Contribution of ethics education to the ethical competence of nursing students: educators' and students' perceptions.

Article

Contribution of ethics education to the ethical competence of nursing students: Educators’ and students’ perceptions

Nursing Ethics 1–18 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014523166 nej.sagepub.com

Nancy Cannaerts, Chris Gastmans and Bernadette Dierckx de Casterle´ Catholic University of Leuven, Belgium

Abstract Aims: To review the literature on perceptions of nursing students and/or educators on the contribution of ethics education to ethical competence in nursing students. Background: Nurses do not always demonstrate the competencies necessary to engage in ethical practice. Educators continue to debate about the best ways to teach ethics to nurses so that they can develop ethical competencies. Data sources: MEDLINE, Embase, CINAHL, PsycINFO, and Web of Science. Review methods: A total of 15 articles with a quantitative, qualitative, or mixed-methods design published between January 1992 and March 2012 were analyzed. Results: According to students and educators, ethics education increases ethical perception of nursing students and the development of reflective and analytical skills. However, its contribution to the development of ethical behavior was barely mentioned. The accounts of students and educators revealed essential features of effective ethics education: active involvement of students in case study discussions and use of ethical frameworks. The use of activating educational strategies requires a safe learning environment where students can openly reflect on values at stake in their care practice. Conclusion: A better understanding of how students learn to develop ethical skills and of influencing factors can guide educators to develop ethics courses for nursing curriculum. Future research needs to focus on the methodological accuracy of sampling and measuring instruments. Keywords Educators’ perceptions, ethics education, literature review, nursing, students’ perceptions

Corresponding author: Nancy Cannaerts, Department of Health and Technology, University College Leuven, Herestraat 49, 3000 Leuven, Belgium. Email: [email protected]

Downloaded from nej.sagepub.com at CARNEGIE MELLON UNIV LIBRARY on January 12, 2015

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Introduction In daily care, nurses are continuously challenged to make decisions with the view to provide ‘‘good care.’’ Making and performing these decisions requires not only clinical competence but also ‘‘ethical competence’’ which involves much more than understanding ethical theories. Gallagher1 defines ethical competence as the possession of ethical knowledge next to the ability to ‘‘see’’ what a situation presents (ethical perception); to reflect critically about what nurses know, are, and do (ethical reflection); to bring out the ethical practice (ethical behavior); and to ‘‘be’’ ethical. With these five ethical skills, Gallagher covers the different existing narrower and broader views of the aims and purposes of nursing education as described in previous argument-based literature about ethics education. Although ethics in nursing education has received growing attention, research suggests that nurses do not always demonstrate the competencies necessary to engage in ethical reflection, ethical decision making, and ethical behavior. Conventions, expectations of others, uncertainty, and confusion seem to guide the ethical reasoning and decision making of quite a few nurses.2–4 These concerns about the ethical preparedness of nurses raise the question whether and how ethics education in nursing really prepares nurses to respond adequately to the ethical demands of current healthcare. The teaching of ethics in nursing education has become increasingly important in recent years. Despite the availability of a lot of argument-based literature about ethics education, there still is much debate among nurse educators concerning the best ways to teach ethics to nurses, so that they can respond fully to ethical issues arising in their practice. A review of the studies focusing on the contribution of ethics education to the development of ethical competence can help develop good practices in ethics teaching. Authors state that ethics education in nursing suffers from confusion and lack of a systematic approach.5–7 Nurse educators face the challenge of deciding whether ethics education is best addressed through ethicsspecific courses or through ethics lectures integrated throughout the curriculum, by teaching abstract theories or by using more skills-based approaches, through lectures, or by stressing clinical experience and reflection.5,8,9 Studies measuring the effectiveness of ethics education by using objective measures such as the Defining Issue Test do not sufficiently support the use of any particular teaching approach.10 In addition to objective measurement, it is equally essential to identify how students and educators perceive ethics education. Involvement of students and educators is a vital prerequisite to course design and for determining whether they believe ethics education contribute to the development of ethical competence of students. Understanding of the educational features that, according to students, have value in supporting and empowering them to deal professionally with ethical problems in practice can contribute to the development of adequate ethics teaching.

Review Aim The objective of this study was to thoroughly review the literature on how nursing students and/or educators perceive the contribution of ethics education to the ethical competence of nursing students. In this review, we specifically address the following research questions: (a) How do students and educators perceive the general contribution of ethics education to ethical competence of nursing students? (b) How do students and educators perceive the contribution of ethics education content to ethical competence? (c) How do students and educators perceive the contribution of ethics education teaching methods to ethical competence? (d) What are according to students and educators essential features of ethics education necessary to promote the ethical competence? (e) How do students and educators perceive the examination system in ethics teaching? 2


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Review methodology The review was conducted by following the guidelines of the UK Centre for Reviews and Dissemination11 Guidelines for systematic reviews. One reviewer (N.C.) conducted the primary search of the literature. After removing duplicate articles, we applied the selection criteria to the titles and abstracts generated from the literature search. Studies were included if they met the following criteria: (a) empirical research with a quantitative, qualitative, or mixed-methods design; (b) written in English, French, or Dutch; and (c) concerned the contribution of ethics education to ethical competence in baccalaureate- and master’s-level nursing curriculum and in postgraduate courses. Systematic reviews, conference proceedings, reports, and other non-peer-reviewed literature were not included. Relevant articles were read in their entirety and assessed by the first reviewer (N.C.). If a candidate article was questionable, the coauthors (B.D.D. and C.G.) screened the entire publication for appropriateness. The quality of the articles was checked using the quality appraisal list of Hawker et al.12 This method enabled us to evaluate the quality of both quantitative and qualitative studies. In addition, the articles were assessed with regard to validity and reliability criteria (for the quantitative studies) and criteria of trustworthiness (for the qualitative studies) according to Polit and Beck.13 Articles were reread, and relevant data were isolated, compared, categorized, and related. After consultation with B.D.D. and C.G., concepts and themes were identified. A narrative approach was used to collate and summarize the results of the individual studies. Microsoft Word databases were constructed for data extraction. These databases contained a set of fields for each study design, including characteristics of the study based on the conceptual outline.

Search methods Electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, and Web of Science) were searched for research articles published from January 1992 until March 2012. The following MeSH terms ‘‘ethics, nursing education,’’ ‘‘students, nursing,’’ ‘‘perception’’ and free labels (with synonyms and closely related words) ‘‘ethics,’’ ‘‘education,’’ ‘‘nursing student,’’ ‘‘nursing teacher,’’ ‘‘view,’’ ‘‘perspective,’’ and ‘‘experience’’ were used. Reference lists of the selected articles and of relevant reviews were examined for additional publications.

Quality appraisal Most quantitative studies implemented a cross-sectional descriptive design.14–17 One study used a longitudinal descriptive design to explore changes in students’ ethical approaches to practice over their 4 years of training.18 One study used a randomized experimental design to compare conventional teaching and problem-based learning in ethics education.19 Although all quantitative studies used a self-developed questionnaire, only a few studies described its development in detail. Only the studies of Lin et al.19 and Hsu16 reported rather high scores for the internal consistency and content validity of their scales. In the quantitative cross-sectional studies, the sample size varied from 15 to 369 nursing students. Three studies mentioned their response rate varying from 36.3% to 75% for the student population.14,17,18 The study of Edward and Preece14 also used a sample of nine nurse educators with a response rate of 100%. The sampling methods were convenience sampling,14,15,17,18 random sampling,19 and purposive sampling.16 The criteria used to purposefully select the participants in this study were not mentioned. In the longitudinal study of Nolan and Markert,18 the convenience sample consisted of 34 students and the dropout rate was 19 of 34 students. 3


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The qualitative studies used participant observation,20 focus groups,21 and semi-structured interviews.22 Two studies used a variety of methods to enhance the trustworthiness: verbatim transcription of the interviews, maintenance of an audit trial, data triangulation, peer debriefing, reflexivity, and investigator triangulation.21,22 Only the study of Vanlaere et al.22 stated that data saturation was probably not reached. Sample sizes varied from 15 to 110 nursing students. The study of Parsons et al.23 used the Delphi technique to explore the views of educators on the teaching of healthcare ethics. Eight of the 25 educators participated in the study from start to finish. In the mixed-methods studies, studies collected data from essays,24,25 anonymized reflection reports, formative evaluations, and tutors’ materials.26 Three studies developed a questionnaire.26–28 To complete data collection, Numminen et al.28 added one open-ended question to the questionnaire and Nasrabadi et al.27 interviewed nursing students. The sample size varied from 24 to 97 students.24,25,27 In the study of Numminen et al.,28 634 questionnaires were sent to educators and 800 questionnaires were sent to students. The return rate was 29% for the educators and 27% for the students.28

Search outcome The electronic database search produced 1783 publications, including 135 duplicates. N.C. evaluated all publications (n ¼ 1648) by title and abstract against the inclusion criteria. A total of 25 papers were identified as potentially meeting the inclusion criteria. Four additional articles were retrieved through the suggestions of B.D.D. and C.G. and by manual searching of reference lists of relevant articles. A total of 29 articles were read in their entirety and assessed again by N.C. in consultation with the coauthors. This resulted in 15 publications (Figure 1). Six studies used a quantitative design14–19 (Table 1), four studies used a qualitative design20–23 (Table 2), and five studies used a mixed-methods design (Table 3).24–28 The quantitative study of Park et al.25 replicated the study of Cameron et al.24 Five studies were conducted in the United Kingdom;14,18,20,23,26 the remaining studies were conducted in Taiwan16,19 (n ¼ 2), or the United States,24 Korea,25 Iran,27 Canada,21 Belgium,22 Turkey,15 Finland,28 and Australia17 (n ¼ 1 for each country). Six studies focused on the perceptions of students and educators on traditional ethics courses in the nursing baccalaureate curriculum.15,17,18,21,23,27 Methods used most frequently were formal lectures combined with case discussions in small groups. The content of ethics courses included ethical theories,16–19,24,25,27 ethical codes,28 ethical decision-making models,24,25 and special issues such as end-of-life decision making, confidentiality, and truth telling.18,20,26 Six studies reported results from research on an experiential working method in ethics education: anonymized reflection,26 reflective analysis,20 empathy sessions in a care-ethics lab,22 interdisciplinary courses,14 problem-based learning,19 and blended learning.16 Only two studies described the perceptions of students with the examination system.15,17 In eight studies, the sample consisted of baccalaureate nursing students in different years of their training.15–19,24,25,27 Other studies used a sample of postgraduate nursing students,20 care providers participating in an empathy session in a care-ethics lab,22 and nursing educators.23 The remaining four studies consisted of a mixed sample of students and educators,14,26,28 and of nursing students, advanced nurse practitioners, and nurses providing direct care.21 The combined research population consisted of about 1400 students and 210 nursing educators. Only seven16,18,22,24,25,27,28 studies provided detailed information about the sample, which consisted mostly of females (84%–100%). The mean ages of all participants were between 18.6 and 27.4 years (range ¼ 18–51 years).

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Records identified through database searching (n = 1783)

Records after duplicates removed (n = 1648) Reject: philosophically oriented articles, not considering the perceptions of students or educators

Records meeting inclusion criteria by title or abstract (n = 25)

Selection of papers to assess in their entirety (n = 29)

Reference list of all selected studies and of relevant reviews + suggestion of ethics expert: +4

Reject: no empirical research, not focusing on perceived effectiveness of ethics education of nursing students or educators

Review: papers included (n = 15)

Figure 1. Flow diagram of the study selection progress.

Findings The studies included in the present review described how, according to students and educators, ethics education contributes to the development of ethical competence. Participants reported that ethics courses increased ethical perception of nursing students and contributed to the development of reflective, analytical, and reasoning skills. According to students and educators, some specific teaching methods and ethics course contents were perceived as influential sources for developing ethical competencies, while others were considered to be less influential. Students and educators also described important features of ethics education essential for it to be effective. In the following sections, we describe the general perceived contribution of ethics education to ethical competence, the perceived contribution of specific teaching methods and course contents, the features of ethics education as described by students and educators being of importance to effective ethics education and students’ and educators’ perceptions with the examination system used in ethics education.

General contribution of ethics education to ethical competence According to students and educators, ethics education increased awareness in nursing students of the importance of ethics in nursing and of the complexity of ethical issues in caring practice (ethical perception).14,18,23,27 Students mentioned how they learned to challenge their established practices. Students 5


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Data collection

Data analysis

Ethical considerations

United Nolan and Kingdom Markert18

(continued)

Descriptive: Convenience Student survey: selfFrequency data Interdisciplinary sessions of To establish the negative and sample—37 second-year administered questionnaire nursing students and medical positive aspects of the nursing students and 40 completed during the last students interdisciplinary sessions as Small group discussion student third-year medical students, seminar; including open- and experienced by both led, with a facilitator, groups RR ¼ 75% (n ¼ 28 nursing closed-questions on the students and facilitators, and of 4/5, case studies þ ethical students and n ¼ 30 medical operational aspects and sugto elicit their views dilemmas that students may concerning the possibility of students); 9 nurse lecturers gestions to improvement have encountered during improving the course and and 13 medical staff, RR ¼ Facilitator survey: selftheir practice settings applying it to other aspects 100% (n ¼ 9 nurse lecturers administered questionnaire of their training and n ¼ 13 medical staff) sent 1 week after the last seminar; asking for comments on negative and positive points of the course and suggestions to improvement 20-h ethics course as part of To determine the views and Descriptive: Convenience Questionnaire developed by Descriptive Informed consent nursing history and ethics opinions of students on the sample—113 second-year the researchers based on statistics course (3 credits) content of the nursing ethics nursing students experience and literature course, the testing system, Questionnaire: 21 items on the Methods: formal lectures, and some educational content subheadings of the question and answer characteristics of the nursing ethics unit, the sessions, case study teachers examination system, the discussions in small groups, educational characteristics presentations of the teacher Examination: presentation, written essays, final multiple-choice examination 30-h ethics course To explore the understanding Descriptive: Longitudinal Questionnaire: 29 forced Descriptive Content: ethical reasoning, of nursing students and study—comparing the choice questions on ethical statistics; deontology, utilitarianism, changes in their results with the study of thinking, with three new quantitative respect for persons, truth understanding and 1995 (study of the ethical items to elicit developments content telling, informed consent, approaches to practice over awareness of first-year in the students’ ethical analysis end-of-life decisions, pertheir 4 years of training medical, dental, nursing stuthinking over the years of sonal choice, fair distribution dents in their first year, their training of healthcare resources To identify and compare the Nolan and Smith, 1995)34 5 vignettes presenting presentation to the peer ethical values and thinking of Descriptive: healthcare dilemmas to group of their clinical pracnursing students at the Convenience sample comment upon tice and analysis from an beginning and at the end of —34 fourth-year ethical perspective their professional studies nursing students, dropout ¼ 19 from 34 nursing students who had completed, in their first year, a questionnaire regarding their ethical awareness

Design: sample, response rate (RR)

United Kingdom— University School of Nursing and Midwifery

Aims of the study

Ethics course: organization, content, and method

Country setting

Turkey— Dinç and University Go¨rgu¨lu¨15 School of Nursing

Edward and Preece14

Author

Table 1. Quantitative studies included in the literature review.

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Ethics course: organization, content, and method Aims of the study

Taiwan—Public Nursing College

Australia— University School of Nursing and Midwifery

Kalaitzidis and Schmitz17

Pretest–posttest experimental design: Random sample— 142 nursing students, experimental group n ¼ 72, control group n ¼ 70


Blended learning: 11 ethical To study students’ satisfaction Descriptive, questionnaire and attitudes as members of survey design: Purposive scenario-based sessions sample—99 baccalaureate Content: four principles, a scenario-based learning second-year nursing ethical issues process in a blended learning Method: 1-h lecture by environment students instructor, group discusTo study the relationship sions, online materials, feedbetween students’ satisfacback by students online tion ratings of nursing ethics course and their attitudes in the blended learning environment 5 h of lectures and another 8 h To elicit students’ perceptions Descriptive, questionnaire of tutorials (discussions, case of the usefulness or survey: Convenience scenarios) relevance of the ethics sample—396 final-year bacContent: overview of ethical teaching to their clinical calaureate nursing students, theories, four ethical nursing work RR ¼ 36.3% (n ¼ 144) principles of autonomy, beneficence, nonmaleficence and justice, applications of these principles in practice, ethical decision models Assessment: group presentation on an ethical issue taken from the students’ clinical practice

Taiwan— 1-h 40-min session every week To compare the educational over 8 weeks results of peer tutor Department problem-based learning and of Nursing at Method: problem-based learning versus conventional Taipei conventional teaching in teaching Medical nursing ethics education Content: virtue ethics, four University ethical principles, nurse– patient relationship, rights and responsibilities of nurses and patients, codes of ethics, ethical guidelines, ethical issues

Country setting

Hsu16

Lin et al.19

Author

Table 1. (continued)

Data analysis

Questionnaire: administered 1 Descriptive year after they had statistics successfully completed the topic þ had undertaken two clinical placements after the ethics topic Questionnaire included closed questions containing background information and addressing the relative value of various aspects of the ethical component of the topic, students’ perceived ability to identify, describe, explain, and justify ethical situations in the context of clinical practice, and open questions addressing additional comments about situations where knowledge made a difference

T-test; analysis Pretest questionnaire of variance administered immediately prior to the education program. Posttest questionnaires administered immediately after the end of the course Pretest and posttest questionnaire: nursing ethical discrimination ability scale: 9 situations and 41 questions Posttest questionnaire: the learning satisfaction survey Included three open-ended questions and six closedended questions on learning satisfaction Demographic questionnaire: Frequency Case Analysis Attitude Scale data; (CAAS)—14 items on descriptive attitudes of students in doing statistics ethical case analysis; Blended Learning Satisfaction Scale (BLSS)—18 items

Data collection

Approval from the University’s social and behavioral research ethics committee

Approval of the institutional review board; consent; confidentiality

Confidentiality


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20

Parsons et al.23

Durgahee

Author

United Kingdom— nine universities

United Kingdom

Country setting

Reflective diary and reflective diary sessions: share through storytelling, group formation, and discussion


To discuss, elaborate, and explore the views of teachers of HCE To gather qualitative data on the teaching of HCE to students of nursing To test the applicability of the Delphi technique

To explore and identify the possible effects of reflective analysis on the nurses’ abilities in ethical decisionmaking

Aim(s) of the study

Table 2. Qualitative studies included in the literature review.

Delphi technique: Convenience sample—25 lecturers in mental health nursing of nine UK universities, RR: 44% in round one (n ¼ 11); 9 lecturers in round 2; 8 lecturers continued until the end of the study (round 3)

Illuminative evaluation and research model: 110 nurses working in community, hospital and psychiatric settings, undertaking a diploma-level course in the care of the dying

Sample

Data analysis

Participant observation of 60 Qualitative reflective diary sessions: analysis; group discussions with 10 constant groups of 11 nurses comparison exploring the learning process that the students felt they underwent and what they learnt about the ethical decision-making process Three rounds; postal Comparison questionnaire, semiand content structured questions and analysis Likert statements Round 1: questions covering the organization, methods, assessment, and content of the HCE module Round 2: role of case studies, reasons for providing nurses with a formal education in HCE, value of role models, interpretations of virtue ethics, positive and negative features of the fourprinciples approach Round 3: content and timing of HCE

Data collection

(continued)

Informed consent


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Belgium— Careethics lab, sTimul

Vanlaere et al.22

Aim(s) of the study

Sample

Data collection

To explore the meaning of and 87 participant nurses, advanced Focus groups (4 with enactment of ethical practitioner nurses, and nursing students, with practice for three groups of third- and fourth-year bac3–7 participants) nurses: nurses providing calaureate nursing students direct care, APN, nursing students To understand: how nurses humanly involve themselves as ethical agents what helps them to develop the knowledge and ability to live in and navigate their way through the shifting terrain of ethical nursing practice? Empathy sessions: two days and To gain insight into the impact Randomized sample—15 care Semi-structured narrative providers: 14 women, 1 interview one night, simulation of care of empathy sessions on the man, age range ¼ 42 years, providers as a patient, empathic abilities of care RN, cleaning or logistic receiving care from nursing providers who underwent assistant, healthcare students, followed by an empathy session in the sTimul care-ethics lab as assistant and kinesistherapy discussion and reflection simulated patients


APN: advanced practice nurse; HCE: healthcare ethics; RN: registered nurse.

Canada— Number of clinical settings

Doane et al.21

Author

Country setting

Table 2. (continued)


Qualitative analysis; thematic analysis

Informed consent; anonymity; confidentiality

Qualitative Approval from the analysis; university research review committee and independent coding from each of the agencies that employed the nurse participants

Data analysis

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Nasrabadi et al.27

Numminen et al.28

To explore nursing students’ experience of an ethical problem involving nursing practice To explore nursing students’ experience of using an ethical decision-making model To explore nursing students’ experience of an ethical problem involving nursing practice To explore nursing students’ experience of using an ethical decision-making model To evaluate the effectiveness of using anonymized reflection when teaching ethics in the ‘‘Care of the dying patient and family module’’

Aim(s) of the study

Data collection

Descriptive: Purposive sample— 24 students (all qualified nurses) and 2 lecturers, RR, postal questionnaire: 42% (n ¼ 10); RR, assignments: 62% (n ¼ 15)

Frequency Ethical enquiry phenomenological Essays designed to evaluate data; application of the nursing approach: Convenience content ethics seminar content, by sample—97 Korean female analysis asking how the ethical decision baccalaureate nursing model helped them in students resolving the ethical dilemma

Approval by the research and ethics committee of the university; informed consent; anonymity

Approval of the university’s ethical committee; informed consent; confidentiality; anonymity Approval of the research ethics committee; informed consent; anonymity; confidentiality

Approval by the ethics committee; consent; anonymity

Approval by the ethics committee; consent; anonymity

Ethical Data analysis considerations

Frequency Ethical enquiry phenomenological Essays designed to evaluate data; application of the nursing approach: Convenience content ethics seminar content, by sample—73 baccalaureate analysis asking how the ethical decision nursing students model helped them in resolving the ethical dilemma


Completed anonymized Descriptive reflection reports statistics; thematic Copies of the students’ analysis theoretical assignments Tutors’ concept maps Formative evaluations Tutors’ personal reflections Postal questionnaires Questionnaire: three structured Descriptive 634 nurse ethics educators and Nursing codes of ethics To describe the views of Finland—39 statistics; questions about the need, the 800 nursing graduating nurse educators and nursing inductive application, and teaching of students: RR, nursing students on teaching education content codes in nursing, with an education units: 96% (n ¼ 24); nurses codes of ethics units from 25 analysis opportunity to provide a RR, educators: 29 (n ¼ 183); polytechnics written response; one open RR, students: 27% (n ¼ 212) question about how teaching of codes should be developed Iran—School of Traditional course: ‘‘nursing history, To compare the perceptions Action research: Traditional Perception questionnaire: Descriptive Nursing and deontology and law’’ Two unit and behavior scores of the course—21 traditional class Behavior checklist—exam statistics; Midwifery course, traditional approach, students in the action first-year baccalaureate nurwith multiple-choice questions t-test; lectures, teacher centered study with the scores of sing students; Innovative and cases for decision making; qualitathe students in the course—57 first-year baccaInterviews—one question: tive Innovative course: short lecture traditional course laureate nursing students what do you think about the analysis followed by case study nursing ethics course? discussions, weekly 2-h sessions, for 16 weeks, 1 semester cases (TV serial All Saints) Content: importance of ethics for nursing, basic principles of ethics, theories, some special issues

Care of the dying module: anonymized reflection, small group discussion, student led

United Kingdom

Kyle26

Three-part model nursing ethics course: (1) integration of ethics in the curriculum, (2) philosophy course in ethical theory, and (3) 4-h nursing ethics seminar using five ethical decision models Three-part model nursing ethics course: (1) integration of ethics in the curriculum, (2) philosophy course in ethical theory, (3) 4-h nursing ethics seminar using five ethical decision models

United States— Nursing college

Cameron et al.24

Ethics course: organization, content and method

Park et al.25 Korea—Two university (replication nursing of the study colleges of Cameron et al.24)

Country

Author

Table 3. Mixed-methods studies included in the literature review.

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felt invited to reveal their predispositions to act in a certain way and their attitudes, prejudices, and frames of references.14,17–20,22 Students also argued that ethics education contributed to the ethical reflecting and ethical beingcomponent of ethical competence.16–18,20,21 Through ethics education, students became aware of their personal qualities and limitations. They discovered personal and professional values.20,21 They could state their thoughts positively, and could conceive counter arguments.16,17,20 At the same time, students mentioned how this increased awareness and reflective attitude created uncertainty.18,20 Educators also experienced that students’ dogmatism was replaced by uncertainty and doubt. In view of this uncertainty, educators stressed the importance of acquiring confidence and security as key in ethics education.23 According to students and educators, ethics education also influenced students’ analytical and problemsolving skills related to ethics. Students perceived that ethics courses had an immediate impact on their ability to identify and describe ethical issues, to understand, explain, and to justify ethical issues.16,17,19,21 Only Vanlaere et al.22 mentioned how ethics education was perceived to affect the ethical behavior of their participants. Some participants mentioned how they introduced minor changes into their own practice, such as avoiding noise during mealtimes or not mixing various foods together, because of their own related negative experiences as a patient in the care-ethics lab.

Perceptions of the contribution of teaching methods Students regarded lectures as dull, impractical, not motivating, and teacher centered. Students did not feel involved in lectures.27,28 Both students and educators considered case studies to be meaningful and appropriate.14–16,23,28 Engaging in ethical case analysis provided students with a better understanding of the ethical conflicts. It made students develop a deeper understanding of the concepts of ethics in nursing and their applications.16 According to students, case studies were also useful for helping them develop ethical decision-making skills.15 They mentioned, however, some important drawbacks of case studies: They were too vague or obvious,14 and time for discussing the cases was limited.15 Educators also warned of the danger of relying too heavily on case studies. According to them, presenting cases as clear-cut scenarios may tempt students to focus on how a certain person acted at one time in one place, causing them to act in the same way without considering the specific context of their practice.23 Students underlined the importance of using patient cases from their own clinical practice.26–28 In addition to case studies, students also appreciated group discussions. Student participation and interaction were perceived to be important.15,16,26–28 In the studies of Durgahee20 and Kyle,26 students perceived group discussions about dilemmas as the ‘‘place’’ where learning happened. While discussing situations in the group, students felt invited to listen to colleagues and to restrain their own views. It helped them to affirm their thoughts positively and to express their thoughts carefully and with clarity.20 Six studies discussed the specific value of innovative teaching methods in ethics education. The study of Hsu reported statistically significant correlations between students’ satisfaction with blended learning, that is, a hybrid of traditional face-to-face classroom lectures and e-learning. By social exchange of ideas with classmates and teachers and by using scenario instruction, students felt enabled to develop critical analysis and problem-solving skills.16 Lin et al.19 indicated that problem-based learning was preferred by students to conventional teaching. According to the students of the experimental (problem-based learning) group, selfmotivated learning, moral self-cultivation, understanding of nursing ethics, and critical thinking were promoted by using problem-based learning. Durgahee20 and Kyle26 suggested that reflection, in combination with group discussions, was perceived as an effective method for teaching ethics. Durgahee20 studied the use of reflective diary sessions where 11


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students were encouraged to share their notes through storytelling. Although students felt vulnerable in reflective groups, the majority of students participating in this study felt that discussion helped them to think about their experiences, and to question their convictions and attitudes. Kyle26 studied the method of anonymized reflection, in which reflections were anonymized, and redistributed to students, so that they never retrieved their own scenario. The reflections were discussed in small groups. The anonymity of the students’ reflections was significant to them, as anonymity prevented the students from feeling vulnerable. Edward and Preece14 studied nursing and medical students’ experiences with interdisciplinary teaching. Student-led small group discussions of cases on different ethical issues were considered to be meaningful. Many students stated that hearing and appreciating the variety of views of others were important. In the care-ethics lab, studied by Vanlaere et al.,22 students experienced how the rather negative experiences of being a simulation patient related, for example, to feelings of cold and pain, powerlessness and insecurity, and not being considered as a person. According to them, these contrasting experiences exposed self-evident beliefs, made them reflect on their own practices, and led to new insights into their view on care. Some participants mentioned how they introduced minor changes into their own practice because of their experiences during the sessions.

Perceptions of the contribution of ethics education content Three studies investigated the perceived effectiveness of ethical theories in nursing ethics education.15,17,23 In the study of Dinç and Go¨rgu¨lu¨,15 91.2% of the students stated that the teaching of ethical theories was adequate. In the study of Kalaitzidis and Schmitz,17 38.2% of the students perceived utilitarianism as useful in practice, and 32.6% of the students perceived deontology as relevant to their clinical nursing work. The four-principles approach was considered useful by 52.1% of the students. According to educators, the positive features of the four-principles approach were that it widens one’s thinking beyond the obvious and provides a framework to base one’s ethical thought. A negative feature of the four-principles approach mentioned by the participants was that it could become formulaic, leading to justification of action rather than to clear ethical thought.23 In the study of Parsons et al.,23 some educators expressed uncertainty surrounding the teaching of virtue ethics due to their limited knowledge of this area. Numminen et al.28 investigated the views of students and educators on the teaching of ethics codes. The majority of students and educators regarded the codes as a basis of professionalism, enhancing professional growth and identity. Codes were perceived as a guide for ethical decision making. However, both educators and students believed that the teaching of ethics codes should be supplemented with other ethics-related material. Some students found the codes to be outdated, limited in scope, or too general in content. Some students even questioned their applicability in practice, because they perceived a difference between theoretical education and nursing practice.28 Two studies examined the experiences nursing students had when attending ethics courses that included five ethical decision-making models.24,25 Students felt supported by the models to understand ethical conflicts, to be more systematic, and to develop the ability to resolve and rationalize ethical issues. Students mentioned how the decision-making models provided a framework, guiding them to think in a more objective way and to clarify values. They reduced stress, provided an ethical lexicon, and helped filter bias and injustice, resulting from one’s own value system.24,25

Essential features of ethics education Features perceived to contribute to the effectiveness of ethics education in nursing were mentioned by the participants of various studies: the combination of theory and practice, organizational elements such as time and integration of ethics in the curriculum, and characteristics of the teacher. 12


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Combining theory and practice was considered to be an essential feature of good teaching. Students argued that ethics education should be grounded in real clinical practice.20,21,26–28 In two studies participants described the effective use of educational tools, such as reflection reports or diaries in which students described cases from their own clinical practice, that provided them the opportunity to link their everyday experience with ethical theory.20,26 Both educators and students noted that ethics education demands significant time.14,15,23,28 Students argued that more time was needed for student discussions in an intimate classroom setting.14,15,28 As educators perceived that ethics was being taught at a superficial level, they argued that more time should be devoted to ethics courses, so that the material could be thoroughly covered.23,28 Some studies raised the question: at what point in the curriculum should ethics be taught? In the study of Nolan and Markert,18 students preferred ethical courses both at the beginning and at the end of their professional training. In the study of Parsons et al.,23 some educators commented that students need a certain amount of ethical knowledge prior to clinical practice. Both students and educators proposed that nursing ethics should be integrated into all nursing subjects and throughout all study years. However, other participants stressed the need for a separate ethics course, which would promote a more systematic approach.23,28 Students stressed the importance of the skills of educators in ethics education. They reported that teachers should be able to stimulate students via gentle persuasion rather than via excessive theoretical commentary. Teachers needed to balance being supportive and being challenging. An educator’s supportive attitude contributed to a sense of confidence and security in those students who might feel uncertain and vulnerable during the reflection process.20,21,26 Other prerequisites mentioned by students contributing to creating a safe learning environment were the explicit knowledge base of the educator,14,15,21,26 the ability to promote student interaction and participation,14–16,28 and the ability to create a positive group atmosphere.26,27

Examination system Of the two studies that mentioned the presence of evaluation activities in the ethics course,15,17 only one study15 asked for the perceptions of the students with the testing system. Group presentations on an ethical case from the students’ clinical practice in combination with a written essay and a final multiple-choice exam were perceived as adequate by more than half of the students. However, about 30% of the students also rated these examination activities as moderate or inadequate.

Discussion Methodological issues The international character of this review enables us to present a broad picture of how students and educators perceive the contribution of ethics education to ethical competence of nursing students. Studies from 10 different countries were included, representing four different continents: Europe (n ¼ 7), North America (n ¼ 2), Australia (n ¼ 1), and Asia (n ¼ 5). Our analyses of the 15 articles suggest that there is an ongoing international discussion about teaching ethics to nursing students. However, combining data that originate from different countries and cultures is a complex task and may impose constraints on our conclusions. Cultural differences might play an important role in comparing perceptions of students and educators about the contribution of ethics education. The different research settings, participants, and data collection methods as well as the inclusion of quantitative, qualitative, and mixed-methods studies add to the diversity of this review. While the quantitative studies mostly considered the degree of student satisfaction or perceived usefulness of ethics 13


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education in practice, the qualitative studies provided additional insight into the meaning of some educational processes that contribute to the development of students’ ethical competencies according to students and educators. When interpreting the results of this review, readers need to consider some methodological shortcomings. The variety of the included studies led to highly fragmented research material that was difficult to integrate. In this review, we focused on self-reported assessment of ethics education. The methods used to assess how students and educators perceive the contribution of ethics education to ethical competence varied among the papers. Within the studies, ‘‘contribution of ethics education’’ was operationalized as the perceived impact on ethical skills, the perceived usefulness in practice, the evaluation of positive and negative aspects of ethics courses, and satisfaction with specific contents or methods implemented in ethics education. Moreover, these perceived effects such as ‘‘usefulness in practice,’’ ‘‘impact on ethical skills,’’ ‘‘adequate,’’ and ‘‘enhancing professional care, growth and identity’’ are not clarified or operationalized in the studies. These diverging approaches and this vagueness in vocabulary to describe the real contribution of ethics education point to the complexity of examining the contribution or effects of education which is just as large and difficult as the topics of ethics and education themselves. The included studies all used a self-developed measure. Yet, few studies provided detailed information about the items in their questionnaire. Hence, it was difficult to compare the results. Moreover, only two studies established the reliability and validity of their questionnaires.16,19 In addition to the limited validation of the instruments used in the studies, the large variation in sample sizes and the meager description of the subjects in the samples can further limit the generalizability of our conclusions. All included articles were published over a 20-year period from 1992 to 2012, during which ethics course content and teaching methods might have evolved significantly. In addition, the small number of studies reveals the paucity of research explicitly concerned with the perceived contribution of ethics education. Yet when considering the argument-based literature about ethics education in nursing, a considerable number of articles have been published. Those articles mostly deal with theoretical or philosophical discussions about ethics education in nursing, suggesting that ethics educators are preoccupied with philosophical and substantive ethics-related topics rather than with empirical outcomes. This review did not identify disparities between the perceptions of students and educators about the impact of ethics education. However, there is little research available on the perceptions of educators about the contribution of ethics education. For this review, we retrieved only one study with a single sample of educators23 and three studies with a mixed sample of educators and students.14,26,28 Moreover, in reporting their results, few studies explicitly differentiated between the perceptions of students and educators.

Substantive findings Despite the methodological limitations of this review, some tentative conclusions about the contribution of ethics education to ethical competence can be drawn. The findings of this review suggest that during training, students and educators perceive an increase in students’ ethical perceptive, reflective, and decisionmaking skills. However, they barely mentioned the contribution of ethics education to the development of ethical behavior in nursing practice. According to students and educators, reflective skills seem to be realized by stimulating students to reflect on personal and professional values, to question their practice, and to clarify their own predispositions and convictions. By implementing ethical decision-making models, by analyzing and discussing cases from clinical practice in a systematic way with other students and with educators, and by using tools such as reflection reports, students feel more able to identify, to explain, and to resolve ethical issues in practice. Only one study mentioned the value of education in the development of ethical behavior in practice. In this study, some participants indicated that their experience not only sparked new insights but also changed their 14


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behavior in practice.22 These findings probably indicate that the whole range of ethical skills (knowing, seeing, reflecting, doing, and being) cannot be realized only by formal teaching. Much ethical learning takes place next to the formal teaching by means of other strategies such as role modeling.1 The qualitative findings of this review allow us to formulate some tentative conclusions about teaching methods and features relevant to students’ ethical development. According to students and educators, active involvement in ethics courses contributed to the development of ethical competencies. This was supported by the studies of Auvinen et al.29 and Numminen and Leino-Kilpi,30 which concluded that curricula emphasizing the active involvement of students in ethical decision making, as opposed to more passive lecture-type exposure to ethical problems, tend to promote the development of ethical judgment. The use of activating teaching strategies, such as group discussions, case analysis, and reflection sessions, enable students to apply ethical knowledge in real care situations.31 However, students and educators emphasized that the use of activating strategies demands careful consideration. First, although students perceived lectures as dull and not motivating, students and educators underlined the need for lectures on basic ethical principles, as students require a certain amount of ethical knowledge before they can apply it in practice. Educators warned against relying solely on case studies to teach ethics, stating that separate theoretical courses should implement a more systematic approach in teaching ethics to nursing students.6,23,28 Second, case studies, considered by students and educators as a meaningful tool for guiding reflection sessions and group discussions, need to be detailed and not superficial. According to them, cases should not be described as definite, and they must be consistent with students’ own clinical practice. Sufficient time is needed to reflect on case studies from the students’ clinical practice. Previous research indicates that more hours of ethics education is associated with higher moral reasoning in students.7 Third, students and educators believe that reflecting on practice, discussing conflicting viewpoints, and self-examination increase the vulnerability in students, thus creating uncertainty. These findings suggest the need for creating a safe environment. Students and educators mentioned some requisite strategies for establishing a safe learning environment. Students felt more confident when they were equipped with frameworks and systematic approaches—such as ethical decision-making models and ethical theories—that permitted them to reflect in a systematic way. Students also considered experienced teachers to be important, as they acted as role models that balanced being supportive and challenging and that provided theoretical input. Other strategies such as the anonymity of cases, an intimate classroom setting, and a democratic climate also contributed significantly to the feeling of security. When considering the content of ethics courses examined in this review, almost all included ethical principles,14–19,23–25,27 ethics codes,28 and ethical theories such as the four-principles approach,16,23–25,27 deontology,24–27 and utilitiarism.15–27 Only three studies mention virtue ethics23–25 and one study22 refers to empathy as a care ethic framework used to develop a very specific ethics course content and method. These course contents indicate that medical and rather rationalistic approaches in nursing ethics teaching remain influential. This finding is confirmed by other argument-based ethics literature reviews indicating the predominance of the principle-based approach rather than a care-ethics approach in nursing ethics-related topics.32,33 Indeed, ethics courses focused very little on care ethics, virtues, and the reciprocal relationships between a patient and a nurse. The study of Parsons et al.23 revealed that educators felt uncertain and hazy about teaching virtue ethics, because of limited knowledge in this area and ambiguity about how to teach virtue ethics. In contrast to the vagueness associated with teaching virtue ethics, teaching normative principles of ethics codes was more clear-cut, because these principles clearly demarcate the boundaries within which nurses must act. They consist of postulated principles, and they result in a justifiable outcome when strictly followed.23 To develop a virtue of caring and a caring attitude next to the development of knowledge of ethical principles and ethical theories, other strategies such as role models and critical 15


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reflection on behavior in clinical internship are considered more appropriate than a traditional ethics course in a classroom setting.31 As this review is focused on ethics education in nursing curricula, the studies retrieved concentrate on traditional ethics courses and not on the contribution of critical reflection on behavior in clinical internship to the development of ethical competence. More research is needed to describe the contribution of reflection on students’ clinical internship to the development of the different skills related to ethical competence. In the studies included in this review, very few studies focus on the perceptions of students with the examination system. This finding suggests that the evaluation of ethical competence (and research about it) might be problematic and challenging as ethical competence comprises a wide range of learning objectives. A variety of methods of evaluation might be necessary to assess ethical competence in nursing students.1

Conclusion This review shows that according to nursing students and educators, ethics education contributes to the ethical awareness (ethical perception) and ethical reasoning competencies (ethical reflection) of nursing students. The accounts of students and educators point to the importance of carefully considering the use of activating and student-centered teaching strategies in addition to theoretical frameworks, a safe learning environment, and adequate support. To develop ethical competencies, students feel invited to question their own values and convictions, to reflect on their care practices, and to discuss these with other students. According to students and educators, this creates a certain amount of vulnerability and uncertainty, which they believe can only exist in a safe learning environment created by supportive educators acting as knowledgeable and competent role models, by small groups, and by providing students with tools such as theoretical frameworks and ethical decision-making models. This review also reveals that studies on the contribution of ethics education to the goals set out by ethics education are scarce. Consequently, there is a clear need for further research. A better understanding of influential factors and of the learning process of nursing students who are developing ethical awareness (perception), ethical reasoning (reflection), and specifically ethical behavior can guide the development of ethics education in the nursing curriculum. In addition, researchers must pay more attention to the methodological accuracy of sampling and measuring instruments and to assessing their validity and reliability. Instruments should be designed to measure the impact of ethics education on reflective and analytical skills as well as on behavioral competencies. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not for profit sectors. References 1. Gallagher A. The teaching of nursing ethics: content and method. In: Davis A, Tschudin V and De Raeve L (eds) Essentials of teaching and learning in nursing ethics: perspectives and methods. London, UK: Churchill Livingstone, 2006, pp. 223–239. 2. Dierckx de Casterle´ B, Izumi S, Godfrey NS, et al. Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis. J Adv Nurs 2008; 63(6): 540–549. 16


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