LOKMAN HEKIM HEALTH SCIENCES DOI: 10.14744/lhhs.2022.12992 Lokman Hekim Health Sci 2023;3(1):68–75 ORIGINAL ARTICLE lokmanhekimhs.com Social Justice Advocacy and Ethical Sensitivity of Nursing Students: A Descriptive Research Hemşirelik Öğrencilerinin Sosyal Adalet Savunuculuğu ve Etik Duyarlılık ile İlişkisi: Tanımlayıcı Çalışma Feyza Kocakurt1, 1 2 Belgin Akın2 Department Public Health Nursing, Lokman Hekim University, Health Sciences Institute, Ankara, Türkiye Department Public Health Nursing, Lokman Hekim University, Faculty of Health Sciences, Ankara, Türkiye Abstract Introduction: In a holistic social defense theory, nurses should defend not only patients in hospitals but also society. The aim of the study was to determine the social justice advocacy (SJA) levels of nursing students in their first, second, third, and fourth years in a private university and to analyze the relationship of SJA with sociodemographic and academic characteristics and ethical sensibility (ES). Methods: This study was descriptive and was conducted in Ankara in Lokman Hekim University, Faculty of Health Sciences, Nursing Department, during the academic year 2021–2022. It comprised students (n=167) who studied in the classroom. The data of this study were collected by the Survey Form, the Scale of Social Justice Defense, and the Ethical Sensitivity Survey. Results: When the SJA scores of the participants according to the class they studied were examined, a significant difference was found between the SJA scores of the fourth graders and the first and second grades (p=0.019). When the scores of the participants from the Moral Sensitivity Questionnaire were compared with the scores they obtained from the SJA Scale subscales, a very weak (r=-0.238) and statistically significant negative correlation was found between the scores they obtained from the Moral Sensitivity Questionnaire and the scores they received from the Applicant’s Empowerment subscale. Discussion and Conclusion: There are very little scientific data about SJA and the relationship of nurses in our country with ES, and it is recommended to do more work to study the knowledge and skills of nursing students on SJA. Keywords: Advocacy; Ethical sensitivity; Social justice advocacy T hroughout history, people have gathered around the concepts of rights and justice in response to the unequal distribution of resources. The concepts of “equality, fraternity, and liberty” that gained prominence with the French Revolution reject feudalism and the bourgeoisie in essence.[1,2] Equality in health care rests on two pillars: Presented as an Abstract Oral Presentation at the 6th International 24th National Public Health Congress (2022). Cite this article as: Kocakurt F, Akın B. Social Justice Advocacy and Ethical Sensitivity of Nursing Students: A Descriptive Research. Lokman Hekim Health Sci 2023;3(1):68–75. Correspondence: Feyza Kocakurt, M.D. Lokman Hekim Üniversitesi, Sağlık Bilimleri Enstitüsü, Ankara, Türkiye E-mail: kocakurtfeyza@gmail.com Submitted: 08.12.2022 Accepted: 20.12.2022 OPEN ACCESS This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/). Kocakurt and Akın; Social Justice Advocacy and Ethical Sensitivity of Nursing Students / doi: 10.14744/lhhs.2022.12992 equality in health care services and equality in social determinants of health.[3] Today, deepening inequalities highlight the concept of advocacy for finding the rights of the individual and society.[4] Advocacy is defined as the actions of an individual who “helps, advocates, or rallies around, someone.”[5] There are two senses of advocacy. The first one involves “providing public support or advice for a cause or policy,” and the second is about “legal practice or profession of a lawyer.”[6] Advocacy is among the fundamental roles and ethical responsibilities of many professional groups working with society. [7] In the context of nursing, advocacy emerged in the 1970s, and the rapidly changing nature of health care services makes advocacy complicated and challenging.[8] Advocacy has several stages including learning, information gathering, interacting, organizing, and training.[9] Patient advocacy theories reveal two types of advocacy definitions: macrosocial and microsocial advocacy. While the microsocial level involves protecting the autonomy, rights, and values of patients, macrosocial advocacy is a form of social justice advocacy (SJA) that addresses individual and social inequalities. [10] In this context, it is fair to say that an integrative social advocacy theory requires nurses to defend not only the patients in the hospitals but also society in a broader sense. This makes SJA a professional code for nurses.[8] In general, social justice covers three main notions: acknowledgment of inequality and oppression, assumption of participation, and responsible action. Those who want to implement a social justice framework should first recognize that there is an unfair distribution of power, resources, and access within society.[11] In these contexts, social justice involves ensuring that individuals from different segments of society benefit from resources and opportunities in a fair and equal manner.[12] Social justice underpins the right to fair treatment regardless of the “economic status, race, ethnicity, age, citizenship, disability status, or sexual orientation” of an individual. Also defined as one of the fundamental values of nursing, social justice forms the basis of professionalism in nursing.[13] As a profession, nursing involves providing holistic care, which also includes social determinants of health.[14] Public health nurses in particular play a key role in advocacy, a field that is intended to eliminate inequality. Accordingly, nurses should play an active role in policies that are among the purpose and solution processes to ensure social justice and develop a curriculum to address advocacy.[15,16] In a randomized controlled study conducted by Demirören and Akın[17] with nursing students, advocacy training proved effective in increasing the level of SJA. Hosseinzadegan et al.[18] defined four themes for the factors affecting nurses’ 69 participation in social justice practices. These are “insufficient professional authority,” “paying insufficient attention to social justice in education,” clinical concerns as obstacles before professional presence in society,” and “reflection of one’s personality to their profession.” A participant commented on the importance of training programs as follows: I was not aware of the significance of social issues in health care until I attended a workshop on social justice in health care. The workshop has really changed my beliefs and broadened my perspective. The results of the interview highlighted that developing comprehensive curricula on social justice would increase students’ participation in SJA in the health care system.[18] In the study of Akın and Kurşun,[19] nursing scholars emphasize that advocacy is ethical behavior and that students should be trained on advocacy and provided with a participatory role model. Einhellig et al.[13] argue that SJA cannot be taught by traditional courses, and trainers should establish simulation environments to stimulate students. A subject of philosophy, ethics is a set of codes that regulate the behaviors of individuals or professionals based on moral norms.[20] The nursing profession is characterized by seven values: altruism, equality, human dignity, social justice, aesthetics, freedom, and truth. These values guide nurses in their interactions with patients, colleagues, and society and in solving ethical dilemmas they may encounter while providing health care services.[21] Without any doubt, nurses also have an ethical and moral obligation to question the policies and practices that lead to social injustice in health care and to advocate justice, dignity, and nonmaleficence in nursing practices.[22] How nurses should treat individuals or groups while advocating social justice is also decided by ethical principles.[17] As emphasized in the literature, taking into consideration the roles and responsibilities of public health nurses, the ones who advocate social justice as a way to combat inequality in health care should also have a high degree of ethical sensitivity. Nurses are not charged solely with providing care, and they are key actors in accomplishing the “Health for all” objective of the World Health Organization. Accordingly, nursing students, that is, the nurses of the future, should graduate with the knowledge and skills necessary for social advocacy. Demirören and Akın[17] aimed to determine the effects of advocacy training on students’ sense of SJA and moral sensibility but did not explore the relationship between SJA and ethical/moral sensibility. The information to be gathered on the relationship between SJA and ethical/ moral sensibility will help to determine the current state of affairs and draw attention to the significance of the matter. Kocakurt and Akın; Social Justice Advocacy and Ethical Sensitivity of Nursing Students / doi: 10.14744/lhhs.2022.12992 70 Aim Research Variables The aim of the study was to determine the SJA levels of nursing students in their first, second, third, and fourth years in a private university and to analyze the relationship of SJA with sociodemographic and academic characteristics and ethical sensibility (ES). The dependent variable of this study was the level of SJA. Research questions: Do students The data of the present study were collected using a Questionnaire Form drawn up by the researchers based on Demirören and Akın and Hosseinzadegan et al.,[17,18] the SJA Scale, and an ES Questionnaire. • Have different levels of SJA based on their sociodemographic characteristics? • Have different levels of SJA based on their academic characteristics? • Have a correlation between SJA and ES? Materials and Methods Study Design This was a descriptive study analyzing the relationship between the SJA levels of students on the one hand and their sociodemographic characteristics, some academic characteristics, and ES on the other hand. Place of the Study and Participants This study was conducted in the spring semester of the academic year 2021–2022 at Lokman Hekim University, Ankara Faculty of Health Sciences, Department of Nursing. Lokman Hekim University focuses predominantly on medical sciences with faculties and vocational schools providing education in the field of health care. The Department of Nursing was established in 2018. Nine faculty members, including 3 professors, 1 associate professor, and 4 PhD lecturers, serve the department. It is presumed that the issues of ethics and advocacy are discussed in various courses from the freshman year. Students practice in clinics and on-site from the second semester of the first year. The population of the study was made up of 167 students (n=167) of the Faculty of Health Sciences, Department of Nursing. The students were in their first, second, third, or fourth years in the department. The entire universe was included in the study with the total population method without selecting a sample. The study was conducted with all students (138 participants) who were present in the classes, who attended the courses, and who agreed to participate in the study during data collection. Five questionnaires were not included in the sample because they were blank at the time of data entry. The study was completed with 133 participants in total. The independent variables were sociodemographic characteristics, academic characteristics, and the level of ES. Data Collection Tools Questionnaire Form The Questionnaire Form consists of 13 questions under two titles: sociodemographic characteristics and academic characteristics. The sociodemographic characteristics questionnaire had 9 questions for age, gender, social class, the location resided in for the longest time, the high school attended, parents’ level of education, mother’s occupation, and perceived educational status. The academic characteristics questionnaire, on the other hand, had 4 questions to measure how willing the participants were to choose nursing, the reason why they chose nursing, their academic success, and whether they attended any training on advocacy. SJA Scale The scale was developed by Dean,[23] translated into Turkish, and checked for validity and reliability by Bayoğlu Serpen et al.[12] In addition, Kıroğlu and Tekin[24] conducted confirmatory factor analyses for the validity of the scale. The scale comprises 4 subdimensions: cooperative action, applicant empowerment, social/political advocacy, and applicant/ community advocacy. Cronbach’s alpha reliability coefficients for internal consistency were calculated for reliability. Cronbach’s alpha reliability coefficients were 0.89 for cooperative action, 0.76 for applicant empowerment, 0.79 for social/political advocacy, and 0.71 for applicant/community advocacy. Cronbach’s alpha coefficient for the overall scale was 0.92. A 7-point Likert scale was designed with 41 questions. The answers ranged from totally disagree 1 to totally agree 7. The minimum and maximum scores of the scale were 43 and indicated the most negative and the most positive attitudes, respectively.[12] Moral Sensibility Questionnaire Tosun[25] verified the validity and reliability of the scale developed by Lutzen et al.[26] in 1997 for Turkish. The scale has 30 items and 6 subdimensions. These subdimensions are holistic approach, implementation, autonomy, conflict, benefit, and orientation. It is a 7-point Likert scale evaluated by Kocakurt and Akın; Social Justice Advocacy and Ethical Sensitivity of Nursing Students / doi: 10.14744/lhhs.2022.12992 a scoring system ranging from completely agree 1 to completely disagree 7. Cronbach’s alpha reliability coefficient for internal consistency was calculated for reliability: 0.99 for autonomy, 0.98 for benefit, 0.99 for holistic approach, 0.96 for conflict, 0.81 for practice, 0.99 for orientation, and 0.98 in total. Croncbach’s alpha coefficient for the overall scale was 0.84. Translated into Turkish for validity, the scale was submitted to 10 scholars for review. Once the scale was validated for linguistic scope, 15 physicians and nurses were interviewed. The expressions were rated clear. The minimum and maximum scores of the scale were 30 and 120, respectively, with higher scores indicating lower ES.[25] Data Collection Method The study data were collected by collective self-reporting of the students in the classroom under the supervision of the researcher. Data Analysis The data were analyzed digitally using the SPSS 23 (Statistical Package for Social Sciences) software package. The descriptive statistics were given as numbers, percentages, averages, medians, first and third quartiles, and minimum and maximum values. The Kolmogorov–Smirnov test and the Shapiro–Wilk tests were used to evaluate the compliance of numerical variables with normal distribution. As the data did not follow a normal distribution, the Kruskal–Wallis and Mann–Whitney U tests were used to compare the groups. The groups in the variables with a difference in the Kruskal– Wallis test were compared in pairs using the Mann–Whitney U test and evaluated using the Bonferroni correction. As the variables did not follow a normal distribution, the correlation coefficients and statistical significance for the relations between the variables were calculated using Spearman’s test. In statistical analyses, a type 1 error value of α < 0.05 was considered significant. Statistical Analysis Process Statistical analysis process was performed using SPSS 23 (Statistical Package for Social Sciences). Data entry and descriptive statistics were made by the researcher. Statistics for numerical variables were made with a statistics teacher working in Ankara. Ethical Consideration The study was found ethically appropriate in accordance with decision no. 2022/84 dated March 31, 2022, of Lokman Hekim University Committee of Ethics for Non-Interventional Research, and written consent was collected from the 71 Table 1. Distribution of students’ sociodemographic and academic characteristics (n=133) Sociodemographic characteristics Gender Female Male Student’s year of education Year 1 Year 2 Year 3 Year 4 Place of longest residence Metropolis/province District/town/village Mother’s education level Illiterate/literate/primary school Secondary school High school/vocational college/bachelor’s degree Father’s education level Illiterate/literate/primary school Secondary school High school/vocational college/bachelor’s degree Perceived level of income Good Medium/poor Mother's employment status Unemployed Employed Academic characteristics Willingness to study nursing Willing Unwilling Reason for choosing to study nursing Easier to find a job/exam score/family’s request Affinity for the profession Perceived level of academic success Poor/medium Good/very good Advocacy training history (self-report) Yes No n % 117 16 88.0 12.0 46 30 36 21 34.6 22.6 27.1 15.8 111 22 83.5 16.5 45 22 66 33.9 16.5 49.6 20 16 97 15.1 12.0 72.9 55 78 41.4 58.6 103 30 77.4 22.6 102 31 76.7 23.3 88 45 66.2 33.8 66 67 49.6 50.4 23 110 17.3 82.7 President of Lokman Hekim University, Dean of the Faculty of Medical Sciences, and the students who consented to participate in the study as per the Declaration of Helsinki under a statement indicating the purpose of the study, and a commitment to protect the personal data and confidentiality of such data, and a declaration that participation is voluntary. 72 Kocakurt and Akın; Social Justice Advocacy and Ethical Sensitivity of Nursing Students / doi: 10.14744/lhhs.2022.12992 Table 2. Distribution of social justice advocacy according to the sociodemographic characteristics of students (n=133) Sociodemographic characteristics Gender Female Male Year Freshman Sophomore Junior Senior Place of longest residence Metropolis/province District/town/village Mother’s education level Illiterate/literate/primary school Secondary school High school/vocational college/bachelor’s degree Father's education level Illiterate/literate/primary school Secondary school High school/vocational college/bachelor’s degree Perceived level of income Good Medium/poor Mother’s employment status Housewife Government/private sector/other Number Mean±SD Median 1Q–3Q 117 16 193.77±42.84 188.06±47.60 195.0 176.0 172.0–219.0 161.0–228.5 46 30 36 21 182.41±44.38 191.63±33.39 193.17±49.58 218.38±32.89 188.0 188.0 195.0 216.0 155.0–216.0 171.0–216.0 172.0–223.5 198.0–234.0 111 22 192.14±43.67 197.82±41.97 195.0 197.0 172.0–219.0 165.0–226.0 45 22 66 196.93±39.63 182.64±43.66 193.94±45.59 200.0 193.5 196.0 172.0–219.0 163.0–215.0 172.0–225.0 p 0.696* 0.019** 0.748* 0.501** 0.225** 20 16 97 193.75±34.87 174.12±53.39 196.07±42.68 186.0 175.0 199.0 172.0–222.0 148.0–200.0 172.0–221.0 55 78 197.82±50.05 189.74±37.79 195.0 192.5 172.0–231.0 165.0–218.0 103 30 196.64±42.33 180.87±45.03 198.0 183.0 172.0–223.0 156.0–209.0 0.270* 0.066* *: Mann–Whitney U test; **: Kruskal–Wallis test; SD: Standard deviation; 1Q: First quartile; 3Q: Third quartile. Results This study analyzed the relationship between the SJA levels of students on the one hand and their sociodemographic characteristics, some academic characteristics, and ES on the other hand. The study population was made up of 133 participants. The mean age of the participants was 21.09±1.55 years. The sociodemographic characteristics of the participants were as follows: majority (88.0%) of the participants were females, 34.6% were in the first year, 83.5% resided in a metropolitan area/province most of the time, 49.6% had a maternal education status of high school or above, 72.9% had a paternal education status of high school or above, 59.7% had a perceived income level of medium/poor, and 77.4% were the child of an unemployed mother. The academic characteristics of the participants were as follows: 76.7% were willing to study nursing, 66.2% chose nursing for the prospect of easy employment, in line with their university placement score, or upon their family’s request, 50.4% perceived their academic success as good/very good, and 82.7% did not have a history of advocacy training (Table 1). The participants scored 91.48±20.48 (median: 91.0) on the Moral Sensibility Questionnaire and 193.08±43.29 (median: 195.0) on the SJA Scale. The participants scored the following median points on the subscales of the SJA Scale: 78.97±20.52 (median 81.0) on cooperative action, 42.89±11.36 (median: 44.0) on applicant empowerment, 35.08±7.58 (median: 36.0) on social/political advocacy, 28.71±7.28 (median: 29.0) on applicant/society advocacy. Distribution of the scores of the participants on the SJA Scale (Table 2) based on their sociodemographic characteristics did not reveal any statistically significant difference among the groups as far as age, gender, place of longest residence, high school, maternal and paternal education statuses, perceived level of income, and maternal employment status (p=0.066) are concerned. Scores of the participants according to their year of study yielded a statistically significant difference among the groups (p=0.019). Accord- Kocakurt and Akın; Social Justice Advocacy and Ethical Sensitivity of Nursing Students / doi: 10.14744/lhhs.2022.12992 73 Table 3. Distribution of social justice advocacy according to the academic characteristics of students (n=133) Academic characteristics Willingness to study nursing Willing Unwilling Reason for choosing to study nursing Easier to find a job/exam score/family’s request Affinity for the profession Academic success Poor/medium Good/superb Advocacy training history Yes No Number Mean±SD Median 1Q–3Q 102 31 194.45±43.97* 188.58±41.34* 195.0 188.0 172.0–221.0* 171.0–215.0* 88 45 193.57±40.49* 192.13±48.77* 196.0 195.0 171.5–219.0* 172.0–221.0* 66 67 190.97±44.68* 195.16±42.11* 192.5 198.0 172.0–218.0* 166.0–226.0* p 0.578 0.712 0.606 0.062 23 110 209.30±47.49* 189.69±41.80* 216.0 191.0 164.0–241.0* 172.0–218.0* *: Mann–Whitney U test; SD: Standard deviation; 1Q: First quartile; 3Q: Third quartile. Table 4. Correlation analysis results of the participants’ scores on the Moral Sensibility Questionnaire on the one hand and the subscales of the Social Justice Advocacy Scale and Social Justice Scale on the other hand (n=133) Moral Sensibility Questionnaire Scores Spear-man’s correla-tion coef-ficient p Number Cooperative action subscale Applicant empowerment subscale Social/political advocacy subscale Applicant/society advocacy subscale Social justice advocacy scale total -0.167 0.055 133 -0.238* 0.006 133 -0.127 0.146 133 -0.141 0.106 133 -0.211* 0.015 133 *: Correlation is significant at the significance level of p<0.01. ingly, SJA scores of the students in their fourth year were significantly different from the ones in their third (195.0), second (188.0), and first (188.0) years (p<0.005) (Table 2). SJA Scale scores of the participants based on their academic characteristics did not yield any statistically significant difference among the groups as far as willingness to study nursing, reason for choosing to study nursing, level of academic success, and history of advocacy training are concerned (Table 3). A comparison between the participants’ scores on the Moral Sensibility Questionnaire and the subscales of the SJA Scale yielded a weak (r=-0.238) statistically significant negative correlation (Table 4). Discussion In the present study, the variables affecting the SJA of nursing students were examined. Based on our findings, the statistical relationship between SJA and sociodemographic characteristics did not reveal a significant correlation among gender, the place of longest residence, mother’s education level, father’s education level, perceived level of income, and mother’s employment status. In parallel with this study, Kalaycı[7] found that evaluating gender based on the total score on the SJA Scale did not yield any significant difference between men and women, but the SJA competence of women was higher than that of men. For the age variable, contrary to what is suggested in the present study, Çetinkaya Büyükbodur[27] found a low-level, negative, significant correlation between the applicant/society advocacy subdimension of the SJA of the age variable. The year of study revealed a significant correlation with the SJA level in sociodemographic characteristics. In parallel with this study, Çetinkaya Büyükbodur[27] found a low-level positive correlation between cooperative action and applicant empowerment, the subscales of SJA, as the year of study of the social service department increased. Based on the results of this study, one may think that sociodemographic characteristics of the students other than the year of study did not affect the level of SJA and that students may benefit from SJA training programs similarly regardless of the basic social characteristics. Differences according to the year of study and a positive change in SJA scores over years imply that theoretical courses and practices over the period of study increase social justice sensibility. 74 Kocakurt and Akın; Social Justice Advocacy and Ethical Sensitivity of Nursing Students / doi: 10.14744/lhhs.2022.12992 No statistically significant correlation was found among the willingness to study nursing, reason for choosing to study nursing, academic success, and advocacy training history as part of the relation between SJA and academic characteristics. In parallel with our study, Bozdemir and Kılıç Ceyhan [28] did not find any correlation between social service specialists’ levels of SJA and willingness to study social service. As mentioned above, the increase in SJA in parallel with the year of study implies that theoretical courses enhance social justice sensibility. According to Hosseinzadegan et al.[18] nurses’ participation in social justice was affected by four main themes. These are insufficient professional authority, paying insufficient attention to social justice in education, clinical concerns as obstacles before professional presence in society, and reflection of one’s personality to their profession. As the undergraduate education of nursing students largely focuses on preparing nurses for the clinic, nurses are not educated on social justice, but it is known that nurses should be educated to understand how social injustice affects our society and exacerbates inequalities in health care.[29] Einhellig et al.[13] found in an interventional study that integrating course content on social justice into the undergraduate nursing curriculum resulted in positive behavioral changes. It was also found that the advocacy training program implemented by Akın and Demirören[17] improved SJA skills and moral sensibility. The fact that the inquiry was based on perception in the present study may have been affected by the students’ knowledge and awareness of SJA. This can be considered a limitation. The sample group of this study was not given any SJA or any other advocacy training. No curriculum content in the faculty where the study was conducted was examined in terms of SJA. Therefore, it is thought that the findings of this study require more information about students’ encounters with the concept of social justice and the effects of the education process. A literature review reveals a randomized controlled study conducted to determine the effect of SJA training on the moral sensibility of nursing students. According to the results of the study, advocacy training programs increased the SJA skills and moral sensibility of nursing students.[17] The interventional study of Baykara et al.[30] on the other hand, revealed that ethics training programs raised nurses’ awareness of distinguishing ethical violations in hospitals. Ethics training was found to raise nursing students’ awareness of moral sensibility according to a study on the effect of the care ethics course on the moral sensibility of nursing students.[31] Although it does not address the concept of social justice, as reported by several studies, there is a correla- tion between ethical knowledge and moral sensibility of students. In the present study, a very weak correlation was found between the Moral Sensibility Questionnaire scores and the SJA Scale scores of the participants. The increase in students’ knowledge of SJA weakly affected their levels of moral sensibility. The fact that the SJA levels of the students in our study group increased with the year of study can be interpreted as an increase in the awareness levels of nursing students concerning social justice over their academic careers. However, this may not be parallel to an increase in knowledge. Therefore, our findings may contradict the results of a study with a high level of evidence. Our findings suggest that students underwent some positive changes in terms of ethics and advocacy in the course of their studies. Social justice has become a global framework that is always a current topic for many disciplines.[32] Enriching the education of nursing students with this awareness appears to be important to help graduates become social justice advocates. The findings obtained in the present study suggest that education has a positive effect, but a lack of knowledge makes it difficult to make clear conclusions. Conclusion Based on the findings and comments obtained in this study, which suggest that education increases the level of SJA and that the level of SJA correlates with moral sensibility, the following recommendations are made: • As there is only little scientific data on the SJA role of nurses in Türkiye, more studies on this subject are required. • We suggest this study can be repeated in different universities with more nursing students. • Nursing students can be examined for their knowledge and skills on SJA. • Studies analyzing the content and weight of SJA ethics education in the nursing curricula can be conducted. Peer-review: Externally peer-reviewed. Ethics Committee Approval: The Lokman Hekim University Ethical Committee of Non-invasive Clinical Research granted approval for this study (date: 31.03.2022, number: 2022). Authorship Contributions: Concept: FK, BA; Design: FK, BA; Supervision: FK, BA; Materials: FK, BA; Data Collection or Processing: FK, BA; Analysis or Interpretation: FK; Literature Search: FK; Writing: FK, BA; Critical Review: BA. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study received no financial support. Kocakurt and Akın; Social Justice Advocacy and Ethical Sensitivity of Nursing Students / doi: 10.14744/lhhs.2022.12992 References 1. Demirel T, Akın B. Sağlıkla ilişkili olarak sosyal adalet, eşitlik ve hemşirelik. DEUHYO ED 2014;7(3):238–45. 2. Çulhaoğlu M. Eşitsizlikler kaçınılmaz mıdır. In: Gözler, EE, editors. Proceedings of 3. Kent ve Sağlık Sempozyumu; 2011, May 27-28;Bursa. 3. Barreto ML. Health inequalities: a global perspective. Cien Saude Colet 2017;22(7):2097–2108. Portuguese, English, Spanish. [CrossRef ] 4. Arcaya MC, Arcaya AL, Subramanian SV. Inequalities in health: definitions, concepts, and theories. Glob Health Action 2015;8:27106. [CrossRef ] 5. Hanks RG, Starnes-Ott K, Stafford L. Patient advocacy at the APRN level: A direction for the future. Nurs Forum 2018;53(1):5–11. [CrossRef ] 6. Abbasinia M, Ahmadi F, Kazemnejad A. Patient advocacy in nursing: A concept analysis. Nurs Ethics 2020;27(1):141–51. 7. Kalaycı E. Sosyal hizmet öğrencilerinin sosyal adalet savunuculuğu yetkinlikleri ile LGBTI birey-lere yönelik tutumları arasındaki ilişkinin incelenmesi. Kastamonu Eğit Derg 2018;1419– 25. [CrossRef ] 8. Ventura CAA, Fumincelli L, Miwa MJ, Souza MC, Wright MDGM, Mendes IAC. Health advocacy and primary health care: evidence for nursing. Rev Bras Enferm 2020;73(3):e20180987. English, Portuguese. [CrossRef ] 9. Pickover AM, Allbaugh LJ, Sun S, Casimir MT, Graves CC, Wood KA, et al. Ecological Frame-work for Social Justice Advocacy by Behavioral Health Professionals in Public Healthcare. Psychol Serv 2020;17(Suppl 1):5-11. [CrossRef ] 10. Bu X, Jezewski MA. Developing a mid-range theory of patient advocacy through concept analysis. J Adv Nurs 2007;57(1):101–10. [CrossRef ] 11. Hochhauser S, Rao S, England-Kennedy E, Roy S. Why social justice matters: a context for suicide prevention efforts. Int J Equity Health 2020;19(1):76. [CrossRef ] 12. Serpen AS, Duyan V, Aldoğan EU. Sosyal adalet savunuculuğu ölçeği güvenirlik ve geçerlik çalışması. Toplum ve Sosyal Hizmet 2014;25(1):21. 13. Einhellig K, Gryskiewicz C, Hummel F. Social justice in nursing education: leap into action. J Nurs Care 2016;5(6). [CrossRef ] 14. Walter RR. Emancipatory Nursing Praxis: A Theory of Social Justice in Nursing. ANS Adv Nurs Sci. 2017;40(3):223–41. [CrossRef] 15. Linton JM, Nagda J, Falusi OO. Advocating for immigration policies that promote children's health. Pediatr Clin North Am 2019;66(3):619–40. [CrossRef ] 16. Aköz S. Politika kavramının siyaset kavramı yerine kullanılması ve bilimsel tartışmalar bağlamında devlet olgusuyla ilişkisi. Van Yyü İibf Dergisi 2018;3(5):160–80. [CrossRef ] 75 17. Demirören N, Akın B. Impact of Education on Student Nurses' Advocacy and Ethical Sensitivity. Nurs Ethics 2022;29(4):899– 14. [CrossRef ] 18. Hosseinzadegan F, Jasemi M, Habibzadeh H. Factors Affecting Nurses' Impact on Social Jus-tice in the Health System. Nurs Ethics 2021;28(1):118–30. [CrossRef ] 19. Akın B, Kurşun Ş. Perception and opinion of nursing faculties regarding advocacy role: A qualitative research. Nurs Forum 2020;55(4):63744. [CrossRef ] 20. Tosun H. Sağlık bakım uygulamalarında etik duyarlılık. SYBD 2021;3(1):101–4. [CrossRef ] 21. Paslı Gürdoğan E, Aksoy B, Kınıcı E. Ethical awareness of of nursing students, and their relati-onship with professional values. J Health Nurs Manag 2018;5(3):147-54. 22. Shahzad S, Younas A, Ali P. Social justice education in nursing: An integrative review of teaching and learning approaches and students' and educators' experiences. Nurse Educ Today 2022;110:105272. [CrossRef ] 23. Dean JK. Quantifying social justice advocacy competency: Development of the social justice advocacy scale. Thesis. Georgia: Department of Counseling and Psychological Services; 2009. Available at: https://scholarworks.gsu.edu/cgi/viewcontent.cgi?article=1039&context=cps_diss Accessed Jan 17, 2023. 24. Kıroğlu M, Tekin HH. Sosyal adalet savunuculuğu ölçeğinin (sasö) doğrulayıcı faktör analizi. DEU Sos Bil East Dergisi 2019;21(3):859–74. [CrossRef ] 25. Tosun H. Ahlaki duyarlılık anketi (ADA): Geçerlik ve güvenirlik çalışması. J Contemp Med 2018;8(4):316–21. [CrossRef ] 26. Lutzen K, Evertzon M, Nordin C. Moral sensitivity in psychiatric practice. Nursing Ethics 1997;4(6):472–482. [CrossRef ] 27. Çetinkaya Büyükbodur A. Sosyal hizmet bölümü öğrencilerinde empati düzeyinin sosyal ada-let savunuculuğuna etkisi. J Int Soc Res 2020;13(70):910–20. [CrossRef ] 28. Bozdemir R, Kılıç Ceyhan E. Kamu ve sivil toplumda çalışan sosyal hizmet uzmanlarının sosyal adalet savunuculuğu düzeylerinin karşılaştırılması. SBBD 2021;3(12),956–70. [CrossRef] 29. Thurman W, Pfitzinger-Lippe M. Returning to the profession's roots: Social justice in nursing education for the 21st century. ANS Adv Nurs Sci 2017;40(2):184–93. [CrossRef ] 30. Baykara ZG, Demir SG, Yaman S. The effect of ethics training on students recognizing ethical violations and developing moral sensitivity. Nurs Ethics 2015;22(6):661–75. [CrossRef ] 31. Boz İ, İnce S. The effect of caring ethics course on study nurses students? Ethical sensitivity level: A comparative study. Turkiye Klinikleri J Med Ethics 2019;27(1):40–47. [CrossRef ] 32. Nemetchek B. A concept analysis of social justice in global health. Nurs Outlook 2019;67(3):244-51. [CrossRef ]