1. Ethics at Bachelor’s level Philip Esterhuizen RN, BA(Cur) MScN, PhD

2. European directives for nurse education leading to registration The educational programme should guarantee:  Adequate knowledge of science and include sufficient understanding of the structure, physiological functions and behaviour of healthy and sick persons.  The relationship between the state of health and physical and social environment of the human being.  Sufficient knowledge of the nature and ethics of the profession.  Adequate clinical experience.  Ability to participate in the training of health personnel.  Experience of working with other professions in the health care sector

3. European directives for nurse education regarding practice In a programme of 3 years/4,600 hours, there should be a 50% balance of theory/practice. Practice can take place in hospitals, other health care institutions and in the community and should include:  General and specialist medicine  General and specialist surgery  Maternity care  Mental health and psychiatry  Care of the old and geriatrics  Home nursing

4. Entrance to nursing education In the Netherlands education the general secondary educational system has three main options, the MAVO (four years), the HAVO (five years) and the VWO (six years), the latter being the entry requirement to university degrees. MAVO HAVO VWO Secondary Professional Education MBOV Higher Professional Education HBOV

5. Nursing education in the Netherlands Level 1 nurse: Housekeeping & non-patient activities Level 2 nurse: Basic nursing activities/assistant to more qualified staff Level 3 nurse Independent nursing activities Level 4 Registered Nurse Regional Educational Centres Level 5 Registered Nurse/BSc Institute for Higher education MSc Degree MPhil/PhD University education No formal qualification MSc Degree

6. Two levels of nurses (NL) Two levels of nurse (Level 4 educated at college level and Level 5 educated at degree level) are both registered as nurses under the Individual Health Care Professions Act. Both levels of nurses are expected to: (a) recognise and analyse actual and/or threatening consequences of physical, mental pathological processes, (b) recognise and analyse disabilities or developmental disorders (c) recognise and analyse the individual’s vital functions (d) provide counselling and assist the individual in situations when necessary. The Level 5 nurse:  Is capable of assessing the whole situation and deciding the appropriate level of care.  Directs Level 4 nurses.

7. Competency-based education (NL) The skill set for the degree level (5) nurse includes the following competencies:  Observation  Direct patient care  Emotional support  Nursing skills  Patient information and education  Preventative and promotive health  Coordination of care

8. Nursing roles and domains included in the nursing programme Five rolesThree domainsNine domain specifications Care providerCareCare for the ill, handicapped and dying. Care director Individual and collective prevention Health information and education Care developerOrganisation of care Programming care Coach Nursing unit Mentorship Quality of care Professional practitionerProfessionProfessional innovation Professional development

9. Clinical practice (NL) The practice part of the programme:  Is usually 10 weeks in the first year, 20 weeks in the second, third and fourth years of the programme.  Occurs in nursing homes, mental health settings, general hospital and/or community settings  In the final placement (4 th year), the student is expected to undertake a practice-based research project.

10. Cooperative nursing education (NL) In addition to the regular BSc Nursing programme, students can choose a second option in the form of a cooperative nursing education programme. This programme is also 4 years in duration, but here the student is employed by a hospital where all practice placements take place. The theory and practice/work balance shift from 60% practice in the first years to 80% practice in the final years. The Cooperative nursing programme is based strongly on the concept of workplace learning by means of clinical placements being a way of achieving academic credits.

11. Position of ethics in the curriculum  Currently: »‘Informal’ reflections during mentorship in all years »Year 3 - Ethics and value system (16 hours)  Future plans: »‘Formal’ integration of ethics and value system during mentorship »Year 1 - Personal philosophy/vision of care (16 hours) »Year 2 - Ethics and value system, palliative care, qualitative research (36 hours) »Year 3 – Ethics and law (16 hours) »Year 4 – Ethics and research (16 hours)

12. Learning from experience Expertise develops when the clinician tests and refines propositions, hypotheses, and principle-based expectations in actual practice situations Benner (1984)

13. Educational philosophy Based on: Personal and professional support for the individual Methodic and systematic supervision The process of personal growth and development Respect for the individuality of the person and attention for the search for self-actualization

14. Approach to schooling on ethics Principle-based ethics  The value of life  Goodness/no harm  Justice  Truth telling  Autonomy  Beneficence Care-based ethics  Moral attention  Sympathetic understanding  Relationship awareness  Accommodation  Response

15. Theoretical approach to ethics education  Move in the direction of virtue-based ethics/theory of presence »Compassion – ‘an awareness of one’s relationship with others’ »Competence – ‘having the necessary knowledge, judgement, skills, energy, experience and motivation’ »Confidence – ‘the quality that fosters trusting relationships’ »Conscience – ‘a state of moral awareness’ »Commitment – ‘convergence between one’s desires and one’s obligations and the deliberate choice to act in accordance’

16. Driscoll: ‘What?’ model of structured reflection (2000) Having an experience in practice What? Description of the event Purposeful reflection on selected aspects of the experience So what? An analysis of the event Discovery of what learning emerges from reflection Now what? Proposed actions following the event Actioning the new learning from the experience

17. Reflection and reflective practice  Reflection-in-action  Reflection-on-action  Reflection prior to action

18. Transformational learning (Lingsma & Scholten, 2001) Choice of motives and values, identity, who are these people? Assumptions and strategic actions ActionsResults Continual improvement Reassessment Transformation Single loop learning Double loop learning Triple loop learning What am I doing? What do I think?What do I want? Underlying

19. Being responsible versus having responsibility Assist students in setting boundaries  Being responsible - ‘being aware of what is happening and prepared to engage with it and work for its positive advance in society’  Having responsibility - ‘to be answerable to someone or something specific, usually defined by contract’

20. Contact information Philip Esterhuizen p.esterhuizen@hva.nl