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Nursing Paper Topic “Nursing Education”

Open Posted By: ahmad8858 Date: 26/04/2021 High School Case Study Writing

  

APA Paper NURSING PAPER INSTRUCTIONS 

There are three peer reviewed scholarly articles that will be used for writing the full paper.

All the instructions and template as well as articles are attached below.

Category: Arts & Education Subjects: Art Deadline: 12 Hours Budget: $150 - $300 Pages: 3-6 Pages (Medium Assignment)

Attachment 1

International Journal of

Environmental Research

and Public Health

Article

What Should Be Taught and What Is Taught: Integrating Gender into Medical and Health Professions Education for Medical and Nursing Students

Hsing-Chen Yang

Graduate Institute of Gender Studies, Kaohsiung Medical University, Kaohsiung City 80708, Taiwan; [email protected]

Received: 31 July 2020; Accepted: 5 September 2020; Published: 9 September 2020 ���������� �������

Abstract: This study focused on gender education for medical and nursing students, because gender competency is essential for them to provide effective and appropriate healthcare and to promote equal rights to health. A questionnaire was administered to 50 health care professionals to explore the gender concepts and gender knowledge that they deem imperative and often teach to medical and nursing undergraduate students in class. Sexism, gender awareness, sexual harassment, the topics of three acts related to gender equity, and patriarchy are the gender concepts participants deemed most crucial for students to learn and understand. However, disparities were noted between the gender concepts frequently taught by the participants and the gender knowledge they considered essential for students. The 50 experts emphasized teaching the concept of patriarchy and the cultivation of students’ structural competency in addition to identifying directions for gender, medical, and health care education. By highlighting the key gender-related concepts, the present research findings may benefit teachers who intend to integrate gender into the curriculum but are limited by time constraints. The results offer a professional development direction for teachers endeavoring to incorporate gender into the curriculum and their teaching.

Keywords: curriculum; gender concept; medical and healthcare professionals; sexism; structural competency

1. Introduction

Awareness and knowledge of gender has been acknowledged to constitute a key competency among medical and healthcare professionals. The value of integrating gender into professional health education is therefore recognized [1–3]. However, gender is currently considered ‘important . . . but of low status,’ occupying a marginal position in medical education [1]. A disparity between ideals and reality, caused by equating gender with biological sex and the treatment of gender neutrality as a naturally occurring phenomenon, is associated with inadequate understanding of gender. This creates challenges in relation to the inclusion of gender in medical and healthcare education [1,4,5].

Medicine and healthcare are specialist areas, and so is gender education. In addition to the proper delivery of professional knowledge, communications between doctors and nurses and patients often require understanding of and sensitivity to gender, necessitating some gender knowledge and gender competency. Studies have shown that lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) people, having lived in a heterosexual society for a long time, tend to accumulate mental stress. When they face medical staff, they often feel awkward and difficult to reveal their true self [6]. Some LGBTQI people are highly private regarding their bodies. When seeking medical treatment, they may experience feelings of discomfort and fear or show resistance when asked to expose or allow

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medical staff to touch their bodies during physical examination [6–8]. Insufficient gender sensitivity or knowledge of LGBTQI culture among medical staff can inflict secondary injuries on the patient and impede disease diagnosis and treatment.

This study asserts that the right to equal health is a matter of concern in medicine and healthcare, as well as a topic to be addressed through education because changes in culture and in values are required rather than mere systematic and policy changes. Education is always crucial in the training of healthcare professionals. This is why multiple scholars have advocated the incorporation of gender into medical and healthcare education [2,4,9–11].

Undergraduate education is the preliminary stage in the career paths of various professionals. To promote equal health rights, crucial professional competencies for medical and nursing students should include, but not be limited to, gender competency. Eliminating health disparity and practicing gender-friendly medical care requires undergraduate gender education for medical and nursing students. For medical and nursing students, exploration and construction of the core gender-related concepts facilitate the development of gender competency.

This study surveyed medical and nursing teachers and healthcare professionals to determine what gender knowledge they deemed crucial for medical and nursing undergraduate students and which gender-related concepts they most frequently taught. This study provided answers to the research question “Which gender-related concepts should be incorporated into curricula to prepare students for the future?”

1.1. Gender Education in Medicine and Healthcare: Reform of the Curriculum and Knowledge Enhancement

Curriculum reform is the core of education reform. Multiple studies have explored the effectiveness of incorporating sex and gender into medical and healthcare courses [4,5,11–13]. Medical education in the Netherlands may be considered as an example. Under the leadership of the research team at Radboud University Nijmegen Medical Center, eight medical schools in the Netherlands implemented the gender curriculum plan developed by the research team to promote gender education. Moreover, a set of indicators was developed to assess the inclusion of gender issues in medical education courses. Examples of the indicators are as follows: inclusion of sex and gender differences in medical education objectives; discussion of gender in the context of professional medical settings with biomedicine and sociocultural structures also taken into account; and consideration of factors relating to gender, age, social class, and race in discussions of human health and disease [14].

Experiences of integrating gender into medical and healthcare education in Australia, Sweden, the United States, Canada, Taiwan, and other countries and territories also demonstrates the benefits of gender courses and the manner in which they contribute to students’ understanding. For example, after studying gender, students can: recognize gender differences; address medical problems from a gender perspective; demonstrate awareness of the influence of social and cultural factors on individual health, which is generally believed to be affected only by biomedicine; and demonstrate increased sensitivity to the healthcare needs of LGBTQI patients [9,10,15–18].

The following measures were adopted during medical education reform in Taiwan: In 2002, the Ministry of Education published the White Paper on Medical Education in which “enhancing gender equity in medical education” was declared to be an objective. In 2007, the Ministry of Health and Welfare revised the Regulations Governing Practice Registration and Continuing Education of Doctors to incorporate gender issues into the curriculum. In 2013, the Taiwan Medical Accreditation Council added gender to the educational evaluation criteria of the new accreditation standards and demanded cooperation between teaching hospitals and universities to provide students with education and training regarding gender equity regulations and to ensure their understanding of key gender issues [19].

Development of the aforementioned national education policies has resulted in administrative measures and regulations in relation to the incorporation of gender into the education system and curricula. However, key topics in relation to gender require identification. Studies have proposed

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that the integration of gender into curricula and professional health education is challenging for the following reasons: problems achieving conceptual clarity; lack of time and space to accommodate gender in the curriculum; skepticism regarding the incorporation of gender into the curriculum; lack of time or willingness to learn about gender among teachers; gender blindness in the medical system and knowledge; treatment of women’s issues as gender issues and negligence of the existence of multiple genders; the categorization of gender in childbirth topics or obstetrics, strengthening of the link between women’s health and reproduction [1,3–5,14,20–22].

Studies have also shown that the lack of concrete gender-related curricula, gender-related theories, or comprehensively addressed gender-related topics has rendered gender education in medicine difficult [1,3]. Risberg et al. [1] noted that inadequate knowledge of gender is a major obstacle to the integration of gender into curricula among male teachers who also serve as leaders of medical universities. Risberg et al. discovered that these male teachers: (1) lacked perception of subtle inequalities between men and women; (2) did not know which areas to address in gender education; and (3) believed that gender education was merely the discussion of the physiological and behavioral differences between men and women, but lacked the time to engage in gender studies. An improvement strategy proposed by Risberg et al. was that gender be considered an individual area of scientific knowledge. To achieve this, the Medical Education Committee or course directors require sufficient understanding of the aspects of gender that should be included in courses to clearly define learning goals and properly allocate time for studying each aspect of gender.

The aforementioned research revealed that, although policies and curricula are being reformed to incorporate gender into professional health education, additional efforts are required for further improvement. To achieve further improvement, the curriculum must be reorganized and the structure of gender-related knowledge reformed to identify the gender-related concepts and concerns that should be taught in health professions education as well as enhancing teachers’ professional knowledge of gender.

1.2. Feminist Lens, Gender Theory, and Gender Learning

The women’s health movement emerged in the 1990s, originating from the awareness of gender bias in a male-dominated medical enterprise [23]. In such settings, women’s health issues, life experiences, and social situations are excluded from the construction of medical knowledge, as well as being neglected in clinical medicine and healthcare.

The central tenet of both feminism and gender theory is how to end sexism, sexist exploitation, and oppression [24,25]. Feminists criticize the male-centered values in biomedicine, which they associate with patriarchy [23,26]. According to sociologist Allen Johnson [27], patriarchy implies male-centeredness, male dominance, and male identification. Sharma [23] noted that patriarchy has ripple effects such as gender segregation in medical specialties and leadership, a gender pay gap, and harassment.

Influenced by feminism, gender theories, and the women’s movement, Taiwan passed the Gender Equity Education Act in 2004, implementing gender equity education in schools at all levels through institutionalization. Stromquist [28] examined the gender education policies implemented by countries worldwide and commented on the distinctive and progressive nature of Taiwan’s Gender Equity Education Act on a global scale. The act focuses on the cultivation of gender awareness through gender education as well as through the elimination of sexism and sexual harassment on campus. Taiwan’s three acts on gender equity, namely the Gender Equity Education Act, the Gender Equality in Employment Act, and the Sexual Harassment Prevention Act, all share a common emphasis on the elimination of sexism and sexual harassment. In particular, the Gender Equality in Employment Act guarantees equal work rights for all genders, prohibits sex discrimination, prevents sexual harassment in the workplace, and focuses on measures to promote work equality and the establishment of a gender-friendly environment.

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Knowledge of Gender Equality in Employment Act and of gender-related regulations is mandatory in the education and training of medical and nursing students during internships governed by the Taiwan Medical Accreditation Council and in the gender curriculum for the continuing education of doctors and nurses, per Ministry of Health and Welfare guidelines. Both education and training programs focus on developing medical and nursing students’ and medical personnel’s awareness of power structure relationships and of the right to work and medical rights. Sharma [23] noted that the application of feminism in medical education and curricula can help to eliminate gender stereotypes and sexism in medicine and clinical practice as well as ultimately resolving various forms of gender inequality, such as sexual harassment. For example, understanding power and privilege improves teachers and students’ awareness of power structures and power relations in medicine and clinical practice, as well as the health disparity among men, women, and LGBTQI people. Moreover, the application of feminism or gender theories to professional health education and students’ study of gender contributes to the creation of more systematic training in professional health education, as advocated by many studies. Healthcare professionals can thereby determine how the interplay of gender, race, social class, and sexual orientation affects individual health, while recognizing how social structures and economic and inequality factors operate in a larger structural environment to provide patients with superior care and humane medical practices [29,30].

2. Methods

In this study, a questionnaire survey enrolled 50 medical or nursing teachers and healthcare professionals. Taiwan’s policies, systems, and organizations in relation to gender equality education have contributed to gender education, as reflected in the reform of university curriculum structures, professional certification, and professional continuing education. Many medical universities or medical/nursing programs have established gender-related courses or have integrated gender into their curricula. The government also requires that courses on gender be included in continuing education for medical personnel.

2.1. Survey Questionnaire

The design of this questionnaire was based on research purposes and questions. The questionnaire items queried respondents on the gender-related concepts that they frequently teach and consider essential for students’ learning and knowledge. Respondents were asked to consider medical/healthcare specialties and occupational competency in completing the self-administered questionnaire. The research team mailed or emailed the questionnaires to the participants for them to complete independently.

The questionnaire was prepared, and expert validity was used to test the content validity of each item. Three gender education experts and scholars tested the validity of, reviewed, and revised the questionnaire. The revised questionnaire included two parts: (1) demographic data; and (2) questions on gender education for students. The second part of the questionnaire was composed of open-ended questions, multiple choice questions, and sequential questions. The sequential questions involved prioritizing and ranking multiple items by their perceived importance. The second part’s questions were as follows:

1. Please list at least three gender concepts or gender knowledge that you often teach in your course or at work.

2. Among the 25 items (the 25th item is “other”), please select 15 gender concepts or gender knowledge that university students must learn (if you select “other,” please specify its content).

3. Continuing from Question 2, please rank the 15 gender concepts or knowledge according to the following three major categories: most important and highest priority, second most important and second highest priority, and least important and lowest priority; please also explain your reasons for the ranking.

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4. Taking the department you teach in or work competency into consideration, among the 25 items, what do you think are the 15 gender concepts or gender knowledge that students must learn to succeed in future workplaces and in their social life?

5. Continuing from Question 4, please rank the 15 gender concepts or knowledge according to the following three major categories: most important and highest priority, second most important and second highest priority, and least important and lowest priority; please also explain your reasons for the ranking.

6. Please provide any further opinions or suggestions on the gender concepts or related knowledge that students must learn and know.

2.2. Participants, Data Collection, and Data Analysis

This study employed purposive sampling and ensured the representativeness of expert opinions by establishing a sampling standard, which addressed the professional knowledge or experience of the participants in the professional fields of gender, medicine, and healthcare. The inclusion criteria required that participants demonstrate gender awareness and possess years of teaching or practical experience in medicine and healthcare, in addition to meeting any of the following requirements regarding professional knowledge: (1) they were teaching courses on gender and medicine or healthcare at universities or had incorporated gender into medicine or healthcare courses; (2) they had published works related to gender and medicine or healthcare; (3) they had conducted research projects on topics related to gender and medicine or healthcare; or (4) they had promoted gender education for medical personnel or gender-friendly medical care.

Participants were recruited through the following channels: (1) the researcher’s interpersonal network; (2) professional associations or gender-related nongovernmental organizations; (3) a search for university professors teaching courses related to gender and healthcare; (4) a search for researchers implementing gender- and healthcare-related research projects commissioned by national institutes; and (5) a search of the various agendas of gender-related conferences/seminars to establish a list of authors who had published papers on gender, medicine, and healthcare. This study used the snowball sampling technique to send invitation emails to those satisfying the sampling criteria.

This study recruited 50 participants, 35 of whom were teachers and 15 of whom were healthcare professionals. Regarding the sex of participants, 18 were males (including one female-to-male transsexual person). Of the participants, 4, 14, 13, 15, and 4 people were aged 20–30 years, 31–40 years, 41–50 years, 51–60 years, and 61 years or older, respectively. Notably, many of the participants teaching in the department of medicine were also licensed doctors. Twenty eight of the participants specialized in medicine, whereas the remainder specialized in nursing.

For data coding, the following methods were adopted separately according to the nature of the open-ended questions: (1) Record participants’ answers. For example, for the sixth question in Section 2.1, this study accurately recorded the answers provided by participants. (2) Categorize and encode participants’ answers. The “other” item in the multiple-choice questions may be used as an example. This study originally provided 25 concept items, one of which was “other.” The “other” answers provided by the participants were categorized according to frequency. A new gender concept code was established when a concept was mentioned by different participants and more than three persons; a total of four new gender concepts were established. These gender concepts were gender role stereotypes, gender traits, feminism, and gender mainstreaming. Non-repeated concepts were still categorized as “other.” A total of 30 gender concepts emerged after data encoding.

For data analysis, this study used different methods for qualitative and quantitative data. Clustering, counting strategy, and thematic analysis were used for qualitative data; descriptive statistics and correspondence analysis were used for quantitative data. For sequential questions, the study adopted a weighted scoring method to assign 15, 10, and 5 points for items deemed most important (top priority), less important (secondary priority), and least important (third priority), respectively. The importance and priority scores for the multiple choice questions were compared.

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For correspondence analysis, 30 items were combined and divided into four groups through an expert validity test: (1) patriarchy and heterosexuality: heterosexual hegemony, heteronormativity, patriarchy, misogyny, homophobia, male-centeredness, male-dominance, male-identification, objectification, patriarchal dividend; (2) sex and gender: LGBTQI, gender awareness, sexual and gender identity, gender traits, sexism, gender role stereotypes; (3) gender violence: sexual harassment, sexual and gender-based bullying, domestic violence, oppression and gender oppression, abuse of power; and (4) gender politics: exploitation, Taiwan’s three acts on gender equity, autonomy, emotional labor, body politics, feminism, gender mainstreaming, and intersectionality.

2.3. Ethical Considerations and Approval

This research complies with the basic principles of research ethics, including informed consent, privacy, autonomy, and protection from harm. The invitation letter clearly explained the research purpose, research questions, questionnaire survey method, and data processing method, including the anonymity of the survey, the number of questionnaire items, the estimated completion time, and the steps required for the termination of participation. Only after consent was obtained from potential participants would the questionnaire and informed consent form be sent out. Therefore, the invitees fully understood the use of and processing methods for research data (e.g., the anonymous processing of data) before deciding, with full autonomy, whether to participate in the study. The National Cheng Kung University Human Research Ethics Committee approved the anonymous questionnaires.

3. Results

3.1. “Sexism” Ranks First among the Gender Concepts That Medical and Nursing Students Must Learn and Understand

Based on medical and healthcare specialties and occupational competency, the 50 experts identified the top 15 gender concepts essential to medical and nursing students’ learning and knowledge, with the top 10 being sexism, sexual harassment, gender awareness, patriarchy, the three gender equity acts, LGBTQI, sexual and gender-based bullying, sexual identity and gender identity, autonomy, objectification, and oppression/gender oppression (Table 1). Up to ≥80% of the participants deemed that medical and nursing students must learn and understand “sexism” and “sexual harassment.”

Table 1. Top 10 gender concepts for medical and nursing students to learn and understand.

Gender Concept All (N = 50)

Sex Academia/Practice

Male (N = 18)

Female (N = 32)

Teacher (N = 35)

Practitioner (N = 15)

Sexism 82% 83% 81% 80% 87%

Sexual Harassment 80% 78% 81% 77% 87%

Gender Awareness 76% 73% 78% 80% 67%

Patriarchy 74% 72% 75% 66% 93%

Taiwan’s Three Acts on Gender Equity 72% 72% 72% 71% 73%

LGBTQI 70% 67% 72% 74% 60%

Sexual & Gender-Based Bullying 68% 72% 66% 69% 67%

Sexual & Gender Identity 62% 67% 59% 60% 67%

Autonomy 60% 67% 53% 54% 73%

Objectification 54% —- 63% 57% —-

Oppression & Gender Oppression 54% 61% 50% —- 67%

Body Politics —- —- 54% 54% —-

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The top three gender concepts considered essential for medical and nursing students to learn and understand were the same for male and female participants: sexism, sexual harassment, and gender awareness. The top 10 gender concepts proposed by male and female participants were relatively similar, with the only difference being that female participants included objectification and body politics, whereas male participants did not. The top three gender concepts proposed by teachers and healthcare professionals varied; the concepts highlighted were sexism, gender awareness, and sexual harassment and patriarchy, sexism, and sexual harassment, respectively. Among the top 10 gender concepts proposed by teachers and healthcare professionals, objectification and body politics were ranked as crucial only by teachers, whereas “oppression and gender oppression” was ranked as crucial only by healthcare professionals.

Notably, up to 93% of healthcare professionals believed that students must learn and understand the concept of “patriarchy.” Eighty percent of the participants working as teachers or healthcare professionals identified the gender concept of “sexism” and “sexual harassment” as essential for medical and nursing students to learn and understand.

Correspondence analysis was used for this study to explore the relationship between demographic variables and concept combinations; the variable of age was added to identify whether generational differences existed. Figure 1 shows the analysis results for the “patriarchy and heterosexuality” grouping. The selections of patriarchy, patriarchal dividend, and heterosexual hegemony were not subject to variable changes. That is, all participants preferred these gender concepts essential for students to learn and understand. Male and female participants preferred that students learn and understand homophobia and objectification, respectively. Teachers and healthcare professionals had no particular preferences for certain concepts. Participants aged 20–40 years, 41–50 years, 51–60 years, and older than 61 years preferred that students learn and understand “male identification and misogyny,” “objectification,” “male-centeredness,” and “male dominance,” respectively.

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The top three gender concepts considered essential for medical and nursing students to learn

and understand were the same for male and female participants: sexism, sexual harassment, and

gender awareness. The top 10 gender concepts proposed by male and female participants were

relatively similar, with the only difference being that female participants included objectification and

body politics, whereas male participants did not. The top three gender concepts proposed by teachers

and healthcare professionals varied; the concepts highlighted were sexism, gender awareness, and

sexual harassment and patriarchy, sexism, and sexual harassment, respectively. Among the top 10

gender concepts proposed by teachers and healthcare professionals, objectification and body politics

were ranked as crucial only by teachers, whereas “oppression and gender oppression” was ranked

as crucial only by healthcare professionals.

Notably, up to 93% of healthcare professionals believed that students must learn and understand

the concept of “patriarchy.” Eighty percent of the participants working as teachers or healthcare

professionals identified the gender concept of “sexism” and “sexual harassment” as essential for

medical and nursing students to learn and understand.

Correspondence analysis was used for this study to explore the relationship between

demographic variables and concept combinations; the variable of age was added to identify whether

generational differences existed. Figure 1 shows the analysis results for the “patriarchy and

heterosexuality” grouping. The selections of patriarchy, patriarchal dividend, and heterosexual

hegemony were not subject to variable changes. That is, all participants preferred these gender

concepts essential for students to learn and understand. Male and female participants preferred that

students learn and understand homophobia and objectification, respectively. Teachers and

healthcare professionals had no particular preferences for certain concepts. Participants aged 20–40

years, 41–50 years, 51–60 years, and older than 61 years preferred that students learn and understand

“male identification and misogyny,” “objectification,” “male-centeredness,” and “male dominance,”

respectively.

Figure 1. Distribution of gender concepts …

Attachment 2

International Journal of

Environmental Research

and Public Health

Article

The Relationship between the COVID-19 Pandemic and Nursing Students’ Sense of Belonging: The Experiences and Nursing Education Management of Pre-Service Nursing Professionals

Luis Miguel Dos Santos

Woosong Language Institute, Woosong University, Daejeon 34514, Korea; [email protected]; Tel.: +82-010-3066-7818

Received: 29 June 2020; Accepted: 11 August 2020; Published: 12 August 2020 ���������� �������

Abstract: The COVID-19 pandemic has changed the orders and structures of societies, particularly in the fields of medical and nursing professions. The researcher aims to understand the experiences, sense of belonging, and decision-making processes about Japanese pre-service nursing students and how the COVID-19 pandemic, social distancing, and lockdown has influenced their understanding as pre-service nursing professionals in Japan. As this study focuses on the issues of pre-service nursing students, the researcher invited forty-nine pre-service nursing students for a virtual interview due to the recommendation of social distancing. To increase the coverage of the population, the researcher employed snowball sampling to recruit participants from all over Japan. Although the COVID-19 pandemic influenced the overall performance of the medical and nursing professions, all participants showed a sense of belonging as Japanese citizens and nursing professionals due to the natural disaster of their country. More importantly, all expressed their desires and missions to upgrade and improve the overall performance of the public health system due to the influence of the COVID-19 pandemic. The results discovered that many Japanese nursing students advocated that Japan’s national development, the benefits and advantages of their country, were of a greater importance than their own personal development and goals.

Keywords: COVID-19 pandemic; nursing education; nursing student; pre-service nursing professional; public health development; sense of belonging; social distancing

1. Introduction

1.1. Purpose of the Study

Nursing training and education is not a liberal arts study, but rather a vocational-oriented training for pre-service nursing professionals at the university level. Although nursing students may spend time on campus for theoretical courses and general education requirements, a large portion of their time should be spent in clinical internships and placements [1]. However, due to the international COVID-19 pandemic, many face-to-face courses and internships in clinical environments are affected by social distancing recommendations. Although the COVID-19 pandemic does not change the enrolment status and registration procedure of pre-service nursing students, their experiences, sense of belonging, and decision-making processes must be influenced by external and environmental problems, particularly the COVID-19 pandemic.

This study has three purposes. First, the researcher aims to understand the experiences, sense of belonging, and career decision-making processes [2–5] of nursing students from two time periods (i.e., before the COVID-19 pandemic and during the COVID-19 pandemic). It is important to understand

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how the COVID-19 pandemic influences and impacts the behaviours of nursing students in order to ensure effective human resource management and school enrolment plans.

Second, due to the COVID-19 pandemic, recommendations of social distancing, and distance learning-based teaching and learning experiences, some students may defer their studies or drop their university studies altogether. Due to the COVID-19 pandemic, many nursing students may not be able to complete their internships and placements at the clinical level due to the lockdown governmental policy. Therefore, the researcher would like to understand how these elements influence the experiences, sense of belonging, and decision-making processes [2–5] of a group of nursing students in Japan.

Finally, with a focus on the sense of belonging, the researcher seeks to understand how the relationship between a sense of patriotism as Japanese citizens and the COVID-19 pandemic influence the experiences and decision-making processes of a group of nursing students in Japan [6,7].

In short, the current research study was guided by one research question:

1. Based on the lens of the social cognitive career theory, what are the motivations and reasons that influenced the experiences, sense of belonging, and career decision-making processes of nursing students in Japan? How would you describe?

The interview questions and focuses on these aspects—and the results and discussion are divided into two time periods (i.e., before the COVID-19 pandemic and during the COVID-19 pandemic)—in order to outline the differences between public health conditions.

1.2. Literature Review

In general, nursing occupations are stable and come with a higher social status, but are also characterised by work and responsibility overloads, usually causing their practitioners to be tired, and are low-paying in order to broaden opportunities across occupational disciplines for those entering the workforce [8]. Although work–life responsibilities are not balanced due to human resource shortages, it is important to increase the overall enrolment and experience of nursing students and in-service nursing professionals in order to ensure adequate workforce management [9]. A previous study [2,10] indicated that a large number of mid-level and senior-level nursing professionals decided to leave the profession due to poor administrative management, overloaded working responsibilities, insufficient salaries, and regular overtime. However, many hospital leaders, clinical managers, policymakers, and government leaders do not have solid and tailor-made human resource plans for this particular workforce (i.e., nursing professionals), as general human resources planning may not be able to respond to the needs of the medical and nursing areas [11].

Besides ineffective human resources management, recruitment in the medical and nursing profession is not the same as in other nonprofit and profit-making industries. Based on the current nonprofit management scheme, many human resources professionals advocate that the medical and nursing profession may share significant elements and factors with education, social care, and psychology professions [10,12]. Although these fields are generally considered to be nonprofit, medical and nursing professionals may start their own business-oriented clinics and hospitals for profit-making purposes. Based on these studies, it is worth noting that the job nature and working environment may not match prospective students’ expectations, experiences, sense of belonging, and decision-making processes, as members of the general public generally believe nursing to be a nonprofit profession. Such unbalanced expectations may cause confusion in pre-service nursing students and junior-level nursing professionals [13,14].

The nature of jobs in Japan is another consideration for individuals’ experiences, their sense of belonging, and decision-making processes in the field of nursing [6]. Unlike many other countries, Japanese people tend to stay in the same company for life-long career development. Although some working environments do not match their expectations, Japanese people always stay in the same organisation once they have graduated from school. An early study [15] explored the relationship

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between gender, job responsibilities, positions and roles of female health and medical professionals in Japan based on their socioeconomic backgrounds, qualifications, career developments and patients’ perspectives. The female participants indicated that the public health sector and the medical profession is their life-long career. They would spend their energies and contribute to the field and their organisations without questioning. More importantly, the results also indicated that the gender differences between males and females might create a social bias due to their gender. However, they could adjust their mindset in order to provide excellent services to their patients. Another recent study [16] indicated that after Japan has a mandatory retraining programme which allowed and encouraged nursing professionals to return to the same organisation after any career breaks and issues. In other words, resigned nursing professionals should have the right to come back to the same nursing position or the same organisation after some situations, such as becoming a mother. As a result, Japanese people always investigate the background, nature, performance, feedback, and reputation of organisations before committing themselves to a life-long career [17].

1.3. Theoretical Framework

Experiences, sense of belonging, and decision-making processes are not single direction elements, but multiple factors which can interconnect with each other [18]. In this study, the researcher tended to understand the experiences, sense of belonging and decision-making processes of Japanese nursing students during the COVID-19 pandemic and how the COVID-19 pandemic influenced their behaviours. As a result, the researcher decided to employ the social cognitive career theory (SCCT) [19–25] as the tool to explore and investigate the abovementioned elements, the performance and the limitation in individuals’ education and career goals [26–30].

The development of the SCCT [1–14] was based on the foundation of social cognitive theory [31,32], with the additional conceptions of career decision, development, and perspective, focusing on the individual’s understanding, behaviour, financial consideration, and external/environmental factors. Both Bandura [31,32] and Lent et al. [24,25] believed that individuals’ behaviours and thinking should not be a direction and single element but multiple connections and interactions [33]. These multiple behaviours and activities can be directions to interact and connect individuals’ career perspectives and understanding [7].

First, human behaviours and decision-making processes are not in a single direction, they go in multiple directions, ways and conducts. Career-related interest is one of the factors influencing individuals’ career decisions. For example, a previous study [29] indicated that female scientists and engineers decided to switch to science, technology, engineering and mathematics (STEM) education due to their personal goals and career interests in training and teaching. Individual career decisions may be changed due to the various elements and situations. The SCCT, therefore, provides the tool to explore this direction.

Second, academic and career achievements also serve as a consideration in career development. For example, a recent study [7] explored the reasons and motivations of why male nursing professionals decided to switch their career development to nursing education. The results indicated that male nursing educators believed their academic and career experiences would be beneficial to the next generation. Therefore, the motivations of these groups of participants were mainly focused on their academic and career achievements for their qualifications and goals.

Third, performance and persistence in educational and occupational pursuits is another significant element for career development and career decisions. A recent study [30] indicated that the connections between educational and occupational pursuits would influence individuals’ career development and career decisions. For example, nursing professionals who face a high level of stress and burnout may leave their position and the profession due to the psychological distress and low-level of satisfaction in their profession [34]. As a result, individuals’ behaviours and career perspectives are impacted by thinking, internal elements, emotions, external/environmental factors, and even financial considerations collectively [29].

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To illustrate the SCCT and the related concepts, the SCCT has three important points for its modelling in the notions and directions of career decision and development [24,25,33].

• First, the formation and elaboration of career-related interest. • Second, the election of academic and career selection and direction options. • Third, the performance and persistence in educational and occupational pursuits.

SCCT [1–14] argues that the theory has categorised the differences and directions between personal intentions and wants (i.e., personal beliefs, personal goals and purposes, internal desires, dreams) and behaviours (i.e., activities, movements, actions, conducts, ways and decision-making processes), as individuals tended to base their conduct on what they usually believe and advocate. In other words, individuals tend to conduct and practice their career decisions and selection based on what they advocate instead of human resources management and practices from other individuals, groups, and government leadership [1–14]. To illustrate, please refer to Figure 1.

Int. J. Environ. Res. Public Health 2020, 17, x 4 of 19

• Third, the performance and persistence in educational and occupational pursuits.

SCCT [1–14] argues that the theory has categorised the differences and directions between personal intentions and wants (i.e., personal beliefs, personal goals and purposes, internal desires, dreams) and behaviours (i.e., activities, movements, actions, conducts, ways and decision-making processes), as individuals tended to base their conduct on what they usually believe and advocate. In other words, individuals tend to conduct and practice their career decisions and selection based on what they advocate instead of human resources management and practices from other individuals, groups, and government leadership [1–14]. To illustrate, please refer to Figure 1.

Figure 1. The social cognitive career connections between career development and decision.

2. Materials and Methods

As an established qualitative researcher [26–28,35–39] in the field of public health, education, nursing, and social sciences, the researcher decided to employ a qualitative research method to collect and analyse the data information into meaningful themes and subthemes for reporting. The nature of this study is to understand and explore the lived stories, shared information, life experiences, sense of belonging, and decision-making processes [33,40–44] of nursing students during the COVID-19 pandemic in Japan.

2.1. Participants and Recruitment

As of April 2017, according to the Japan Nursing Association [45], there were 277 public health nursing schools and nearly 22,000 active nursing students in Japan. Over 95% of these nursing students were enrolled at one of the nursing schools at the senior-level colleges and universities for at least a bachelor’s degree qualification.

A total of forty-nine Japanese nursing students were invited. All agreed to participate in this study. The snowball sampling strategy [38,46] was employed to recruit the participants. First, based on personal networking and connections, the researcher was able to invite 11 nursing students who could meet the criteria of the research study. Second, the participants were encouraged to forward the research protocol to other potential nursing students with a similar background. Third, after several rounds of invitations and referral activities, a total of forty-nine participants joined the study. After the researcher believed the meaningful data information and shared information had met the

Figure 1. The social cognitive career connections between career development and decision.

2. Materials and Methods

As an established qualitative researcher [26–28,35–39] in the field of public health, education, nursing, and social sciences, the researcher decided to employ a qualitative research method to collect and analyse the data information into meaningful themes and subthemes for reporting. The nature of this study is to understand and explore the lived stories, shared information, life experiences, sense of belonging, and decision-making processes [33,40–44] of nursing students during the COVID-19 pandemic in Japan.

2.1. Participants and Recruitment

As of April 2017, according to the Japan Nursing Association [45], there were 277 public health nursing schools and nearly 22,000 active nursing students in Japan. Over 95% of these nursing students were enrolled at one of the nursing schools at the senior-level colleges and universities for at least a bachelor’s degree qualification.

Int. J. Environ. Res. Public Health 2020, 17, 5848 5 of 18

A total of forty-nine Japanese nursing students were invited. All agreed to participate in this study. The snowball sampling strategy [38,46] was employed to recruit the participants. First, based on personal networking and connections, the researcher was able to invite 11 nursing students who could meet the criteria of the research study. Second, the participants were encouraged to forward the research protocol to other potential nursing students with a similar background. Third, after several rounds of invitations and referral activities, a total of forty-nine participants joined the study. After the researcher believed the meaningful data information and shared information had met the saturation (i.e., similar shared information and feedback were repeated without additional themes and ideas), the researcher decided to suspend the recommendations of referral activities.

First, some scholars may make arguments about the numbers of participants in this study (i.e., the numbers are not enough). According to Moustakas [47], qualitative research studies tend to focus on interpersonal communication, the sharing of lived stories and the quality of the data information. The quality of the data information is more important than the quantity of the numbers. Clandnin and Connelly [41] also suggested that qualitative researchers should focus on intensive sharing and an in-depth understanding of the participants in order to collect the real and true data from the shared information of the participants.

Second, in order to increase the rich and meaningful data information of the qualitative research studies, Merriam [46] suggested that qualitative research studies should recruit at least three participants and no more than 100 participants. Moustakas [47] further suggested that a standard phenomenological analysis should recruit no more than 50 participants for a high-level qualitative study. Therefore, based on the guidelines from various qualitative researchers, the current research study met the expectations as a qualitative research study.

Due to the concerns of privacy, particularly in the field of medical and nursing professions with limited networks and connections, the researcher needed to assign a pseudonym to each participant in order to mask their identity to potential supervisors, clinical sites, internship and placement managers, government agencies, and policymakers. Therefore, the official name, university name, place of origin, and specialisation have been masked as these elements did not impact the results of the study. The demography of the participants has been listed within the Appendix Table A1 section.

2.2. Data Collection

As this research study was conducted during the COVID-19 pandemic, the government and the World Health Organisation (WHO, Geneva, Switzerland) had established the social distancing recommendation. Therefore, face-to-face interview sessions were not encouraged. As a result, the researcher could only conduct the interview sessions via social media virtual chats (i.e., WhatsApp and Line Chat).

The open-ended and semi-structured interview tools [38,39,46] were employed to collect meaningful data and information from the participants. The individuals shared their understanding, life experiences, sense of belonging, decision-making processes, and feedback as Japanese nursing students [33,40–44] and how the COVID-19 pandemic influenced their behaviours. All participants have voluntarily participated in this study. The general inductive approach [48] was employed for the qualitative data collection and analysis. Appendix B lists the interview questions. It is worth noting that the interview questions were developed based on the recommendations and guidelines of SCCT [1–14], recent studies [6,7], and the objectives of the study.

In order to seek rich, informative data from the participants, the researcher first sent a detailed academic and personal background to the participants. According to Seidman [49,50], a relationship between the researcher and participants should be established in order to collect in-depth data information and sharing. However, due to the COVID-19 pandemic and the related limitations, such as the social distancing recommendation, the in-depth interview sessions [38,46] and closed relationships could not be established. However, in order to establish a virtual relationship between each other, first, the researcher sent detailed information to each for review. Second, before the interview session,

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each received the interview questions at least ten days before the virtual chat. Third, the participants could contact the researcher for any academic recommendations and suggestions, on topics such as homework tuition or career development. Although not all participants contacted the researcher prior to the formal interview session(s), the researcher tried his best to increase the interactions between each other during this COVID-19 pandemic.

As for the virtual interview sessions, each interview session lasted from 58 to 78 min. Before the interview sessions started, the researcher explained the rights of participation, risks, and benefit to each participant [38,46]. Additionally, the researcher used an audio recorder to record the interview sessions for further data analysis. All orally agreed and finished the interview sessions without interruption. In addition to the interview sessions, after the researcher finished the data collection and analysis procedures, the researcher sent the related materials to each participant for confirmation and member checking. All agreed with their collected data and confirmed the validity [35].

None of the participants were native English speakers but Japanese speakers. However, all had a superior level of English language skills with solid third-language backgrounds (e.g., Chinese Mandarin, Russian, Arabic, Korean, French, German, and Spanish). All were informed that they could use both English and Japanese for the interview sessions. However, all decided to use English as the language for sharing.

2.3. Data Analysis

After the data collection procedure, the oral conversation has been transcribed to written transcripts for reporting. Qualitative researchers [26–28,35–39] advocated that large-size data information should be narrowed down to systematic themes and groups for reporting. Therefore, the researcher employed the open-coping strategy [6,7,33,38,46] to narrow down the data information to the first-level themes and subthemes. As a result, 23 themes and 34 subthemes were categorised.

However, it is not recommended to have more than ten themes and ten subthemes for a manuscript. Therefore, the researcher continued to employ the axial-coding strategy [38,46] to narrow down the first-level themes and subthemes into second-level themes and subthemes [6,7,33,38,46]. As a result, two themes and four subthemes were categorised. Please refer to Table 1 for the themes and subthemes.

Table 1. Themes and subthemes.

Themes and Subthemes

3.1 Before the COVID-19 Pandemic: I Have the Mission to Help Minorities

3.1.1 Promoting Rural and Suburban Public Health Performance and Knowledge 3.1.2 Increasing the Quality of the Public Health System as a Citizen

3.2 During the COVID-19 Pandemic: My Country Needs my Effort and Energy

3.2.1 Personal Sacrifice: National Developments and Caring Rather than Personal Interests 3.2.2 Concerning the Need for Medical and Nursing Development

2.4. Human Subjects Protection

All of the signed and unsigned agreements and content forms, personal contacts, audio recordings, written transcripts, computers, and related materials were locked in a password-protected cabinet. Only the researcher has the rights to read the materials. After the study was completed, the researcher immediately destroyed and deleted the materials for personal privacy.

Due to the content forms and agreements, the official names, university names, places of origin, and specialisations have been masked as these elements did not impact the results of the study. However, the participants agreed that their university location and current grade could be shown. All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the University Ethics Committee (2020/02/03).

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2.5. Validity of the Qualitative Data Information

The validity of the qualitative research data information is important. Therefore, the researcher tried his best to exercise some procedures in order to increase the rate of validity. According to Robson [51], qualitative researchers should exercise at least one solution to ensure the validity of qualitative research studies. In this study, the researcher exercised three ways to increase validity. First, the prolonged involvement, although the researcher could not see the participants in private due to the recommendation of social distancing. However, the researcher provided the tutorial sessions and practices as the tool to increase the involvement between each other.

Second, as mentioned above, the researcher asked the participants for the member checking procedure. The researcher sent the related materials to each participant for confirmation and member checking. All agreed with their data information and confirmed the validity.

Third, the audit trail was used in this study as well. The researcher kept all the related materials and data information in his diary and notebooks. Each step was recorded and marked with detailed information and notices.

After the researcher exercised these three procedures for the validity of the data information, the current research results and findings should meet the recommendation on how to confirm the qualitative research data information [46,51].

3. Results and Discussion

During the interview sessions, the participants answered the same general semi-structured questions, which aimed to capture their personal lived stories, understanding, concepts, perspectives, and opinions about their intentions and motivations (i.e., to become a nurse in the future). Although their places of origin, living environments, family backgrounds, educational histories, and personal expectations were not the same, many shared a similar understanding and feedback about their motivations and reasons for pursuing nursing education and training, as well as their decision-making process (i.e., becoming a nurse).

According to SCCT [19–25], people’s experiences, sense of belonging, and decision-making processes might be different due to the current international COVID-19 pandemic; an internal understanding and external/environmental factors [19–25] can highly influence the overall understanding, behaviours, and decision-making processes of individuals. In this case, in order to measure the differences between the period before and after the COVID-19 pandemic, the researcher categorised the themes and subthemes based on two different timeframes (i.e., before the COVID-19 pandemic and during the COVID-19 pandemic). In fact, as this research study was conducted during the COVID-19 pandemic, the researcher could only capture data for the second timeframe (i.e., during the COVID-19 pandemic).

Based on the data, none of the participants changed their mind regarding becoming a registered nurse after university graduation due to the COVID-19 pandemic and related influences. Although the COVID-19 pandemic may damage some government policies, benefits packages, job responsibilities, expectations, and even working hours, none of the participants decided to quit their dream job as they all had solid purposes and personal goals. Table 1 outlines the themes and subthemes of this study.

3.1. Before the COVID-19 Pandemic: I Have the Mission to Help Minorities

The original aim of this study was to explore the experiences, sense of belonging, and decision-making processes [19–25] of university nursing students in Japan. However, as the COVID-19 pandemic has influenced the …

Attachment 3

RESEARCH ARTICLE Open Access

Social justice in health system; a neglected component of academic nursing education: a qualitative study Hosein Habibzadeh, Madineh Jasemi and Fariba Hosseinzadegan*

Abstract

Background: In recent decades, increasing social and health inequalities all over the world has highlighted the importance of social justice as a core nursing value. Therefore, proper education of nursing students is necessary for preparing them to comply with social justice in health systems. This study is aimed to identify the main factors for teaching the concept of social justice in the nursing curriculum.

Method: This is a qualitative study, in which the conventional content analysis approach was employed to analyze a sample of 13 participants selected using purposive sampling method. Semi-structured interviews were conducted to collect and analyze the data.

Results: Analysis of the interviews indicated that insufficient education content, incompetency of educators, and inappropriate education approaches made social justice a neglected component in the academic nursing education. These factors were the main sub-categories of the study and showed the negligence of social justice in academic nursing education.

Conclusion: Research findings revealed the weaknesses in teaching the concept of social justice in the nursing education. Accordingly, it is necessary to modify the content of nursing curriculum and education approaches in order to convey this core value. Since nursing educators act as role models for students, especially in practical and ethical areas, more attention should be paid to competency of nursing educators, specially training in the area of ethical ideology and social justice.

Keywords: Social justice, Health equity, Education, Nursing, Qualitative study

Background Professional values include action standards that are ac- cepted by group members and provide a framework for evaluating beliefs and notions affecting behavior [1]. Ac- quisition of professional nursing values is a prerequisite for resolving conflicts; it improves service quality and in- creases job satisfaction of nurses [2]. The core values ac- cepted and presented by American Association of Colleges of Nursing (AACN) (1998) include human

dignity, integrity, autonomy, altruism, and social justice [3], out of which social justice has attracted more atten- tion in recent years. Disproportionate burden of diseases and deaths in parts of the society associated with envir- onmental and socioeconomic factors has been recog- nized for decades; however, the number of documents on these issues has increased dramatically over the past 15 years [4]. The WHO Commission on Social Determi- nants of Health attributes these differences to social in- equalities in the distribution of power, income, shelter, education, and healthcare as well as climate change, vul- nerability, and other life conditions. It also prioritizes

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] Faculty of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran

Habibzadeh et al. BMC Nursing (2021) 20:16 https://doi.org/10.1186/s12912-021-00534-1

social justice as a mechanism for correcting and elimin- ating inequalities [5]. Social justice in the health system refers to providing equal healthcare services for all indi- viduals, regardless of their personal characteristics [6]. The AACN defines social justice as fair treatment, re- gardless of one’s economic status, race, ethnicity, age, citizenship, disability, or sexual orientation [7]. Although social justice has been identified as a profes-

sional value in documents issued by reputable nursing associations such as International Council of Nurses (ICN), Canadian Nurses Association (CNA), American Nurses Association (ANA), and AACN [8], the discus- sion of social justice in nursing profession has always been accompanied by serious doubts and concerns [9]. In addition, nurses’ responses to social injustice have not always been admirable, and nursing profession’s poor performance originates from various factors such as un- awareness [10]. Development of a professional value such as social

justice is a continuous and long-term process that begins with professional nursing education and continues throughout years of nursing practice. Education plays a key role in acquiring professional values [11]. Students, educators, faculties, clinical and educational experiences, and individual values are among the most important components of learning and development of professional values [12]. It is very important to train highly skilled and qualified nurses to provide necessary care for het- erogeneous populations in today’s ever-changing demo- graphic prospect. Nursing students must understand their responsibility for poplulation health issues and so- cial factors affecting health (eg, world hunger, environ- mental pollution, lack of access to health care, violation of human rights, and inequitable distribution of health care resources, including nursing services) and in this re- gard acquire the necessary knowledge and skills [13]. To institutionalize the concept of social justice in

nursing students, especially in developed countries, mea- sures have been taken in the area of education, which in- clude modifications made to nursing curriculum and education approaches [14]. For instance, simulation is a one of new methods utilized for teaching this concept [15]. Since the mid-2000s, there has been an increase in tendency towards online learning [16], co-curricular ex- periences [17], and digital storytelling [18] in order to promote students’ understanding of social justice issues. Nevertheless, some studies have addressed the weak- nesses of nursing curriculum in teaching social justice [19, 20] and have attributed nurses’ inability in pursuing social justice to their poor scientific and practical com- petencies [21]. Although several quantitative and qualita- tive studies have been conducted in recent decades to institutionalize the concept of social justice among nurs- ing graduates [22–25], academic nursing education has

unfortunately failed to train competent nurses who seek information and training on social justice. Considering the importance of this subject, a qualitative approach [26] was adopted to provide an in-depth understanding of social justice based on the realistic results derived from the participants’ real experiences. Therefore, in this study, the experiences of nursing educators and students in identifying the main factors for teaching the concept of social justice in nursing education program were analyzed.

Method Study design and setting This qualitative study was conducted using a conven- tional content analysis method. The participants were recruited from three nursing faculties (Urmia, Tabriz, and Tehran) and two teaching hospitals of Tehran (Motahari Hospital) and Urmia (Talegani Hospital) in Iran. These cities were selected due to their large size and forerun in educational, clinical, and social nursing activities.

Study participants In view of the objective of the study - identify the main factors for teaching the concept of social justice in the nursing curriculum - we initially selected nursing educa- tors by purposive sampling method. Nursing educators who had more than 5 years of service experience and among the prominent educators with activity in nursing institutions that involved in developing social justice were selected. The data from the study then led us to students and clinical nurses. Among the students, the final year undergraduate students, exemplary and active in social fields, and among the nurses, those with more than 2 years of service experience, accepted by the sys- tem professionally and actively in the field of social just- ice, such as voluntary activities in public health promotion, were selected for the interview. The participants included 6 men and 9 women with

the mean age of 39.07 ± 12.92 years old and mean work experience of 20.00 ± 7.22 years. Out of all the partici- pants, 5 individuals had PhD, whereas 2 had Master’s degrees; the rest had Bachelor’s degrees in nursing. In total, 7 individuals were nursing educators, 2 individuals were clinical nurses, and 4 individuals were nursing stu- dents (Table 1).

Data collection The data were collected using in-depth, semi-structured individual interviews conducted at the times and in the places selected by the participants (mainly at nursing faculties). Each interview lasted for 30–90 min; they were audio recorded upon the participants’ permission and transcribed verbatim. All the 13 interviews were

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conducted by the research team (FH, MJ, and HH) be- tween February and November 2019. The participants were asked questions about their experiences of (learn- ing/teaching) social justice issues. Considering the ab- stract nature of the research subject, the researchers raised more objective questions. For instance, the educa- tors were asked to “describe their experiences of modifi- cation to the curriculum to cover social justice issues”, whereas the students were asked to “describe their expe- riences of social justice-based practices during intern- ships”. In addition, to better identify factors affecting social justice education in nursing, the educators and students were asked questions such as “Considering your experiences, what factors have affected your engagement in social justice in education?” and “How do you de- scribe education approaches adopted by educators for teaching social justice?”, respectively. (See Add- itional file 1 for details). The researchers continued the interviews until the data were completely saturated, i.e. when no new idea, concept, or category was derived from the final interviews. To better relate to the environments of the study and

the participants and analyze the data realistically, the re- searchers also used field notes. Field notes are a brief summary of the observations made while collecting data. This is not limited to a particular type of activity or be- havior and assesses the non-verbal behaviors of the par- ticipants and their interactions with others. It also depicts a picture of a social position. In this study, field notes also made a detailed presentation of the situation in the right place immediately after the interview and provided the opportunity to confirm the psychological and emotional reactions of the participants. For example, attending the emergency ward of one of the teaching hospitals in Urmia city and observing nursing education

in the clinical environment led to a field note focusing the training on the clinical procedures that confirm the insufficient educational content and lack of attention to social justice in nursing education.

Data analysis After the data were collected, they were analyzed using the conventional content analysis approach. For this purpose, Grundheim and Lundman’s (2004) method was adopted [27]. In this method, an entire interview is regarded as an analysis unit involving notes that must be analyzed and coded. The researchers listened to the in- terviews for several times and transcribed the recorded interviews verbatim. The paragraphs, sentences, and words were considered meaning units. A meaning unit is a set of words and sentences that are related to each other in content and are categorized based on their con- tent and context. The texts were reviewed several times to highlight words containing key concepts or meaning units and extract the initial codes. The codes were then reviewed several times in a continuous process from code extraction to labeling. Similar codes were merged, categorized, and labeled and the subcategories were de- termined. The extracted subcategories were finally com- pared and merged (if possible) to form the main categories.

Assessing data accuracy and stability Guba and Lincoln’s (1986) criteria were used to ensure the accuracy and stability of the research data. The cred- ibility of the data was assessed using member-checking and prolonged engagement techniques. For member- checking technique, the participants reviewed the con- tent of the interview and the resulting codes to ensure the accurate meaning and for really reflecting their

Table 1 Demographic Characteristics of the Participants

No. Education Work experience Position City

1 PhD 28 Faculty member Urmia

2 PhD 25 Faculty member Urmia

3 Master’s 28 Faculty member Urmia

4 PhD 24 Faculty member Tabriz

5 PhD 22 Faculty member Tabriz

6 Bachelor’s N/A Student Urmia

7 Bachelor’s N/A Student Urmia

8 Master’s 10 Faculty member Urmia

9 PhD 11 Faculty member/Policymaker Tehran

10 Bachelor’s 20 Clinical nurse Urmia

11 Bachelor’s 12 Clinical nurse Tehran

12 Bachelor’s N/A Student Urmia

13 Bachelor’s N/A Student Urmia

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experiences. The data were also assessed by an external researcher (peer debriefing). To ensure the dependabil- ity, data collection methods, interview, taking notes, cod- ing, and data analysis were expressed in detail in order to make judging by the external auditor (external audit- ing). In order to achieve confirmability, the audit trail method was used, so that all stages of the research, espe- cially the stages of data analysis and the results, were provided to checking of two expert colleagues in the field of qualitative research. The transferability of the findings was also established by providing a rich descrip- tion of the research report and the content of the inter- views was represented by the selected quotations from the participants [28].

Ethical considerations The participants were selected after the approval of Eth- ics Committee of Urmia University of Medical Sciences and the necessary permissions (Code: IR.UM- SU.REC.1397.223) were granted. Prior to the interviews, the participants were informed about their anonymity, confidentiality of their information, the research method and objectives, and their right to leave the study at will. The participants also signed informed consent forms.

Results Classification of the interviews showed that three sub- categories of “insufficient educational content”, “limited competency of nursing educators”, and “inappropriate education approaches” led to the emergence of the main category called “social justice; a neglected component of academic education” (Table 2).

Social justice; a neglected component of academic education Proper education plays a major role in training justice- seeking nurses. Social justice and its importance in healthcare are constituents of the nursing syllabus. Pay- ing more attention to this issue in practical and objective areas of education by educators can influence students’ thoughts, attitudes, and behaviors to pursue justice in health systems. However, Iran’s education system has unfortunately failed to promote justice because of insuf- ficient educational content, limited competency of nurs- ing educators, and inappropriate education approaches.

Insufficient educational content Development of a comprehensive nursing curriculum, especially on ethical issues such as social justice, could substantially contribute to the preparation of socially and morally conscious nurses who are able to make sig- nificant changes in the public health at local, national, and international levels. In this study, the participants highlighted some weaknesses in the content of the

existing nursing curriculum such as lack of attention to social justice, discontinuity in presenting courses on eth- ical values, and allocating most of the nursing courses to medical issues and clinical care.

Lack of attention to social justice in nursing curriculum Social justice is a core nursing value which plays a sig- nificant role in promoting justice by nursing students and nurses. However, according to the participants, it has unfortunately been neglected in the existing nursing curriculum. In this regard, one participant stated,

“In the fourth semester, we studied a course on nursing ethics. I think there was no discussion on social justice because I don’t remember anything about this topic” (Participant No. 7/Nursing Student).

Regarding the importance of teaching social determi- nants of health, another participant stated,

“I was not aware of the importance of social issues in health until I participated in a workshop called ‘Social Justice in Health’. It really changed my be- liefs and broadened my perspective” (Participant No. 10/Clinical Nurse).

Discontinuity in presenting courses on ethical values Values are major components of the nursing profession. The institutionalization and development of professional values such as social justice contribute significantly to the future of this profession. The few number of courses presented on ethical values and discontinuity in the pre- sented courses (for instance, no course on ethical values is provided for post-graduate students) were major items mentioned by the participants. In this regard, one of the participants stated,

“When students are repeatedly reminded of the im- portance of a value, they will realize its importance and the value will be institutionalized in them. We partially studied professional values and social just- ice issues in the fourth semester of our undergradu- ate courses; however, no similar course was provided for us afterwards during the Master’s pro- gram” (Participant No. 5/ Faculty Member).

Or another participant stated:

“We cannot deny that the ethical issues have been institutionalized in our professional graduates to some extent. But, these issues are not worked on in a principled and scientific manner and that there is no constant focus on them. After all, the effect of

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the hidden curriculum has been more prominent.”(- Participant No.1/Faculty Member).

Allocating most of nursing courses to medical issues and clinical care Diseases and clinical care are among the most fun- damental parts of theoretical and practical training provided for nursing students; however, due to the multi-dimensional nature of the nursing profession, special attention should be paid to other dimensions as well. According to the research results, the exist- ing nursing curriculum focuses mainly on transfer- ring knowledge and skills associated with physical and routine care. One participant expressed,

“Most of our courses were related to various diseases and nursing care, and educators rarely talked about ethical and legal issues during their lectures” (Participant No. 6/ Nursing Student).

Another participant stated the reasons for the focus of nursing education on the physical and caring dimensions:

“Well, when we see that our graduates have prob- lems in providing quality clinical care, we also have to do more in the field of clinical care.”(Participant No.3/ Faculty Member).

Limited competency of nursing educators Educators play an undeniable role in training competent nurses through institutionalizing beliefs and behaviors. Using proper teaching and behavioral approaches, educa- tors can improve students’ critical thinking skills and pre- pare them to promote justice in health systems. According to the participants, insufficient competency of nursing educators in teaching social justice issues and in- appropriate value perspectives of educators in developing social justice were the main properties of this category.

Table 2 Categories, Subcategories, and Codes Extracted from the Interview Analysis Core Category Subcategories (1) Primary concepts Open Codes

Social justice; a neglected component of academic nursing education

Insufficient educational content

Lack of attention to the issue of social justice in nursing curriculum

Deficiencies in academic courses provided on nursing ethics Deficiencies in academic courses provided on professional rights Insufficient attention to social determinants of health in education Lack of educational courses on culture-oriented care Insufficient attention to the topic of community-based care

Discontinuity in presenting courses on ethical values

Presenting ethics course only for Bachelor’s program Failing to present ethics course for nursing students at all programs Failing to adequately repeat the discussed ethical topics presented to nursing students

Allocating most nursing courses to medical issues and clinical care

Putting unnecessary emphasis on biological health factors Allocating a large number of courses to medical issues Focusing educations on clinical care

Limited competency of educators

Insufficient capabilities of educators in teaching social justice issues

Insufficient knowledge of educators about ethical values Insufficient experience in teaching social justice issues Insufficient experience in social justice due to lack of regular attendance in clinical and social settings

Inappropriate value perspectives of educators in developing social justice

Discussing social justice issues based on personal beliefs Placing little importance on professional ethics Believing that nurses cannot play an effective role in justice promotion

Inappropriate education approaches

Focusing on traditional education approaches

Use of teacher-based approaches in teaching ethical issues Concentration on lecturing approach Rare use of group discussions in teaching ethical issues

Weakness in using affective learning approaches

Ignoring students’ attitudes towards the issue of social justice Paying less attention to changes occurring in students’ behaviors following an educational course Failing to prepare a proper scenario for teaching ethical issues Paying less attention to self-awareness and self- reflection techniques Failing to encourage students to improve their critical thinking skills

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Insufficient capabilities of educators in teaching social justice issues Educators must be equipped with sufficient scientific, practical, and ethical capacities in order to effectively institutionalize the concept of social justice in stu- dents. According to the participants, nursing educa- tors’ insufficient knowledge and experience about social justice issues make it difficult for them to transfer such knowledge to their students. One par- ticipant said,

“When I was a student, I once informed my educa- tor about the unjust patient admission procedure in the surgical department. Yet, my educator recom- mended me to do what the head nurses would say. I did not see the necessary authority in my educator to establish justice” (Participant No. 11/ Clinical Nurse).

Low presence of nursing educators in clinical and community settings is also one of the factors that, ac- cording to the participants, has contributed to this problem.

“Unfortunately, our professors are so involved in education and research, especially to promote them- selves, that they do not have the opportunity to ad- dress social issues.” (Participant No.9/ Faculty Member).

Inappropriate value perspectives of educators in developing social justice The participants highlighted the important role of nurs- ing educators’ ethical perspectives in promoting the quality of education and training qualified nurses who would provide services tailored to the needs of the soci- ety. They also argued that ethical values could help edu- cators establish and expand social justice in health systems. According to the results, most of the educators had undesirable value perspectives on establishing social justice in the area of health. In this respect, participant no. 5 stated,

“When a nurse has no right to make any decisions in a healthcare system, what can I say to the student about social justice?” (Participant No. 5/ Faculty Member).

Or another participant stated:

“My main responsibility is to transfer knowledge in the field of nursing and I think ethics should be taught by educators in medical ethics.” (Participant No.2/ Faculty Member).

Inappropriate education approaches Education approaches are considered an essential part of the educational structure and play a key role in transfer- ring ethical values such as social justice to students. Given the abstract nature of social justice, choosing the best education approach could help educators resolve complicated problems during teaching in order to institutionalize professional values and beliefs. According to the findings, educators adopt poor education ap- proaches to transfer ethical values such as social justice and self-awareness to students. In this regard, focusing on traditional education approaches and using insuffi- cient affective learning approaches were cited by the participants.

Focusing on traditional education approaches Undoubtedly, lecturing is one of the most widely used education approaches; however, this traditional method is very ineffective in teaching abstract concepts such as social justice. According to the participants, educators mostly use lecturing approach to teach social justice is- sues and students are rarely involved in the teaching process. One participant argued that educators mainly use teacher-centered approaches in ethical discussions, stating,

“We (the students) had no active role in the profes- sional ethics class. The educator spoke on relevant topics based on the availed syllabus and provided some examples of clinical ethical issues. However, I think that educators must discuss social justice is- sues with students to help them visualize and understand cases of injustice and discuss appropri- ate reactions in such situations” (Participant No. 13/ Nursing Student).

Another participant stated this:

“The predominant teaching method in professional ethics classes has been lecturing. Every now and then, there was some discussions in between, but it was very rare. Other nursing educators were also using the lecture method when talking about ethics” (Participant No. 7/ Nursing Student).

Using insufficient affective learning approaches The use of affective learning strategies such as reflective activities and simulations leading to emotional responses plays an important role in creating self-reflection and transferring professional knowledge and skills to nursing students. However, based on the participants’ experi- ence, affective learning approaches are not used effect- ively and systematically in teaching ethical issues such as social justice. In this regard, one participant stated,

Habibzadeh et al. BMC Nursing (2021) 20:16 Page 6 of 9

“Since there are too many topics on professional ethics, we (educators) can only convey basic issues to students and it is difficult for us to adopt other learning strategies such as the affective approach” (Participant No. 4/ Faculty Member).

The same participant further stated:

“Now, in the professional ethics class, I do my best to teach the content with a combination of methods. For example, we have formed a group for medical students in the cyberspace (WhatsApp) and asked students to express the issues and questions of clinical ethics. They should raise it there because there is no time in the classroom for these issues. However, we have not performed the same for nurs- ing students yet” (Participant No. 4/ Faculty Member).

Discussion According to the research findings, social justice in a health system is a neglected component of academic nursing education due to factors including insufficient educational content, limited competency of nursing edu- cators, and inappropriate education approaches. These factors were introduced as the main research subcat- egories in this study. Some weaknesses were observed in the content of

nursing curriculum, which is an main factor in promot- ing professional nursing values such as social justice in nursing students. Lack of attention to the …