Teaching ethics in nursing

Nursing Ethics http://nej.sagepub.com Teaching Ethics in Nursing Leyla Dinç and Refia Selma Görgülü Nurs Ethics 2002; 9; 259 DOI: 10.1177/096973300200900305 The online version of this article can be found at: http://nej.sagepub.com/cgi/content/abstract/9/3/259 Published by: http://www.sagepublications.com Additional services and information for Nursing Ethics can be found at: Email Alerts: http://nej.sagepub.com/cgi/alerts Subscriptions: http://nej.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. TEACHING ETHICS IN NURSING Leyla Dinç and Refia Selma Görgülü Key words: case study analysis; ethical decision-making skills; nurse education; nursing ethics Being a professional nurse requires ethical decision making and this in turn necessitates an effective learning process. The active participation of students in the teaching of ethics will contribute to this process. This study was conducted at Hacettepe University School of Nursing, Ankara, Turkey, to determine the views of students about the nursing ethics content in the curriculum, the examination system, and some educational characteristics of the teachers responsible for the course. The sample comprised 113 students who participated voluntarily. In general, the students expressed a positive view relating to the course content and the teachers. The majority stated that the discussions on case study analysis by using ethical principles, rights, legal aspects and the use of the International Council of Nurses Code of Ethics were very useful in developing ethical decision-making skills. We believe that the results of this study will enhance our efforts in amending this course and improving the ethical decision-making skills of our students. Introduction As a result of advances in science and technology, more ethical problems and dilemmas surrounding health care issues have been identified. The general public, policy makers and health care professionals are now more aware of these dilemmas. In addition, because of advances in communication technology, our knowledge of ethical issues in other parts of the world has increased. Thus, interest in ethical issues is growing faster than ever before.1 Health care professionals deal directly with the life and health of individuals, so they are more likely to encounter ethical problems. People entrust even their lives and their naked bodies to the health professionals who are responsible for their care and treatment and they want to be sure that their trust will not be abused. This belief and trust demands that health care professionals carry out their responsibilities without relying on their own personal beliefs and values and without discriminating for religion, race, sex, nationality, or political or social status. In the past, nurses were expected to be obedient without question and did not participate in ethical decision making. 2 Because of this traditional view towards Address for correspondence: Assist Prof. Leyla Dinç, Hacettepe Üniversitesi, Hems,irelik Yüks,ekokulu, 06100 – Ankara, Türkiye. E-mail: leylad@hacettepe.edu.tr Arnold Nursing Ethics 2002 9 Downloaded (3) © 2002 from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April10.1191/0969733002ne508oa 10, 2008 © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. 260 L Dinç and RS Görgülü nursing, ethics was regarded as the science of conduct, and the ethics content of nursing courses focused on the duties and obligations of nurses.3 However, the growing complexity of our health care system requires increasing responsibility for ethical decision making in nursing care. In their practice nurses can be confronted with issues related to initiating resuscitation, discontinuing life-saving treatment, or patients refusing treatment. They may also find themselves involved in research being conducted without informed consent or in situations where information is withheld from patients. Ethical decision making requires guidance and a knowledge of the theory of ethics, ethical principles and practice. Without formal preparation, this process may be intuitive and based on a personal sense of ethically correct actions.2 Nurses need to be prepared by their basic education to develop ethical decision-making skills. According to Duckett et al.,4 moral reasoning among undergraduate nursing students tends to increase with age and educational level, and is comparable with and often more developed than that of their academic peers. Riesch et al.,5 reported that graduate students in nursing who were near the end of their master’s training as advanced practice nurses and candidate doctoral students scored higher in moral reasoning than is the norm for other graduate students. They stated that advanced levels of moral reasoning are achieved with higher levels of education. Gaul6 investigated the relationship between knowledge of the ethically correct action (ethical choice) and choosing the ethically correct action (ethical action) in students who had completed a course in nursing ethics and those who had not. The teaching of ethics in nursing education has become increasingly important in recent years and, in order to train nurses better to participate in ethical decision making, more contemporary models of ethics teaching (e.g. moral concepts, clinical practice models, case analyses) are being implemented in nursing programmes.2 Cassels and Redman7 made some suggestions for improving the ethical decision-making skills of students. In short, their recommendations were to teach students the basic theories and principles of ethics, the International Council of Nurses (ICN) Code of Ethics for Nurses,8 and the rights and laws that guide practice when nurses are faced with any kind of ethical problem. In addition, they stated that evaluations of ethical choices should be made with each student. Another important factor that contributes to teaching ethics is the teacher’s characteristics. Teachers of ethics courses should have practical experience in ethics as well as in nursing and have the ability to adapt appropriate teaching methodologies to the course content. However, despite the availability of textbook material and articles related to ethics, there still remains an uncertainty about the substance of ethics teaching in nurse education. Sometimes a nurse educator who has expertise in ethics is not available and the ethics component of the course is taught by a faculty member who is a specialist in some other area, or by a philosopher who has experience in ethics, but in another subject.2,3 Teachers of ethics courses should also use the principles of teaching to enhance their effectiveness. As Bayik reported in her article, 9 effective teacher characteristics, according to students, were as follows: being encouraging, self-confident, genuine, dynamic, impressive and informative; using clear language; answering questions; conveying a facial expression displaying concern and a reassuring tone of voice; offering printed materials that are organized and well prepared; and using audio- Nursing Ethics 2002 9 (3) Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. Teaching ethics in nursing 261 visual instructional aids. In her study, Bayik9 asked students to score the effective teacher characteristics on a scale of 0–9, according to their significance. The findings revealed that students consider using audiovisual aids (mean score 8.06), and counselling and guidance (mean score 7.98) as the most important teacher characteristics. Besides the characteristics of the teacher, effective measurement and evaluation of learning outcomes and student behavioural changes, and providing feedback to them, is another important contributing factor to the learning process. Theoretical ethics can be tested by written essays or objective tests, but case studies are more appropriate ways to determine analytical skills. Participation in class discussion is also an important tool for evaluating the progress of learners in integrating ethics into their practice. On the other hand, contemporary thinking about the nature and purpose of teaching and education recognizes that adult learners do better with less direction and more participation. This reasoning includes the concept that adult baccalaureate students should be seen as active participants, not as passive recipients. Thornton and Chapman10 reported that students’ voice must become an integral part of the alternatives from which curriculum-making choices are made. Quinn 11 also suggested that nursing students should be part of a curriculum configuration team. However, Playle 12 stated that, traditionally, university nursing faculty members make all the decisions about aspects of the curriculum and reference to the views of students has been minimal. Our literature review carried out in Turkey also showed minimal reference to students’ perceptions of their learning and their participation in the development of the curriculum. In the light of the previously mentioned studies and opinions we carried out this descriptive study to determine the views and opinions of students on the content of the nursing ethics unit, the testing system, and some educational characteristics of the teachers. We suggest that it will make a contribution to course implementation, and to students’ learning process and clinical experience. Method This was a descriptive study that aimed to determine the views of students about the content of the ‘Ethics in nursing’ unit (which is a part of the ‘Nursing history and ethics’ course), the examination system, and some characteristics of the teachers responsible for the course. It was conducted at Hacettepe University School of Nursing, Ankara, Turkey. The ‘Nursing history and ethics’ course (three credits) is scheduled in the second semester of the second year and is required for graduation. Nursing ethics is a 20-hour unit of this course. The study protocol was approved by the school administration and written permission was obtained. The primary objective of the nursing ethics unit is to convey a basic understanding about ethics and to develop the ethical decision-making skills of the students. For this purpose the subheadings mentioned in group 1 of the ‘Data collection and processing’ section below were included in this unit. The teaching methods used were formal lectures, question-and-answer sessions, and case study discussions. For the case study discussions the students were divided into small groups, where they prepared case studies with ethical problems and scrutinized Nursing Ethics 2002 9 (3) Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. 262 L Dinç and RS Görgülü them as a group in relation to human rights, patients’ rights, ethical principles, and nurses’ responsibilities based on the ICN Code. Counselling and guidance during the preparation and investigation of the case studies were provided, and printed material relating to rights, laws and codes were offered by the teachers.8,13,14 During the last week of this course, the students presented their case studies to the class and led class discussions. These presentations and discussions were considered by the teachers as a mid-term examination. On the other hand, theoretical ethics was tested by means of two written essays. At the end of this semester, there was a final multiple-choice examination. Students who achieved 60% or more were considered to have satisfactorily completed the course. The scope of this study was a total of 115 students enrolled on this course for the year of 1999–2000. The sample comprised 113 students who were available on the day the data were collected. The students were informed about the purpose and content of the study; they were told that their participation was voluntary and their verbal consent was obtained. All of the students agreed to participate. Data collection and processing Data were collected by using a questionnaire developed by the two researchers, based on their experience and a literature review.10,11,15 The students were invited to reflect on their views about the subjects covered in the nursing ethics unit, the examination system, and the educational characteristics of their teachers. They took about 30 minutes to complete the questionnaire. The questionnaire items were divided into three groups: 1) The content subheadings of the nursing ethics unit: – – – – – – Definition of ethical concepts and principles; Explanation of basic theories of ethics; Ethical problems and dilemmas in nursing practice; Rights and the ICN Code of Ethics for Nurses; Legal issues in nursing (in Turkey); Case study discussion. 2) The examination system: – Effective measurement of knowledge; – The written essays; – Grading criteria and level. 3) The educational characteristics of the teachers (selected from the literature review as the most important): – – – – – – – Knowledge base; Ability to deliver formal lectures; Effective use of language; Appropriate use of instructional methods; Interaction with students; Creating a positive environment for discussion; Reinforcement; Nursing Ethics 2002 9 (3) Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. Teaching ethics in nursing – – – – – 263 Appropriate use of instructional aids; Availability; Guidance; Openness to self-criticism; Maintaining class control. The students’ responses were grouped manually as adequate, moderate or inadequate. This forced three-level grouping was made because there were only a few responses for the ‘very inadequate’ and ‘very adequate’ categories. Five groups of responses might have reflected more accurately the students views, but they also would have limited the statistical analysis. Each statement was then coded and input into the computer. The data were processed using the SPSS for Windows 9.0 program. Findings and discussion The students’ views on the content of the nursing ethics unit and the examination system are shown in Table 1. The majority stated that the definition of the concepts and principles of ethics (89.7%), explanation of the basic theories of ethics (91.5%), and coverage of ethical problems and dilemmas in nursing practice (83.8%) were adequate. Most (85.7%) of the students also identified teaching on rights and the ICN Code as adequate. It was rewarding to see that the majority of students responded favourably concerning the group 1 subheadings mentioned above, implying that the course objectives were met. In addition, about threequarters of the students reported that the coverage of legal issues in nursing (76.5%) and the case study discussions (73.1%) were adequate. However, more students thought that these aspects were inadequate when compared with the other subheadings used. We believe that the limited time scheduled for this course in the undergraduate programme may have influenced these findings, particularly regarding the case study discussions. In the light of this finding, it is therefore worth while for us to consider the length of discussion sessions scheduled for case study analysis in subsequent courses. Case study analysis has been shown to be an effective method of teaching ethics. It facilitates easy comprehension of the theories of ethics and philosophical principles; repeated opportunities to apply philosophical material in certain situations are likely to stimulate the desire to acquire knowledge based on the perceived needs and interests of students.2,16 Case study also helps students to analyse the nature of moral problems and to distinguish these from the nonmoral problems involved in the case situation.3 The findings indicate that approximately a quarter of the students thought that the course content covering legal issues in nursing was inadequate or moderately so; this may have been due to old, but still used, regulations and laws regarding nursing that are now inconsistent with our present conditions (e.g. the role, tasks and responsibilities of nurses today) and the old style of the Turkish language that had been used in writing the codes and descriptions of laws. Although the percentages of students who identified as ‘inadequate’ the course content of all the subheadings studied in this unit was very low, they do suggest a need to change the organization of course content, the length of time allocated for the unit, and instruction methods. Nursing Ethics 2002 9 (3) Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. 264 Students’ views about the content of the nursing ethics unit and the examination system Inadequate: no. (%) Content of the nursing ethics unit Definition of ethical concepts and principles Explanation of basic theories of ethics Ethical problems and dilemmas in nursing practice Rights and the ICN Code Legal issues in nursing Case study discussion Examination system Question technique Testing knowledge Grading aStudents Moderate: no. (%) Adequate: no. (%) Totala 2 (2.1) 8 (8.2) 87 (89.7) 97 3 (3.2) 5 (5.3) 86 (91.5) 94 2 1 6 6 (2.0) (1.0) (6.1) (6.5) 14 13 17 19 (14.1) (13.3) (17.3) (20.4) 83 84 75 68 (83.8) (85.7) (76.5) (73.1) 99 98 98 93 4 3 5 (4.3) (3.1) (5.4) 27 (29.3) 20 (20.4) 17 (18.3) 61 (66.3) 75 (76.5) 71 (76.3) 92 98 93 who did not answer were excluded L Dinç and RS Görgülü © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. Nursing Ethics 2002 9 (3) Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 Table 1 Teaching ethics in nursing 265 The students’ evaluation of the examination system used for the nursing ethics unit is also illustrated in Table 1. More than half stated that the examination system was adequate; however, the proportions who considered it to be moderate or inadequate were also notable. The grading was thought to be inadequate by 5.4%. This result was probably due to the mid-term examination of open-ended questions that required students to organize and write their answers. However, if the contribution of measurement and evaluation activities to the learning process is taken into consideration, it was a positive feature that there was a higher proportion of students who identified the examination system as adequate. Table 2 displays the students’ views about some of the teaching characteristics of the two instructors who were responsible for this course. The students were asked to evaluate them separately. It can be seen that the majority of students identified the educational characteristics of teacher ‘A’ as adequate. When the table is examined for teacher ‘B’, it is revealed that the views of students were more or less parallel with those for teacher ‘A’. This finding may be the result of the teachers entering the class together or of a positive interaction between them that developed during course implementation. However, almost all of the students viewed both teachers as adequate in terms of effective educational characteristics such as their knowledge base, their ability to provide formal lectures, and their effective use of language, all of which are very important for meeting the objectives of the course. However a notable percentage of the students identified the ‘student interaction’ (9.0%) and ‘availability’ (5.2%) characteristics of teacher ‘B’ as inadequate, a finding suggesting that teacher ‘B’ needs to consider how to improve herself in these two directions. The use of instructional aids by the teachers was reported by 18.6% of the students as inadequate or moderate. Although aids such as an overhead projector and printed materials were used during lectures, this finding indicated an inefficiency that is probably due to the current limited resources. It is worth while to emphasize that, to ensure a desirable learning experience for students, the course content should be interesting and directed towards their learning needs. Overall, 88.4% of the students stated that their expectations from this course were met, which was a positive finding for both lesson content and the manner of teaching. The average score attained by the students on this course was also very high (mean = 75.45, standard deviation (SD) = 10.41). It is considered that this result supported the students’ expectations. The educational characteristics of the teachers reported by the majority of students as adequate must also have influenced how well the students’ expectations were met. When all the findings are considered together, it is shown that the unit objectives of building a basic understanding of ethics and developing the ethical decision-making skills of students were effective. In a study conducted by BabadagÆ et al.,17 the percentage of baccalaureate students who stated that they understood the course objectives was 59.8% and the mean final examaination score for these students was 60 (SD = 11.2). Some of our students recommended an increase in the amount of classroom discussion (18.5%) and a change in the mid-term examination system. They suggested that multiple-choice tests in the mid-term examinations would be more useful and easy for them to respond to. However, it is well known that every question technique measures different abilities in each of the learning domains, Nursing Ethics 2002 9 (3) Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. 266 Students’ views about educational characteristics of the teacher Characteristic Teacher ‘A’ Inadequate: no. (%) Knowledge base Ability to deliver formal lectures Effective use of language Appropriate use of instructional methods Student interaction Creating a positive environment for discussion Reinforcement Appropriate use of instructional aids Availability Guidance Openness to self-criticism Maintaining class control aStudents Moderate: no. (%) Teacher ‘B’ Adequate: no. (%) Totala Inadequate: no. (%) Moderate: no. (%) Adequate: no. (%) Totala 0 0 0 (0) (0) (0) 0 (0) 1 (1.0) 0 (0) 100 (100.0) 100 (99.0) 99 (100.0) 100 101 99 0 2 3 (0) (2.0) (2.0) 4 (4.0) 8 (8.0) 8 (8.1) 96 90 88 (96.0) (90.0) (88.9) 100 100 99 2 5 (2.0) (5.0) 7 (7.1) 4 (4.0) 89 (90.8) 92 (91.0) 98 101 1 9 (1.0) (9.0) 5 (5.2) 9 (9.0) 91 82 (93.8) (82.0) 97 100 2 1 (2.0) (1.0) 8 (7.8) 2 (2.0) 92 (90.2) 97 (97.0) 102 100 4 1 (4.0) (1.0) 7 (6.9) 7 (6.9) 90 94 (89.1) (92.2) 101 102 7 1 3 2 0 (7.2) (1.0) (3.2) (2.2) (0) 97 97 94 92 101 2 5 4 4 1 (2.1) (5.2) (4.3) (4.4) (1.0) 79 81 79 81 97 (81.4) (83.5) (85.9) (90.0) (96.0) 97 97 92 90 101 who did not answer were excluded 11 10 8 5 1 (11.3) (10.3) (8.5) (5.4) (1.0) 79 86 83 85 100 (81.4) (88.7) (88.3) (92.4) (99.0) 16 11 9 5 3 (16.5) (11.3) (9.8) (5.6) (3.0) L Dinç and RS Görgülü © 2002 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution. Nursing Ethics 2002 9 (3) Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 Table 2 Teaching ethics in nursing 267 such as reading speed and writing skills. In conclusion, the results of this study have demonstrated a positive view of these students relating to the content of the nursing ethics unit and some educational characteristics of the teachers. The students also made some useful recommendations about the course. The majority stated that the discussions of case study analysis using ethical principles, the topics of human and patients’ rights, consideration of legal aspects, and the ICN Code were very useful in developing ethical decision-making skills. The generalizability of the findings obtained in this study is limited by the small sample size. However, we believe that the results will enlighten our efforts towards the amendment of this course in order to design a more effective content and instruction method that will improve the ethical decision-making skills of our students. As suggested by Riesch et al.,5 the educational experiences that allow nursing students to develop skills in analysing the issues, consequences and obligations inherent in a moral dilemma can possibly help to improve performance during graduate education and in professional practice. Being a professional requires participation in ethical decision making and this in turn requires an effective teaching–learning process. The involvement and active participation of students in teaching ethics will contribute to the effectiveness of this process. We will therefore take into consideration the views and evaluations of our students and propose that they should participate actively in this process, and that nurse educators should listen to their perceptions and opinions. Acknowledgements We wish to thank Professor Mahir Ulusoy, who has reviewed our manuscript for statistical procedures and to Professor Filiz Ulusoy for her support. We thank our students who have participated in our study. We also thank the anonymous reviewers of the article, and Verena Tschudin, Editor of Nursing Ethics, for their encouragement and comments. Leyla Dinç and Refia Selma Görgülü, Hacettepe University School of Nursing, Ankara, Turkey. References 1 2 3 4 5 6 7 8 Davis AJ. New developments in international nursing ethics. Nurs Clin North Am 1989; 24: 571–77. Gaul AL. Ethics content in baccalaureate degree curricula. Nurs Clin North Am 1989; 24: 475–83. Fry ST. Teaching ethics in nursing curricula: traditional and contemporary models. 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