Educational Ethical Challenges in the Viewpoint of Students in Medical Sciences: A Qualitative Study with Content Analysis Approach

AUTHORS

Samireh Abedini ORCID 1 , Elham Imani ORCID 2 , * , Abbas Fazli ORCID 3

1 Education Development Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

2 Department of Nursing, Faculty of Nursing and Midwifery, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

3 Department of Sciences, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

How to Cite: Abedini S , Imani E, Fazli A. Educational Ethical Challenges in the Viewpoint of Students in Medical Sciences: A Qualitative Study with Content Analysis Approach, Hormozgan Med J. 2019 ; 23(2):e89932. doi: 10.5812/hmj.89932.

ARTICLE INFORMATION

Hormozgan Medical Journal: 23 (2); e89932
Published Online: May 21, 2019
Article Type: Research Article
Received: January 27, 2019
Revised: April 14, 2019
Accepted: May 13, 2019
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Abstract

Background: Ethical behaviors of students can result from moral decisions based on moral knowledge and dispositions of them.

Objectives: This study aimed to explore the students’ perception of educational ethical challenges.

Methods: This qualitative study used a content analysis approach. Purposeful sampling was used to select participants. In order to collect data, in-depth, face-to-face, semi-structured individual interviews were conducted. Each interview lasted approximately 60 to 100 minutes. The analysis of data was performed simultaneously with data collection using qualitative content analysis with an inductive approach.

Results: Data saturation reached after interviewing with 40 students. The students were studying in the fields of medicine, nursing, midwifery, paramedicine, allied health, dentistry, and pharmacy. There were 45% were men and 55% were women in the sample. The average age of men and women was 22 ± 1 and 22 ± 1.04 years, respectively. After the analysis of interviews, three themes including scientific challenges, communication challenges, and professional challenges and eight categories were achieved.

Conclusions: The study indicate that students are facing scientific, communication, and professional challenges in education. Therefore, the factors influencing ethics in education must identify to increase the effectiveness of education and strength moral values in medical education.

Keywords

Content Analysis Ethical Issues Qualitative Research Student

Copyright © 2019, Hormozgan Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Ethics is defined as a set of spiritual and inner traits of a human, manifested in the form of his actions and behaviors, deriving from the inner moods of the human (1). In medical ethics, we deal with terms such as humanity, human dignity, respect for rights, individual and social freedom, and real human values (2). It should be noted that the patient’s physical health is affected by his mental status in many cases. Admission to the unfamiliar setting of a hospital and the patient’s physical problems will cause mental problems, anxiety, and stress for the patient. In addition, inappropriate behaviors of medical staff and students of medical sciences with the patient and non-observing the ethical principles and rights of the patient, if any, will cause problems for the patient (3).

Kuzu et al. conducted a study in Turkey and found that the privacy of patients was protected in 86.1% of the cases (4). Employees and students in medical professions are responsible for protecting the rights of clients. The observance of rights promotes the care and satisfaction of the patient. It also improves the patient and caregiver relationship, which is considered an important issue in the better and faster treatment of the patient (3). Respecting the dignity of the patient, in addition to increasing satisfaction and creating a good relationship, is associated with good outcomes such as creating a sense of security, reducing the duration of hospitalization, reducing costs, and increasing motivation in the healthcare team. In order to achieve these goals and appropriate ethical behaviors, the personnel and students’ knowledge of general concepts of the ethics in medical sciences is required (5, 6). The findings of a study in India showed that one-quarter of nurses was not aware of the ethical nursing codes; only a small number of them were aware of these codes and 37% were not aware of the ethics committee in the hospital (7). The results of studies show that nurses do not correctly apply ethical principles in their decision making due to the lack of the development of ethical principles in this country. Other study results on the way of nurses’ dealing with ethical issues in their ethical decision-making process show that nurses have different psychological responses to ethical decision making (8). There are many reports on the importance of observing the ethical and legal issues in medical science planning and some of them suggest unethical behavioral patterns of medical and nursing students with patients in medical education centers (7).

Various studies have been conducted on observing the ethics by medical students. A study conducted by Ghodsi and Hojjatoleslami showed that 47% of the students explained that they are not familiar with the rights. The level of awareness was low in 31%, moderate in 53%, and high among only 16% (9). In a study conducted by Bathaee and Asayesh, 58.8% of the medical students had a moderate level of knowledge of the patient’s rights charter (2). Auvinen et al. examined the moral judgment of nursing students in Finland and the effect of ethics education on their moral judgment. They found that last-year students had better judgment than first-year students, and ethical education had a significant effect on students’ ethical judgment (10).

As ethical issues are more considered in medical societies, many universities around the world provide ethical programs for medical students. The behavior of individuals is the result of their decision (1) and the decision is based on the knowledge and tendency of individuals (11). Thus, students’ ethical behavior can be derived from ethical decisions based on their knowledge and ethical tendency. The younger students need serious attention regarding ethical phenomena, especially ethics education. Researchers argue that recognizing the students’ ethical indices can be effective in improving the process of ethics education provided for students and developing an appropriate curriculum. In several searches conducted by the researchers, the less has addressed the problem of ethical challenges in the students of Hormozgan University of Medical Sciences, and this important educational issue in the viewpoint of students was not deeply studied by previous researchers. As ethics issues are completely subjective and require a deep examination of ethical issues from the students.

2. Objectives

Perspective, a qualitative study was designed with a content analysis approach to explain the medical students’ perception of ethical challenges of education.

3. Methods

This study was conducted with the aim of identifying the perception of medical students of ethical challenges in education. A qualitative content analysis by conventional approach was employed using semi-structured, deep, face-to-face interviews with 40 medical students in Hormozgan University of Medical Sciences in Iran. The qualitative approach was ideally suited for this study because it seeks to understand the perception of medical students of ethical challenges of education.

A purposive sample of volunteer students was recruited to this study from both male and female students in all fields. To collect data, individual, deep, semi-structured interviews were used. The interviews were conducted at dormitories, faculties, and teaching hospitals affiliated to Hormozgan University of Medical Sciences in 2017. The interviews included questions on the students’ perception and experiences of ethical challenges by the opportunity to provide open comments and memories about issues that had affected their experiences. Interviews continued to access sufficient and deep data. Each interview lasted for 60 to 100 minutes.

Inductive qualitative content analysis was conducted to analyze the interviews. For this purpose, the qualitative data would be organized in steps including open coding, creating categories, and abstraction. In the open coding process, notes and headings were written in the text while reading it. For categorizing data, the number of categories was reduced by integrating those that were similar to higher-order categories. In the abstraction phase, a general description of the research topic was formulated through generating categories. Each category was named using content-characteristic words (12). Two researchers read each of the transcripts to independently assign codes and identify themes. Recordings were listened for several times and then transcribed word by word so that the researchers became familiar with the content. In order to provide feedback for the next interview and decide on the adequacy of data, the interviews were written down verbatim as soon as possible. The data were read several times again. The sentences and paragraphs were analyzed to identify the key concepts within each interview. Concepts with a similar meaning were grouped together. Abstract labels were assigned to these concepts and a coding framework was created gradually that included the views expressed by participants in the study. Finally, a list of medical students’ perception of ethical challenges was formulated.

To confirm the accuracy and validity of the study protocol, four criteria given by Lincoln and Guba, including dependability, credibility, conformability, and transferability of data, were assessed. The data and findings of qualitative research should be acceptable and trustable, which require true data collection. Increasing the number of interviews was the first step to increase the accuracy of the data. In addition, collecting data from various sources, according to many researchers, is a positive point to increase the acceptability and external validity of the study. To assure credibility and dependability, the researcher increased the relationship with the participants and after the interviews were transcribed, the findings of the study were given to participants to assess the consistency of the findings with their experiences and confirm accuracy. Moreover, collaborative reflection about emerged themes was conducted by the research team. The researchers reviewed the interviews, extracted meanings, and patterns and additionally, a number of qualitative research experts were asked to examine the transcripts and evaluate the accuracy of the analysis process. Other activities to increase the study accuracy included conducting research based on the study design and recording/transcribing the participants’ quotes and revising them by the participants prior to analysis in order to verify their precision. Other factors ensuring the confirmability included the researcher’s interest in the studied phenomenon, continuous involvement with the data, and the assessment by qualitative research experts. In addition, the current study was conducted by a research team and with the guidance and supervision of experts that enabled dependability and confirmability of data. In this study, to increase the transferability of data during sampling, a purposive sampling method was used and we tried to provide the background for the transferability of data by expansive descriptions for other’s judgment and assessment.

Ethical approval was obtained from the Ethics Committees of Hormozgan University of Medical Sciences. Issues such as informed consent, confidentiality, and anonymity were considered. Information about the study was provided for all participants and they were asked to sign written consent forms for agreeing with the study protocol and recording their voice with a recorder. Participants had the right to withdraw from the study without prejudice and were assigned pseudonyms of protecting their identities when reporting of findings.

4. Results

In this qualitative study, 40 students of Hormozgan Medical Sciences University were interviewed. The students were studying in medical, nursing, midwifery, paramedicine, health, dentistry, and pharmacy faculties. The sample included 45% men and 55% women with a mean age 22 ± 1 and 22 ± 1.04 years, respectively. After analyzing the transcripts of the interviews, three themes and eight categories were finally obtained (Box 1). The obtained themes were named scientific challenges, communication challenges, and professional challenges. Educational ethics challenges from the view point of students of Hormozgan University of Medical Sciences were defined using the themes and categories extracted as follows: “Medical students face ethical challenges during their education. Scientific stinginess, impractical science, and abnormal and non-standard evaluations in some disciplines are among the academic challenges faced by students. They also face challenges such as unfair treatment, unfair judgments, and lack of empathy with students in communication matters. Students expect ethics to be observed well in professional matters, but observing the gap between the theory and practice and the low experience of some of the professors poses a professional challenge to them”.

Box 1. Themes Extracted in Educational Ethical Challenges in Viewpoint of Students
Theme/Classes
Scientific challenges
Scientific stinginess
Impractical science
Abnormal evaluation class
Communication challenges
Friendly treatment
Unfair judgment
Lack of empathy
Professional challenges
The gap between theory and practice
Low experience of some professors

4.1. The Theme of Scientific Challenges

Educational ethics is one of the requirements, which should be emphasized at universities in order to provide a healthy environment for educating students and ensuring the ethical competences expected during their studies. Educational ethics has numerous and broad aspects of the academic and educational life of students. Students might face challenges in this regard for various reasons and they might observe issues, which are in contrast to the ethics of society. These challenges have been reported under the title of scientific stinginess, inappropriate and impractical science, and abnormal evaluation.

4.2. Scientific Stinginess Class

The purpose of scientific stinginess is to provide the content of lessons in volume less than defined standards. Due to the increased responsibilities and executive duties of some professors, there is not the adequate and proper opportunity for them to provide adequate educational materials and, unfortunately, it is sometimes observed that the number of their efficient and productive sessions has decreased and we face with reduced quality of teaching in some courses.

“Some professors do not care about their work or teaching, or they are overwhelmed with other responsibilities. Some people also prefer to assign their little time and do not pay attention to the class and the student” (participant No. 5, a student of Medical Faculty).

4.3. Impractical Science Class

This class is intended to address the mismatch between the teachers’ speech and behavior. Observing the behavior of professors towards their speech has a greater impact on student education. Students model what they see and the actions of professors. Thus, the contradiction between professor behavior and speech can be challenging for them.

“Professor in the classroom tells you are to behave like that, do these things, while he behaves in the opposite way. They themselves do not act as they say” (participant No. 8, a student of Dentistry Faculty).

4.4. Abnormal Evaluation Class

The purpose of the abnormal evaluation is the lack of standardized criteria for student evaluation. The appropriate standards and criteria of evaluation can increase student confidence and increase motivation for further efforts. Non- transparency in evaluation and scoring of is followed by challenges.

“It is not clear how they evaluate us. Our score would be lower even if we do anything well. There is no standard at all. One student would gain good score if he or she is favored by the educator” (participant No. 13, a student of Nursing and Midwifery Faculty).

4.5. Communication Challenges Theme

In educational settings, there are some types of communication among the individuals, some of which are not ethical from the point of view of students and are not acceptable to them. Students have referred to cases such as unfair treatment, unfair judgment and lack of empathy as communication challenges in educational ethics.

4.6. Friendly Treatment Class

This class is meant to be inappropriate with disrespectful feeling in interpersonal relationships. The employees and professors’ treatment and dealing with students and considering them as humans who have rights need respect and sense of security is very important and can create motivation in students.

“We have problems with some professors or some officials in the interns. We are badly treated as if we were an unnecessary thing. Another case happened in the hospital. There was a person who had a very bad tone and he annoyed me so much” (participant No. 28, a student of Paramedicine Faculty).

4.7. Unfair Judgment Class

The meaning of unfair judgments is judgment regardless of all aspects with injustice. Properly and fairly treated and dealing with students can contribute to establishing appropriate communication and having a fair look towards them. This is a very challenging issue for students, especially male ones.

“There is a problem. More attention is paid to girls in the classroom. The questions of the girls are answered, but they do not pay attention to those of boys at all. We boys are always in a minority” (participant No. 22, a student of Health Faculty).

4.8. Lack of Empathy Class

Empathy means mutual understanding and putting yourself in place of the other. Understanding the student’s conditions and his family and social problems, in addition to the scientific and educational issues, can help to establish a proper relationship between the teacher and the student and create a sense of empathy for the student.

“They do not understand us at all. Some students are forced to work and earn money because of the economic conditions of their families. However, the professors regularly tease us and say why you are working to be tired. They say us less follow the material issues” (participant No. 20, a student of Nursing and Midwifery Faculty).

4.9. Professional Challenges Themes

The content of the medical professions is closely related to ethical issues, and the slightest deviations and changes in the profession can be regarded as an ethical challenge for the students.

4.10. The Gap Between Theory and Practice Class

The gap between theory and practice means the discrepancy between theoretical knowledge and what the student sees in the real field at the clinic. Unfortunately, due to various reasons such as the lack of resources and facilities and the lack of educational spaces, many of the topics in the reference books, written often by Western writers, are not actually experienced by students in the real world, and this issue is considered as a challenge of educational ethics by them.

“They teach one thing in the classroom, but when we are in the hospital setting, we see other things. These issues we read in the book are not in reality. It is stated that our education should be standard, so why do not we learn according to the texts?”(participant No. 30, a student of Paramedicine Faculty).

4.11. The Class of Low Experience of Some Professors

The lack of experience of professors is the lack of sufficient experience to provide educational content, Transferring content to students and insufficient effort to facilitate their learning. Professors’ valuable experience during their teaching years will help them be careful in dealing with students and answering their questions. However, some problems are created for professors with less work experience and newly recruited professors due to lack of adequate experience of them.

“Another problem is that when we raise the problems in meetings with officials, the professors complain why you stated it for the officials. They say that you should not say the problems for the officials since this is nonprofessional” (participant No. 23, a student of Health Faculty).

5. Discussion

The contents derived from interviews with medical students in this study included scientific challenges, communication challenges, and professional challenges. With regard to scientific challenges, it can be stated that students consider ethics in education as one of the most important and necessary requirements in the university and they are aware of its importance. Scientific stinginess, impractical and inappropriate science, and abnormal evaluation are important these, which are challenging for students. The adherence of the faculty members to the values and principles of professional ethics is important both from the perspective of developing ethics-based organizational culture, and from the perspective of transferring human distinctive traits and characteristics to students and, consequently, disseminating them in society (13). University professors not only should be skilled in their specialized discipline and in the teaching profession but also they should be aware of the professional ethics of it since education is considered the first mission and function of the university. Educations provided by an educational system may lead to special behaviors in society, which might be criticized. For example, the teaching method might or not lead to the desired learning of students in line with scientific developments and society. Educational resources, content, and syllabus of courses may be developed in such a way that strengthens or weaken a particular type of thinking, leaving beneficial or harmful outcomes for the society. The type of professor’s behavior can have a positive or negative effect on the students’ behavior (14). The reason for the importance of ethics in education from the viewpoint of students participating in the research might relate to the fact that ethics in education leads to greater productivity and greater effectiveness of education and it results in respecting the students’ rights in having the best education on one hand and learning and the position of science and learning on the other hand (15). It also contributes to the institutionalization of ethical and professional values, which have great importance in the critical and human sciences of medical sciences.

The results of the study conducted by Badiyepeymaie-Jahromi et al. in Jahrom University of Medical Sciences on the observance of the ethics by professors in 2014 showed that observance of professional ethics by professors in the clinical area was at an undesirable level. The clinical professor is a fundamental element in the clinical education process and is considered to be a critical component in planning and acquiring clinical experiences. One of the important factors involved in developing and forming the ethical and professional personality of students is their clinical professors since clinical professors play an important role in developing the student behavior and improving the ethical virtues (16). As a result, clinical educators should be equipped with ethical virtues and have full knowledge of professional ethics so that provide the conditions for the institutionalization of ethical and professional values in students and try to enhance the students’ ethical knowledge and readiness to solve the ethical problems created in work setting in the future.

The second class of challenges faced by students is communication challenges, which include unfriendly treatment, unfair judgments and lack of empathy. Many universities in various countries have developed a set of guidelines for ethical codes in order to provide a set of ethical standards, which all people believe in them and to increase the adherence to professional principles for the education sector, especially teachers. For example, according to the American Teachers Association, teachers are obliged to establish an educational setting providing the conditions for completing the potential of all students. The association believes that teachers are obliged to observe the issues such as commitment to civil law such as perseverance and diligence, responsibility, cooperation, conscientiousness, loyalty, honesty, respect for the law, respect for others and self-esteem. In general, the codes of professional ethics are classified into four areas of treatment with the student, treatment with colleagues, treatment with parents and society, carrying out the activities, and each case is discussed with an example (1, 17).

The Ontario Teachers College also lists a number of ethical standards for teachers, including: caring in the sense of compassion, acceptance, interest and having insight on development of potential of students, trust in sense of observing the imparity and fairness; transparency, honesty with regard to students, professionals, parents, colleagues and others, respect in the sense of observing the human dignity, emotional well-being, and cognitive development, integrity in the sense of observing the honesty, trustworthiness and ethical conduct (18). In the professional ethics defined by the American Universities Professors Association, principles such as realism, objectivity, and scientific neutrality are strongly emphasized (1, 17).

In general, although the professional ethics related to teachers in higher education institutions of different countries are subject to the laws of each country, the principles such as empowerment of students, impartial relationship with students, secrecy, respect for colleagues, respect for the institution, content mastery, valid evaluation of students, and mastery on educational principles are trained (11, 17).

While cases such as mastery on principles of valid evaluation and education of students are among the standard professional ethics codes of most countries in the world, most university instructors enter this profession without prior preparation of the principles of teaching. For example, most of the instructors and faculty members of the medical sciences learn the process of teaching through trial and error while working with students. However, having skill and knowledge of the profession of teaching is one of the effective ways to meet the needs of students and to promote and improve the quality of education (17, 18). Thus, given the fact that mastery on principles of professional education is one of the ethical requirements of this profession, it is necessary to pay more attention to the issue of empowering professors and faculty members of the universities in the process of teaching and education.

With regard to the theme of the professional challenges, students referred to gap between the theory and practice and the lack of experience of some of the professors. As the criteria and standards for recruiting the university professors focus on academic and practical capabilities of the professors in their specialty and most university instructors, although highly capable in their specialty, they do not have the prior preparedness on professional principles of teaching and the process of education and they often teach the students through trial and error (1, 17). This issue can affect non-observing some of the ethical principles of education and non-meeting some of the needs of the students by the professors and the lack of promotion and improvement of the general quality of education. These factors can affect the students’ view of ethical principles in education. In a study conducted by Byrne et al. in 2015, 45 percent of female residents stated that the high volume of curriculum has been one of the major barriers to ethics education and 67% of them considered lack of teachers’ experience in teaching ethics as a moderate barrier in the area giving less importance to ethical issues in their curriculum (19).

Fawzi conducted a descriptive study in 2011 to evaluate the ethical needs and ethical problems of medical students at Shams Medical Faculty in Egypt. The results of the study showed that the majority of respondents prefer that teacher to have adequate experience in bioethics and his teaching method to be in the form of problem-solving, along with examples of their daily problems and 60% of respondents also suggested integrating ethics course with other specialized courses throughout the study course (20). Studies emphasize that ethics education is effective in promoting students’ awareness of ethical issues and their practical use in the workplace (21). The role of instructors and professors in the clinic should not be neglected since if they do not have complete knowledge, they can become a practical model for the student. In this study, there were general limitations of qualitative studies such as the use of voice recorder in interviews. Before the interview, the researcher explained the research objectives and stated that the subjects can withdraw at any stage of the study. He also ensured that the information would remain confidential.

5.1. Conclusions

The results of this study showed that while ethics in education is important to participants, its observing is challenging and there are scientific challenges, communication challenges, and professional challenges in this regard. Thus, the factors affecting ethical standards in education should be identified in order to make education effective and strengthen the ethical values in the teaching of medical science. Gaining knowledge on the ethical problems and making a distinction between ethical issues and legal issues, knowing ethics principles and knowing the decision-making process are some of the cases, which are useful and effective in having capable and ethical forces and a competent medical team. Adopting any role has responsibilities and the fulfillment of these responsibilities requires observing many ethical aspects. Teaching is also a profession, which has essentially an ethical nature. Teaching ethics has been considered in most countries around the world in recent decades, and the principles of teaching ethics have been developed in the form of professional ethics codes. Examining the students’ views and understanding of the behavioral and verbal effects of professors in different fields of study can help identify the factors affecting the ethical education of students. The most important effective measure taken to achieve these goals is to establish ethical education courses for students and holding continuous ethics courses for instructors and employees. Thus, more quantitative and qualitative studies are required on ethics focusing on teaching the students, clinical educators and the effect of continuous education in ethics. In general, identifying the best and most effective practical solutions to promote the level of ethics in universities is one of the issues, which requires more field studies.

Acknowledgements

Footnotes

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