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. Paying 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 insufficient educational content, limited competency of nursing educators, and inappropriate education approaches.
1. 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 significant 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 ethical values, and allocating most of the nursing courses to medical issues and clinical care.
1.1 Lack of Attention to Social Justice in Nursing Curriculum
Social justice is a core nursing value which plays a significant 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 determinants 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 beliefs and broadened my perspective” (Participant No. 10/Clinical Nurse).
1.2 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 presented 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 importance of a value, they will realize its importance and the value will be institutionalized in them. We partially studied professional values and social justice issues in the fourth semester of our undergraduate courses; however, no similar course was provided for us afterwards during the Master’s program” (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 the hidden curriculum has been more prominent."(Participant No.1/Faculty Member)
1.3 Allocating Most of Nursing Courses to Medical Issues and Clinical Care
Diseases and clinical care are among the most fundamental 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 existing nursing curriculum focuses mainly on transferring 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 problems in providing quality clinical care, we also have to do more in the field of clinical care."(Participant No.3/ Faculty Member)
2. 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, educators can improve students’ critical thinking skills and prepare them to promote justice in health systems. According to the participants, insufficient competency of nursing educators in teaching social justice issues and inappropriate value perspectives of educators in developing social justice were the main properties of this category.
2.1 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 students. According to the participants, nursing educators’ insufficient knowledge and experience about social justice issues make it difficult for them to transfer such knowledge to their students. One participant said,
“When I was a student, I once informed my educator about the unjust patient admission procedure in the surgical department. Yet, my educator recommended 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, according to the participants, has contributed to this problem
"Unfortunately, our professors are so involved in education and research, especially to promote themselves, that they do not have the opportunity to address social issues." (Participant No.9/ Faculty Member)
2.2 Inappropriate Value Perspectives of Educators in Developing Social Justice
The participants highlighted the important role of nursing educators’ ethical perspectives in promoting the quality of education and training qualified nurses who would provide services tailored to the needs of the society. They also argued that ethical values could help educators 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)
3. Inappropriate Education Approaches
Education approaches are considered an essential part of the educational structure and play a key role in transferring 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 approaches to transfer ethical values such as social justice and self-awareness to students. In this regard, focusing on traditional education approaches and using insufficient affective learning approaches were cited by the participants.
3.1 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 issues 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 professional 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 issues with students to help them visualize and understand cases of injustice and discuss appropriate 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).
3.2 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’ experience, affective learning approaches are not used effectively and systematically in teaching ethical issues such as social justice. In this regard, one participant stated,
“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 nursing students yet" (Participant No. 4/ Faculty Member).