International Journal of Africa Nursing Sciences 9 (2018) 68–72

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Teaching and practicing nursing code of ethics and values in the Gambia T
⁎
Haddy Tunkara Bah , Jainaba Sey-Sawo
Department of Nursing, University of the Gambia, Gambia
Department of Nursing, University of Benin, Nigeria

A R T I C LE I N FO A B S T R A C T

Keywords: Nursing has a professional autonomy which goes along with responsibility and accountability of nursing actions.
Teaching Nursing practice should always be guided by a code of ethics and values. However, the concepts of nursing ethics
Implementing and values are contained only in the introductory courses of the nursing curriculum in the Gambia. Many nurse
Nursing educators and clinicians are not knowledgeable about the code of ethics of nursing in this country. Lectures on
Ethics
nursing ethics and values are mostly taught by invited guest lecturers in only one or two lecture sessions of the
Values
The Gambia
entire nurse training programme. Teaching nursing ethics and values at clinical level is poor due to the limited
number of trained senior nurses to serve as mentors and supervisors for students and junior nurses. Most of the
Gambian public health facilities do not have standard guidelines on various nursing procedures. Low status of
nurses and conformist style of training nurses hinder the effective implementation of the code of nursing ethics
and values among professional nurses in this country. There is, therefore, inadequate teaching and im-
plementation of the code of nursing ethics and values which calls for urgent reforms in nursing education and
practice to improve the standard and image of the Nursing Profession in the Gambia.

1. Introduction ethics, ethical analysis, and ethical decision-making to produce ethical

Ethics refers to the study of moral judgements based on values,
beliefs and attitudes that an individual or group possesses (Sinclair,
Papps & Marshall, 2016). Ethics in nursing means the set of rules or
principles which guide decision making and behaviour of nurses. Nur-
sing has professional autonomy and nurses are reasonably independent
and self-governing in making decisions in practice. The nurse can in-
dependently initiate decisions without medical orders (American
Society of Registered Nurses, 2007). This has been achieved in nursing
today due to the nursing profession’s ability to build for its members a
high level of academic excellence leading them to a state where they
have the ability to provide specific services and client advocates. Hence,
the autonomy nursing profession comes along with responsibility and
accountability. It is important that this professional autonomy is always
governed by a code of ethics and values.
Individuals who aspire to enter the nursing profession need addi-
tional guidance and education within nursing school curriculum. Yet,
nursing ethics and values are usually taught as part of the introductory
courses in most of the nursing curriculum in the Gambia. This may not
be sufficient to produce a highly competent and ethically oriented
professional nurses. Nurse educators in this country have the opportu-
nity and obligation to guide nursing students in the areas of nursing
practitioners.
The training of nursing professionals on the values and ethics in
nursing should not be limited to the academic institutions only. Nursing
ethics and values should also be learnt at clinical practical areas
through role modelling and supervision by mentors and preceptors who
should be experienced nurses with good moral disposition. Extensive
experiences and supervision from mentors, preceptors and supervisors
are necessary to achieve a considerable nursing competency through
ethics and values orientation. Unfortunately in many developing
countries including the Gambia, there is high attrition rate of senior
trained nurses due to poor working conditions and salaries (Saho, 2011;
WHO, 2010; The Gambia Ministry of Health and Social Welfare, 2009).
There is no formal mentorship programme in the Gambia (Bah, 2016)
and young inexperienced nurses are sometimes posted to clinical areas
without the support of a senior nurse to build their knowledge and skill
competencies on nursing ethics and values.
Throughout the past years, Gambian Nurses were using the
International Council of Nurses (ICN) code of ethics until of recent
when the National Nurses and Midwives Council in collaboration with
the Gambia Nurses and Midwives Association and other stakeholders
developed a national code of ethics in 2014 putting into consideration
the cultural values of the Gambians. However, many nurse educators

⁎
Corresponding author.
E-mail address: htbah@utg.edu.gm (H.T. Bah).

https://doi.org/10.1016/j.ijans.2018.08.005
Received 22 March 2018; Received in revised form 1 August 2018; Accepted 23 August 2018
Available online 24 August 2018
2214-1391/ © 2018 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
H.T. Bah, J. Sey-Sawo
and clinicians are not conversant with this new code of ethics. This has
created a knowledge gap among nurses and nurse educators on the
existing values and ethical principles governing the nursing profession
which can have direct impact on the standard of nursing care in this
country.
2. Teaching nursing ethics and values
Nursing education in the Gambia is provided by two Universities,
Gambia College, School of Enrolled Nurses and School of Enrolled
Community Health Nurses. Bachelor of Science Degrees in Nursing are
provided by the Universities and a postgraduate in Nursing is offered
only by the University of The Gambia. The theoretical foundation of
nursing ethics education is grounded in ethical principles, value for-
mation of the individual, and patterns of knowing. Nursing ethics in
education has immense competition with an already content filled
curriculum (Aydt, 2015). Currently, the concepts of nursing ethics and
values are contained in the introductory courses or as a single course of
the nursing curriculum in The Gambia which is not sufficient for the
students to master the ethical principles of the Nursing Profession.
Principles and concepts of nursing ethics and values should not be
treated as a single course but should be integrated in all nursing courses
in the curriculum. Nursing ethics education integrated throughout a
nursing programme has been praised for its effectiveness (International
Council of Nurses, 2015) and for establishing best ethical framework in
nursing education (Milton, 2004). This is because nursing ethics and
values are relevant in all the nursing disciplines and specialties. It is the
role of the nurse educator to select strategies to creatively integrate
nursing ethics into the curriculum.
Nurses face ethical dilemmas on a daily basis which need experi-
ence, critical thinking, and an ability to evaluate the ethical principles
relating to an existing problem and make the best ethical decision that
helps to solve the problem. Thus, teaching nursing ethics and values
should be practice-based in order to ensure competency on their ap-
plication. Teaching and learning ethical comportment in interpersonal
and relational skills require thoughtfulness, good curriculum and ped-
agogical development and planning as postulated by Benner, Suphen,
Leonard and Day (2010). Unfortunately, nursing ethics and values are
taught in The Gambia’s nursing training institutions mostly using lec-
ture discussions in which the role of the teacher is that of an expert and
that of the student is listening, taking notes, answering and giving re-
sponses when required by the teacher. In addition, lectures on nursing
ethics and values are commonly delivered by invited guests from The
Gambia Nurses and Midwives Council and content is usually covered in
one or two lecture sessions. These guest lecturers are usually not trained
teachers and may not have the required skills for effective teaching of
nursing ethics and values. This inadequate and theory-based teaching of
nursing ethics and values in this country, limits the translation of
nursing ethics from theory to practice thereby creating a gap and dif-
ferent perceptions among nurses in the training institutions and those in
the actual professional situations. Many researchers have found that a
gap between theory and practice in nursing education do exist (Abu
Salah, Aljerjawy & Salama, 2018; Estrada, Socorro, GuanHing & Susan,
2015; Tel Hussein & Osuji, 2017). According to Sawo, Bah & Kanteh,
(2017), in The Gambia, the challenges faced by nursing institutions
include the shortage of faculty members and lack of clinical tutors at
the practical areas due to the brain drain of highly qualified and edu-
cated nurses migrating to countries with higher salaries and better
working conditions. Student nurses are posted to health facilities to be
supervised and assisted by the trained nurses in the clinical areas who
might be too busy to attend to their learning needs thus, leaving a big
theory and practice gap to be filled. Hence, there is an urgent need to
bridge this gap.
Nursing ethics can be effectively taught by a combination of
teaching methods that enhance visualization of the concept scenario
that is being taught and promotes translation of theory to practice.
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International Journal of Africa Nursing Sciences 9 (2018) 68–72
These teaching methods include problem-based learning, group
teaching, role play, modeling, case studies, debates and clinical ex-
perience. Benner et al. (2010) discussed the importance of developing
the individual’s ethical behavior with a focus on modeling the behavior
through “doing, knowing, and being” as they relate to teaching ethics in
the classroom. According to Lin, Lu, Chang and Yang (2010), problem-
based learning (PBL) can enhance the efficacy of teaching nursing
ethics. These authors revealed that students did express increased
feelings of motivated learning and critical thinking when PBL was used.
PBL framework also has the potential to improve self-directed learning,
critical thinking, communication, and ability to work as a team
(Alexander, McDaniel, Baldwin & Money, 2002). Other authors (Garity,
2009; Bijani, Tehranineshat & Torabizadehadd, 2017) recommend
peer-tutored PBL in situations where there is lack of qualified educators
to teach nursing ethics such as in The Gambia. This will give enough
time to nurse educators to provide more in-depth discussion and ap-
plication of what is being taught. Team-Based Learning (TBL) is another
type of teaching and learning nursing ethics and values strategy, which
focuses on small group learning, student preparation and application of
class content (Vanderbilt University Center for Teaching, 2015). Garity
(2009) suggests combining theory and practice using small group dis-
cussion. The use of case studies provides students with the opportunity
to dissect real life situations and develop a deeper understanding of
concepts in nursing ethics education. Lin et al. (2010) identified the
importance of using a combination of case studies, simulation, and
reflection experiences to develop critical analysis skills. Garity (2009)
explored the use of debate in nursing ethics education and found that
debate as a teaching methodology supports students in developing
critical thinking, which is an important component in learning nursing
ethics and values.
Furthermore, codes of nursing ethics and values are continually
being revised and modified to meet the changing needs and values of
the nursing clientele. This calls for lifelong learning of new concepts
and principles of nursing codes of ethics as they are developed. Thus,
the teaching and learning of nursing ethics should not be focused only
in nurse training institutions but also in clinical areas. Experienced
senior nurses should serve as role models and mentors for students and
junior nurses in guiding their development in competency of ethical
decision making and behavior skills in the clinical environment.
However, there is a limited number of trained senior nurses in many
public health facilities in The Gambia due to a high attrition rate among
this category of staff (Saho, 2011; The Gambia Ministry of Health and
Social Welfare, 2009). Under this situation, students and inexperienced
nurses lack role models to translate the theory of ethics and values
learned during training to practice when they encounter real ethical
situations.
The Gambia Code of Ethics for nurses requires that nurses follow the
best practice guidelines to ensure quality of patient care. Yet nursing
care guidelines are scarce in many health facilities in this country. Most
of the health facilities do not provide standard guidelines on the various
nursing procedures and sometimes what is taught in the training in-
stitution cannot be applied at health facility level due to lack of trained
nurses and equipment. For instance, students are taught to always
maintain privacy when caring for patients but at health facility level,
many of them do not have enough screens. Nurses face dilemmas in
applying the code of ethics due to this theory-practice gap. Ethics
learning and application are personal processes that always go with
everyday nursing work. Hence, there is also a need for the development
of a pedagogy that integrates this self-learning experience along with
professional training where ethics is seen as a natural component of
nurses’ work instead of a rule that they should follow as professionals. It
is imperative for nurse educators and clinicians to be at the forefront of
not only establishing an ethical foundation in the nursing curriculum,
but also emulating how one should conduct oneself in professional and
personal environments. It may be considered flawed thinking to expect
students to act with virtue, if those teachings are not also virtuous.
H.T. Bah, J. Sey-Sawo
3. Practicing nursing ethics and values
Florence Nightingale contributed immensely in the advancement of
nursing as an honest and ethical profession that is enjoyed today (Hoyt,
2010). The “Nightingale Pledge” was the first code of ethics for nurses
(American Nurses Association, 2015). The Gambia adopted and mod-
ified the ICN Code of Ethics for Nurses, considering the moral values of
its society. This code of nursing ethics has four principal elements that
outline the standards of ethical conduct. These elements of the nursing
code of ethics are, nurses and the people, nurses and practice, nurses
and the nursing profession, and nurses and co-workers. The first ele-
ment which is on nurses and people states that the nurse’s primary
professional responsibility is to the people requiring nursing care and in
providing care, the nurse should promote an environment in which the
human rights, privacy, values, customs and spiritual beliefs of the in-
dividual, family and community are respected. It continues to state that
the nurse should serve as an advocate for equity and social justice and
demonstrates professional values such as respectfulness, responsive-
ness, compassion, trustworthiness and integrity both within and outside
the nurse’s work place. Ethical principles and professionalism must
guide the relationship between the nurse and the client. However, the
practice of this ethical element sadly seems to elude most nurses in the
Gambia. Apart from consent for surgical operations, most nurses believe
that routine nursing procedures such as vital signs monitoring, bed
making and the like do not need seeking patients’ consent. According to
a media report (Teranga FM Radio, 2014), nurses do not care about the
consent of the clients and may not be nice when communicating with
them and their relatives. In a telephone programme aired over Teranga
FM Radio in the Gambia (2014), on Nurse/patient relationships, dif-
ferent respondents and commentators, most of whom stated that they
had personally experienced aggression from nurses, were of the opinion
that it was somehow a part of nurse training. One of these radio –talk
show programme participants reported that she was shouting for help
while in active labor pain and the respond she received from one of the
midwives in one of the major health centers was “keep quiet, you en-
joyed it while you were putting it there”. One may be quick to say that
they may have encountered quack nurses, but this would be simply
living in denial. Similarly, Sawo, Bah and Kanteh (2017) reported in
their study on workplace violence against nurses in The Gambia, that
nurses at times give their clients the cause to abuse them by making
offensive utterances against patients. If Gambians were more aware of
their rights, many nurses would probably lose their practicing licenses.
The privacy of patients are also compromised in many areas when
giving nursing care. For instance, some labor wards in public facilities
are just like general wards without cubicles or screens for individual
women in labor. Women in this type of labor ward will be seeing the
care given to each of them. Similar finding was reported by Aguerd,
Chaouqui, Haddadi and Tounssi (2001) in Morocco, in which some of
the problems that hindered the provision of quality nursing care were
shortage of necessary materials, lack of dialogue between the nurse and
the patient, nurses not respecting the privacy norms when dressing and
collecting urine samples and negligence of rules in the execution of care
in the area of communication, information and well-being of the pa-
tient. Studies done in Nigeria on perception of the nursing profession
(John, 2007; Mohammed, 2008) also portrayed the stereotypical ne-
gative image the public has about nurses.
This negative public image of nurses in African countries is in
contrast with the yearly poll in America that tracks public opinions of
various professions and nurses were found to be the most ethical and
honest profession for the 11th year, with 81 percent of respondents in a
Gallup survey ranking them as “very high” or “high”. Similar surveys in
Britain yielded the same result, where nurses were rated number one.
Caring promotes health more than does curing making it the core
aspect of nursing activities and is the most important aspect that pa-
tients value and expect. Patients’ perceptions of having a caring nurse
seem proportional to their expectations of quality nursing care. Sadly,
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International Journal of Africa Nursing Sciences 9 (2018) 68–72
many nurses are not conscious of the ethical principles guiding the
nurse/patient relationship neither do they care about the damage such
unprofessional conduct does to the profession. In a study of the ethical
issues encountered by nurses, Ulrich et al. (2010) found that more than
60% of nurses identified patient’s rights, autonomy, and informed
consent as frequent or daily problems. Other common issues included
advanced care planning, surrogate decision making, end-of-life decision
making, and breeches of confidentiality (Ulrich et al., 2007). Pavlish,
Brown-Saltzman, Hersh, Shirk and Rounkle (2011) explored the ethical
issues, actions and regrets of nurses and found that unnecessary pain
and suffering, difficult decision making, and inattention to patient au-
tonomy were problematic.
The second element of the code of ethics deals with how the nurse
should perform the nursing job. It highlights that the nurse carries
personal responsibility and accountability for nursing practice, and for
maintaining competence by continual learning and should strive to
foster and maintain a practice culture promoting ethical behavior and
open dialogue. However, due to the previous government of The
Gambia reluctance to build a national University, a critical mass of
Gambian nurses hold the registered and enrolled nurse certificates and
need more academic qualifications for wider academic career progres-
sion. The Bachelor and Master of Science Degrees in Nursing
Programmes of the University of The Gambia were inaugurated in 1999
and 2009 respectively. This has created delay and few opportunities for
nurses to earn higher degrees in Nursing. Unlike other health practi-
tioners, nurses were slow in embracing university education. The
mandatory continual education as a requirement for yearly renewal of
nurses’ license is not enforced by the Gambia Nurses and Midwives
Council which serves as the regulatory body. This reluctance of nurses
to enroll in university programmes coupled with lapses in the license
renewal regulation, have limited nurses’ opportunities to progress
academically thereby breeding lack of knowledge on the principles of
the nursing ethics and values. This invariably slowed down the rate of
improvement of quality of nursing care rendered in this country.
Educational level affects proper understanding and utilization of the
most current concepts in nursing such as nursing ethics, nursing pro-
cess, evidence- based practice, best practices, advanced nursing practice
and reflective practice which are designed to improve quality of care
rendered by nurses globally. All these factors impact negatively on the
implementation of the second element and principles of the code of
ethics and values by nurses in The Gambia.
The third element of the code of ethics of nursing in The Gambia is
on developing and maintaining the integrity of the nursing profession.
This element orders that the nurse should assume the major role in
determining and implementing acceptable standards of clinical nursing
practice, management, research and education and should be active in
developing a core of research-based professional knowledge that sup-
ports evidence-based practice. The nurse, acting through the profes-
sional organization, participates in creating a positive practice en-
vironment and maintaining safe, equitable social and economic
working conditions in nursing. However, problem of gender margin-
alization is very pronounced in nursing because a large majority of
nurses are females. According to Ojo (2010), there is low voice of
nursing at management levels of the health care delivery system
thereby making the introduction and implementation of new and ben-
eficial ideas, methods, strategies in nursing care difficult and as a result
impeding nursing development and quality of care rendered. The pro-
fessional association of nurses – National Association of Gambian
Nurses and Midwives (NAGNM)- focuses more on the welfare of its
members at the expense of the development, maintenance and mon-
itoring of nursing ethics application and practice standards.
The fourth element of the code of ethics describes how the nurse
should relate with co-workers. The nurse sustains a collaborative and
respectful relationship with co-workers in nursing and other fields but
should also take appropriate action to safeguard individuals, families
and communities when their health is endangered by a co-worker or
H.T. Bah, J. Sey-Sawo
any other person. Away from the nurse/patient relationship, pro-
fessionalism is conspicuously absent in the relationship between nurses
and other professionals, and most worryingly in the training of nurses.
Societal perceptions of nursing as an occupation which is dependent on
medicine marginalizes the nurse as a vital medical or para-medical
professional (Ojo, 2010). In addition, a considerable percentage of
nurses are still trained in the schools of nursing that promote complete
subservience to the medical doctors. Give treatment as ordered by the
doctor is a common message for nursing students in these training in-
stitutions. In their analysis of the moral habitability of the nursing work
environment, Peter, Macfarlane and O’Brien-Pallas (2004) found evi-
dence of oppressive environments, moral suffering, and unclear, over-
whelming role expectations. Every profession has a culture, an identity,
a mode of behavior and a common ideology. This ideology is engraved
and forced into the minds of the students of that profession, to the
extent that the ideology becomes their identity, defines their behavior
and mode of action. Nurses are trained to be ‘conformists’ and they
enter the workforce with a ‘slave mentality’, unwilling and unable to
stand up to other professionals who have been ‘radicalized’ from the
university. Nurses are ready to do or accept whatever is thrown at them.
Even when they become irritated, they only complain in secret, unable
to fight for their rights. In turn, these nurses may direct their inbuilt
anger and frustration towards their younger colleagues or students and
train them exactly the way they were trained. Thus another generation
of ‘conformists’ is born. The situation is not any better in the civil
service where the senior nursing officers have a way of demoralizing
their subordinates. Some go as far as putting their nurses down before
other professionals. They can neither stand up for nor stick out their
necks for a junior colleague. Therefore, to ensure that nurses are able to
take appropriate action to safeguard individuals, families and commu-
nities when their health is endangered by a co-worker or any other
person as enshrined in the fourth element of the code of ethics, the
mode of training nurses should be radically changed. Nursing is a
profession in its own right and should not be subject to the control of
another profession. Nursing has its own body of knowledge and pro-
fessional standards and nurses must do everything in their power to
defend the profession and protect its image. This ideology must be in-
culcated from the first day of training of each nurse. Nurse educators,
practitioners and leaders should train young nurses to be reformists
instead of conformists nurses. Reformist nurses will have the drive to
challenge the ‘status quo’, break old boundaries, set new landmarks and
uphold the ethics of the profession.
4. Conclusion
Nursing ethics in education has immense competition with already
content filled nursing programmes. The concepts of nursing ethics and
values are contained only in the introductory courses of the nursing
curriculum in the Gambia which is not sufficient for the students to
master the ethical principles of the Nursing Profession. Many nurse
educators and clinicians are not conversant with the nursing code of
ethics. Lectures on nursing ethics and values are mostly taught by in-
vited guest lecturers using the lecture discussion teaching method and
are usually covered in only one or two lecture sessions. Teaching nur-
sing ethics and values at clinical level is poor due to the limited number
of trained senior nurses to serve as mentors and supervisors for students
and junior nurses. Most of the health facilities do not provide standard
guidelines on the various nursing procedures and sometimes what is
taught in the training institution cannot be applied at health facility
level due to lack of trained nurses and equipment. Low status and
conformist style of training nurses hinder the effective implementation
of the code of nursing ethics and values among professional nurses in
the Gambia.
In conclusion, there is inadequate teaching and implementation of
the code of ethics and values in nursing profession which can have a
negative impact on the quality of nursing care and result in increased
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International Journal of Africa Nursing Sciences 9 (2018) 68–72
risk for legal litigation of nurses in the Gambia.
5. Recommendations
In order to improve the level of teaching and application of nursing
ethics and values in the Gambia, the following recommendations are
advanced for consideration:
• The nursing curricular of nurse training institutions in the Gambia
should be revised in order to creatively integrate nursing ethics and
values in all the courses.
• Nurse educators should be required to develop the skills needed to
teach nursing ethics and values through professional development
training.
• Combinations of teaching methods that promote application of the
concepts and principles of the code of ethics should be used
throughout the nurse training programmes.
• It is essential that nursing licensure regulations should clearly define
the requirements of ethics education within a nursing programme.
• More senior nurses need to be trained on nursing ethics and values
and should be retained to serve as mentors and supervisors for
students and junior nurses in the clinical areas.
• Collaborative training of nurse educators and clinicians on the
principles of nursing ethics and values should be enforced in order
to bridge the theory- practice gap.
• Standard guidelines should be developed and made accessible to all
nurses to guide nursing actions.
• The style of training nurses in the Gambia should be revolutionized
in order to breed ‘reformists’ instead of ‘conformists’ nurses that can
challenge the ‘status quo’, break old boundaries, set new landmarks
and uphold the ethics of the profession.
When these are achieved, it is expected that teaching and im-
plementation of a Nursing Code of Ethics and Values towards pro-
moting reforms and standards in the Nursing Profession in The Gambia
will not only be enhanced but also assured.
6. Conflict of interest
The authors are hereby declaring that there is not conflict of interest
in the article submitted and no funding was received from anybody
during the preparation and submission of the article.
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