Article

Effectiveness of ethics education as perceived by nursing students: Development and testing of a novel assessment instrument

Nursing Ethics 2015, Vol. 22(3) 287–306 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014538888 nej.sagepub.com

Tine Vynckier Catholic University of Leuven, Belgium; University Hospitals Leuven, Belgium

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

Abstract Background: The effectiveness of ethics education continues to be disputed. No studies exist on how nursing students perceive the effectiveness of nursing ethics education in Flanders, Belgium. Objectives: To develop a valid and reliable instrument, named the ‘Students’ Perceived Effectiveness of Ethics Education Scale’ (SPEEES), to measure students’ perceptions of the effectiveness of ethics education, and to conduct a pilot study in Flemish nursing students to investigate the perceived efficacy of nursing ethics education in Flanders. Research design: Content validity, comprehensibility and usability of the SPEEES were assessed. Reliability was assessed by means of a quantitative descriptive non-experimental pilot study. Participants and research context: 86 third-year baccalaureate nursing students of two purposefully selected university colleges answered the SPEEES. Ethical considerations: Formal approval was given by the ethics committee. Informed consent was obtained and anonymity was ensured for both colleges and their participating students. Findings: The scale content validity index/Ave scores for the subscales were 1.00, 1.00 and 0.86. The comprehensibility and user-friendliness were favourable. Cronbach’s alpha was 0.94 for general effectiveness, 0.89 for teaching methods and 0.85 for ethical content. Students perceived ‘case study’, ‘lecture’ and ‘instructional dialogue’ to be effective teaching methods and ‘general ethical concepts’ to contain effective content. ‘Reflecting critically on their own values’ was mentioned as the only ethical competence that, was promoted by the ethics courses. The study revealed rather large differences between both schools in students’ perceptions of the contribution of ethics education to other ethical competences. Discussion and conclusion: The study revealed that according to the students, ethics courses failed to meet some basic objectives of ethics education. Although the SPEEES proved to be a valid and reliable measure, the pilot study suggests that there is still space for improvement and a need for larger scale research. Additional insights will enable educators to improve current nursing ethics education.

Corresponding author: Tine Vynckier, Department of Health Care and Technology, Catholic University of Leuven, Herestraat 49, 3000 Leuven, Belgium. Email: [email protected]

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Keywords Ethics education, nursing, psychometric testing, pilot study, students

Background Ethics training is paramount for all professionals in healthcare. According to the European Directive 2005/ 36/EC,1 nursing training programmes must ensure that students acquire sufficient knowledge about nursing ethics and skills needed to deal with ethically sensitive situations. Research shows that ethics education in general has a positive effect on the ethical development of nursing students.2–10 Moreover, students themselves claim that ethics is an important part of their training.5,10,11 However, studies reveal that nurses do not feel adequately prepared to deal with ethical problems in daily practice.10,12–14 This raises the question of whether ethics education in nursing is sufficiently effective in developing ethical knowledge and skills in nursing students. It also raises the question of which method or content really contributes to the ethical preparedness of nursing students and nurses. Several methods2–6,11,15–19 are used to study the effectiveness of ethics education. Some questionnaires focus on content (e.g. ethical codes18) or on a specific method (e.g. problem-based learning4). No general instrument is available for measuring the impact of ethics courses on developing ethical competences. Besides focussing on different aspects of ethics education, instruments used thus far to study the efficacy of ethics education have some significant methodological limitations. These include limited descriptions of the development of the questionnaires; limited descriptions of the questionnaire items and limited information about the reliability, validity, user-friendliness and usability of the instruments. Although Lin et al.’s4 instrument is clearly defined and has been assessed for its reliability and validity, it is rather limited because it consists of only six closed-ended and three open-ended questions, focussing rather on learning satisfaction issues than on ethical competencies related to clinical practice such as ethical decision-making. To our knowledge, no studies exist on how nursing students perceive the effectiveness of nursing ethics education in Flanders, Belgium. More insight into the perceived effectiveness of ethics education would enable us to better prepare students to take ethical responsibility in their future nursing jobs.

Research objectives The objectives of this study were first to develop a valid and reliable instrument that measures the effectiveness of ethics education as perceived by baccalaureate nursing students and second to conduct a pilot study in Flemish nursing students to provide new insight into the perceived efficacy of nursing ethics education in Flanders.

Research design – participants and research context Scale development and validity testing Development of the Students’ Perceived Effectiveness of Ethics Education Scale. Figure 1 outlines the scale development process for the Students’ Perceived Effectiveness of Ethics Education Scale (SPEEES), the name we give our novel instrument. Steps in development (A) to content validation (B) and usability (C) are shown. We first produced a list of topics that are relevant for ethics education in Flanders, based on a literature search and on the current ethics curricula of the university colleges of nursing in Flanders. The SPEEES-1a questionnaire resulted from these first development steps. The list and the SPEEES-1a were presented to the research group, which consisted of the researcher (i.e. first author) and three experts in

289

A. Scale development

B. Step 2: Content validity 7 experts in nursing ethics & education. Relevance scoring of the items by e-mail. Calculation of I-CVI & S-CVI SPEEES-2b

Research team + 4 external experts: Expertise: nursing ethics & education SPEEES-2a

Researcher: 1st version of SPEEES (SPEEES-1a)

B. Step 1: expert meeting

Researcher: based on literature & ethics curricula topic list 1

A. Step 2: scale development 1st meeting: Research group: experts in nursing ethics & education Topic list 2 SPEEES-1b

A. Step 3: adaptation of topic list and SPEEES

2nd meeting: Research group: consensus Topic list 3 SPEEES-1c

A. Step 4: final topic list & adaptation SPEEES

11 students of target population: Questions about clarity, comprehensibility and user-friendliness final version (SPEEES)

C. Step 1: usability & comprehensibility

SPEEES: Students’ Perceived Effectiveness of Ethics Education Scale; I-CVI: item content validity index; S-CVI: scale content validity index.

Figure 1. Scale development, validity testing and pretest process: methodology.

B. Validity testing

A. Step 1: development of topic list

C. Pre-test

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nursing ethics. The group discussed these and produced a modified second topic list and the SPEEES-1b. Subsequently, the research group carefully discussed all the items of the topic list and of the SPEEES-1b until consensus was reached. This resulted in the final topic list and SPEEES-1c. Content validity. The content validity of the SPEEES was evaluated in two stages. For the first stage, an expert meeting with the research group and four external experts in nursing ethics and education was organised to determine whether all major and relevant aspects of ethics education were present in the questionnaire and whether the questionnaire was suitable for measuring the concept of perceived effectiveness of ethics education. ‘Effectiveness’ was defined as the contribution of an ethics course to the ethical development of students. After this meeting, SPEEES-1c was modified, based on the comments of the experts, producing the SPEEES-2a. For the second stage, the content validity of the SPEEES-2a was evaluated by computing the item content validity index (I-CVI) and the scale content validity index (S-CVI). Seven independent experts in nursing ethics and/or nursing education were asked to rate the relevance of each questionnaire item on a 4-point Likert scale. The I-CVI was calculated as follows: the number of experts giving a rating of 3 (¼ quite relevant) or 4 (¼ highly relevant), divided by the total number of experts.20 An I-CVI greater than 0.78 is generally considered to be excellent.21 To adjust the CVI for the risk of spurious, chance agreement, a modified kappa index (k*) was calculated to adjust each I-CVI for chance agreement on relevancy. Modified kappa coefficients are considered to be poor (0.74), according to Polit et al.21 To calculate the S-CVI, we averaged I-CVIs for each of the three subscales. This is known as the S-CVI/Ave method.20 Our aim was to achieve a S-CVI/Ave higher than 0.90, as recommended by Polit and colleagues.20,21 We adapted the SPEEES-2a according to the results of the I-CVI scores, producing the SPEEES-2b. Pretest: comprehensibility and usability. Finally, we tested the comprehensibility and user-friendliness of the SPEEES-2b by means of a small pretest. In total, 11 subjects from the target population were asked to answer some dichotomous questions about the clarity and comprehensibility of the scale items, the accompanying instructions and the user-friendliness of the instrument. Based on the results of this pretest, the final version of the SPEEES was created.

Explorative pilot study Design. A quantitative, descriptive, non-experimental pilot study was conducted. Sample/participants. In Flanders, 15 university colleges offer a bachelor nursing education programme consisting of 180 credits, ideally to be completed within 3 years. Colleges are free to shape their ethics course as they deem appropriate, as long as students are able to achieve the competences described in the competence profile for baccalaureate nurses.22 This pilot study was conducted at two university colleges with a baccalaureate nursing education programme. We purposefully selected two university colleges that employed a completely different approach in terms of teaching methods and ethics course content in order to expand the variety of experiences (Table 1). A course is considered to be ‘college ethics’ if it is a discrete course and if it is offered in at least one of the 3 years of training. In university college 1, students received an ethic course during the first semester of each training year. During the first 2 years, the course is given in large groups in which the lecturer mainly uses classroom lectures. Within these lectures, the lecturer uses ex cathedra teaching, group discussion, instructional dialogue, theoretical analysis and discussions of case studies. Other teaching forms the lecturer uses include problembased learning, self-reflection, internship assignments and self-study. The ethic course in the third year is

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Table 1. Comparison of the ethic courses between both university colleges. University college 1 Ethics course

1st year 2nd year 1st semester 1st semester

University college 2

3rd year 1st semester

Internship in Internship in the first Place in curriculum Internship and second semesters the first during the and second second semesters semester

1st year 1st semester Half of the students: before the internship took place; the other half of the students: half of the lectures before their clinical internship of 3 weeks, and half of the lectures after their internship

Number of credits

3

3

3

2

Number of contact hours

20

34

29

14

Teaching methods Lecture Lecture/seminar Lecture/seminar  ex cathedra teaching  ex cathedra teaching  ex cathedra teaching  group discussion  group discussion  group discussion  instructional dialogue  instructional dialogue  instructional dialogue  the analysis and  the analysis and  the analysis and discussion of case discussion of case discussion of case studies studies studies  film review  film review  theoretical analysis  theoretical analysis Problem-based learning Self-study Self-study Self-reflection Internship assignments Internship assignments Testimonies Literature discussion Task-driven education Workshops Content

Moral philosophy Care ethics Ethical principles Ethical theories Ethical concepts Ethical decision-making models Case studies Nursing ethics general topics Nursing ethics–specific themes Theological ethics topics Biomedical ethics topics Ethics consultation

Moral philosophy Care ethics

Ethical concepts

Moral philosophy Care ethics Ethical principles Ethical theories Ethical concepts Ethical decision-making models

Case studies Case studies Nursing ethics general topics Nursing ethics general topics Nursing ethics–specific themes

Visions of world religion

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given in smaller groups which allows the lecturer to use other teaching forms. Next to task-driven education, self-study, internship assignments and workshops, the students received lectures and seminars. During the lectures and seminars, the lecturer uses ex cathedra teaching, group discussion, testimonies, instructional dialogue, film review, theoretical analysis, literature discussion and discussions of case studies. The first-year students followed the lectures before any internship took place. The second-year students already had a minimum of 6 weeks internship experience, and the third-year students had at least 19 weeks of internship before their ethic course took place. In university college 2, students received 14 h of lectures in class groups of about 120 students during the first semester of the first year of their training. Within these classroom lectures, the lecturer uses – next to lectures about theoretical issues – also instructional dialogue, group discussions on case studies and film review (2 h) to promote reflection and application of theoretical issues in practice. Half of the students followed the lectures before any internship took place, the other half received half of the lectures before their internship of 3 weeks and half of the lectures after this internship. Next to these lectures, students received also in the second year of their training 1.5 h of ethical reflection on case studies integrated in the courses ‘chronic care’ and ‘palliative care’. They also make an assignment during their clinical internship in the second year of their training. A convenience sample of students was used. Students were included if they met the following criteria: third-year baccalaureate nursing student, Dutch-speaking, majoring in general hospital nursing and present at the scheduled time for completing the questionnaire. Students majoring in geriatric, paediatric, psychiatric or social nursing were excluded from the sample, because not all majors receive the same number of ethics courses. In this way, we could ensure that the sample of students was homogeneous in terms of ethics courses. Moreover, since most students opt for the general hospital nursing major, we were assured that the sample would be sufficiently large. Data collection procedure. Detailed information on the ethics courses was collected from the colleges’ website and by questioning the ethics teachers. A participation consent form was sent to department heads of the selected colleges in November 2011. After obtaining approval, the researcher contacted the colleges’ ethics teachers to organise an appropriate time for students to take the survey. In one college, students completed the questionnaire 1 h before a compulsory lesson. Their ethics teacher informed them about the study, and a reminder was posted on the electronic education platform. In the other college, all third-year students must complete 12 weeks of internships in different departments, and once a month, they gather for a reunion day. Thus, an extra hour was scheduled during one of these obligatory reunion days for the students to complete the questionnaire. However, although attendance during this reunion was obligatory, taking part in the study was not, and students were offered voluntary participation. Unlike the students of the first college, these students were not informed in advance of the study. Both visits were planned for February 2012. The researcher presented the study to the students during these visits. Afterwards, they received a questionnaire containing an information letter and a sociodemographic data sheet together with the SPEEES. Data analysis. STATISTICA 64 version 10 (StatSoft, Inc., Tulsa, OK, USA) was used for data analysis. Descriptive statistics, including frequency and percentage distributions and means, were used to profile the students and describe their perceptions about the effectiveness of the ethics course. Mann–Whitney U-tests were used for non-normally distributed, continuous data. Chi-square, Fisher’s exact and Fisher–Freeman– Halton exact tests were used for categorical variables and to compare the proportions of generally perceived effectiveness between colleges. Significance level was set at a 0.05. Questionnaires were excluded from further analysis if more than three items in the subscales had missing answers. These items were reported as ‘missing values’.

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The internal consistency of the SPEEES was assessed separately for each subscale using the Cronbach’s alpha coefficient. A coefficient above 0.7 suggests good internal consistency.20

Ethical considerations The research proposal was approved by the ethics committee of the Faculty of Medicine, Catholic University of Leuven. The head of the university colleges received written information on the purpose of the study, data collection procedures and their rights as study participants. Consent forms from both university colleges were obtained. Standard procedures were used to assure anonymity for both the institutions and their students. Students received this information orally from the researcher. Returning the completed questionnaire was considered as informed consent for participation in the study.

Findings Scale development and validity testing Development of topic list and SPEEES. The first topic list was based on a literature search on nursing ethics education3–5,11,15,18,19,22–26 and consisted of four major categories: teaching methods, content, materials and objectives of ethics education (see Figure 2). The first version of the SPEEES (SPEEES-1a) was based on topic list 1. In the second version of the topic list (topic list 2), the major categories were divided into subclasses. Some items were deleted due to overlap with other items. In the subsequent version of the SPEEES (SPEEES-1b), the content and the layout were modified to reflect topic list 2. In the final topic list (topic list 3), definitions and examples were added to make items more clear and understandable for students. Because some subclasses or categories were unclear or considered irrelevant, they were deleted from the topic list. The SPEEES was then modified to reflect topic list 3 (SPEEES-1c). To prevent students from adopting a neutral position during assessment, the original 5-point Likert scale was changed to a 4-point Likert scale. Content validity. After the expert meeting, the SPEEES was adjusted according to the remarks of the experts. This resulted in the SPEEES-2a. One item was added to subscales 1 and 2, enabling students to include other methods used or content observed during their ethics courses. None of the items had an I-CVI score less than 0.78. Also, the kappa designating agreements on relevance largely corresponded to these I-CVI scores. The subscale teaching methods had an S-CVI/Ave of 1.00, ethical content had an S-CVI/Ave of 0.86 and general effectiveness had an S-CVI of 1.00. Comprehensibility and user-friendliness. The comprehensibility and user-friendliness of the SPEEES-2b were rated by 11 third-year baccalaureate nursing students from one of the participating colleges. Completing the entire questionnaire took 15 min, on average. Two students (18%) reported that it took them too long to complete the entire questionnaire. Most students, however, found the questionnaire interesting (73%) and sufficiently clear (100%). Of the students, 91% stated that the questions were clear and easy to understand. All students (100%) agreed that the layout of the instrument was orderly. Overall, the instrument received a mostly positive evaluation from most students. One student, however, stated in the additional remarks section: ‘It was not always clear if the whole questionnaire was about one specific course’. Thus, we reformulated the questioning at the beginning of each subscale to ensure that the scale only covered ethics courses the students attended during their nursing education. We also drafted a brief introductory letter stating the

A. Scale development

SPEEES-2a (expert meeting) Subcale 1: Teaching Methods (24 items) yes/no and 4 point LS + 3 items: ‘Task Driven Education’,‘Internship as part of the ethics course’ and ‘Testimonies’ - 1 item: ‘Analysing ethical texts’ * items altered: ‘Workshops’ * new definition: ‘Problem-based Learning’ and ‘Project Education’ Subscale 2: Content (17 items) yes/no and 4 point LS * items altered: ‘General Ethical Concepts’ and ‘Ethical Decision Models’ Subscale 3: General Effectiveness (21items) 4 point LS + 1 item: ‘Transcending own emotions’ - 1 item: ‘Being involved in conducting ethical decisions’ * alteration of the order of the items SPEEES-2b (CVI) * items excluded: 0

B. Step 1&2: expert meeting and CVI : SPEEES-2

1.Teaching methods: 29 items 2.Content: 15 items 3.Materials: 8 items 4.Objectives of ethics education: 24 items

A. Step 2: SPEEES-1a Part 1: General Effectiveness (24items) 5 point LS Part 2: Teaching Methods (29 items) yes/no and 5 point LS Part 3: Content (15 items) yes/no and 5 point LS Part 4: Materials (8 items) yes/no and 5 point LS

Subscale 1: Teaching Methods (24 items) yes/no and 4 point LS * new definition: ‘Ex-cathedra Teaching’ Subscale 2: Content (17 items) yes/no and 4 point LS Subscale 3: General Effectiveness (21items) 4 point LS Reformulation of the questioning at the beginning of each subscale Information letter with general instructions on how to complete the scale

C. Step 1: usability & Comprehensibility: SPEEES final version

A. Step 4: topic list 3/ SPEEES-1c Topic list3 1.Teaching methods: 23 items * 2 subcategories: ‘types of education’ + definition & examples + 4 items: ‘Problem-based Learning’ , ‘Project Education’ ,’ E-Learning’ and ‘Blended Learning’ 2. Content: 17 items + definition & examples + changes in 8 items2 3. Supporting tools for ethics education 4. Objectives of ethics education : 20 items * 3 subcategories: ‘Development of ethical decision making and ethical reasoning’ SPEEES-1c: Subscale 1: Teaching Methods (23 items) yes/no and 4 point LS Subscale 2: Content (17 items) yes/no and 4 point LS Subscale 3: General Effectiveness (20items) 4 point

A. Step 3: topic list 2/SPEEES-1b Topic list2 1.Teaching methods: 22 items * 3 subcategories: ‘types of education’, ‘methods’ & ‘methods used in lectures and seminars’ + 1 item: ‘Knowledge Based Learning’ - 7 items1 2. Content: 15 items 3. Supporting tools for ethics education: 8 items * 2 subcategories: ‘presentation material’ and ‘study material’ 4. Objectives of ethics education : 24 items * 4 subcategories: ‘moral self development’, ‘development of ethical decision making’, ‘development of ethical behaviour’ and ‘development of ethical reasoning’ SPEEES-1b lay out + subcategories

Figure 2. Scale development, validity testing and pretest process of the SPEEES: results. LS: Likert scale; SPEEES: Students’ Perceived Effectiveness of Ethics Education Scale; CVI: content validity index. 1 ‘Response Lecture’, ‘Class Discussion’, ‘Ethical Debate’, ‘Learning and Group Conversations’, ‘Socratic Dialogue’, ‘Jointly Solve Ethical Problems’ and ‘Reflective Notebook’. 2 ‘Moral Philosophical Themes: Central Ideas of Major Philosophers & Central Themes’, ‘Moral Theological Themes: Church’s Teaching on Ethics & Ethical Vision of World Religions’, ‘Ethical Principles: Principle Approach in Medical Ethics & Other Ethical Principles’ and Themes from Nursing Ethics: General Concepts & Specific Themes.

B. Validity testing

A. Step 1: topic list 1

C. Pre-test

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purpose of the survey and general instructions so that the students would have some written information about the survey. The final version of the SPEEES consisted of three subscales: teaching methods, ethical content and overall effectiveness of ethics course. The teaching methods subscale contains 48 questions. Of them, 24 are ‘yes–no’ questions that assess whether students believe they encountered the given teaching method in their ethics courses and 24 are rating questions using a 4-point Likert scale. These questions measure the perceived effectiveness of the teaching methods. The ethical content subscale is similarly organised to the teaching method subscale, but it consists of 17 questions. The third subscale, overall effectiveness of ethics course, uses a 4-point Likert scale to measure the overall effectiveness of the ethics course. This subscale contains 6 questions about moral selfdevelopment, 11 questions about ethical reasoning and ethical decision-making and 4 questions on ethical behaviour.

Explorative pilot study Characteristics of the sample. The university colleges selected for this study had different approaches to teaching ethics (Table 1). Although there was some overlap, they differed in course credits, teaching methods and content covered. Of the 141 third-year students, 91 returned the questionnaire, resulting in a response rate of 64.5%. For university college 1, the response rate was 65.5% (n ¼ 19); and for university college 2, the response rate was 63.7% (n ¼ 72). One questionnaire was excluded from analysis due to missing answers in all sections of the SPEEES, leaving 90 questionnaires for analysis. One questionnaire was excluded because all ‘no’ boxes were ticked for the ethical content subscale. Given that students in both university colleges received an ethics course, it is impossible that they are answering they have not seen any content at all. Some other questionnaires were excluded because more than three items were blank: three in the teaching methods subscale, two in the ethical content subscale and two in the general effectiveness subscale. This left 86 questionnaires for analysis regarding the teaching methods subscale, 87 for the ethical content subscale and 88 for the general effectiveness subscale. SPEEES scores. We only describe the scores of the course methods and contents that were actually used by teachers in the respective colleges. Where necessary and/or useful, the scores are described separately for each college, and if possible, the scores of both colleges are compared. The teaching methods subscale assessed the perceived effectiveness of the teaching methods on a 4-point Likert scale. Students were asked to indicate to what extent the teaching method contributed to their ethical development. A complete summary of these results is displayed in Table 2. According to 60.5% of the students, ‘case study’ contributed greatly to very greatly to their ethical development. The majority of the students agreed that ‘lecture’ (57.9%) and ‘instructional dialogue’ (56.9%) were methods that had a great to very great contribution. Meanwhile, more than 60% of all students perceived that ‘film review’, ‘group discussion’ and ‘ex cathedra teaching’ had no or little contribution to their ethical development. The opinions of the students on the contribution of ‘seminar’ were divided. Of the students of college 1, 71% agreed that ‘workshops’, ‘self-reflection’ and ‘problem-based learning’ were teaching methods that contributed greatly to very greatly to their ethical development. ‘Literature discussion’ (63.2%) and ‘theoretical analysis’ (61.6%), on the other hand, had little or no contribution to their ethical development. Although about one-fifth of the students of college 1 stated that ‘self-study’ (21.1%) and ‘internship assignments’ (17.6%) had a very great contribution, 11.8% stated that internship assignments had no

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Table 2. Effectiveness of teaching methods’ overview. Students’ perceived contribution to their ethical development Teaching method used in both university colleges Film review

Lecture

Case study

Group discussion

Instructional dialogue

Seminar

Ex cathedra teaching

(n)

No, % (n)

Little, % Great, % Very great, % (n) (n) (n) Missing

Total (43) 7.0 (3) 55.8 (24) 32.6 (14) School 1 (19) 0.0 (0) 52.6 (10) 36.8 (7) School 2 (24) 12.5 (3) 58.3 (14) 29.2 (7) Total (83) 6.0 (5) 36.1 (30) 38.6 (32) School 1 (18) 0.0 (0) 22.2 (4) 55.6 (10) School 2 (65) 7.7 (5) 40.0 (26) 33.9 (22) Total (81) 2.5 (2) 35.8 (29) 49.4 (40) School 1 (17) 0.0 (0) 29.4 (5) 52.9 (9) School 2 (51) 3.1 (2) 37.5 (24) 48.4 (31) Total (68) 2.9 (2) 60.3 (41) 30.9 (21) School 1 (17) 0.0 (0) 52.9 (9) 35.3 (6) School 2 (51) 3.9 (2) 62.8 (32) 29.4 (15) Total (56) 3.4 (2) 36.2 (21) 50.0 (29) School 1 (12) 0.0 (0) 33.3 (4) 58.3 (7) School 2 (46) 4.3 (2) 37.0 (17) 47.8 (22) Total (50) 4.0 (2) 42.0 (21) 42.0 (21) School 1 (12) 0.0 (0) 33.3 (4) 58.3 (7) School 2 (38) 5.3 (2) 44.7 (17) 36.8 (14) Total (49) 14.3 (7) 67.3 (33) 16.3 (8) School 1 (12) 0.0 (0) 66.7 (8) 33.3 (4) School 2 (37) 18.9 (7) 67.6 (25) 10.8 (4)

2.3 (1) 5.3 (1) 0.0 (0) 19.3 (16) 22.2 (4) 18.5 (12) 11.1 (9) 17.7 (3) 9.4 (6) 5.9 (4) 11.8 (2) 3.9 (2) 6.9 (4) 8.3 (1) 6.5 (3) 12.0 (6) 8.3 (1) 13.2 (5) 2.0 (1) 0.0 (0) 2.7 (1)

2.3 (1) 5.3 (1) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 1.2 (1) 0.0 (0) 1.6 (1) 0.0 (0) 0.0 (0) 0.0 (0) 3.4 (2) 0.0 (0) 4.3 (2) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0)

Students’ perceived contribution to their ethical development Teaching methods used only in university college 1 Literature discussion Problem-based learning Self-study Task-driven education Workshops Testimonies Internship assignments Self-reflection Theoretical analysis

(n)

No, % (n)

Little, % Great, % Very great, % Missing (n) (n) (n)

School 1 (19) 5.3 (1) 57.9 (11) School 1 (19) 0.0 (0) 31.6 (6) School 1 (19) 0.0 (0) 47.4 (9) School 1 (19) 0.0 (0) 42.1 (8) School 1 (19) 5.3 (1) 21.1 (4) School 1 (18) 5.6 (1) 44.4 (8) School 1 (17) 11.8 (2) 23.5 (4) School 1 (14) 0.0 (0) 28.6 (4) School 1 (13) 7.7 (1) 53.9 (7)

26.3 (5) 57.9 (11) 26.3 (5) 47.4 (9) 63.2 (12) 50.0 (9) 41.2 (7) 50.0 (7) 38.5 (5)

10.5 (2) 10.5 (2) 21.1 (4) 10.5 (2) 10.5 (2) 0.0 (0) 17.6 (3) 21.4 (3) 0.0 (0)

0.0 (0) 0.0 (0) 5.3 (1) 0.0 (0) 0.0 (0) 0.0 (0) 5.9 (1) 0.0 (0) 0.0 (0)

contribution at all and almost half of the students (47.4%) stated that self-study contributed little to their ethical development. Their opinions were also divided about ‘task-driven education’. In college 1, more than 80% of the students correctly stated that they experienced 11 of 16 teaching methods, and 60% of the students stated that they experienced the remaining 5 methods. In college 2, more than 95% of the students indicated correctly that they experienced 7 of the 12 methods used at that college, and 65% of the students stated that they experienced the remaining 2 methods – instructional dialogue and

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Table 3. Methods’ overview. Teaching methods used according to the teachers Film review Lecture Case study Group discussion Instructional dialogue Seminar Ex cathedra teaching Literature discussion Problem-based learning Self-study Task-driven education Workshops Testimonies Internship assignments Self-reflection Theoretical analysis

University college 1: number of students who University college 2: number of students who answered correctly that they experienced answered correctly that they experienced this teaching method, % (n) this teaching method, % (n) 100 (19) 94.7 (18) 89.5 (17) 89.5 (17) 63.2 (12) 63.2 (12)a 63.2 (12) 100 (19) 100 (19) 100 (19) 100 (19) 100 (19) 94.7 (18) 89.5 (17) 73.7 (14) 68.4 (13)

35.8 (24) 97.0 (65)a 95.5 (64) 76.1 (51)a 68.7 (46) 56.7 (38) 55.2 (37)

Teaching methods that are marked italic are teaching methods of which less than 60% of the students of university college 2 answered correctly that they did/did not experience this teaching method. a Missing values were scored as incorrect.

seminar. The percentage of students who correctly stated that they experienced film review, ex cathedra teaching and seminar as teaching methods was less than 60% (Table 3). The ethical content subscale examined the effectiveness of ethical content, as perceived by the students. Students indicated on a 4-point Likert scale the extent to which the ethical content had contributed to their ethical development. The majority of students (61.7%) stated that ‘general ethical concepts’ had a great to very great contribution to their ethical development. On the other hand, more than 60% of the students from both colleges agreed that ‘moral philosophical themes’, ‘ethical theories’ and ‘care ethics’ had little or no contribution to their ethical development. It is unclear how other ethical content in the ethics courses contributed to the students’ ethical development because of the large variation in the students’ scores. These differences were noticeable between colleges and between students of the same college. A complete summary of the perceived effectiveness of ethical content is shown in Table 4. In college 1, more than 85% of the students stated correctly that they had observed their teachers discuss 12 of the 15 ethical content items, and 60% of the students stated that they recalled learning about the remaining three ethical content items. In college 2, more than 85% of the students observed 7 of the 10 items used, and more than 75% of the students recalled the other three items (Table 5). For the overall effectiveness of ethics course general effectiveness subscale, students were asked to rate on a 4-point Likert scale the overall effectiveness of ethics courses on their ethical reasoning and ethical behaviour skills. For the purpose of this study, the scores ‘no’ and ‘little’ were combined, and the scores ‘great’ and ‘very great’ were combined (Table 6). The contribution of the ethics courses to the students’ competence in ‘reflecting critically on their personal norms and values hierarchies’ was the only competence that more than half of the students of both

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Table 4. Effectiveness of content aspects’ overview. Ethical content seen in both university colleges Moral Philosophical Themes: Central Ideas of Major Philosophers Moral Philosophical Themes: Central Themes Ethical Principles: Principle Approach in Medical Ethics Ethical Theories

General Ethical Concepts

Case Studies from the Field Themes from Nursing Ethics: General Concepts Ethical Principles: Other Ethical Principles Ethical Decision Models

Care Ethics

Contribution to students’ ethical development (n)

No, % (n) Little, % (n) Great, % (n) Very great, % (n) Missing, % (n)

Total (81) 21.0 (17) School 1 (19) 21.1 (4) School 2 (62) 21.0 (13) Total (79) 11.4 (9) School 1 (19) 15.8 (3) School 2 (60) 10.0 (6) Total (76) 2.6 (2) School 1 (19) 0.0 (0) School 2 (57) 3.5 (2) Total (80) 10.0 (8) School 1 (19) 10.5 (2) School 2 (61) 9.8 (6) Total (86) 2.3 (2) School 1 (19) 0.0 (0) School 2 (67) 3.0 (2) Total (83) 1.2 (1) School 1 (17) 0.0 (0) School 2 (66) 1.5 (1) Total (75) 4.0 (3) School 1 (17) 0.0 (0) School 2 (58) 5.2 (3) Total (68) 1.4 (1) School 1 (17) 0.0 (0) School 2 (52) 1.9 (1) Total (81) 8.6 (7) School 1 (13) 7.7 (1) School 2 (68) 8.8 (6) Total (63) 6.3 (4) School 1 (12) 0.0 (0) School 2 (51) 7.8 (4)

58.0 (47) 57.9 (11) 58.1 (36) 55.7 (44) 47.4 (9) 58.3 (35) 42.1 (32) 31.6 (6) 45.6 (26) 62.5 (50) 68.4 (13) 60.7 (37) 36.0 (31) 5.3 (1) 44.8 (30) 38.6 (32) 52.9 (9) 34.9 (23) 50.7 (38) 23.5 (4) 58.6 (34) 52.2 (36) 35.3 (6) 57.7 (30) 42.0 (34) 84.6 (11) 33.8 (23) 58.7 (37) 66.7 (8) 56.9 (29)

18.5 (15) 21.1 (4) 17.7 (11) 30.4 (24) 26.3 (5) 31.7 (19) 44.7 (34) 57.9 (11) 40.4 (23) 25.0 (20) 15.8 (3) 27.9 (17) 54.7 (47) 84.2 (16) 46.3 (31) 47.0 (39) 35.3 (6) 50.0 (33) 37.3 (28) 64.7 (11) 29.3 (17) 36.2 (25) 47.1 (8) 32.7 (17) 34.6 (28) 0.0 (0) 41.2 (28) 30.2 (19) 33.3 (4) 29.4 (15)

2.5 (2) 0.0 (0) 3.2 (2) 2.5 (2) 10.5 (2) 0.0 (0) 9.2 (7) 10.5 (2) 8.8 (5) 2.5 (2) 5.3 (1) 1.6 (1) 7.0 (6) 10.5 (2) 6.0 (4) 13.3 (11) 11.8 (2) 13.6 (9) 4.0 (3) 5.9 (1) 3.4 (2) 8.7 (6) 17.7 (3) 5.8 (3) 13.6 (11) 7.7 (1) 14.7 (10) 4.8 (3) 0.0 (0) 5.9 (3)

0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 1.3 (1) 0.0 (0) 1.8 (1) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) 4.0 (3) 5.9 (1) 3.4 (2) 1.4 (1) 0.0 (0) 1.9 (1) 1.2 (1) 0.0 (0) 1.5 (1) 0.0 (0) 0.0 (0) 0.0 (0)

Contribution to students’ ethical development Ethical content only seen in university college 1 Moral Theological Themes: Church’s Teaching on Ethics Moral Theological Themes: Ethical Vision of World Religions Themes from Nursing Ethics: Specific Themes Themes from Biomedical Ethics Ethical Forms of Consultation

(n)

No, % (n) Little, % (n) Great, % (n) Very great, % (n)

Missing

School 1 (19)

5.3 (1)

52.6 (10)

36.8 (7)

5.3 (1)

0.0 (0)

School 1 (18)

11.1 (2)

33.3 (6)

50.0 (9)

5.6 (1)

0.0 (0)

School 1 (18)

0.0 (0)

22.2 (4)

66.7 (12)

5.6 (1)

5.6 (1)

School 1 (17)

11.8 (2)

70.6 (12)

11.8 (2)

5.9 (1)

0.0 (0)

School 1 (16)

6.3 (1)

87.5 (14)

6.3 (1)

0.0 (0)

0.0 (0)

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Table 5. Overview of content aspects. University college 1: ethical content given according to the teachers Moral Philosophical Themes: Central Ideas of Major Philosophers Moral Philosophical Themes: Central Themes Ethical Principles: Principle Approach in Medical Ethics Ethical Theories General Ethical Concepts Case Studies from the Field Themes from Nursing Ethics: General Concepts Ethical Principles: Other Ethical Principles Ethical Decision Models Care Ethics Moral Theological Themes: Church’s Teaching on Ethics Moral Theological Themes: Ethical Vision of World Religions Themes from Nursing Ethics: Specific Themes Themes from Biomedical Ethics Ethical Forms of Consultation

Number of students who answered correctly that they did see this ethical content, % (n) 100 (19)

100 (19)

100 (19)

100 (19) 100 (19) 89.5 (17) 89.5 (17)

89.5 (17)

68.4 (13) 63.2 (12) 100 (19)

University college 2: ethical content given according to the teachers Moral Philosophical Themes: Central Ideas of Major Philosophers Moral Philosophical Themes: Central Themes Ethical Principles: Principle Approach in Medical Ethics Ethical Theories General Ethical Concepts Case Studies from the Field Themes from Nursing Ethics: General Concepts Ethical Principles: Other Ethical Principles Ethical Decision Models Care Ethics

Number of students who answered correctly that they did see this ethical content, % (n) 91.2 (62)

88.2 (60)

83.8 (57)

89.7 (61) 98.5 (67) 97.1 (66) 85.3 (58)

76.5 (52)

100 (68) 75.0 (51)

94.7 (18)a

94.7 (18)

89.5 (17) 84.2 (16)

a

Missing values were scored as incorrect.

colleges scored great or very great (59.1%). More than 70% of all students assigned little or no contribution to ‘using ethical theories and principles of ethical reasoning’ (90.9%), ‘transcending their own emotions’ (83.0%) and ‘reaching an ethical conclusion for a particular problem in a certain context: being able to justify your decision’ (76.1%).

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Table 6. General effectiveness of the ethics courses. Perceived contribution of the ethics course to Reflecting critically on own norms and values hierarchies  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Developing own ethical awareness (values and norms)  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Developing own vision of ethical issues  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Analysing own actions in perspective of their own values and those of others  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) To be able to take an own ethical (critical) position  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Transcending own emotions  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Communicating ethical problems in team  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Communicating own vision and point of view  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Critically evaluate own care from an ethical point of view  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Critically reflect on nursing practice (care provided by others)  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Discussing potential ethical problems and conflicts in team  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Using ethical theories and principles in ethical reasoning  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69)

No/little, Great/very Missing, % (n) great, % (n) % (n)

Test

p

Chi2 w2: 0.12 0.73 39.8 (35) 36.8 (7) 40.6 (28)

59.1 (52) 63.2 (12) 58.0 (40)

1.1 (1) 0.0 (0) 1.5 (1) Chi2 w2: 6.89 0.009**

52.3 (46) 26.3 (5) 59.4 (41)

46.6 (41) 73.7 (14) 39.1 (27)

1.1 (1) 0.0 (0) 1.4 (1)

51.1 (45) 31.6 (6) 56.5 (39)

48.9 (43) 68.4 (13) 43.5 (30)

0.0 (0) 0.0 (0) 0.0 (0)

Chi2 w2: 3.71 0.05

Chi2 w2: 0.07 0.80 50.0 (44) 47.4 (9) 50.7 (35)

50.0 (44) 52.6 (10) 49.3 (34)

0.0 (0) 0.0 (0) 0.0 (0) Chi2 w2: 1.40 0.24

48.9 (43) 36.8 (7) 52.2 (36)

51.1 (45) 63.2 (12) 47.8 (33)

0.0 (0) 0.0 (0) 0.0 (0)

83.0 (73) 79.0 (15) 84.0 (58)

17.0 (15) 21.0 (4) 16.0 (11)

0.0 (0) 0.0 (0) 0.0 (0)

FE

0.73

Chi2 w2: 7.86 0.005** 72.7 (64) 47.4 (9) 79.7 (55)

27.3 (24) 52.6 (10) 20.3 (14)

0.0 (0) 0.0 (0) 0.0 (0)

55.7 (49) 26.3 (5) 63.8 (44)

44.3 (39) 73.7 (14) 36.2 (25)

0.0 (0) 0.0 (0) 0.0 (0)

Chi2 w2: 8.47 0.004**

Chi2 w2: 7.59 0.006** 59.1 (52) 31.6 (6) 66.7 (46)

40.9 (36) 68.4 (13) 33.3 (23)

0.0 (0) 0.0 (0) 0.0 (0) Chi2 w2: 4.16 0.04*

52.3 (46) 31.6 (6) 58.0 (40)

47.7 (42) 68.4 (13) 42.0 (29)

0.0 (0) 0.0 (0) 0.0 (0)

62.5 (55) 47.4 (9) 66.7 (46)

34.1 (30) 52.6 (10) 29.0 (20)

3.4 (3) 0.0 (0) 4.4 (3)

90.9 (80) 89.5 (17) 91.3 (63)

9.1 (8) 10.5 (2) 8.7 (6)

0.0 (0) 0.0 (0) 0.0 (0)

Chi2 w2: 3.22 0.07

FE

1.00

(continued)

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Table 6. (continued) Perceived contribution of the ethics course to To reach an ethical conclusion for a particular problem in a certain context: being able to justify your decision  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Being able to participate in ethical decision-making in team  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Developing an understanding of ethical decision-making processes  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Analysing ethical problems in a given context  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Observing and recognising ethical problems in a certain context  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Developing a care relationship with your patient and his family/environment  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) The ability to take action when ethical issues arise  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) The ability to apply ethical decisions in practice  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69) Developing confidence to deal with ethical problems  Total (n ¼ 88)  School 1 (n ¼ 19)  School 2 (n ¼ 69)

No/little, Great/very Missing, % (n) great, % (n) % (n)

76.1 (67) 79.0 (15) 75.4 (52)

23.9 (21) 21.1 (4) 24.6 (17)

0.0 (0) 0.0 (0) 0.0 (0)

75.0 (66) 63.2 (12) 78.3 (54)

25.0 (22) 36.8 (7) 21.7 (15)

0.0 (0) 0.0 (0) 0.0 (0)

Test

p

FE

1.00

FE

0.23

Chi2 w2: 0.28 0.60 68.2 (60) 63.2 (12) 69.6 (48)

31.8 (28) 36.8 (7) 30.4 (21)

0.0 (0) 0.0 (0) 0.0 (0) Chi2 w2: 0.55 0.81

60.2 (53) 57.9 (11) 60.9 (42)

39.8 (35) 42.1 (8) 39.1 (27)

0.0 (0) 0.0 (0) 0.0 (0) Chi2 w2: 0.02 0.88

51.1 (45) 52.6 (10) 50.7 (35)

48.9 (43) 47.4 (9) 49.3 (34)

0.0 (0) 0.0 (0) 0.0 (0) Chi2 w2: 9.47 0.002**

52.3 (46) 21.1 (4) 60.9 (42)

47.7 (42) 79.0 (15) 39.1 (27)

0.0 (0) 0.0 (0) 0.0 (0)

73.9 (65) 57.9 (11) 78.3 (54)

26.1 (23) 42.1 (8) 21.7 (15)

0.0 (0) 0.0 (0) 0.0 (0)

FE

0.08

Chi2 w2: 2.01 0.16 69.3 (61) 57.9 (11) 72.5 (50)

28.4 (25) 42.1 (8) 24.6 (17)

2.3 (2) 0.0 (0) 2.9 (2) Chi2 w2: 0.92 0.34

67.0 (59) 57.9 (11) 69.6 (48)

33.0 (29) 42.1 (8) 30.4 (21)

0.0 (0) 0.0 (0) 0.0 (0)

FE: Fisher’s exact test; Chi2: Pearson chi-square test. *p < 0.05, **p < 0.01.

In college 1, more than 60% of the students stated that their ethics courses contributed greatly to very greatly to the following: ‘developing a care relationship with your patient and his family/environment’ (79.0%), ‘developing own ethical awareness’ (73.7%), ‘communicating own vision and point of view’ (73.7%), ‘critically evaluating own care from an ethical point of view’ (68.4%) and ‘critically reflecting

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on nursing practice’ (68.4%). In college 2, however, about 60% of the students stated that their ethics course made little or no contribution to these above-mentioned competences. These differences were statistically significant at the 0.05 level. Reliability testing. The Cronbach’s alpha scores for the subscales on teaching methods, ethical content and general effectiveness were 0.89, 0.85 and 0.94, respectively.

Discussion Prior to this study, there was scare information on how nursing students in Belgium perceive the effectiveness of their nursing ethics education. Development and pilot testing of this novel ethics education assessment instrument – the SPEEES – gave us more insight into local nursing ethics education and how nursing students view it. Surprisingly, the pilot study revealed that the ethics courses currently being conducted at the two participating colleges did not always succeed to meet some basic objectives of ethics education mandated by European Directive 2005/36/EC according to the perceptions of students. The strength of the SPEEES is that it was developed systematically in a rigorous and accurate way. We worked together with several experts in nursing ethics, leading to a high level of content validity for all three subscales, as is demonstrated in the CVI and kappa scores. The Cronbach’s alpha scores of each of the three subscales were rather high, as they were all well above the 0.70 value required to support internal consistency. Our results showed that the SPEEES is a valid and user-friendly instrument that is useful for examining the effectiveness of ethics education as perceived by baccalaureate nursing students in Flanders. Our study suggests that the SPEEES is applicable in different settings as we questioned students in two different teaching settings. However, the results of the pilot study indicate that the instrument can be improved and modified further. Discussion of some methodological shortcomings of the explorative pilot study is warranted. These shortcomings mainly address the limited sample size of university college 1. The response rate amounts 64.5%, but we have no information about students who did not participate; this causes possible bias when interpreting our results. Furthermore, we only used internal consistency to assess the validity of the instrument. The results of this study revealed that case studies are valued teaching methods and that lectures are also appreciated by the students. In addition, students appreciated to varying degrees certain aspects of their ethics education that included self-reflection, workshops and instructional dialogue. Generally, students believed that it is important that the contents of ethics courses are realistic, practical and suited to their own practice. They also indicated that they are in need of general ethical concepts. The overall effectiveness of ethics courses is limited according to the students. College 1 scored only slightly better than college 2. The only skill achieved according to students’ perceptions from both colleges was reflecting critically on own values. Students of neither colleges had the perception that they achieved any competencies related to ethical decision-making. Closer inspection of the teaching methods revealed that students perceived case study, instructional dialogue, workshops, self-reflection, problem-based learning and lectures to be teaching methods that contributed greatly to very greatly to their ethical development. The literature confirms that, with the exception of lectures, the above-mentioned teaching methods are indeed perceived as adequate. In the study of Dinc¸ and Go¨rgu¨lu¨,3 about three-quarters of the students reported that they found case study to be an adequate form of teaching. Hsu27 and Edward and Preece9 confirm these findings. Similar results were reported by Nolan and Markert.5 They stated that courses must be clearly related to nursing practice and to real-world care situations that students may face during their careers.5 Nasrabadi and colleagues15 demonstrated that students who were exposed to case studies during

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their ethics courses scored significantly higher in ethical perception and ethical behaviour than students who were not exposed to this form of teaching. Lin et al.4 indicated that problem-based learning was superior to conventional teaching methods, which is consistent with our findings that problem-based learning, according to students, contributes to the development of their ethical knowledge and skills. Kyle19 and Durgahee8 suggested that self-reflection in combination with other teaching methods is an effective method for teaching ethics. In contrast to our results, those of Nasrabadi et al.15 and Numminen et al.18 found that students regarded lectures to be dull, impractical, demotivating and teacher-centred. Moreover, students did not feel involved in lectures. In our study, more than 60% of the students felt that film review, group discussion and ex cathedra teaching made little or no contribution to their ethical development. Group discussion and ex cathedra teaching require active participation of the students. Some studies indicate that active participation is a prerequisite in teaching ethics.3,8,15,18,19,27 In contrast to our study, other studies found that group discussion is seen as an effective method for teaching ethics.8,18,19 This difference can possibly be explained in that group discussions at the two participating university colleges took place in large groups, thereby making the learning effect small. Group discussion is a teaching method that requires small groups to maximise learning, as students feel less inhibited to express their opinions in small groups.8,10,19 Another explanation might be that students received these teaching methods less frequently than others, and therefore perceived these methods as less effective than the ones they had more frequently received. Unfortunately, we do not have an idea of the amount of contact hours the students had with the various teaching methods used during the courses. More research is needed to study the effectiveness of specific teaching methods on the development of ethical competences. Regarding ethics course content, students in this study perceived teaching of general ethical concepts to be the most effective in their ethical training. According to the literature, students emphasise the importance of teaching clear ethical concepts and principles.3,5,15 In this study, students felt that moral philosophical themes, ethical theories and care ethics, which are rather theoretical, contributed little or not at all to their ethical development. In Nolan and Markert,5 students considered ‘practical ethics’ courses to be useful, while only few students considered ‘moral philosophy’ to be useful. With regard to the general effectiveness of ethics courses, our pilot study results suggest that some objectives of ethics education might not be achieved by ethics courses. ‘Transcending own emotions’, ‘using ethical theories and principles in ethical reasoning’ and ‘reaching an ethical conclusion for a particular problem in a certain context: being able to justify your decisions’ are competences needed in order to develop ethical reasoning and ethical decision-making. However, the majority of students stated that ethics courses failed to prepare them for these competences. In much the same way, the skills necessary for ethical behaviour (e.g. the ability to apply ethical decisions in practice) were not acquired, according to the majority of students. In our study, the skill that was most strongly developed in students during their ethics courses was reflecting critically on their own norms and values hierarchies. The majority of the students in college 1 stated that ethics courses also helped them to develop their ethical awareness. Other studies also reported that ethics courses increase students’ ethical awareness and critically reflective attitudes.4,5,8,9,11 In our study, students stated that ethics courses enhanced their ability to observe, recognise and analyse ethical problems more than their ability to reach an ethical decision. In the study by Kalaitzidis and Schmitz,11 students saw themselves as being able to identify, describe and explain ethical situations more than to justify ethical decisions. The notion that ethics education contributes very little to practice of ethical behaviour is also supported by the literature. Only one study reported that ethics education affected the ethical behaviour of their participants.28 In this study, students from college 2 perceived ethics courses to be less effective in fostering their ethical development than did students from college 1. For 14 of the 21 competences, more than 60% of the students

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from college 2 stated that the ethics course made little or no contribution to these competences. However, this was the case in only 5 of the 21 competences for students from college 1. Furthermore, more than 60% of the students from college 1 stated that ethics courses contributed greatly to very greatly to 8 of the 21 competences. This disparity might be due to differences in the organisation of ethics courses of the two participating colleges (Table 1). The students of college 2 did not have the immediate opportunity to apply what they learned in the ethics course within daily practice because most of the courses of ethics took place before clinical internship. Indeed, our results and those from previous studies clearly indicate that linking ethics with daily practices is important.8,10 Internships offer students the opportunity to link theoretical concepts to their daily practice, which in itself contributes to the ethical formation of the theoretical concepts. Recall bias might be another possible explanation for the differences in perceived effectiveness between the students of both colleges. We only questioned third-year students; students of college 2 took an ethics course during their first year. Furthermore, differences in how teachers interpreted and taught course content could account for at least part of the differences we observed. Finally, the differences revealed in this pilot study might also be due to actual differences in the effectiveness of teaching methods and ethical course content. The students’ scores also varied widely, particularly with regard to items dealing with the ethical content of the courses and the general effectiveness of ethics courses. These differences were noticeable not only between colleges but also between students within the same college. These differences may be related to individual learning styles. If these were the case, then determining which methods are most effective and which course contents are most pertinent for teaching ethics would be even more difficult. On the basis of the pilot study, we found that the views of students and teachers concerning which methods and content are taught in ethics education differ. This was mainly for the methods used, slightly less for the content. We observed these phenomena in both colleges, but it was more prominent in college 2. How might this result be explained? First of all, we have to consider that there may have been some recall bias, especially for students in college 2, where one ethics course is offered only during the first year of training. When questioning the respective teachers, it appeared that some contents and methods were also used in other classes, which potentially could lead to confusion. This suggests that the students might also have had other courses in mind when they completed the questionnaire. Thus, the instructions for the questionnaire need to be adjusted so that students are encouraged to refer only to ethics courses when answering questions, not other courses that may have some overlap in content. A second possible explanation is that since questionnaire items were created in collaboration with specialists in nursing ethics and education, some of the concepts and terms embodied in particular items might have been unclear or too advanced for students. Thus in hindsight, a stronger instrument may have resulted if students had provided input during test development. It might also be useful to assess or interview the students at the end of the year they attend the ethics course, instead of only assessing them during their last year.

Conclusion Refinement of the SPEEES instrument through further research is strongly recommended. The inclusion of students’ ideas and suggestions early on in this process is warranted. Validity testing is an ongoing process and we took the first step in our study. Further research is necessary to describe the psychometric features of the SPEEES. One of the next steps is to test the stability and equivalence of the SPEEES to its internal consistency in order to assess reliability of the instrument. Larger scale research with an improved SPEEES would make it possible to compare different ethics teaching methods across many different nurse training programmes. Quantitative research should be complemented with qualitative research on what helps students the most and on what they need the most to achieve their ethical responsibility.

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