding of nurses' perceptions of ethical issues, quality of life, and adherence to patient rights in order to enhance the care delivered in these settings.

AIM

This study aims to assess the ethical issues encountered by nurses in palliative care, evaluate their quality of life, and measure their understanding and adherence to patient rights.

METHODS

A quantitative cross-sectional survey was conducted among a sample of 85 nurses working in palliative care settings, specifically within the Oncology Department and Pain Clinic at a Specialized Hospital in Egypt. A stratified random sampling technique was employed. The data were collected using standardised questionnaires, including the Ethical Issues Scale (EIS), the Nursing Quality of Life Scale (NQOLS), and the Patient Rights Questionnaire (PRQ). The validity and reliability of these instruments were established prior to the commencement of the study. The collected data were subjected to mean and standard deviation (SD) calculations. Statistical analyses, including the calculation of Pearson correlation coefficients, were conducted.

RESULTS

The study sample comprised a diverse cohort of nurses, with a mean age of 40 years. The ethical issues were evaluated, yielding a mean score of 4.03 (SD = 0.74) on the EIS, with the highest score for "Patient Care" (M = 4.2, SD = 0.7). The overall quality of life mean score was 6.75, with the working dimension exhibiting the highest mean score at 7.1. The PRQ results indicated a high level of awareness regarding patient rights, with a total mean score of 49.5 (SD = 6.8). The results of the correlation analysis indicated a moderate positive correlation between ethical issues and patient rights (r = 0.52, p < 0.01), and ethical issues and quality of life (r = 0.45, p < 0.01). Conversely, a weaker correlation was found between quality of life and patient rights (r = 0.40, p < 0.05).

CONCLUSIONS

The findings elucidate the ethical challenges confronted by nurses in palliative care and their ramifications for the quality of life and adherence to patient rights. It is imperative that nurses engaged in palliative care undergo continuous education and training in order to enhance their ethical decision-making abilities and thereby improve the quality of care they provide.

RECOMMENDATIONS

It is imperative that strategies be developed to support nurses in addressing ethical dilemmas, to promote awareness of patient rights, and to enhance their overall quality of life through targeted interventions and resources.

CLINICAL TRIAL

No clinical Trial.

The relationship between nurses' moral courage and whistleblowing approaches

BACKGROUND

Whistleblowing is an action that particularly requires moral courage. Understanding the relationship between nurses' levels of moral courage and their whistleblowing approaches is important for reducing adverse situations in healthcare services.

OBJECTIVES

This study aims to understand and analyze the relationship between nurses' levels of moral courage and their whistleblowing approaches.

RESEARCH DESIGN

This is a descriptive and correlational study.

METHODS

The study sample consists of 582 nurses actively working in a province in northwest Türkiye. Research data were collected using an Information Form, the Nurses' Moral Courage Scale, and the Whistleblowing Scale.

ETHICAL CONSIDERATIONS

Ethical approval from the ethics committee, institutional permission, and informed consent from the participants were obtained for data collection.

FINDINGS

Nurses were found to perceive their moral courage as high, and their whistleblowing levels were at a moderate level. There was a significant and moderate relationship between participants' levels of moral courage and whistleblowing levels (p < .05).

CONCLUSIONS

The findings emphasize the importance of promoting moral courage and creating an appropriate environment for exposing ethical violations. This study can contribute to the development of strategies to enhance nurses' moral courage and foster a more ethical working environment in healthcare services.

Mediating effect of moral sensitivity and professional identity between moral courage and compassion fatigue among nursing interns: a cross-sectional study

BACKGROUND

Compassion fatigue in nursing interns contributes to career indecision and worsens the nursing shortage. While work environment and psychological factors are well-studied, the ethical dimension remains unexplored. Understanding these mechanisms, particularly the role of moral courage, is essential for designing interventions to combat compassion fatigue and address the workforce crisis. This study investigates the influence of moral courage on compassion fatigue among Chinese nursing interns, focusing on the mediating roles of moral sensitivity and professional identity.

METHODS

A quantitative, cross-sectional study was conducted in accordance with the STROBE guidelines. We used the convenience sampling method to recruit 467 nursing interns from four public junior colleges in Hunan Province, China in February, 2024. Data were collected using Compassion Fatigue Short Scale, Moral Courage Scale, Revised Moral Sensitivity Questionnaire, and Professional Identity Scale. Data analyses were conducted using SPSS 22.0 and Amos 21.0.

RESULTS

The modified model exhibited a good fit (χ2/df = 3.437, AGFI = 0.928, IFI = 0.984, TLI = 0.976, CFI = 0.984, NFI = 0.977, RMSEA = 0.072). Moral sensitivity positively influenced both moral courage and professional identity, while professional identity negatively impacted compassion fatigue. Importantly, the effect of moral courage on compassion fatigue was entirely mediated by moral sensitivity and professional identity (β = -0.114, P = 0.001).

CONCLUSION

This study suggests that moral courage in nursing interns mitigates compassion fatigue through the combined mediating effects of moral sensitivity and professional identity. Ethics education programs fostering moral courage, moral sensitivity, and professional values in nursing students could be crucial in alleviating compassion fatigue.

Moral courage level of nurses: a systematic review and meta-analysis

BACKGROUND

Moral distress occurs in daily nursing work and plagues nurses. Improving the level of moral courage is one of the main strategies to reduce moral distress, and low levels of moral courage may lead to nurse burnout, increased turnover, and reduced quality of care.

METHODS

Nine electronic databases in Chinese and English were searched for the level of moral courage among nurses, including PubMed, Web of Science, EMBASE, CINAHL, CNKI, Wan fang, Wei pu, CBM and Cochrane Library, for the period from the date of database creation to April 5, 2023. The Agency for Healthcare Research and Quality (AHRQ) was used to assess the methodological quality of the included studies, followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Meta-analysis and Systematic Reviews of Observational Studies guidelines, and data from the included studies were meta-analyzed in STATA version 15 using a fixed-effects model.

RESULTS

Seventeen cross-sectional studies of moderate or high quality met the eligibility criteria and involved 7718 nurses, and the Nurses' Moral Courage Scale (NMCS) was used to measure the self-assessed moral courage level of nurses. Eleven of these studies reported total scores for nurses' moral courage, and the meta-analysis results showed a pooled mean score of 78.94 (95% CI: 72.17, 85.72); Fourteen studies reported mean entry scores for nurses' moral courage, and the meta-analysis results showed a pooled mean score of 3.93 (95% CI: 3.64, 4.23).

CONCLUSION

The results of the meta-analysis showed that nurses' moral courage levels were in the medium to high range, among the nurses who seemed to be male, non-nursing managers, high school education, had not experienced ethical issues, and considering resignation had lower levels of moral courage. The results of the meta-analysis may provide some reference for nursing managers and even hospital administrators to develop strategies to optimize nursing quality.

Nurses' moral courage and related factors: A systematic review

BACKGROUND

Nurses face various ethical conflicts when taking care of patients, and such conflicts require moral courage. This systematic review was conducted with the aim of investigating moral courage and its related factors among nurses.

METHODS

To find related studies, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The PubMed, Web of Science, Google Scholar, Scopus, Embase and Science Direct databases were searched using keywords such as Courage, Moral Courage, and Nurses, and no lower time limit was imposed when conducting the searches. The identified studies were published between January 2000 and March 2023. Quality of articles was assessed using the STROBE checklist.

RESULTS

The pooled sample size for the 19 included studies was 7863. All studies were observational and cross-sectional. The results showed that three categories of factors most related to moral courage are individual, moral, and factors related to the organization. Underlying factors of each category are also provided within this paper.

CONCLUSION

Moral courage is an integral part of nursing, which as a profession, is becoming even more challenging with the advancement of science and technology. Therefore, there is a need for nurses and especially nursing managers to be considerate of factors affecting moral courage of nurses, with a view to strengthening the positive factors and reducing the negative impacts.

Moral courage and its influencing factor among oncology specialist nurses: A multi-centre cross-sectional study

AIM

Moral courage among healthcare workers has been extensively studied. However, few studies have been conducted on oncology specialist nurses, who frequently encounter complex moral situations. This study aimed to describe the current situation regarding moral courage and explored its influence on oncology specialist nurses in China.

DESIGN

This was an exploratory, descriptive study.

METHODS

A convenience sample of 390 nurses was conducted from 15 hospitals in Sichuan Province, China, between March and May 2023. Participants were assessed using the Moral Distress Scale-Revised, Nurses' Moral Courage Scale and the Moral Sensitivity Questionnaire.

RESULTS

The results demonstrated that moral courage was negatively associated with moral distress, and positively associated with moral sensitivity. Having a master's degree or above, an intermediate title or senior title, medical ethics training, moral distress or moral sensitivity contributed to explaining 54.1% of the variance in moral courage.

CONCLUSIONS

Moral courage was associated with several factors. Developing clinical intervention strategies and effective teaching methods will be critical for improving moral courage. No Patient or Public Contribution.

Moral distress and moral courage among Iraqi nurses during the COVID-19 pandemic: a cross-sectional study

In the years following its outbreak in 2019, COVID-19 changed the health-care system structures, the context of professional activity, and nurses' moral performance. The present study aimed to examine the moral distress and moral courage of Iraqi nurses during the COVID-19 pandemic. This cross-sectional and correlational study was conducted in 2021 on 168 nurses selected by convenience sampling methods. Data were collected by self-reported instruments including a demographic questionnaire, the Professional Moral Courage (PMC), and the Moral Distress Scale (MDS). Data were analysed using descriptive statistics, the Spearman, Mann-Whitney and Kruskal-Wallis tests, and SPSS version 22. Most nurses showed a moderate level of moral distress (98.80%) and a high level of moral courage (99.40%). The dimension of multiple values had the highest mean (12.45 ± 1.47) and endurance of threats had the lowest mean (9.15 ± 1.79). There was a statistically significant correlation between moral distress and moral courage (P = 0.007, r = - 0.2), and moral distress and the dimensions of endurance of threat (P < 0.001, r = - 0.26), going beyond compliance (P < 0.001, r = - 0.037), and moral goals (P < 0.001, r = - 0.173). A statistically significant relationship was also found between moral distress and work shift, position and gender (P < 0.05), and between moral courage and position (P < 0.05). We concluded that nurses need more organizational support in terms of protective facilities, job security and organizational incentives to be able to show ethical behaviors.

Moral courage, job-esteem, and social responsibility in disaster relief nurses

BACKGROUND

Social responsibility can motivate disaster relief nurses to devote themselves to safeguarding rights and interests of people when facing challenges that threaten public health. However, few studies focused on the relationship of moral courage, job-esteem, and social responsibility among disaster relief nurses.

OBJECTIVE

To explore the influence of moral courage and job-esteem on the social responsibility in disaster relief nurses and clarify the relationship model between them.

METHODS

A cross-sectional study was conducted among 716 disaster relief nurses from 14 hospitals in central China through an online survey, including moral courage scale, job-esteem scale, and social responsibility questionnaire. The data were analyzed by Pearson's correlation, and the mechanism of the effect of moral courage and job-esteem on social responsibility was completed.

ETHICAL CONSIDERATIONS

This study was approved by the Medical Ethics Committee of the Second Xiangya Hospital of Central South University (Approval Number: 2019016).

RESULTS

Disaster relief nurses' moral courage positively impacted social responsibility (r = 0.677, p < 0.01), and moral courage could affect social responsibility through the mediating role of job-esteem.

CONCLUSION

Job-esteem mediated between moral courage and social responsibility among disaster relief nurses. Nursing managers regular assessment of nurses' moral courage and interventions such as meetings and workshops can reduce moral distress, foster morally courageous behavior, enhance job-esteem, and improve social responsibility performance among disaster relief nurses.

The relationship between teamwork, moral sensitivity, and missed nursing care in intensive care unit nurses

BACKGROUND

Teamwork, moral sensitivity, and missed nursing care are important healthcare challenges for Intensive Care Unit (ICU) nurses and the existence of a relationship between these variables can be useful for developing better care improvement strategies. This study aimed to determine the relationship between teamwork, moral sensitivity, and missed nursing care in ICU nurses.

METHODS

This is a descriptive cross-sectional study conducted on a total of 200 ICU nurses working at teaching hospitals affiliated to Semnan and Shahroud Universities of Medical Sciences, Semnan, Iran in 2022. Sampling was conducted using the census method. Data collection was conducted using a demographic checklist, the TeamSTEPPS Team Perception Questionnaire (T-TPQ), Lützén Moral Sensitivity Questionnaire (L-MSQ), and Kalisch and Williams Missed Nursing Care (MISSCARE) Survey. The examination of the relationship between the three variables was conducted using Pearson's correlation coefficient and multiple regression analysis.

RESULTS

The mean and standard deviation of teamwork, moral sensitivity, and missed nursing care was 3.47 ± 0.69, 64.19 ± 13.43, and 55.04 ± 34.10, respectively. The variable of teamwork had a significant positive relationship with moral sensitivity (p < .001) and a significant negative relationship with missed nursing care (p < .001). Teamwork was also a positive predictor of moral sensitivity (p < .001) and a negative predictor of missed nursing care (p < .001). The clinical experience of ICU nurses was a positive predictor of teamwork (p = .01) and a negative predictor of missed nursing care (p = .001). The age of ICU nurses was a positive predictor of moral sensitivity (p = .001) and a negative predictor of missed nursing care (p = .008).

CONCLUSION

The findings showed that a higher level of teamwork was associated with increased moral sensitivity and reduced missed nursing care among ICU nurses. Therefore, focusing on planning interventions on teamwork improvement can lead ICU nurses to improve moral sensitivity, lower missed nursing care, and promote the quality of patient care.

Analysis of moral courage and related factors among undergraduate nursing students: a scoping review

OBJECTIVE

to analyze scientific evidence on moral courage and related factors among nursing undergraduate students.

METHOD

the protocol of this scoping review was registered on Open Science Framework. A search was performed in five databases, according to the method provided by Joanna Briggs Institute Reviewers, the mnemonic strategy Population, Concept and Context, and a specific checklist.

RESULTS

a total of 2,812 results were identified, but only nine studies were eligible and presented three thematic approaches: Moral courage from the perspective of nursing students; Moral courage and related factors; and The teaching of moral courage in the training of nursing students. The factors related to moral courage include moral distress, moral sensitivity, age, and having a previous degree in the health field.

FINAL CONSIDERATIONS

few studies were found with a low evidence level. Most were performed in developed countries, indicating some gaps that need to be addressed in the future.

Evaluation of moral sensitivity and moral courage in intensive care nurses in Turkey during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, intensive care nurses may experience ethical issues related to fear of transmission, limited resources, and increased workload. Nurses' moral sensitivity and courage may have a role in dealing with these problems.

AIM

The purpose of this study was to assess intensive care nurses' moral sensitivity and moral courage during the COVID-19 pandemic.

DESIGN

Descriptive cross-sectional survey.

METHODS

A total of 362 nurses working in the intensive care units of pandemic hospitals in Turkey participated in the study between January and March 2021. Data were obtained using a personal information form, the Moral Sensitivity Questionnaire, and the Nurses' Moral Courage Scale. A link to the online data collection tools was sent to the management of participating institutions, who forwarded it to nurses. Reporting followed the CHERRIES guidelines.

RESULTS

In this study, the response rate of nurses was 89%. The nurses' total mean moral sensitivity score was 90.70 ± 28.89 and their mean moral courage score was 82.08 ± 13.51. A weak inverse correlation was found between the nurses' moral sensitivity and moral courage scores (r = -.176, p = .001). Total moral sensitivity score differed significantly according to years of Intensive care unit (ICU) experience (p = .007). Total moral courage scores increased significantly with education level (p = .012), years of nursing experience (p = .016), and willingness to work in the ICU (p < .001).

CONCLUSION

The study suggests that nurses working in the intensive care unit during the pandemic had moderate moral sensitivity and high levels of moral courage. Nurses' sociodemographic characteristics and ICU work conditions may affect their moral sensitivity and moral courage.

RELEVANCE TO CLINICAL PRACTICE

The results of this study can help guide efforts to improve moral courage and sensitivity and address ethical issues among ICU nurses.

Can a structured model of ethical reflection be used to teach ethics to nursing students? An approach to teaching nursing students a tool for systematic ethical reflection

BACKGROUND

Nurses encounter many ethical dilemmas in their practice. The ability to make good ethical decisions is a necessary competence in healthcare professions. International studies call for development and research on various methods to teach healthcare professionals ethics. This article describes an approach for learning how to be aware of and discover ethical dilemmas. By applying experienced narratives from healthcare practice and using question guidelines from a structured ethical model, nursing students learn to discover and find possible solutions for ethical problem in their practice.

AIM

The aim of this study was to describe second- and third-year nursing students' experiences by using structured ethical reflection as an approach to increase ethical awareness and deal with ethical decisions.

DESIGN

This study has a descriptive exploratory design. A three-day ethics seminar was carried out to help students learn how to recognize and explore ethical dilemmas in their practice.

MATERIALS AND METHODS

The data are collected from questionnaires used to evaluate the ethics seminar where 52 nursing students participated. The questionnaire contained open-ended and closed questions and was analysed using Braun and Clarke's reflexive thematic analysis. The empirical data were collected by 52 nursing students answering an evaluation questionnaire after the ethics seminar.

FINDINGS

Four themes were developed: Becoming aware of ethical dilemmas, Learning ethics by discussing knowledge and experiences with other students, Increased curiosity about ethics as a subject and Understanding the importance of critical ethical reflection work in clinical practice.

DISCUSSION

The process of learning how to understand the ethical principles in real-life nursing context continues progressing through the bachelor's program. Using group discussions and discussing examples of ethical dilemmas from practice help the students to a more comprehensive reflection process.

CONCLUSION

The nursing students experienced video lessons, group discussions and the use of a structured reflection model as a valuable approach in learning to recognize ethical dilemmas and how to deal with real-life ethical dilemmas.

Whistle-blowers - morally courageous actors in health care?

BACKGROUND

Moral courage means courage to act according to individual's own ethical values and principles despite the risk of negative consequences for them. Research about the moral courage of whistle-blowers in health care is scarce, although whistleblowing involves a significant risk for the whistle-blower.

OBJECTIVE

To analyse the moral courage of potential whistle-blowers and its association with their background variables in health care.

RESEARCH DESIGN

Was a descriptive-correlational study using a questionnaire, containing Nurses Moral Courage Scale©, a video vignette of the wrongdoing situation with an open question about the vignette, and several background variables. Data were analysed statistically and inductive content analysis was used for the narratives.

PARTICIPANTS AND RESEARCH CONTEXT

Nurses as healthcare professionals (including registered nurses, public health nurses, midwives, and nurse paramedics) were recruited from the membership register of the Nurses' Association via email in 2019. A total of 454 nurses responded. The research context was simulated using a vignette.

ETHICAL CONSIDERATIONS

Good scientific inquiry guidelines were followed. Permission to use the Nurses' Moral Courage Scale© was obtained from the copyright holder. The ethical approval and permission to conduct the study were obtained from the participating university and the Nurses' Association.

FINDINGS

The mean value of potential whistle-blowers' moral courage on a Visual Analogue Scale (0-10) was 8.55 and the mean score was 4.34 on a 5-point Likert scale. Potential whistle-blowers' moral courage was associated with their socio-demographics, education, work, personality and social responsibility related background variables.

DISCUSSION AND CONCLUSION

In health care, potential whistle-blowers seem to be quite morally courageous actors. The results offer opportunities for developing interventions, practices and education to support and encourage healthcare professionals in their whistleblowing. Research is needed for developing a theoretical construction to eventually increase whistleblowing and decrease and prevent wrongdoing.

The nurse teacher's pedagogical cooperation with students, the clinical learning environment and supervision in clinical practicum: a European cross-sectional study of graduating nursing students

BACKGROUND

A supportive clinical practicum experience may enhance the successful transition and socialization to working life of graduating nursing students. Nurse teachers have the main responsibility of supporting and guiding nursing students with their pedagogical expertise during the students' clinical practicum. Thus, the clinical role of nurse teachers is seen as an essential part of a high-quality clinical practicum. Nursing students appreciate the nurse teacher's cooperation with students, but it is often reported to be unattainable. The aim of this study was to explore and compare graduating nursing students' experiences of the nurse teacher's pedagogical cooperation with students, the clinical learning environment and supervision in their final clinical practicum, and to analyze factors associated with these experiences in six European countries.

METHODS

A cross-sectional comparative international survey design was used. The modified Clinical Learning Environment, Supervision and Nurse Teacher (CLES+T) Scale, with a new subscale measuring the nurse teacher's pedagogical cooperation with students, was used. A convenience sample of graduating nursing students in Finland, Germany, Iceland, Ireland, Lithuania and Spain completed the online survey in 2018-2019. The data were analyzed using a Chi-Square test, Pearson's correlation coefficients, and linear models.

RESULTS

A total of 1796 (response rate 49%) nursing students completed the survey. Overall, students had positive experiences of the nurse teacher's pedagogical cooperation, the clinical learning environment and supervision in their final clinical practicum. Students in Spain had the most positive experiences. Educational background factors appeared to be associated with the students' experiences of the nurse teacher's pedagogical cooperation with students, the clinical learning environment and supervision. The relationships between the subscale Nurse teacher's pedagogical cooperation with students and the Clinical Learning Environment and Supervision Scale were perceived as weak to strong depending on the country.

CONCLUSIONS

This study reveals that nurse teachers play an essential role in supporting and guiding nursing students' final clinical practicum. In this light, researchers, educators, and leaders should collaborate seamlessly between educational institutions and healthcare organizations to establish the nurse teachers' pedagogical cooperation role within the clinical learning environment.

A vulnerable journey towards professional empathy and moral courage

Background: Empathy and moral courage are important virtues in nursing and nursing ethics. Hence, it is of great importance that nursing students and nurses develop their ability to empathize and their willingness to demonstrate moral courage. Research aim: The aim of this article is to explore third-year undergraduate nursing students’ perceptions and experiences in developing empathy and moral courage. Research design: This study employed a longitudinal qualitative design based on individual interviews. Participants and research context: Seven undergraduate nursing students were interviewed during or immediately following their final clinical placement. Ethical considerations: The Norwegian Social Science Data Services (NSD) approved the study. Participants were informed that their participation was voluntary and were assured confidentiality. They were informed that they could withdraw from the study at any time, without providing reasons. Findings: Affective empathy seemed to be strong among third-year undergraduate nursing students. However, they tried to handle the situations in a ‘professional’ way, and to balance their emotions. At the same time, they expressed how difficult it can be to show moral courage when confronted with poor patient care. In addition, they spoke about a lack of role models during clinical practice and supervision. Conclusions: Undergraduate nursing students are in a vulnerable position throughout their journey to become professional and to develop empathy and moral courage. The professional socialisation and forming of professional empathy and moral courage among nursing students, may be seen as a complex interaction of formal and hidden curriculum, where role models play an important role. We argue that the main theme ‘Vulnerable students – a journey towards professional empathy and moral courage’ may cover the longitudinal project as a whole. This vulnerability is something both teachers and supervisors should be aware of when following up with students in their clinical placements.