Ethics and patient safety in nursing education

Abstract

The goal of this study is to identify and describe disciplines in undergraduate nursing courses that address patient safety and health ethics. This is a documentary research focusing on political-pedagogical projects and curriculum frameworks of higher education institutions that offer nursing courses in the metropolitan area of Porto Alegre. Twelve documents were examined, from which two analytical topics emerged: 1) teaching of ethics, covering content such as professional ethics, bioethics and professional legislation in nursing; and 2) teaching of patient safety, covering content such as biosafety, health education and communication, and infection control. The topic of ethics was predominantly mentioned compared to patient safety. New studies are needed to better understand how these concepts are being addressed in nursing education.

Keywords:
Nursing; Nursing education; Curriculum; Ethics; Patient safety

Resumo

O objetivo deste estudo é identificar e descrever disciplinas em que são abordadas as temáticas segurança do paciente e ética em saúde em cursos de graduação em enfermagem. Trata-se de pesquisa documental, com foco em projetos político-pedagógicos e matrizes curriculares de instituições de ensino superior que oferecem cursos de enfermagem na região metropolitana de Porto Alegre. Foram examinados 12 documentos, a partir dos quais emergiram dois tópicos analíticos: 1) ensino da ética, abrangendo conteúdos como ética profissional, bioética e legislação profissional em enfermagem; e 2) ensino da segurança do paciente, abrangendo conteúdos como biossegurança, educação e comunicação em saúde e controle de infecção. O tema ética foi majoritariamente mencionado quando comparado a segurança do paciente. Novos estudos são necessários para entender melhor como esses conceitos estão sendo desenvolvidos na formação de enfermeiros.

Palavras-chave:
Enfermagem; Educação em enfermagem; Currículo; Ética; Segurança do paciente

Resumen

El objetivo de este estudio es identificar y describir las asignaturas que abordan la seguridad del paciente y ética de la salud en el grado en enfermería. Se trata de una investigación documental, con foco en proyectos político-pedagógicos y programas de estudios de instituciones de educación superior que ofrecen carreras de enfermería en la región metropolitana de Porto Alegre (Brasil). Del análisis de doce documentos, surgieron dos temas de análisis: 1) Enseñanza de la ética, que abarca contenidos como la ética profesional, bioética y legislación profesional en enfermería; y 2) enseñanza de seguridad del paciente, que trata contenidos como bioseguridad, educación y comunicación en salud y control de infecciones. El tema de la ética fue más mencionado que el de la seguridad del paciente. Se necesitan más estudios para comprender mejor cómo estos conceptos se están desarrollando en la formación enfermera.

Palabras clave:
Enfermería; Educación en enfermería; Curriculum; Ética; Seguridad del paciente

The Brazilian Unified Health System (SUS) encourages nurses to act in accordance with a strong sense of ethical judgment in the defense of life and to cooperate towards a project of universal, egalitarian and assertive public policy in addressing health problems. There is increasing awareness of the need to expand the scope of ethics in professional behavior, which must uphold technical quality and humanistic attitudes in preserving the health and safety of patients ¹.

Nursing practice is intrinsically linked to ethics, as it is always related in some way to patients’ well-being and the preservation of their integrity ². Working in the healthcare network, with its diversified services and lines of care, nurses perform tasks that involve a wide range of skills. Those skills, in turn, enable them to perform technical procedures, carry out educational duties, lead managerial initiatives and establish a political position in favor of a greater appreciation of the profession, social participation and support of SUS in the construction of a welfare state, with safety for all the actors involved ³.

Globally speaking, initiatives to provide patient safety gained ground when the World Health Organization (WHO) launched, in 2004, the World Alliance for Patient Safety ⁴. More recently, WHO presented a plan towards “zero patient harm,” aiming to reduce avoidable harm to health as much as possible. This plan is based on seven strategic goals: 1) policies for zero patient harm; 2) high reliability systems; 3) safety of clinical processes; 4) patient and family engagement; 5) health worker education and skills; 6) information, research, risk management and improvement; and 7) synergies, partnerships and solidarity ⁵.

To drive the reconstructive aspirations of an increasingly humanized nursing care in line with current demands, one possibility would be to integrate the concepts of ethics and patient safety into health practices ⁶. Regarding such demands, one can cite the recent health and social problems generated by the COVID-19 pandemic and the health risks caused by climate change. In a recent reflection on the current pandemic context, Prado and collaborators ⁷ argue that the shortage of healthcare resources and qualified providers observed during this period may impact decision-making, ethical behavior and, consequently, the safe care of patients.

Nursing has a growing interest in these issues, as it will still be some time before a culture of patient safety is incorporated into the daily practice of health services and ethics becomes the normative guideline for decision-making in this context. Thus, as changes occur in health care services, it is opportune to return to the issue of nursing education ⁸.

The literature points out the need of teaching the topics of patient safety and ethics to undergraduate nursing students. However, the best methodology and the priority areas that should be addressed remain unknown ⁹. Patient safety thus remains as a “hidden element” in the curriculum over the years ⁹ and the subject of ethics in nursing is still viewed as relatively unimportant ¹⁰.

To contribute to the debate, this study undertook documentary research on educational planning and curriculum frameworks of undergraduate nursing courses in higher education institutions (HEI) in the metropolitan area of Porto Alegre, guided by the following question: how are ethics and patient safety addressed in the political-pedagogical projects (PPP) of undergraduate nursing courses in institutions in the metropolitan area of Porto Alegre? Thus, this study aimed to identify and describe in which disciplines the aforementioned themes are addressed in said documents.

Method

This is an article derived from documentary research ¹¹, based on the analysis of PPP and/or curriculum frameworks which must be made available online on the websites of universities. These are official documents that contain the educational proposal for the professional training of students ¹².

The research universe consisted of all 18 HEIs in the metropolitan area of Porto Alegre, the city of residence of the authors of this article. The preliminary review of the documents resulted in the inclusion of 12 institutions with explicit references to the subject in their programs. The inclusion criterion was the online existence of the PPP and/or curriculum framework of the undergraduate nursing course of the institutions in text document or portable document format (PDF).

The searches were carried out online on the institutions’ websites between April and May 2020 and December 2020 and February 2021. When no PPP and/or curriculum framework was located, an email was sent to the coordinator or head of the courses requesting access to the documents.

To ensure uniformity in the study, the WHO curriculum guide ¹³ was read in full to draw up a list of tracking terms that would make it possible to identify the terminologies and analyze content related to the teaching of patient safety. This guide ¹⁴, released in 2011 in a multi-professional edition, addresses patient safety in order to provide educational approaches and a variety of concepts and teaching and assessment methods on the subject. It features 11 topics based on certain items that can be used together or independently: 1) what is patient safety?; 2) why applying human factors is important for patient safety?; 3) understanding systems and the effect of complexity on patient care; 4) being an effective team player; 5) learning from errors to prevent harm; 6) understanding and managing clinical risk; 7) using quality-improvement methods to improve care; 8) engaging with patients and cares; 9) infection prevention and control; 10) patient safety and invasive procedures; and 11) improving medication safety ¹⁴.

Regarding ethics, the analytical approach of the research aimed to look for the following terms in the documents: bioethics, ethical concepts, legislation and ethics in nursing, healthcare work relationships, ethics and culture, historical background, nursing ethics and legislation, ethics and philosophical anthropology, professional ethics and deontology.

All selected and available PPPs and/or curriculum frameworks were read and the data were entered in a Microsoft Excel spreadsheet. The following aspects were observed: identification of the discipline, academic term in which it was taught, distribution of workload, type of document and mention of the themes.

This work derives from a matrix project approved in its ethical and methodological aspects by the Federal University of Rio Grande do Sul (UFRGS) and relates to one of the specific goals of said project. The study complies with Resolutions 466/2012 ¹⁵ and 510/2016 ¹⁶ of the Brazilian National Health Council (CNS) and does not cite the names of the teaching institutions, which are identified by the abbreviation HEI followed by a letter of the alphabet.

Results and discussion

Of the 18 potentially eligible HEIs, access to data (PPP and/or curriculum framework) of 12 was obtained. Regarding the others, four did not have the documents available online and there was no response from the administration by e-mail, and the leaders of two HEIs chose not to participate in the study. Of the institutions included in the sample, six had the PPP and six had the curriculum framework.

The topic of ethics featured in 11 PPP and/or curriculum frameworks and the workload for its teaching in disciplines ranged from 30 to 80 hours, with one discipline with two credits and another with four credits. Regarding academic terms, only three are taught in the final terms of the course, while the rest are taught in the initial semesters, such as the first, second and third academic terms of the undergraduate nursing course (Chart 1).

Chart 1
Type of institution, discipline, workload/credits, type of document and term of the course in which the theme is addressed

Higher education institutions	Discipline	Workload/credits	Type of document	Term
A – University center (private)	Ethics and professionalism	2 credits	PPP	8th
B – University center (private)	Bioethics, professional ethics and legislation	40 hours	PPP	5th
C – University center (private)	Nursing practices; Quality of life, safety and health at work	99 hours; 66 hours	PPP	1st, 6th or 7th
D – College/Vocational training (private)	Care technologies and safety culture	100 hours	Curriculum framework	7th
E – College (private)	History and ethics of nursing; Health, individual and society; bioethics	4 credits	PPP	1st, 2nd and 6th
F – University (private)	Professional ethics in nursing	60 hours	Curriculum framework	7th
G – University (private)	Nursing legislation and professional ethics	40 hours	Curriculum framework	3rd
H – University (federal public)	Bioethics	30 hours	PPP	2nd
I – University (federal public)	Philosophical foundations of nursing care; Collective health	45 hours	PPP	2nd
J – University (private)	Legislation and professional ethics in nursing	80 hours	Curriculum framework	3rd
K – University (private)	Bioethics and biosafety; Professional ethics	76 hours	Curriculum framework	1st and 5th
L – University (private)	Ethics	Not mentioned	Curriculum framework	Not mentioned

• PPP: political-pedagogical project

In the teaching of ethics, examples of prominent topics in undergraduate nursing were: professional ethics (n=8); bioethics (n=5); professional legislation in nursing (n=3); history of nursing (n=2); ethics and technoculture (n=2); society and contemporaneity (n=1); identity, language and culture (n=1); nursing in the social context (n=1); social practices and ethics (n=1); and sociology and anthropology of health (n=1).

A recurring subject was professional ethics with issues that involve the regulation of the professional practice of nursing, such as the profession’s code of ethics, the legal implications of professional practice, the ethical and moral principles governing the behavior of nurses and the professional associations and organizations. Related topics were: morals, ethics, bioethics, deontology and human rights.

In the second topic, related to the teaching of patient safety, examples of prominent themes were: biosafety (n=3); health education and communication (n=2); infection control (n=2); waste management (n=2); safety and health at work (n=2); teamwork (n=1); quality of life (n=1); communication and information systems (n=1); and health surveillance (n=1).

In the analysis of PPP and curriculum frameworks, it was evident that the topic of ethics was predominantly mentioned compared to patient safety, which, in most institutions, is addressed in non-mandatory disciplines.

From the moment they enter an undergraduate course, nursing students start preparing to provide safe and quality care when engaging with patients, family relatives and members of the healthcare team. These are often complex relationships that usually give rise to ethical problems. In this sense, preparing ethically competent nurses who provide safe nursing care should be a fundamental principle of nursing education ¹⁷.

The topics of ethics and patient safety are interconnected when addressing organizational and team factors, communication with patients, incident reporting, beneficence and non-maleficence, and justice and autonomy ¹⁸, evidenced, for example, in situations of ineffective communication. Considered one of the main contributors to the occurrence of incidents and adverse events, communication noise between professionals and patients is also identified as causing ethical problems ¹⁹.

Nursing care must be appropriate and adequate for the patient, which links patient safety not only to the best available evidence, but also to ethics, which provides the arguments and principles required by humanized care ²⁰. One of the fundamental principles of ethics in nursing is “first, do no harm” (principle of non-maleficence), hence the issue of safety is indispensable ²¹. Therefore, as a quality requirement, care must be safe, in addition to being effective, from a clinical point of view ²².

Understanding educational gaps in nursing training and professional practice requires more detailed analysis and evaluation of ethics and patient safety during and after education. The study by Lee and collaborators ²³ corroborates these findings by describing basic concepts related to ethics in health that some nursing schools adopt in their curricula: basic concepts of ethics, deontological theory, ethical principles, ethical issues in health care, rights of the patient and codes of ethics for nurses. The most commonly used methods to teach the subject included classroom debates, lectures, case studies, small group discussion, role playing and demonstration.

The study by Numminen, van der Arend and Leino-Kilpi ²⁴ argues that the presence of ethics education in the curriculum increases the self-perception of nursing students in relation to their attitudes and the development of reflective and analytical skills. Essential characteristics of effective ethics education include the active engagement of students in case study discussions and the use of ethical precepts in their practices.

Ethical education in nursing provides students with the opportunity to recognize ethical issues in daily professional practice, practice ethical decision-making, establish skills, virtues, attitudes and values and learn to apply ethical rules in health care ²⁵. In a context of social inequalities and health crises, education should emphasize the idea of care enhanced by principles and knowledge stemming from philosophy, politics, economics and culture, among other fields. Thus, the biological elements are part of a web of well-being elements that simultaneously reaches individuals and society ²⁶.

In this sense, providing ethical education and preparing nursing students are important to support newly-graduated nurses in dealing with ethical conflicts that commonly arise in clinical environments ¹⁸. Stress occurs in such environments due to the pressure of providing care and preserving lives, situations that do not allow mistakes, and given the complexity of the problems, conflicts may escalate ²⁷. A study on the management of bioethical conflicts in primary health care (PHC) ²⁸ revealed that some health providers, motivated by self-interest, would not cooperate in solving such conflicts, an attitude that resulted in the fragmentation of teamwork. On the other hand, some of them were able to undertake communicative action that translated into patient care and safety.

When addressing patient safety in the nursing curriculum, doing no harm is a basic ethical principle that underpins the provision of health care. There are good examples of international education systems that have integrated patient safety into teaching. However, research efforts are required to demonstrate the conditions in which this occurs, especially under a consolidated theoretical framework on the subject. In carrying out such an investigation based on the patient safety curriculum guide ⁹, WHO identified in several countries the universal nature of the topics covered in that document, observing also that adaptations were made to specific local realities.

Incorporating patient safety into undergraduate nursing education still requires overcoming many challenges in several countries, but in contexts such as Brazil, meeting the demands is even more challenging. A survey carried out with PHC staff in a Brazilian city highlighted that the difficulties in implementing patient safety are often associated with shortage of supplies and poor working conditions ²⁹. This problem has historically and predominantly affected nursing staff, precisely those who dedicate more time to health care ³⁰.

Teaching patient safety in undergraduate nursing courses requires including important elements in this area of knowledge, such as human factors and evidence related to effective teaching strategies. Such an approach has already been recommended by the WHO Patient Safety Program ³¹, which suggests that any patient safety training tailored to professional healthcare—including human factors and technical and non-technical skills—should be provided at the beginning of the undergraduate nursing course, since introducing such an approach at the end of the course, when professional behavior has been virtually developed, may be too late ³².

Although there is a consensus on the importance of integrating patient safety teaching in the undergraduate nursing curriculum, it still remains to be explored which teaching strategies are best to be used in this sense. The 11 topics suggested in the patient safety curriculum guide ³¹ are important to raise awareness among nursing students and faculty about modern thinking related to the topic. This can help better prepare them to manage, in practice, the challenging requirements in this field.

Another model that can be adopted is the Quality and Safety Education for Nurses framework ³³, developed in the United States specifically for the undergraduate nursing curriculum. This model aims to transform nursing education by integrating six attributes of knowledge, skills and attitudes for each competence, which include: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety and informatics.

The study by Chen and collaborators ³⁴ corroborates the findings, showing that patient safety teaching was not formally explicit in the undergraduate nursing curriculum. Another challenge faced for the effective implementation of patient safety in the nursing curriculum is the lack of competent educators familiar with the teaching of patient safety concepts based on knowledge and learning from the health system as a whole ³².

Patient safety should not be merely added to a discipline of the already overloaded nursing curricula. Rather, it is necessary to seriously think about how faculty can integrate its competences in teaching and clinical practices. Patient safety is critical to the provision of quality health care and should be a key component of undergraduate nursing education ³⁵.

For SUS, not having professionals trained in patient safety during their education is an important gap, since it is estimated that, worldwide, one in ten patients have experienced safety problems when receiving hospital care, which is the 14th cause of the global burden of disease ³⁶. Furthermore, the economic burden of providing care that is not aimed at patient safety is a significant annual cost, with common adverse events such as pressure ulcers, infections and errors in administering medication and performing procedures ³⁷. It is also alarming to realize that many adverse events are preventable. Such facts erode public trust and increase the financial and ethical burdens on health systems and society as a whole ⁹.

In addition, it is important to note that nurses are the largest group of healthcare providers in the Brazilian health system and play a key role in protecting patient safety, as they provide the longest care and are in direct contact with patients ³⁸. Thus, nurses, more than other healthcare providers, are able to recognize, prevent and correct bad practices in workflow and communication.

Addressing these topics in undergraduate nursing courses is an important starting point to improve the preparation of future nurses in terms of knowledge, attitude and skills. The synthetic nature of the researched materials prevented the expansion of results and limited the analyses, especially in relation to teaching methodologies for the development of the topics in nursing education. This limitation also affected analyses on the possible interaction between ethics and patient safety in nursing education. The scarcity of information, curriculum frameworks and PPP available online also affected the research.

According to the Brazilian Law of Education Guidelines and Bases ³⁶, the list of subjects that make up the curriculum framework of each course and the respective workloads must be publicly available online on a specific page the official HEI website. Unfortunately, despite such regulation, access to information is deficient, which hinders a more in-depth analysis of the context and the opportunities it affords.

Nevertheless, this study contributes to the debate on the need to introduce, expand and deepen the themes of ethics and patient safety in nursing education. Due to their importance, they should run across all disciplines and their interaction should be documented in the teaching plans and PPP of the courses. Nursing faculty and responsible bodies should urgently encourage this discussion in order to meet the Brazilian National Curriculum Guidelines for Health Professions.

Final considerations

The analysis of the curriculum frameworks and PPP showed that the topic of ethics was more extensively addressed in undergraduate nursing education, especially in the early terms of the courses, compared to the topic of patient safety. However, in some HEIs, the disciplines were not mandatory or did not have specific content on the subject. This raised the question of why patient safety does not have the same importance in curricula as ethics.

Constant efforts are needed to promote the teaching of patient safety and ethics in nursing education, using innovative teaching material, as these topics are vital to improve the skills of nursing students and strengthen the SUS with qualified professionals committed to their doctrinal principles.

Educators who encourage the teaching of ethics can help mitigate the negative effects of morally challenging situations that students may experience during their education and later as professionals. Incident reduction strategies should be taught, developed and sustained during undergraduate courses with a view to promoting patient safety.

More research is needed to better understand how the teaching and instruction of patient safety and ethics can be included in the undergraduate nursing curriculum. The introduction of education for patient safety and ethics in the undergraduate nursing curriculum is therefore necessary and timely.

• Approval CEP-UFRGS-CAAE 06194819.3.0000.5347

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Publication Dates

• Publication in this collection
  28 Nov 2022
• Date of issue
  Jul-Sep 2022

History

• Received
  08 Mar 2022
• Reviewed
  11 Aug 2022
• Accepted
  22 Aug 2022