Over the past couple of weeks I have been giving a lot of thought to the issues of integrity that Carey wrote about last week. Personal integrity is a challenge that increasingly affects 
not only academics, but also practice and research. And, this is at the core of what we are seeking to address in the Nurse Manifest Project. So this deserves lots of attention, and I hope that folks will get involved in some of this discussion!
In this post I want to lay some groundwork for things I will write about over the next several days and weeks — ways that we can work toward change, and interrupt ways that we are (often unknowingly) complicit.
Years ago I read Nel Noddings wonderful book “Women and Evil,” which has provided a grounding for me in thinking through issues like this one. (You can “look inside” this book on Amazon.com!). Noddings challenges the notions that western cultures have acquired from the judeo-christian perspective on evil — those ideas alone are well worth getting into her book.
But the ideas from her work that are most pertinent to our discussion about integrity has to do with her alternative view of “evil.” Noddings defines “evil” as anything that harms someone. She bases her view on the premise that evil does exist, and that as humans we are all both perpetrators and victims. We are also all both perpetrators and beneficiaries of the best intentions of all humans — the things we do that nurture and sustain one another. But where evil is concerned, she conceptualized three kinds of evil, each calling for a different kind of “ethical” response.
The first is natural evil – things that happen that are beyond any person’s control – earthquakes, tsunamis, tornados, as recent examples. Any of us can be victimized, and the response that is required from all of us is to help those who are affected with as much compassion and caring as is humanly possible.
The second is cultural evil – things that are ingrained in the culture and that do, or can do great harm to people – racism, heterosexism, mysogyny, classism, to name a few. Aside from these “isms,” there are also practices that are institutionalized in governments and organizations that sustain injustice and harm, but that go unchallenged because of the assumption that this is the way things are. All of us are victims or perpetrators in any number of cultural evils, even if we do not want to be. The ethical response to this kind of evil is to recognize it, and participate as little as possible, and to help those who are victimized by any form of cultural evil. I will come back to this form of evil because it is central to what I want to discuss.
The third form of evil is intentional – the things that people do intentionally to harm others. Obviously we are all capable of doing these kinds of things but ethical comportment calls forth our highest intentions not to do so; as a culture, we are all obligated to stop perpetrators and to insist on the kinds of social interventions that call forth justice for those who commit intentional crimes, and to care for those who are victims.
When I was an undergraduate student at the University of Hawaii, we were taught that we were to become change agents … but in fact, little has changed where personal integrity is concerned since those days. And in fact, some would claim that the situation has become worse. Regardless, it is time for those of us who are thinking about these issues to seriously consider constructive alternatives in the direction of change and to become real change agents.
We need some very creative thinking about how we can participate as little as possible in the dynamics of the cultural evils of things like cheating, writing for hire, etc. I believe that those of us who teach actually perpetrate these practices by the traditional practices that we engage in day in and day out. For example, when we give exams, especially exams that are proctored and administered under great stress in a highly competitive environment, we are setting up the perfect ground for which to inspire students to engage in practices that we call “cheating.” If we step back from the situation, we might instead view many of their approaches to dealing with the situation as creative, clever, and sometimes even wise! What we are teaching in this situation is not the content of the exam, but rather, ways of coping with a highly stressful environment so that success is more probably than failure.
So what are we to do? The first thing that I think we need to examine is “what am I really doing in this situation?” “Are my actions congruent with my intentions [to teach content, to promote learning, to nurture a stable and productive staff]?” “What are the unintended consequences of my actions?”
I do not have answers, but I do have suggestions and I hope that some of my ideas will prompt others to share yours as well. I will share specific suggestions in the days to come. My suggestions come from ideas that others have developed and some that I have developed and used (that have also been successful — I won’t mention the ones that have flopped!). So stay tuned … this is enough for today!
NurseManifest 
Thanks for continuing the discussion, Peggy. I am newly responsible for overseeing and teaching an entirely online program. My new academic institution has historically offered in-person (which I refer to as “live” classes, although it does not imply that online classes are “dead”) courses. As a result, this is a process of trail-blazing in many, if not most, areas. One area of interest is academic integrity.
I have been teaching in two different online environments for the past two years. I have found the level of discussion that is possible online can actually far outshine that in the classroom. This is because students who would feel uncomfortable speaking up in a live class, are often (usually) inspired to contribute online. Students and faculty, alike, can take their time responding to questions and posts (look things up, talk or think it over first, etc.). It has definitely helped me learn how to temper my own responses – even on hot button areas!
The papers that were submitted in one of my online courses were all run through a plagiarism checker. This seemed to work well in terms of catching plagiarism (intentional or not), but now that I really think about academic honesty, I realize this does not help us (faculty) know who wrote the paper. I am very curious to hear your ideas and the ideas of others as far as minimizing (or eliminating) “cheating” in academics. Although I consider myself an absolute novice in the teaching world, I feel that the level of class discussion does contribute to learning and a student’s ability to demonstrate what they know. Then again, how do I know it’s really the student posting in the discussion?
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Peggy, some great thoughts here. I think the idea of cultural evil relates well to Riane Eisler’s work on Partnership versus Dominator social systems.
Unfortunately most academic environments are part of the greater social system where a hierarchial “dominator” approach reigns. In this sort of system in academia, the students are not supported in learning (and by learning I mean transformative learning, where people actually learn, change, grow, evolve) so much as oppressed toward achieving certain measurable outcomes as demonstrated by their ability to pass tests similar to what is expected by the national nursing licensure body. I actually think this sort of “learning” environment leads to nursing students entering the profession already heavily stressed, dis-empowered, and discouraged. Their unhealthy behaviors are often evident, yet we offer them little to grow in healthy ways. It’s almost like a socialization toward de-evolution versus toward growth, empowerment, and evolution to higher levels of knowing and being. This sort of learning environment may also be supported or even required by the governing accrediting agencies and state BRN’s, even as their remains a public call for transforming how we educate nurses. It has been clearly demonstrated that critical thinking skills decline during pre-licensure educational processes, yet we in general continue on with the same old approaches.
Of course, I know there are exceptions to this approach in nursing education, but having taught for about a dozen schools of nursing from associate to graduate level, in both traditional and online settings, I feel comfortable stating that this Dominator social system remains in place. It is often the cheaters and manipulators of the system that excel in these environments.
In some respects, we have been socialized into thinking that change is difficult and it’s easier to just go with the norms and carry on the traditional modalities in our academic environments. The system keeps us stressed out, tired, and wired; if we are not taking care of ourselves, we may not be able to perceive how we can facilitate change in a meaningful way. Little emphasis is placed on quality of teaching and little recognition paid toward excellent teachers who are willing to try new modalities. Incompetence is sometimes accepted, as is domination over students. We don’t want to hurt feelings or have anybody out of a job, so we turn the blind eye toward it or feel we can do nothing to help people grow and change in their abilities. Release time to create new approaches is hard to come by, as is mentoring and support to do so. We may turn toward ineffective ways of coping just as our students do.
It may sound cliche, but the real change has to start with each and every individual. As educators we need to be working on creating caring environments for our students, and in order to do this, we have to be practicing self-care. We need to name our professional issues, and begin dialogue toward creating these environments and culture of care. If you have ever tried this in a traditional environment, you likely know the resistance you are met with!
I am currently implementing a caring-holistic-integral educational experience for RN- BSN students, and I am also “housed” with a very traditional ASN program. I can see changes happening, but it is a slow process. What keeps me from giving up is seeing the students’ empowerment and growth. I am hoping by creating a space and energetic field for change, change can be fostered. If the students and faculty alike are cared for, then I believe academic integrity can also begin to be an expected norm, and if students have the opportunity to demonstrate their learning via a variety of modalities, then the pressure may be off for them to cheat in order to succeed.
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Aah academic dishonesty. One of my favorite topics.
Before I entered nursing school I had earned a bachelors and two masters degrees. I had never encountered cheating on the level it occurred in my BSN program. 20-30 years of old exams, recycled class projects, and papers, slightly improved and updated by the latest submitter but an incredible advantage compared with the small number of us who had to do all our projects, papers, and tests on our own.
I’d ride in a campus shuttle on the way to a test with people who said that they had been out all night drinking until 3 AM and then a couple of hours later they were complaining about only getting a 96 or 98 on the exam. Having spent days studying for the same exam and knowing that the test questions themselves were so poorly worded that multiple answers were correct, I found such behavior truly offensive.
But the worst of it was that the faculty didn’t even try to prevent it. On test reviews teachers would say that nobody could take notes and yet there were students feverishly writing and recording test answers and explanations to pass on to some, but not all of next year’s class. When I suggested to faculty that the only fair way to manage such a situation would be to put all old tests and papers in the library, so there would be no unfair advantage for some students who already had such access I was told that would be encouraging cheating!
In once case, moments before a big exam, I noticed a group of students clustered together looking at a piece of paper. It was an exam from the previous summer session. Uncharacteristically, i walked over and was allowed to see it. In less than a minute I scanned the entire exam. Of 51 odd questions on my exam, 21 were from the Summer exam. As was my usual practice I completed the 2 hour exam in about 12 minutes.
I immediately went to see the teacher to explain what had happened. I convinced her to give me the current exam (I had turned mine in as required which sort of makes one wonder how the prior Summer exam was available to students at all). I ticked off the questions I thought were from the Summer exam and those that I thought were not. I got a perfect score on that activity. The teacher reviewed the other exam and verified that all the exam questions I had picked were from an earlier exam and none of the ones I had not designated were.
My score on the Summer questions – 100%. My score on the non-Summer questions 67% – probably the worst score I ever got on any nursing school exam. 1 minute of scanning a single prior test was the difference between a perfect exam score and a D. A 33 point advantage.
Being a mathematician, I put some thinking into it and decided that there was a good chance that an exponential decay model would properly account for the distribution of exam questions recycled from past exams: 40% from the first prior exam, 16% from the second prior exam, 6.4% from the third prior exam, and perhaps 3 – 5% total from all prior exams, or about 2/3 of all current exam questions being readily accessible to some, but not all, students.
So, I figured that throughout my BSN program career if I had been a modestly accomplished cheater I would have had access to 2/3 of all the exam questions I would actually see. If, as would be reasonable, I got 100% on the known questions and at least 2/3 on the 1/3 of the exam questions from other sources, my average score would have been at least 89 out of 100.
Don’t even get me started on the questions with two correct answers where 80% of the students got what the teacher thought was the only right answer, because they knew what answer the teacher thought was correct from past exams. No greater thrill than trying to engage a teacher in a discussion of how there are actually two correct answers, a matter of logic rather than pure data, and having the cheaters complain that the answer is correct and the teacher come up with a great euphemisms like: Well, you should have chosen the best answer of the two, as though there was a best answer.
So, I graduated with a B average and the biggest insult, when I wanted to enter the graduate program, was being told I didn’t have a high enough average to enter their program while the cheating students were welcomed.
Interesting tidbit. About a dozen “honors students” failed our proctored NCLEX prep test in our senior year. How did the faculty and administration handle what should have been a very troubling revelation? The honors students who failed were allowed to repeat the NCLEX prep test in a non-proctored setting. They literally sat around with open books, asking each other the correct answers, and repeatedly taking the test until they passed. Then, when they passed the exam, they took the printout to the teacher, two floors away, who was “overseeing” the re-examination process.
One student, who I knew had been cheating all along kept taking the test until (s)he scored 100%. I’d be thinking – if I had a student who failed a proctored examination and then got 100% in a non-proctored exam I’d be just the slightest bit skeptical that something was amiss. Her/His reward for getting 100% on the NCLEX prep exam? Full scholarship for a PhD. Instead of scratching their heads about how someone goes from a failing grade to a perfect grade in a few days, an obvious cheater got rewarded by with a full ride for a PhD.
So, what’s my bottom line? The actual exams themselves weren’t particularly dehumanizing or demeaning. We need all of our graduates to have core skills. I don’t want someone giving me insulin who doesn’t know the difference between nph and regular, or the difference between a 1 cc and 10 cc syringe.
What was really hard, from about the second week, til the end of my BSN program, was knowing that a majority of my classmates were cheating on every evaluative procedure and that the faculty and administration encouraged and supported it.
There are institutional cultures beyond the classroom that favor some students and disadvantage other students. Nursing is a stressful profession – some of it inherent to nursing, some of it is a dysfunctional culture with all the hallmarks of Paulo Freire’s work. But as educators, we all have a profound duty to make sure that students are being fairly evaluated, that nobody has an unfair advantage, and we ought to take steps, however onerous it may be for those who need to make up tests, that no set of students have access to old classroom exams, papers, and assignments that others do not have available.
No matter how dehumanizing an evaluative process may be – it is ever the more onerous and dehumanizing if the oppression is not equally borne.
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What an amazing account of your experience!! Thanks so much for sharing this. I have been mulling around my next post on this blog about how to shift from being complicit in the cheating machine, to working from a place of “bringing out the best”, ethically, in everyone involved. Your comment inspires me to get with it! Peggy
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As your work has, and continues, to inspire me.
On different, though not unrelated tack, I think we might also want address the issue of informed nursing practice and its cultural and financial embeddedness.
As you probably noticed I did release the first edition of “Standard Errors: Our failing health care (finance) systems and how to fix them” suitably retitled to reduce the pejorative nature of the original title. With all its worts, inadequacies, omissions, and flaws it is available at
http://www.afn.org/~mathstat/
Releasing it, particularly on the shared birthday of Florence Nightingale and Martha E Rogers was a matter of leaping off a cliff. I am sure that there will be some who will view with nothing but a critical eye, questioning my rigor, analysis, and conclusions. Others will hopefully balance that with a more appreciative, evolutionary glance.
In the book I show that the dominant health care finance mechanisms – all based on some form of capitation, put providers in undocumented roles as their patient’s insurers. There is, I believe, no greater evil in our health care system.
As their patients insurers, from the freshest CNA to the most sophisticated and experienced caregiver is compelled to participate in a health care service delivery that provides less care than required. ARNPs, TNs, MDs have no real choice to buck this system. One might argue that given this we might not choose to see them as complicit – in the same sense that it would hardly be appropriate to hold the nurses in a publicly funded health center to be complicit because they go home when they day is done.
But acting as patient insurers is a fundamentally different form of complicity for at least two reasons:
1. It is not disclosed to patients
2. The providers perversely benefit from their complicity. ARNPs, TNs, MDs who willingly accept the limitations imposed retain employment, get promoted, earn performance bonuses. and achieve other forms of personal and professional rewards while the needs of their patients go unmet.
Examples are always helpful for some. So, let’s consider an example. As a patient’s provider/insurer, a provider has two different conflicted roles:
The provider alerts the patient to the existence of a need for service: Diagnosis
The provider provides, or fails to provide the service: Treatment
So, if a patient shows up at the office, hospital, long term care facility or has a home health visit and the provider “knows” the patient requires 10 different diagnoses and treatments, but only provides 3-4, delaying or denying the 6-7 other diagnoses and treatments to what is a more convenient time for the provider, the provider has solidified the core operating parameters of the capitation system, reduced their current cash outflows, and accomplished this be failing to fulfill both their clinical and financial obligations to the patient.
There may, of course, be many other ways providers fail their patients. Personal integrity is certainly important. But no health care provider can sustain a practice based on personal integrity when the system itself is so flawed at its core.
We can all recognize and encourage personal examples of personal integrity, but if we fail to recognize that the system supports only rare, random acts of integrity we may be distracted from the systemic reforms that are needed.
But understanding the nature of our flawed financial system and how it must impact the informed practice of nursing is no easy matter. So much misinformation is advanced that suggests that ARNPs, TNs, MDs can surmount the challenges of our finance mechanisms, when, in the aggregate, they cannot.
We can do a lot worse than focusing on the financial context of nursing care, as I have no doubt Florence Nightingale would, were she here today, and strive to bring to the light of day, for patients and nurses, what is actually happening in their most intimate encounters.
It was with that idea in mind that I took that leap off the cliff by releasing the book – because continued silence was too great an ethical failing.
I may well not be the voice that will deliver the final polished form of Professional Caregiver Insurance Risk, but somewhere out there that person exists and they are missing the link that Standard Errors can provide.
🙂
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