Promoting dignity in nursing education – How educators manoeuvre to promote dignity

Background: Dignity is a core value in nursing. One of the objectives in nursing education is to promote dignity and contribute to the students' discovery of this value. Research shows that dignity in nursing education is threatened, due to lack of attention and an increasing problem with incivility. Purpose: The study aims to explore how nursing educators experience their contribution in promoting dignity in nursing education. Method: Five focus group conversations were conducted with nursing educators, and Gadamer's philosophical hermeneutics was chosen as the study's scientific theoretical approach. Findings: The educators experienced that they promoted dignity by safeguarding the dignity in the nursing profession in general, by promoting the dignity of the nursing students in particular, and through promoting dignity in challenging situations. Conclusion: The study emphasizes the importance of promoting dignity in nursing education. It found that the nursing educators promoted dignity by safeguarding the dignity of both the nursing profession and the nursing students, and by manoeuvring judiciously between these two when there was disharmony between them. By manoeuvring challenging situations using discretion, the ethical demand will be given room. Dignity can then be fulfilled between people in harmony with professional, social and cultural norms, and in that way promote dignity in nursing education.


Introduction
Dignity is a core value in nursing and is described as the very cornerstone of nursing practice (Condon & Hegge, 2011;Gallagher et al., 2008;Horton et al., 2007).The basis for all nursing care must be respect for people's dignity and dignity as value must be demonstrated in all stages of the nursing profession, also in nursing education (International Council of Nurses, 2021).Nursing education is the foundation of the nursing profession (Booth et al., 2016), and aims to prepare nursing students to practice caring and professionally responsible nursing (Forskrift om nasjonal retningslinje for sykepleierutdanning, 2019).An essential part of the education program is to give the students an ethical education, which ensures that ethical values, such as dignity, are promoted (Kalb & O'Conner-Von, 2007;NOU 2020NOU : 2, 2020)).This ethical education must be established by creating an environment where dignity is recognized, respected, maintained and protected (International Council of Nurses, 2021).This study aims to explore how dignity is experienced and promoted in nursing education.The study is part of a larger research project where nursing students' experiences with dignity have also been explored.It therefore seems important to gain insight into the nursing educators' perspective on dignity in education, as well.
It is a general belief that dignity means to possess an inherent value and worth (Gallagher et al., 2008).Dignity is described as a value, but also as a human need, and as a competence or skill.Dignity can be both experienced and conveyed (Edlund, 2002).In order for nursing students to be enabled to safeguard dignity in future encounters with patients, it is crucial that students discover the importance of dignity in education (Stikholmen et al., 2022a).Experiences of dignity may help to recognize and promote the dignity of others (Gallagher, 2004;Munoz et al., 2017).Dignity in education may promote pride, integrity and hope, and strengthen coping skills, well-being and self-confidence (Franco et al., 2021).Increased attention to dignity in nursing education may also improve professional development and formation of students (Shaw & Degazon, 2008).It is therefore important to explore how dignity is safeguarded in education.It is particularly important to learn how the educators experience this, as they play a decisive role in creating a culture that facilitates learning and promotes dignity (Clark & Springer, 2010).
Previous research on how dignity is promoted is linked to patients' dignity (Baillie, 2009;Caspari et al., 2013).Nevertheless, the elements highlighted in this research can be of importance to dignity in education.This applies in particular to findings that can be transferred to all human institutions and relationships.The research shows the importance of the influence of the environment and culture.For example, external conditions such as which frameworks and systems exist, and internal conditions such as which values and individual competence is prevailing (Baillie et al., 2009;Haddock, 1996;Manookian et al., 2014;Woolhead et al., 2006).Another prominent element that promotes dignity is how individuals are looked after in a relationship.Here, the importance of autonomy, right of expression, individuality and respect for rights is emphasized (Baillie et al., 2009;Caspari et al., 2013;Haddock, 1996;Manookian et al., 2014;Walsh & Kowanko, 2002;Woolhead et al., 2004).The research also shows that it is crucial to be seen, respected, listened to and given time (Caspari et al., 2013;Hall & Høy, 2012;Walsh & Kowanko, 2002).
In general, there is a demand for research that can provide a deeper understanding of dignity in nursing education (Franco et al., 2021).Research shows that dignity in nursing education may be under threat.Dignity is often de-prioritized and the findings challenge nursing education to prioritize dignity and value issues to a greater extent (Buchanan, 2016;Condon & Hegge, 2011;Franco et al., 2021;Nåden & Eriksson, 2004).Research also shows a growing problem with incivility in education, which is identified as a threat to dignity.Disruptive behaviour, dishonesty, bullying and downgrading of others are incidents that in various ways have a negative effect on the learning environment (Clark, 2017;Clark & Springer, 2007;Eka & Chambers, 2019).Studies show that students have experienced this in education (Bjorklund & Rehling, 2009;Del Prato, 2013;Masoumpoor et al., 2017;Mott, 2013).Nursing students' experiences with dignity in education in particular have also been highlighted (Stikholmen et al., 2022b;Tehranineshat & Torabizadeh, 2022), but it has not been possible to find studies that deal with educators' experiences of dignity or how it is promoted in education.We therefore found it important and necessary to perform this study.
The study's research question is: How do nursing educators experience that they can promote dignity in nursing education?

Theoretical framework
In this article, dignity will be understood according to the description of this phenomenon by Eriksson (1996), Edlund (2002) and Edlund et al. (2013).They describe dignity consisting of an absolute and a relative dimension.The absolute dignity is given to all people, and is constant and inviolable.Through creation, man is given a human obligation, which implies sanctity, human dignity, freedom, responsibility and duty to serve.However, the relative dignity is changeable and can be violated and rebuilt.It is created and shaped by culture and society, and is experienced in relation to others.The relative dignity contains an inner ethical and an outer aesthetic dignity, both of which are expressions of the absolute dignity.The inner dignity expresses pride, esteem, position, rank and independence, and contains the morals and norms that people have made their own.The external dignity expresses respect, esteem, control and propriety in actions, attributes or symbols (Edlund, 2002;Edlund et al., 2013).
Dignity can be promoted in various ways.This article wants to see this in the light of Løgstrup (2000Løgstrup ( , 2014Løgstrup ( , 2019) and Martinsen's (2003Martinsen's ( , 2012Martinsen's ( , 2021) ) philosophy.According to the authors, the ethical demand and the cultural and social norms can be guiding for how others are cared for.The ethical demand and the norms can serve to protect both people, relationships and institutions (Løgstrup, 2000;Martinsen, 2012).Løgstrup (2000Løgstrup ( , 2014Løgstrup ( , 2019) and Martinsen's (2003Martinsen's ( , 2012Martinsen's ( , 2021) ) point to phenomena in life that are created and given to all people, such as dignity.Løgstrup (2000Løgstrup ( , 2014Løgstrup ( , 2019) calls these the sovereign and spontaneous expressions of life, such as trust, openness of speech, mercy, compassion, sincerity and hope.These are all given to man.The expressions of life are the basis for a good life, they live among us and we have no power over them.We have though, the power to give the expressions of life space to be fulfilled among us, or to make this space narrow.
Ethics, according to Løgstrup, originates in people's dependence on each other.People are exposed to each other, and are thus each other's world and destiny.Vulnerable and dependent, we encounter each other, and are at the mercy of how the other receives us (Løgstrup, 2000;Martinsen, 2012).Ethics unfolds in situations (Løgstrup, 2019;Martinsen, 2012).Situations with human encounters can set a mood that brings life, or make the person wither.In the extradition, there is an appeal to take care of what is entrusted to the person in the situation.The situation places man under an ethical demand to take care of the other's life.It involves taking care of the life-sustaining aspects of the other's existence, their vulnerability and unconditional dignity (Løgstrup, 2000;Martinsen, 2012).
The ethical demand is radical.Primarily because it is silent and unspoken.The individuals who are faced with it must decide for themselves how they can best take care of the other person's life in the situation (Løgstrup, 2000(Løgstrup, , 2014)).Since the ethical demand is silent on how to practically look after one's neighbour, the golden rule can be a guide for what this may entail.We are to do to others what you would have them do to you.The golden rule requires that we use imagination, insight, judgment and understanding to put ourselves in the other's place, and try to understand how best to look after the other (Løgstrup, 2000(Løgstrup, , 2019;;Martinsen, 2012).
The cultural social norms are not silent like the radical ethical demand.They can give precise instructions about what is best to do in the situation (Løgstrup, 2000).They give people a common understanding of what is right at all times.When we have to protect what really matters, the norms can help guide our actions (Martinsen, 2021).Nevertheless, following the norms need not be what serves the other best (Løgstrup, 2000).It therefore becomes problematic if one takes the cultural norms for granted, without problematizing them.When rules are created for the sake of rules, and structures for the sake of structures, the norms become binding and blocking.They can then shut people out of relationships with each other, prevent people from gaining experiences in meeting each other, and in the worst case, lead to abuse (Løgstrup, 2000;Martinsen, 2021).
The ethical demand and the cultural and social norms can therefore be of help when people and institutions are to be looked after and protected.The ethical demand leaves room for the golden rule, and the norms are needed as ideals in a situation.In human encounters, there are always deliberations.The person considers the situation.Løgstrup describes two forms of "should", both of which are necessary in the deliberation.One "should" lies in the ethical demand; the other "should" is expressed through cultural norms (Martinsen, 2012).Martinsen (2021) describes it as an ethical triad between the expressions of life, the ethical demand and the norms created by society.Ethics is a complicated triad interaction between these and the triad plays out in the situations people are in, and none of the triad's notes can be dispensed with.There must be both an interaction and a harmony.However, the tones can have different strength and timbre, depending on the situation (Martinsen, 2012(Martinsen, , 2021)).

Method
Overall design Gadamer's (2010) philosophical hermeneutics has been chosen as the study's scientific theoretical approach.His ideas are not intended to provide a method for how understanding is created, but to clarify the conditions under which understanding occurs.The fundamental premise in Gadamer's philosophy is that understanding takes place through interpretation and that the interpretation process takes place on the basis of people's pre-understanding.The process of interpretation is dialectical.Questions arise when something unexpected happens during the investigation.By questioning what lies behind, the strange and inaccessible becomes more familiar and accessible.When one encounters something that violates their own pre-understanding, the preunderstanding is corrected (Gadamer, 2010).As Gadamer refers to, understanding in this study was achieved through dialogue with the participants and with the transcribed text.When something unexpected appeared in the dialogue with the participants, or when the researcher's pre-understanding did not fit in with what the transcribed text conveyed, the pre-understanding had to be modified and new meaning emerged after constant corrections.Researchers then asked questions about the legitimacy of their own pre-understanding, and by putting the pre-understanding at stake new understanding was formed.To have a hermeneutically trained awareness means to be sensitive to the uniqueness in what is examined, and to constantly have a movement between seeing the whole and the parts (Nåden, 2010).The whole is understood based on the parts and the parts on the basis of the whole.This process is called the hermeneutic circle, where meaning emerges through the fusion of past and present horizons of understanding.Expansion of the horizon occurs and new understanding is achieved (Gadamer, 2010).This circular movement can also be called a hermeneutic spiral, because the movement never stops.It constantly creates new reflections in encounters with what is being investigated (Nåden, 2010).How the hermeneutic spiral took shape in this study is further explained under data interpretation.

Participants and research context
The study has a strategic accessibility sample.The strategic sample criteria were nursing educators with a minimum of two years' (full-time) professional experience at teaching at bachelor level, with at least a master's degree, and who understood and spoke Norwegian.All those who made themselves available for participation in the study and who signed a declaration of consent were included.Three educational institutions distributed over five different nursing education campuses granted access to the study.The educational campuses represented both universities and university colleges.An assigned contact person at each of the campuses distributed information about the study to their colleagues and helped organize the focus group conversations.The nursing educators who were interested in participating reported their interest to the researcher, who gave further information about the study and sent them an informed consent form.The study's sample consists of 21 nursing educators, 18 women and 3 men.The nursing educators were aged 33-65, and they held a doctoral or master's degree.On average, they had been employed as nursing educators in bachelor's education for over 14 years.

Data collection
Five focus group conversations were conducted with the nursing educators, in suitable rooms at the nursing educators' workplaces.There were three to six participants in each focus group.It was preferred to have approximately the same number of participants in each focus group, but due to unforeseen circumstances, some participants had to withdraw at short notice.Therefore, two of the focus groups only had three participants.Focus group conversations were chosen because they are suitable for creating data about social processes, and for illuminating norms in groups' practices (Halkier, 2010).The objective of the conversations was that the group interaction should produce synergistic effects in the form of one participant's opinions creating associations with other participants.An indicative conversation guide was used.Topics that were discussed in the focus group conversations were how the educators understood dignity as a phenomenon, how dignity was promoted, experiences they had with dignity in education and what significance dignity could have.The researcher was the moderator of the conversations and received the help of a co-moderator, who noted keywords around group dynamics, non-verbal observations and themes that could be elaborated more in conclusion.The nursing educators were perceived as welcoming, pleasant, engaged, listening and reflective.A good atmosphere, generosity, trust and a good flow of conversation characterized the focus group discussions, where the participants built on each other's input.Although some participants in the focus groups were more active than others, everyone participated in a good way.All the nursing educators in each focus group were colleagues and knew each other, apart from one of the focus groups where the participants represented two different educational campuses.The focus group conversations were recorded on audio tape.On average, the focus group conversations lasted 101 min.

Data interpretation
Gadamer's (2010) ideas about the conditions under which understanding occurs has been a guide for the interpretation process.Fleming et al. (2003) have created research steps that are intended to operationalize Gadamer's philosophy into empirical research.These steps are: Deciding upon a question, identification of pre-understandings, gaining understanding through dialogue with participants, gaining understanding through dialogue with text and establishing trustworthiness.In particular, the step; gaining understanding through dialogue with text, has been a guide for systematizing and organizing the data material.The step includes the points: Examining the whole text, examining parts of the text, relating the parts to the whole, and selecting passages that seem to be representative of the whole (Fleming et al., 2003;Fleming & Robb, 2019).
First, all focus group conversations were transcribed verbatim.In this process, the audio files from the focus group conversations were listened to by primary author several times, as well as the transcribed text read repeatedly by all authors.The overall impression after this review was written in the form of a theme that should reflect the basic meaning of the text as a whole.The overall impression formed the starting point for how the data material was further understood in the interpretation process.
Through a new reading and a dialectical process with the transcribed text, meaning units were identified and themed based on the overall impression.Related themes with associated meaning units, from all the focus group discussions, were read together.Through this reading, different shades of the themes emerged and formed subthemes.Through discussions in the research team about what meaning the data material gave and how different themes related to each other, themes and subthemes were abstracted into overarching main themes.All parts of the interpretation process were subject to constant movement between theme/subtheme/main theme, and the researcher's overall impression and pre-understanding.
The interpretation process resulted in three main themes: 1) Promoting dignity in the nursing profession, 2) Promoting the dignity of nursing students, and 3) Promoting dignity in challenging situations (Table 1).

Ethical considerations
The study was approved by The Norwegian Center of Reporting Data T. Stikholmen et al. (NSD), and current guidelines followed.At the same time, the World Medical Association (2013) has been guiding throughout the entire research process.The nursing educators were informed that participation in the study was voluntary and that they could withdraw from the study at any time.It was informed that the researcher was employed by a nursing university, but not by any of the educational institutions that were included in the study.The researcher's duty of confidentiality was emphasized, and the demand for confidentiality was met by deidentifying the audio files during transcription.The focus group conversations were numbered from 1 to 5. Audio files, consent forms and connection keys were stored in accordance with regulations.

Findings
The nursing teachers experienced that they promoted dignity in three different ways.First by promoting dignity in the profession in general, and then by promoting the dignity of nursing students in particular.In some situations, the educators found it difficult to both maintain the dignity in the profession and at the same time safeguard the dignity of the students.Being able to manoeuvre so that dignity was also promoted in such challenging situations was the third way in which the educators promoted dignity.These three main findings will be presented below.

Promoting dignity in the nursing profession
Although several of the nursing educators were unaccustomed to talking about dignity in an educational context, they emphasized the importance and place of dignity both in nursing education and in the nursing profession in general.They recognized that they had a responsibility to promote dignity in education and to safeguard the dignity in nursing profession as a whole.This was ensured by setting a high standard for the education.For example, they said that they aspired for high quality at all levels of education, from overall systems to the individual educator's knowledge, attitudes and actions.
"For me, it's very much about us having really good plans.That there is quality and that there is predictability.That we are orderly and clear and that we meet deadlines and that we have a system that works and that the educators are representative and wise.For me, it's very much about the system in every way.That there is order in the drawers and cupboards."(2).
Maintaining professionalism, planning well, having good processes and appropriate routines were elements that promoted dignity.The educators pointed out the importance that teaching and guidance were not left to chance, but were well thought through and carefully adapted to the students' level.In particular, the educators believed that it was crucial to maintain good quality in the clinical studies.The supervision the students received in clinical studies could sometimes threaten their dignity.
Furthermore, the educators believed that they promoted dignity in nursing profession through the conveying of competence and values.They had a responsibility to manage the social mandate they were assigned by educating future nurses.
"I realize that being an educator is a huge responsibility.When it is you who must, in a way, bring the knowledge out to the student and in any case try to ensure that they learn something.In other words, we train people who are supposed to take care of life and health, so it's a huge responsibility."(4).
By managing this social mandate in a good way, the educators believed that they contributed to promoting dignity in nursing profession.Primarily, this was about ensuring that future nurses had the right skills to be able to provide good and sound nursing care.The educators were aware that society, through given regulations and guidelines, had certain expectations of a fully qualified nurse, and experienced promoting dignity if they managed to educate students who met these expectations.This concerns the integrity and credibility of nursing as a profession.Overall, these expectations consisted of fully trained nurses possessing knowledge, skills and attitudes that made them worthy of trust, and that they could use their expertise to look after people's lives and health.
Nursing is a special profession that the educators believed required unique skills.In particular, it required maturation on a personal and interpersonal level, which the educators believed had too little emphasis in education.Nursing requires an encounter with life, with oneself and one's own vulnerability.This was necessary to safeguard the vulnerability of others.The educators therefore saw it as their responsibility to train robust and courageous nurses, who were equipped to face adversity."Which nurses do we want to train?What is our objective?I think they must be quite brave to meet the patients of the future with the demands and understanding of their rights.Facing a crisis requires courage and integrity.(…) I think we need to see more of that.We need to find out more about who the individual student is and what resources they have.(…)." (5).
The educators expressed pride in managing a profession that is based on a value base where all people are understood to have an inherent and inviolable human dignity.This value base was worth promoting, and guiding for encounters between people.Educating for dignity, and helping students to discover and safeguard dignity in nursing, was significant.Against this background, it was important that dignity was expressed both in education in general and through being good role models.
"Dignity is expressed through who you are as a person.And then it is also about how life, humans and education are viewed.And about the environments and contexts you are in."(2).
The educators were aware that they conveyed values, directly or indirectly, and that they were quickly exposed if they were not sincere.Through their own demeanour, they helped shape the students.Several emphasized that they put their honour and pride in doing a good job and being representative role models.
"We are automatically role models, whether we are aware of it or not.And that is why it is so important to actually be aware that we are.Often it is said that one learns not from what you say, but one learns from what you do.And therein lies the fact that they take after us.They do." (3).

Promoting the dignity of nursing students
The educators were convinced that the students' experience of their own dignity was of great importance, both during their education and as future nurses.Although the students' dignity was emphasized on a system level, through securing their rights, involving and including them in various committees, and arranging for close follow-up, they said that the students' dignity was primarily promoted on a relational individual level.
"For me, dignity unfolds in meetings.So it's about physical presence.How to enter a room.It's about how you use your voice.It's about how you use your gaze.(…) For me, I see that it is very much about the consultations as well.That we can play in a way that both play better or we can play in a way that puts us both on the side-lines in the way we are."(2).
The educators emphasized that the relationships with the students could promote dignity.They had to see the individual student.This could be expressed, for example, by showing interest in the person in front of them, trying to understand who the student was, and being responsive to the story and the overall situation.It could be about showing care, presence and availability, and through expressing that they knew the students.
"They are very happy when they find out that you know who they are and remember their name.And you notice that this touches them a little.Someone called me, and then she said my name is so-and-so, you probably don't know who I am.Also I said; Yes, I know who you are.(…) Wow, she was completely put out by that.I think it really means a lot.That you have seen them."(3).
Seeing the individual student could also be about striving for individual facilitation.This was not about lowering requirements, but that the individual student could complete the education in a way that meant that they retained their dignity.Not all students could be treated equally.The fairest thing in some situations was to treat the students differently.
"I think dignity is perhaps more often at stake with those who do not fit into the so-called sheep flock.I find myself seeing them quite quickly if I get a new group of students.So it is relatively easy for me to see who might stand out.In any case, I try to be extra vigilant and make sure that they are looked after and seen.I have a bit of antennae like that, and try to think about it as an educator.See that he or she may need a little more help than the others in their group, to master the practice or whatever it might be."(5).
The educators believed that seeing the individual student was also expressed through showing the student respect in the way they followed the student up, and that they could be trusted.
"That we take them seriously in any case.Do we have time for them when we should have time for them?Keeping our agreements in relation to them.Are we there at ten when we are supposed to be there at ten?" (3).
The educators pointed out that it was important to create and strive for equality in the relationship.They emphasized that dignity was about taking the students seriously as adults, who can make independent choices.At the same time, the students were respected as lacking in nursing skills but being on their way to becoming qualified nurses.
"I strongly believe that there are unimaginable resources in everyone, when they are allowed to.However, they must be allowed.Therefore, we have to kind of make them flourish.We have to fertilize well."(2).
The educators also said that they saw the students and their needs, by giving them predictability and control.Everyday life of the study had to be experienced as predictable and the students had to have control over their own situation and external frameworks, such as timetables, syllabuses and learning plans.To achieve this, it was crucial that they were clear, open and honest, in relation to both clarifying expectations and providing information and feedback.
"I think that dignity in an academic setting is about being clear.In other words, we have some learning outcomes, but that we are still clear and can articulate what expectations we have and what resources we can contribute."(1).
By being clear about what expectations they had of the students, they believed that the students had the opportunity to understand their own situation better, and had increased opportunities to improve.It was necessary to give clear and honest feedback, as well as to have continuous open dialogue, so that feedback did not come as a surprise.The educators experienced that the students could tolerate receiving direct feedback, if the feedback was orderly and constructive.

Promoting dignity in challenging situations
The educators felt a great responsibility for managing the social mandate.This involved a continuous assessment of the students, to ensure that they achieved the right and adequate competence for future professional practice.
"So we have a social mandate.It is not difficult to roll out the red carpet for all the talented students, because most of them are talented.But we have a very important task in saying that someone will be a disaster out in the field.They're going to do a lot of crazy things.I really know that.I spend day and night on that, so to speak."(2).
Through thorough assessment of the individual student, the educators experienced promoting dignity by ensuring the value of the nursing profession.If students did not achieve the standard worthy of the nursing profession, this would bring disrepute and the profession's reputation and credibility would be violated.The assessment was about making demands, observing students' competence and sometimes stopping them in their education.To set requirements would express the value of the nursing profession.A nursing education without requirements could testify to indifference to both the students and the nursing profession.It would also be undignified if students who did not have the expected competence graduated.Students could lose face, and future patients could suffer if students graduate with lacking competence.The educators pointed out that dignity was standing in these boundary-setting situations, even if they could be experienced as unpleasant.The responsibility and loyalty of the future vulnerable patients that they, as future nurses, were supposed to look after weighed most heavily.The educators expressed that they could not compromise on the well-being of patients, and all assessments and actions they took were justified in this."That's the painful thing in relation to student.True, you know in your mind that you are responsible for those patients, but it hurts terribly in relation to the student to say that you are not good enough.Your future hangs in the balance.It's tough."(2).
Several felt that by fulfilling the social mandate, they put the students' dignity at risk.This was particularly evident in situations where the students did not meet expectations, and the educators had to stop them midway through their education.In such situations, the educators expressed that it was challenging to stand face to face with the individual student, and see and take in the pain the student experienced."It's always tough to fail people and it's tough to get those reactions from the student, even though we're the ones with the authority, it still affects us.I think it's quite exhausting and it should be that way, because it's not something you do lightly."(4).
Several had experienced demanding emotional confrontations with the students in such situations.This put the educators' self-esteem and security at stake, and affected how they assessed the students.To deal with this, the educators said that they often had a dialogue with themselves about how they could best promote the students' dignity and at the same time safeguard the dignity of the profession.
In order to balance the various needs at stake, the educators explained that they relied on their own discretionary assessment.They felt that the situations required prudence and discretion.They had experienced that the systems, frameworks and rules could not always give them an answer to what was the right thing to do in the current situation.
"When I think the system is not working, it is my job to influence the system.(…).I think that we humans have an advantage there.I think that's where humans are different from artificial intelligence.Because I think artificial intelligence will run with the rule in any situation."(5).
The educators also used their own discretion when they felt that the systems and frameworks were becoming too rigid.They pointed out that they were different, both as people and as professionals.It was important to have opportunities to exercise the teaching profession in one's own personal way, and that the teaching role did not become a straitjacket.This could be about relaxing the rules a little in encounters with the students, or following up the students more than the framework allowed.
"We do have frameworks within which we work, for example the number of practice hours.But I think, at the risk of saying something terribly wrong, that we can have some wiggle room within those limits.At least I have.I look after the students.For example, in clinical practice, what they are like and what the learning process has been like.How much knowledge they have acquired.How much interest they have shown.It is easier for me then to be more flexible, than if everything is wrong.(…) So I think it's a bit of an individual assessment."(5).
Even with individual adaptations, the educator still sometimes had to stop students in their education.In such situations, they strove to make this as dignified as possible.It required time, good planning and good processes.The educators realized that the students in such situations were extra vulnerable.It was therefore crucial to have a reflective relationship with what power they had and how they managed that power when meeting with the students.The negative feedback had to be given in such a way that the student did not feel exposed, ridiculed or ashamed.Although the situation was experienced as a defeat for the student, it was important to maintain hope.The goal was for the student to come out of the situation being able to stand upright.The educators linked this to the experience of dignity.
"For me, dignity is being able to stand upright.To be oppressed or held down by others, I experience that as indignity.But if I can be lifted by others, then I experience dignity.So for me, dignity is symbolically about being able to stand upright and having the opportunity for others to help me lift myself up, and stand even more upright."(1).

Discussion
The main finding of the study is that the nursing educators experienced that they promoted dignity by safeguarding both the dignity in the nursing profession and the dignity of the students, and by manoeuvring challenging situations where this was at stake.Below, these main findings will be discussed.

Taking responsibility for the dignity in the nursing profession
Dignity is both absolute and relative (Edlund, 2002;Edlund et al., 2013).It is absolute because it is given to all people in creation and therefore makes people unique and equal.The dignity is given as a human obligation to take responsibility for serving one's neighbour (Edlund, 2002;Edlund et al., 2013;Eriksson, 1996).How one executes this responsibility and serves, is expressed in the relative dignity.This dignity is shaped by society, cultures and relationships, and can be violated and rebuilt (Edlund et al., 2013).The nursing educators expressed a great sense of responsibility linked to dignity in education, both as human beings and in their work as educators.They felt a responsibility to serve their fellow human beings and a responsibility for the social mandate that had been given to them in educating future nurses.
The educators took pride and honour in doing a good job, and in being representative role models for the students.According to Edlund (2002) and Edlund et al. (2013), the relative dignity consists of an inner ethical and an outer aesthetic dignity.The inner ethical dignity carries the experience of dignity and contains the morality and the norms that people have made their own.It is expressed through pride, and it is experienced whether we live up to our own and others' expectations.The educators had a standard they wanted to live up to in order to experience pride.It consisted of values, attitudes and a morality they sought to live by.Among other things, they wanted high quality in the education, both in terms of having good overall systems, and that the educators' knowledge, attitudes and actions met the objective.They wanted to be good role models, both as individuals and as representatives of the nursing profession.By doing a good job, fulfilling their own and others' expectations, the educators maintained their own dignity.It also became important to express one's own values and attitudes to others.The dignity is expressed in the external aesthetic dimension.By expressing respect, restraint and propriety, dignity can be experienced (Edlund, 2002;Edlund et al., 2013).Not only was it important for the educators to express themselves as individuals, it was also crucial that the nursing profession itself had a good aesthetic expression.The profession had to express both respect and propriety, so that its value was maintained.
Although it was unfamiliar for the educators to talk about the concept of dignity in education, the phenomenon of dignity was directly and indirectly present in the way they talked and what they thought was important for the students to learn.This is in line with previous research that shows that dignity, in addition to being a value, is also a competence or skill that must be learned (Edlund, 2002).Eriksson (1995Eriksson ( , 1996) ) describes dignity as nursing's most fundamental value, and that ensuring people's dignity is nursing's primary purpose.This is also clarified in nursing's professional ethical guidelines (International Council of Nurses, 2021).The educators recognized the importance of dignity in nursing practice.They further stated that nursing is a special profession that requires unique competence.In particular, it requires courage, integrity, presence, weight and maturity on an interpersonal level.By promoting dignity as a value for the students, the educators experienced that they contributed to students gaining the unique competence the nursing profession required, in order to safeguard the dignity in the profession in general.
In these different ways, the educators tried to maintain the dignity in the nursing profession.They wanted to fulfil their responsibility to serve, maintain good ideals and standards, and educate to quality, to ensure good and dignified nursing practice in the future.Etymologically, dignity means, among other things, credibility (Eriksson, 1996), and it was crucial for the educators that the nursing profession maintained its credibility.According to them, they were responsible for ensuring that the nursing profession did not lose its value, integrity and reputation, and it was important for them not to become indifferent to quality and competence.In the debate on dignity, reference is made both to the dignity of patients (Wainwright, 2011) and to the dignity of nurses (Gallagher, 2004;Sabatino et al., 2014).Wainwright (2011) wants to add another aspect to the debate, namely to look at the dignity of a practice.He believes that the nursing profession in itself can have dignity, because it is supported by human and moral activities, is defined according to a standard, and is a practice that aims to safeguard values.The nursing profession has an inherent value through the nurses' collective intention and because of the moral character of the profession.By protecting the credibility of the nursing profession, perhaps the educators experienced that they were safeguarding the dignity of the profession itself.

Creating space for dignity in nursing education
Although dignity is a complicated phenomenon, promoting dignity in everyday life is neither mysterious nor unattainable (Gallagher et al., 2008).The educators determined that the students' experience of dignity in the education was of great importance, both for them as students and as future nurses.An overall objective in all education is to promote human dignity, and in nursing education an ethical standard for nursing practice must be established (United Nations, 1948;International Council of Nurses, 2021).In the education, students must be prepared to practice caring and responsible nursing (Forskrift om nasjonal retningslinje for sykepleierutdanning, 2019), and formed into a culture that safeguards ethical values, such as dignity (Kalb & O'Conner-Von, 2007).In order to achieve this, it is crucial that students discover dignity and its importance in education (Stikholmen et al., 2022a).This can have a positive impact on professional development and education (Shaw & Degazon, 2008), enhance learning, the sense of self-worth and the mastery experience (Hill & Tollerud, 1996), as well as make students better equipped to promote the dignity of others (Gallagher, 2004;Munoz et al., 2017).
The educators felt the responsibility for creating a dignified environment in education, which could have ripple effects into the future.They tried to live as moral people, to be good role models and to practice what they teach.The educators experienced that the students' dignity was safeguarded, through their rights being preserved, they were involved and included in various committees and received good followup.Nevertheless, the educators emphasized that the students' dignity could be at stake.In particular, this applied to relational situations where the students felt inferior, often linked to clinical studies.This is also consistent with previous research on students' experiences in nursing education (Cantrell & Farer, 2019;Monrouxe et al., 2014).
Challenges in safeguarding students' dignity can be linked to the growing problem of incivility in education.Incivility creates, in fact, poor growth conditions for dignity (Clark, 2017;Clark & Springer, 2007;Eka & Chambers, 2019).Seedhouse and Gallagher (2002) call institutions that do not recognize dignity for undignified institutions.These are institutions that, even with the best intentions, fail to promote dignity, because various circumstances make this difficult.Løgstrup (2000) writes that the sovereign and spontaneous expressions of life must be given room to be fulfilled.The same applies to dignity.It must be given room to be realized in education.Dignity must be given good conditions so that it can both be expressed and recognized.Several refer to the importance of environment and culture in promoting dignity (Edlund, 2002;Edlund et al., 2013;Gallagher, 2004;Gallagher et al., 2009;Haddock, 1996).The physical and psychosocial environment, organizational culture and processes, as well as people's attitudes and actions can affect the conditions of dignity positively or negatively (Gallagher et al., 2009).These premises also apply in educational institutions and the people here must create an environment and a culture that promotes a dignified everyday life.According to Løgstrup (2000) and Martinsen (2012), the social and cultural norms are intended to protect institutions, for example nursing education.They must shape the education according to some ideals that apply to the people there.Examples of social and cultural norms in nursing education can be various laws and guidelines (Forskrift om nasjonal retningslinje for sykepleierutdanning, 2019; International Council of Nurses, 2021; United Nations, 1948), unwritten rules, customs, cultures, values and attitudes.These aim at giving dignity good conditions in education and counteract incivility and undignified institutions.
Although the educators relied on social and cultural norms and through these received a kind of guideline for how to handle different situations, it was when encountering the individual student that it was decided whether they were able to take care of the student's vulnerability and dignity.Edlund (2002) and Edlund et al. (2013), point out that the perceived dignity is relative.It is vulnerable and shaped in relationships.The educators expressed that they were of great importance to the student's experience of dignity, and felt responsible to manage this in a good way.In order to promote the students' dignity, they believed it was important to see and know the individual student, and his or her history and overall situation.They further believed that it was important to show care, presence, availability and meet the students individually.The relationship between them had to be characterized by equality, respect, honesty, openness, clarity and predictability.Sometimes they succeeded; sometimes they did not.Eriksson (1995) states that the character of relationships is determined by the motives, sense of responsibility and ability to be compassionate and inviting, the leading party has, and that it is only when you meet and see the other that the ethical becomes real.This was clearly shown in the data material.The students' dignity became clear when it was at stake.For example, in situations where the students fell short academically, were exposed and was ashamed because of this.It was only in these individual encounters that the educators really noticed and felt the discomfort of seeing the student's pain.It became important for the educators to act dignified in the situation, and to make what was perceived as undignified as dignified as possible.The individual student was exposed, dependent on and at the mercy of how the educators received them, as Løgstrup (2000) describes human encounters.Expressions of life are at stake and the appeal to take care of the other person's life is challenged in the situation.The absolute ethical is found in people's recognition of other people's dignity.When encountering people who are suffering, this person must have their dignity confirmed (Nåden & Lohne, 2020).Eriksson (2013) calls this the ethical core.In situations where ethics are played out, one must be truly present, really see, and have the courage to bear witness to it.The educators must be T. Stikholmen et al. ready to take responsibility for the situation and the individual person.By being there, seeing and witnessing, the educators became responsible.
Using discretion to promote dignity in challenging situations Løgstrup (2014) points out that man becomes responsible when something depends on him.It can be in the execution of a job, in the solution of a task or the manoeuvring of a situation.If you fail to take responsibility, you become guilty.The educators were responsible for assessing the students, and in that way help to ensure that the students achieved the expected level of competence.It would be a disaster if students who should not have become nurses nevertheless did.This would be undignified for both the students, the education, the nursing profession and future patients and relatives.Therefore, the educators believed that they promoted dignity through careful assessment of the students, by making demands and setting boundaries, and in some cases stopped them in their education.Although the educators thought this was necessary, the responsibility surrounding this felt burdensome.Several said that they wanted to shrug off the burdensome responsibility.
For example, when the students' dignity was put at risk in situations where students did not live up to expectations and they had to be guided out of their studies.These situations were challenging for the educators, and pained them.The educators were aware of the crucial importance of good relationships with the students, and that nurturing this relationship was essential for the students' experience of dignity.Although the educators wanted to strengthen the students' dignity, they felt that taking care of one consideration came at the expense of the other.It would be easiest to give the student a passing grade.However, that could result in putting the dignity of the profession and the dignity of future patients at risk.Research shows that educators find it difficult to stop students in their education, but it is sometimes necessary in order to maintain the profession's credibility and integrity (Diekelmann & McGregor, 2003;Duke, 1996;McGregor, 2007).
These challenging boundary-setting situations required careful consideration on how to manoeuvre.For Løgstrup, ethics does not come from outside, it is in our reality, and occurs in concrete situations (Nyberg, 1995).A main finding in the data material is how the educators maneuverer in challenging situations to promote dignity.Gallagher (2004) points out that when nurses are in such situations, where patients' dignity is at stake, it is crucial to continuously reflect on the situation and create dignity-promoting zones.This requires courage and care, and the ability to accept that all people are fallible and vulnerable.The educators tried both to see the students as evolving and learning, and that such situations are vulnerable.Nevertheless, they also had to consider whether their nursing practice was good enough to qualify them for the nursing profession, and they had to consider the responsibility and loyalty of future patients.Martinsen (2012) points out that there is always a consideration in human encounters; the person considers the situation.Here, according to Løgstrup, it is necessary to use two forms of "should", namely the "should" that lies in the ethical demand to look after the other, and the "should" that lies in the social and cultural norms.In their deliberations, the educators relied on both of these forms of "should".
In order to manoeuvre in challenging situations, the educators relied on the social and cultural norms of education.They searched for different systems and rules for how such situations had been manoeuvred in the past.At the same time, the data material shows that the educators also discovered the demand in the situations.They described how, in challenging situations, they entered into a dialogue with themselves, reflected and used experience, accumulated insight and wisdom to explore how they could look after the students in the best possible way.Since the ethical demand is silent, the person must decide for himself how best to take care of the other's life.Here the golden rule can be a guide and it is precisely described as using one's imagination, insight, understanding and judgment, in order to put oneself in the other's place and try to understand how best to look after the other (Løgstrup, 2000(Løgstrup, , 2019;;Martinsen, 2012).In this way, the educators tried to make room for the golden rule in the demand, while at the same time relying on the social and cultural norms.Giving room to the golden rule is perhaps the most important thing one can do to confirm the dignity of others (Eriksson, 1996).This provides opportunities for the tones of the ethical triad (Martinsen, 2012(Martinsen, , 2021)).Both the expressions of life, the ethical demand and the social and cultural norms are then allowed to play and chime together in situations.
By giving room for the golden rule in such situations, room was also given for discretion.Discretion is a work of interpretation where the senses and specialist knowledge work together (Martinsen, 2003).The exercise of discretion helps to manoeuvre situations, using one's own understanding of life and understanding of what it means for a person to succeed (Løgstrup, 2000;Martinsen, 2012).It was clear in the data that the educators used discretion to manoeuvre challenging situations, and in that way tried to promote dignity in education.Alvsvåg and Førland (2007) emphasize that discretion is needed in complex and complicated situations where standard procedures or rules are not sufficient.Sometimes it was completely obvious to the educators how they had to act in the situation, and it was necessary to act according to the applicable rules and system.While at other times, the situations were more unclear.This is when the exercise of discretion contributes to opening up for the best actions (Alvsvåg, 2007).A space is created for experiences, thoughts and reflections.A room where the educators open themselves up to the sensuous impression of the situation.Where they really see, listen and let themselves be touched (Martinsen, 2003(Martinsen, , 2012(Martinsen, , 2021)).The educators assessed the individual student and were curious about the student in the encounter.Instead of acting according to fixed patterns of action, they tried to see and listen anew, in order to promote the students' dignity.Furthermore, they allowed themselves to be touched by what the relationship provided and what the individual student needed.The educators were more generous with terms and time than what the norms dictated, in order to get the individual on board.Sometimes they had to tighten the boundaries.This was not done randomly, but on the basis of experience and specialist knowledge accumulated over several years in education.
It is crucial to have distance from the social and cultural norms, in order to give discretionary space.One gives discretionary space if one has a flexible relationship with the norm, so the norms don't become a straitjacket (Martinsen, 2021).If one fails to do this, the discretion is put out of action, as the space in which the discretion is supposed to move is lost (Løgstrup, 2000).If everything is done according to rules and standards, people become prejudiced and draw conclusions before the situation is well considered.Attention is shifted from the situation at hand, to instructions and commands, and the chime of the ethical triad becomes out of tune.The "should" of the norms is given more importance than the "should" of the ethical demand.It can stifle the ethical demand.If one only acts according to rules and principles, discretion is put out of play and the other's vulnerability and dignity are not met (Martinsen, 2012(Martinsen, , 2021)).

Strengths and limitations
In order to safeguard the credibility of the study, no guidelines were laid down for how dignity should be understood in the focus group conversations.The participants themselves were allowed to describe their understanding of the phenomenon.As part of raising awareness of one's own pre-understanding, the researcher's pre-understanding was recorded and made available for reflection.This was put at stake when encountering the data material.Peer debriefing was used when the entire research team participated in the interpretation process, as well as searching for statements that challenged previous understanding.An attempt was made to take a critical look at various choices that were made, and also at how the participants were met and the empirical material understood.
The selection had a fine balance between homogeneity and variety.The participants all had higher education and the same profession.A good spread in age, number of years of professional experience and field of expertise, gave good variety.This gave the opportunity to make constructive associations between them in the conversation, and breadth in the views and experiences they shared.
Two of the focus group conversations only had three participants, because some participants had to cancel the appointments.This influenced the breadth of experiences that emerged and the dynamics that were created during the conversations.At the same time, it became possible to go more in-depth into the topic.The individual participant was given ample time to speak.
The participants in the focus groups were known to each other in all but one group.Originally, it was pointed out in the literature that participants in focus groups should be unknown to each other.Unknown participants will provide new and fresh dialogues in the focus group that are not hampered by the fact that the participants already have established ways of talking together, about topics that already exist (Malterud, 2012).However, it can be an advantage if the participants already know each other, for example through working together.Then the topic is discussed in its natural context, where ideas are usually formed and decisions are usually made (Kitzinger & Barbour, 1999).This was seen as an advantage in this study.The participants could utilize a greater repertoire of shared experiences than if they had been unknown to each other.This also had the advantage that the participants got a good flow in the conversations more quickly.It was nevertheless reflected on how the fact that the participants knew each other was important for the empirical material.Especially considering that in some focus groups there could already have been established some unwritten rules about what could and could not be said, and that a hierarchy could have formed within the group.
Two participants did not meet the selection criteria, as one had moved into a management position and the other had less than two years' professional experience at the bachelor's program.In both cases, the discrepancy was discovered so late that it became ethically problematic to exclude them.The danger of "eager to please" is always present when the balance of power is uneven between the participants.Nevertheless, the researcher did not experience any restraint in the conversations in question.The participant who did not meet the requirement for work experience contributed relevantly to the conversation with unique perspectives as a new nursing educator.

Conclusion
The study found that the nursing educators promoted dignity by safeguarding the dignity of both the nursing profession and the students.When the educators experienced the difficulty of safeguarding the dignity of both the nursing profession and the students, the educators tried to manoeuvre the situations using discretion, so that dignity was also promoted in these challenging situations.Manoeuvring challenging ethical situations with discretion means making room for the ethical demand and the golden rule.In the contemplation of how best to safeguard people's lives, dignity can be promoted.In this way, the sovereign and spontaneous expressions of life can be fulfilled between people in harmony with professional, social and cultural norms.This will harmonize the ethical triad and give dignity to both the nursing students, the nursing education and the nursing profession.

Implications for nursing education
The study emphasizes the importance of promoting dignity in education.This has implications for the students' experiences during their education, as well as implications for future nursing practice and safeguarding patients' dignity.The study also points to the importance of exercising discretion, in order to be able to promote dignity and manoeuvre in situations that are challenging for educators to be in.The study emphasizes the importance of promoting dignity in education both at an overall system level and at a relational individual level.

Future research
The study shows that there is a need for more insight into experiences with dignity in nursing education, both in view of how little research there is in the field, and in view of how essential the value dignity is, in the education and for future professional practice.In particular, research is called for on how educators in nursing education experience dignity.This study points out that educators are a vulnerable group who find themselves in challenging educational situations, and it would be useful to gain more insight into how this is experienced.

Table 1
Example of the interpretation process