Research Brief
Reactions of Nursing Students When Faced With Violations of the
American Nurses Association Code of Ethics
Katelyn M. Wentworth, Lisette Dorfman, and Justine Taddeo
Abstract
A qualitative study was conducted with 10 nursing students to evaluate how students respond to breaches of standards of
practice by clinical nurses. Statements were identified and analyzed with Colaizzi’s method. Three main themes emerged:
1) Violations of the ANA Code of Ethics were witnessed by students (handling medications/equipment incorrectly, failing to
comply with infection control, violating patient privacy). 2) Students were upset and felt they should have responded differently
when witnessing a violation. 3) Students need preparation on how to react to violations of practice, with proper enforcement
of practice within the clinical.
KEY WORDS American Nurses Association Code of Ethics – Clinical Nursing Education – Moral Apathy – Nurse Educators –
Nursing Students
T
he American Nurses Association (ANA, 2015) Code of Ethics
for Nurses dictates the nonnegotiable ethical obligations and
duties of every individual entering the nursing profession.
Nurses act based on values that they have selected. In order to
recognize and understand these values, nurses must first be provided
with ethical knowledge to manage situations and provide safe and
ethical care (Shahriari, Mohammadi, Abbaszadeh, & Bahrami, 2013).
Moral distress can be defined as the painful feelings and psychological disequilibrium that result from recognizing an ethically appropriate action and not taking action. Obstacles to taking action vary
and may include lack of time, supervisory reluctance, an inhibiting
medical power structure, institutional policy, or legal considerations
(Range & Rothman, 2010). Nurses, according to Wojtowicz, Hagen,
and Van Daalen-Smith (2014), may fear reprisal when speaking up
against practices that are seen to be morally wrong. Perceived or actual fear of reprisal is particularly pronounced in organizational structures that are overly concerned about appearances and reputation.
There is minimal information in the literature regarding the reactions of nursing students when witnessing ethical breaches. The
About the Authors Katelyn M. Wentworth, BSN, RN, is a cardiovascular
surgical nurse, Catholic Medical Center, Manchester, New Hampshire.
Lisette Dorfman, PhD, FNP, RN, is an assistant professor, College
of Mount Saint Vincent Department of Nursing, Bronx, New York.
Justine Taddeo, EdD, RN, now retired, was a full professor, College
of Mount Saint Vincent. For more information, contact Dr. Dorfman at
lisetter914@aol.com.
The authors have declared no conflict of interest.
Copyright © 2019 National League for Nursing
doi: 10.1097/01.NEP.0000000000000580
364 November/December 2020
purpose of this study was to help broaden ethical reflection and discourse by evaluating the ways in which nursing students respond to
breaches of standards of practice by clinical nurses.
METHOD
Institutional review board approval was obtained for this qualitative
study, which focused on the lived experience of nursing students.
A phenomenological approach was selected to achieve a deeper understanding of the lived experience from the participant’s perspective
(Schmidt & Brown, 2015). A purposeful sampling method was used,
and individual interviews were recorded and transcribed verbatim.
Colaizzi's (1978) strategy of descriptive phenomenological data analysis was used to extract, organize, and analyze the narrative data set,
in this instance, participants’ responses to a series of open-ended
questions. A number of significant statements and theme clusters
were integrated to formulate the overall themes that describe the phenomenon. Data saturation was reached as no new themes emerged
from interviews.
Trustworthiness was established with peer debriefing, member
checking, and a self-reflection journal. Peer debriefing is a process
through which the researcher enlists the help of a peer expert, in this
case the co-investigator of this study, to discuss the data (Schmidt &
Brown, 2015). Peer debriefing ensures the truth emerges from the
findings. Member checks were done by asking participants to review
and confirm the results of the data to ensure the findings reflected
what they said. To assess individual biases, the principal researcher
used a self-reflective journal and bracketing.
Participants were 10 nursing students enrolled at a four-year college at various clinical sites who responded to flyers and emails. Nine
were women; three were seniors with four semesters of clinical experience, and seven were juniors with two semesters of clinical
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Research Brief
experience. Six of the 10 were Caucasian, three were Asian/Pacific
Islander, and one was Hispanic.
FINDINGS
A serious issue raised throughout the study pertained to nurses who
did not follow proper standards of care in accordance with the ANA
(2015) Code of Ethics. Equally serious were nursing students who
did not react to the violations witnessed. The majority of students in
the study did not react or stand up to the nurses when a violation
was witnessed, and only two students informed their instructor about
a witnessed violation. Similarly, Cannaerts, Gastmans, and Casterle
(2014) found that nurses do not always exhibit the abilities necessary
to respond to ethical decision-making and behavior.
Violations of the ANA Code of Ethics Witnessed by
Students
Violations included nurses handling medications and equipment incorrectly, failing to comply with infection control, and violating patient
privacy. Nine of the 10 students claimed that they witnessed a violation of the ANA Code of Ethics. All violations witnessed by students
were by the nurses the students were assigned to follow. Six students claimed they saw a nurse handling medications and equipment
incorrectly; three students claimed the nurses would be called out of
the room by another staff member while administering a medication,
leaving the medications unattended. One student stated: “One nurse
didn’t know what a medication was being given for when I asked
her.” Another claimed that a nurse was administering narcotics and
needed a second nurse’s signature; the second nurse provided her
signature but was not present when the narcotic was administered.
Three students witnessed their nurse failing to comply with infection
control measures. One student stated: “The nurse was putting a urinary catheter into a patient…it’s supposed to be a sterile procedure
and the nurse never washed her hands.”
Two students witnessed improper use of personal protective
equipment, with one nurse running into a patient’s room to give a
medication without putting on the proper personal protective equipment. Two students witnessed nurses violating patient privacy.
“There was a patient who couldn’t speak English…our nurse was
talking about her right in front of us and there was a patient in the
other bed.” Another student claimed that the nurse had left the patient’s door open during a procedure.
Students Were Upset When Witnessing a Violation
When witnessing a violation, students, feeling inferior toward the
nurse, did not know how to handle the situation and wished they
had done something, leaving them with negative feelings. Responses
included: “It’s an awkward situation because we’re supposed to be
like a student — inferior to the nurse”; “It just showed me what I didn’t
want to be…Just ignoring the problem doesn’t fix anything”; “It just
made me uncomfortable because I know the correct way of doing
it. It bothered me a lot”; “I wish I could have done something. I wish
I had more power to do something.”
The majority of students acknowledged that they did not say
anything when witnessing a violation, with one student stating: “I kind
of just brushed it away. I didn’t really acknowledge it…I definitely
didn’t stand up for them.” Another student stated: “I feel like if a nurse
does something, who am I to question it because I’m a student.
I didn’t want to tell them how to do their job.” Some students did
not speak up to the nurse but instead carried out patient requests
Nursing Education Perspectives
on their own. One student explained, “One time the patient asked
for water and I would just go get it for them because I saw that the
nurse wasn’t going to get it.” Three students tried to mention an issue
to nurses, but the nurses responded by trying to justify their actions.
One student stated: “I said something to the nurse like, ‘Hey, why
didn’t you put a gown on?’ and her response was that she was just
giving a medication.” Another claimed, “I tried mentioning it [the patient’s pain] to the nurse and they were like ‘Just ignore her, she’s
faking it.’”
One student explained how a nurse failed to assess a patient
after the student had heard crackles while auscultating the patient’s
lungs. The nurse simply said that the patient was fine; the student
then responded: “No, I really think something might be wrong with
him…Then the doctor came in and said, ‘Oh, we have a student!
What did you hear?’ and so I told him…It turned out he had
pneumocystis pneumonia from the intubation.”
Need To Be Better Prepared With a Greater Educational
Focus
All students, including the student who did not witness a violation,
stated that they would like to see some form of change. The most
common response involved empowering students to speak up, for
example: “If there’s a problem, say something to the instructor and
then they can handle it if it’s something severe.” Other students mentioned the need for a greater educational focus: “To teach more
about what we should look out for, and when it would be OK to open
our mouth to say something.”
A few students stated that nurses should enforce proper practice within the clinical, for example, one student claimed: “Especially
at teaching hospitals — Don’t tell the students, ‘You would never
do this’ and then do it…It sort of makes all that we learn seem almost
pointless.” Another student stated, “I wish that more nurses would
care about the person. People don’t see the patient as a person
sometimes…they just see it as I’m doing my job. That’s somebody’s
sister, daughter, or mother — and I feel like that part gets lost and
that’s when people start to break the rules.”
DISCUSSION AND IMPLICATIONS
The results of this study suggest that most nursing students do not
speak up when witnessing breaches in the ANA (2015) Code of
Ethics; they feel inferior to the nurse, are fearful of saying something,
do not know what to do, or do not even realize that they witnessed
a violation. There was no evidence that students who were further
along in the program were more likely to speak up to the nurses or
clinical instructors when witnessing a breach. Two questions would
benefit from further research: Do nurses who violate their moral obligations have the potential to extend these maladaptive habits to
the incoming generation of nurses? Is it possible that students who
work with nurses who commit breaches are more likely to commit
breaches themselves?
Concerns about the preparedness of nurses to face ethical situations lead to questions about whether or not ethics education really
prepares incoming nurses to respond to the ethical demands of
health care (Cannaerts et al., 2014). Nursing programs should explore
ways to collaborate with health care facilities to provide simulated,
ethically based workshops for students, faculty, and nurse employees. It would be important to emphasize in these scenarios the
importance of communication with instructors when issues, concerns, or breaches occur. This also has the potential to create a
VOLUME 41 NUMBER 6
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365
Research Brief
collaborative partnership in supporting quality patient outcomes in
accordance with the ANA Code of Ethics. Research on the effectiveness of ethically based simulations and their translation into clinical
practice is warranted.
CONCLUSION
Nursing students are accountable to seek guidance from their nurse
educators who are in a position to educate, guide, and empower
them to act in the best interest of the patient. It is the responsibility
of nurse educators as well as institutions to send nursing graduates
in the workforce with the preparation necessary to provide quality
care according to standards of practice. Likewise, nursing students
must also acknowledge that they hold accountability and responsibility for their own practice while serving as patent advocates.
366 November/December 2020
REFERENCES
American Nurses Association. (2015). Code of ethics for nurses with interpretive
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Cannaerts, N., Gastmans, C., & Casterle, B. D. (2014). Contribution of ethics education to the ethical competence of nursing students: Educators' and students'
perceptions. Nursing Ethics, 21(8), 861-878.
Colaizzi, P. (1978). Psychological research as a phenomenologist views it. In R.
S. Valle, & M. King (Eds.), Existential phenomenological alternatives for psychology
(pp. 48-71). New York, NY: Oxford University Press.
Range, L. M., & Rothman, A. L. (2010). Moral distress among nursing and nonnursing students. Nursing Ethics, 17(2), 225-232.
Schmidt, N. A., & Brown, J. M. (2015). Evidence-based practice for nurses:
Appraisal and application of research. Burlington, MA: Jones & Bartlett Learning.
Shahriari, M., Mohammadi, E., Abbaszadeh, A., & Bahrami, M. (2013). Nursing
ethical values and definitions: A literature review. Iranian Journal of Nursing
Midwifery Research, 18(1), 1-8.
Wojtowicz, B., Hagen, B., & Van Daalen-Smith, C. (2014). No place to turn: Nursing
students' experience of moral distress in mental health settings. International
Journal of Mental Health Nursing, 23(3), 257-264.
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