title: Ethical violations in the clinical setting: the hidden curriculum learning experience of Pakistani nurses.
abstract: BACKGROUND
  The importance of the hidden curriculum is recognised as a practical training ground for the absorption of medical ethics by healthcare professionals. Pakistan's healthcare sector is hampered by the exclusion of ethics from medical and nursing education curricula and the absence of monitoring of ethical violations in the clinical setting. Nurses have significant knowledge of the hidden curriculum taught during clinical practice, due to long working hours in the clinic and front-line interaction with patients and other practitioners.
  
  
  METHODS
  The means of inquiry for this study was qualitative, with 20 interviews and four focus group discussions used to identify nurses' clinical experiences of ethical violations. Content analysis was used to discover sub-categories of ethical violations, as perceived by nurses, within four pre-defined categories of nursing codes of ethics: 1) professional guidelines and integrity, 2) patient informed consent, 3) patient rights, and 4) co-worker coordination for competency, learning and patient safety.
  
  
  RESULTS
  Ten sub-categories of ethical violations were found: nursing students being used as adjunct staff, nurses having to face frequent violence in the hospital setting, patient reluctance to receive treatment from nurses, the near-absence of consent taken from patients for most non-surgical medical procedures, the absence of patient consent taking for receiving treatment from student nurses, the practice of patient discrimination on the basis of a patient's socio-demographic status, nurses withdrawing treatment out of fear for their safety, a non-learning culture and, finally, blame-shifting and non-reportage of errors.
  
  
  CONCLUSIONS
  Immediate and urgent attention is required to reduce ethical violations in the healthcare sector in Pakistan through collaborative efforts by the government, the healthcare sector, and ethics regulatory bodies. Also, changes in socio-cultural values in hospital organisation, public awareness of how to conveniently report ethical violations by practitioners and public perceptions of nurse identity are needed.
authors.affiliation: Institute of Social and Cultural Studies, University of the Punjab, P.O. Box 54590, Lahore, Pakistan. sararizvijafree@gmail.com.|Forman Christian College, Sociology Department, University of the Punjab, 21 FCC Maratib Ali Road, 54000, Gulberg, Lahore, Pakistan. sararizvijafree@gmail.com.
authors.forename: Sara Rizvi
authors.initials: SR
authors.lastname: Jafree
authors.affiliation: Institute of Social and Cultural Studies, University of the Punjab, P.O. Box 54590, Lahore, Pakistan. rubeena499@hotmail.com.
authors.forename: Rubeena
authors.initials: R
authors.lastname: Zakar
authors.affiliation: School of Public Health, Department of Public Health Medicine, Bielefeld University, P.O. Box 100 131, 33501, Bielefeld, Germany. f.fischer@uni-bielefeld.de.
authors.forename: Florian
authors.initials: F
authors.lastname: Fischer
authors.affiliation: Institute of Social and Cultural Studies, University of the Punjab, P.O. Box 54590, Lahore, Pakistan. mzzakir@yahoo.com.
authors.forename: Muhammad Zakria
authors.initials: MZ
authors.lastname: Zakar
mesh_terms: D001291:Attitude of Health Personnel; D032781:Codes of Ethics; D003479:Curriculum; D003906:Developing Countries; D004992:Ethics, Medical; D004993:Ethics, Nursing; D017144:Focus Groups; D006761:Hospitals; D006801:Humans; D007258:Informed Consent; D007858:Learning; D009014:Morals; D024802:Nurse's Role; D009726:Nurses; D010154:Pakistan; D028701:Patient Rights; D036301:Qualitative Research