Ethical Decision Making Levels of Nursing Students

Dilek Sari,1 Ebru Baysal,2 Gul Gunes Celik,3 and Ismet Eser4

Author information Article notes Copyright and License information Disclaimer

Abstract
Go to:

INTRODUCTION
Advances in science and technology have made patient care more and more
complicated.1,2 As a result decision making responsibilities in nursing care to increase as
well. Thus, nurses have begun to face many ethical problems such as initiating heart-lung
resuscitation, ending a life-supporting treatment and patients rejecting treatment.2 Ethical
decision making is a logical process which involves making the best moral decisions through
systematic reasoning in a situation that brings about conflicting choices.3
Professional decisions of nurses affect their ethical problem solving skills and professional
development of nursing students as well as the quality of patient care.4,5 If nurses fail to act
in accordance with the principles taught at school in their practical applications, nursing
students may fall into ethical conflict.6 Nursing students attend practical applications in the
guidance of nurses and professors and make decisions in care. Therefore, nurses and
professors must be role models for nursing students in clinical practices.4,5 Ethics education
cannot be effective alone unless students have good role models. Practical norms and
hierarchical structures may adversely affect new-graduates’ enthusiasm for ethical behavior.7
Studies conducted on nurses’ ethical sensitivity and ethical decision making levels have
shown that they are not at the desired levels in ethical decision making.8,9 Likewise, studies
carried out with student nurses have presented similar results.3,10,11 It has been found by
studies on the ethical dilemmas experienced by nursing students and ethical decision making
that the most frequent ethical dilemmas are telling the truth to incurable patients and their
relatives,4 euthanasia, privacy,10,11 tapering of therapy,4,11 resuscitation of patients and
patient rights.11
In order to improve nurses’ ethical decision making skills, they have to be undergo through
basic education.2 Courses on ethics need be included within nursing curriculum. In-service
training should cover ethical thinking skills and decision making process after
graduation.1,12 It will enable them to identify when faced with an ethical problem, make the
decisions in conflicts of ethical principles and develop solutions.13
It has been seen that the related literature includes few studies on the ethical decision making
levels of nursing students.5,11,12,14,15 Considering the importance and necessity of ethical
decision making, we believe that our study in which we measured nursing students’ levels of
moral reasoning and ethical decision making will contribute to the literature.
Go to:

METHODS
The present descriptive cross-sectional study was consisted of the 637 students receiving
education and training in the second and fourth years of the College of Nursing in the
academic year 2016-2017. The formula [n=(Nx2xpxq)/(d2x(N-1)+t2xpxq)] was used to
calculate the size of the sample over the population.16,17 The calculation showed that the
appropriate sample size would be minimum 240 students (105 students from second year and
135 students from fourth year). A stratified random sampling method was used in selecting
the students to be taken in the sample according to class.16

Data Collection Student Information Form

The form included four questions on students’ personal characteristics (class level, age, sex)
and six questions about ethics and ethical dilemmas.

Nursing Dilemma Test

Nursing Dilemma Test was developed by Patricia Crisham in 1981. The Turkish version of
the test was analyzed for validation and reliability by Cerit (2010). The test formulated six
scenarios. In each scenario, a situation is presented to possibly generate moral confusion for
nurses offering care to the patient and family. The ethical dilemmas include: (a) newborn
with anomalies considering the issue of defining and promoting the quality of life; (b) forcing
medication; (c) adults’ requests to die; (d) orientation of a new nurse; (e) medication errors
and (f) terminally ill adults. Each of the ethical dilemmas consists of three sections. The first
section asks about the necessary action to be taken in case of the ethical dilemma given in the
scenario and wants the answerer to mark one of the three options provided for each ethical
dilemma. In the second section, six statements are presented which could be taken into
consideration in the approach to the given scenario including the ethical dilemma. The
participants are asked to choose the most important statement among these six and to put the
statements in order of importance for themselves. The responses given in this section of the
test aim at determining the levels of Principled Thinking” (PT) and “Practical Consideration”
(PC). The possible minimum PT score on the test is 18, while the maximum PT score is 66.
The lowest PC score that could be obtained on the test is 6 and the highest PC score is 36. PT
shows the importance attached to considering moral principles when making a moral decision
in nursing. PC, on the other hand, measures the importance given to environmental factors
such as the number of patients, the number of available resources, institutional policies, the
degree of nurses’ perception of the support given by the administration and the doctor’s
control when making decisions about ethical problems. In the third section, the participants
are asked to state whether they have any past experience with a similar dilemma or not.
Based on the answers given to the question in this section, the state of having experience with
a similar dilemma was assessed on a likert type scale and the “Familiarity” score was
obtained. A familiarity score between 6 and 17 shows that the participants are familiar with a
similar dilemma, while a score falling within the 18-30 range reveals no familiarity with a
similar dilemma.8

Ethical Considerations
Prior to data collection, an approval was obtained from X University College of Nursing
Ethics Committee. Permission to use the Turkish version of the Nursing Dilemma Test was
obtained from Birgül Cerit. Written approval was taken from school administrators to
conduct the study. The study was conducted according to the Helsinki Declaration. Verbal
consent was obtained from each student who agreed to participate after they were informed
about the study content.
Statistical Analysis
Statistical analysis was performed by using SPSS (version 17.0, SPSS Inc, Chicago, Illinois).
General subject characteristics were analyzed using descriptive analysis through frequency,
percentage, and means. Categorical variables were tested with Student t test and p<0.05 was
considered statistically significant.
Go to:

RESULTS
It was found that the mean age of the students was 22.18 ± 1.41 years, a great majority of
them (81.2%) were female and 18.8% were male. More than the half of the students (56.2%)
was in their fourth year. Most of the students (62.9%) knew the definition of ethical dilemma,
more than one third of them (38.4%) defined ethical dilemma as the conflict of values, very
few students (6.2%) experienced ethical dilemma during their clinical internship and that the
greatest ethical dilemma they experienced (33.5%) was in the case that the practices
performed were different from what had theoretically been explained.
The data obtained from the second section of the Nursing Dilemma Test were evaluated and
mean scores of PT, PC and familiarity that student nurses could get over this test were
calculated. Accordingly, it was determined that the mean PT score 48.38±7.97 was a little
above the average level, while the mean PC score 17.87±4.13 had a close value to average.
The mean Familiarity score was 17.75±2.77 which showed that they were unfamiliar with
similar dilemmas (Table-I).
Table-I
Mean Scores of Students in Nursing Dilemma Test.

Nursing Dilemma Test M (SD) Minimum Maximum

Nursing Principled Thinking 48.38±7.97 27 62

Practical Consideration 17.87±4.13 8 30

Familiarity 17.75±2.77 6 30

The data obtained from section A of each scenario of Nursing Dilemma Test, 52.1% of the
students were in favor of resuscitation of a newborn with abnormalities, nearly one third
(31.2%) supported administering medication against the will of the patient while, and 38.8%
of them remained undecided. As for the third scenario, 71.7% of the students stated that they
would provide respiratory support although a competent adult patient requested to die.
According to fewer than half of the students (40.4%) there is no time for the orientation of
new nurses into the pediatric nursing clinic 40.4% remaining undecided. A great majority of
the students (74.2%) stated that medication errors must be informed. The last scenario
presented a dilemma about a terminally ill adult who asked his diagnosis despite his doctors’
and family members’ wishes. One third of the students (33.3%) thought that patients
questions must be answered, 26.7% agreed with the doctor and family and 40.0% remained
undecided (Table-II).
Table-II
Nursing student’s responses to section A of the Nursing Dilemma Test (n= 240).

Dilemmas ‘What should nurse do?’ n %

Newborn with anomalies Should resuscitate the newborn 125 52.1

Cannot decide 73 30.4

Should not resuscitate the newborn 42 17.5

Forcing medication Should forcefully give the medication 75 31.2

Cannot decide 93 38.8

Should not forcefully give the medication 72 30.0

Adult’s request to die Should provide assistance for artificial respiration 172 71.7

Cannot decide 56 23.3

Dilemmas ‘What should nurse do?’ n %

Should not provide assistance for artificial respiration 12 5.0

New nurse orientation Should allocate time for orientation of the nurse 97 40.4

Cannot decide 97 40.4

Should not allocate time for orientation of the nurse 46 19.2

Medication error Should report the medication error now 178 74.2

Cannot decide 48 20.0

Should not report the medication error now 14 5.8

Terminally ill adults Should answer the patient’s questions 80 33.3

Cannot decide 96 40.0

Should not answer the patient’s questions 64 26.7

While second year students’ Familiarity and PT scores were good, PC scores of the fourth
year students were found to be higher (p<0.05). It was observed that female students’
Principled Thinking scores were high while male students had their PC scores higher
(p<0.05). The students who knew the definition of ethical dilemma had higher Familiarity
and PT scores whereas those who did not know the definition of ethical dilemma had higher
PC scores (p<0.05) (Table-III).
Table-III
The Distribution of the Score of Nursing Dilemma Test by Several Variables.

Principled Thinking Practical Consideration Familiarity Score

Score Score

Class n Mean±SD T P Mean±SD t p Mean±SD t p

Second year 105 51.09±6.86 4.955 0.000 16.92±3.75 - 0.001 18.21±1.60 2.523 0.012
3.257

Fourth year 135 46.28±8.17 18.61±4.27 17.38±3.38

Sex

Male 45 45.31±8.37 - 0.004 20.11±4.83 3.574 .001 17.57±3.48 -.384 0.702

2.914

Female 195 49.09±7.73 17.35±3.78 17.78±2.59

To know
definition of
ethical
dilemma
 Principled Thinking Practical Consideration Familiarity Score
Score Score

Class n Mean±SD T P Mean±SD t p Mean±SD t p

Knowing 151 49.64±7.30 3.117 0.002 17.19±3.85 - 0.001 18.04±2.13 2.171 0.031
3.408

Unknowing 89 46.24±8.63 19.03±4.34 17.24±3.57

Go to:

DISCUSSION
When the ethical dilemmas experienced by nursing students in their clinical practices were
examined, it was seen that the most frequently faced dilemmas included the fact that clinical
practices did not comply with the standards in theoretical education, not telling the truth to
the patient and making the decision of not applying CPR. These findings are similar to the
results of previous studies carried out with student nurses.4,11
Principled Thinking show the importance attached to considering moral principles when
making a moral decision in nursing. The present study found that mean PT scores of nursing
students were a little above the average level (Table-I). In this respect, it could be said that -
albeit not at the desired levels-student nurses think by taking ethical principles into
consideration when faced with ethical problems. In some studies conducted with
nurses,9,12,15,19,20 and nursing students5,12,18,15 PT scores were found to be above
average, which supports our findings as well.
Moreover, students’ mean PT scores vary by their class levels, sex and their knowledge of the
definition of ethical dilemma in the study. It was found that fourth year students, male
students and those who fail to define ethical dilemma had lower mean PT scores (p<0,05)
(Table-III). Fourth year nursing students are expected to have faced more ethical dilemmas
and solutions since they have more experience in clinical practices.12 However, our study
found that second year nursing students had higher mean PT scores than those students in
their fourth year. As ethics courses are included in the first and second years in our school
curriculum, this difference may have been affected by the fact that second year students have
more recent knowledge of ethics. The study conducted by Ham (2004) support those obtained
in our study. In the study they carried out with experienced nurses and graduate nursing
students, it was found that the more years of experience the nurses had, the lower their mean
PT scores got.18 On the other hand, Crisham (1981) stated that class levels of nursing
students did not affect their man PT scores while Park et al. (2003) showed that PT scores of
fourth year students were higher.6,19 In their study, Kurt et al. (2013) determined that male
students had lower PT scores, but that their scores did not vary by class level.5
Practical consideration measures the importance given to environmental factors such as the
number of patients, the number of available resources, institutional policies, the degree of
nurses’ perception of the support given by the administration and the doctor’s control when
making decisions about ethical problems.8 It was found in the present study that students’
mean PC scores were close to average (Table-I). Based on this finding, it could be asserted
that students relatively remain under the influence of environmental factors when making
decisions about the solutions of ethical dilemmas. Mean PC scores in our study are similar to
those obtained in previous studies.12,14,21 On the other hand, in two different studies
conducted with students5 and one study with nurses, mean PC scores are higher than those
obtained in our study.8
In addition, mean PC scores of the students vary by their class level, sex and their knowledge
of ethical dilemma. It was found that fourth year students, male students and those who were
unable to define ethical dilemma had significantly higher mean PC scores (p< 0,05) (Table-
III). Since they have more experience in clinical practice, fourth year students are considered
to include environmental factors into the evaluation process when making decisions on
ethical dilemmas.
It is seen in the study that, students with lower PT scores have higher PC scores. This could
have resulted from the fact that the students are not familiar with similar ethical dilemmas.
Familiarity may help nurses be able to discuss an ethical problem they are faced with, find
appropriate solutions and make ethical decisions. Being unfamiliar with ethical dilemmas
make is difficult to make ethical decisions and cause the nurse to use practical thinking.5 In
our study, students’ mean familiarity score was 17.75±2.77, which showed that they were not
familiar with similar ethical dilemmas (Table-I). In this respect, it could be said that students
do not face with situations that are similar to those included in the scale in their real-life
clinical practices. One study with students support our findings, while in studies conducted
with nurses4,9 it is seen that nurses come across similar dilemmas more frequently in their
clinical practices.
Also, familiarity scores of the students vary by their class level, sex and their knowledge of
ethical dilemma. It was found that second year students, and those who were able to define
ethical dilemma had significantly higher mean familiarity scores (Table-III).
It can be said that familiarity scores of the fourth year students might be affected by the fact
that although they have more clinical experience, they took ethical courses in their second
year.
When the responses of the students given to the sample ethical dilemmas in the scenarios
were looked into. (Table-II), it was seen them most students assess patients’ well-being with
a paternalist point of view and support survival instead of respecting patient autonomy and
quality of life. In the field of healthcare, the concept of paternalism is mostly used to refer to
professionals who restrict others’ autonomy in order to protect them from an anticipated or
perceived damage. Sometimes professionals tend to make a dangerous assumption that they
are the only ones who can make decisions on healthcare due to their professional knowledge
and even that the sole knowledge required to decide for patients is professional
knowledge.22 Previous studies showed that nursing students act as supporters of patient
rights and behave more traditionally instead of using autonomy in the process of ethical
decision making.23 Although students sometimes support the wholeness of the patients and
their rights to designate their own destiny, they may perceive their authority insufficiently as
students and fail to take action. Moreover, they may be afraid to be accused by others when
they consider the patient’s will and personal values.18 In addition, nurses are officially
responsible for fulfilling the written duties by doctors in Turkey. It is not the nurses’ legal
obligation to inform the patient about the disease due to the respect for patient rights and,
answering the questions about the diagnosis or situation of a terminally ill patient is beyond
the official duties of a nurse in Turkey. Because of all these restrictions, nurses may think that
they would be unable to make their own ethical decisions when they are faced with ethical
dilemmas due to environmental conditions or professional and official
responsibilities.9 These reasons may have caused the students to remain undecided about the
given scenarios.
Go to:

CONCLUSION
The dilemmas most frequently faced by the student nurses included the fact that clinical
practices did not comply with the standards in theoretical education, not telling the truth to
the patient and making the decision of not applying CPR. Student nurses, albeit rarely, face
with ethical dilemmas in the clinical environment, but that they are not familiar with similar
ethical dilemmas from their previous experience. It was also concluded that they consider
ethical principles at a level above average when deciding on ethical dilemmas and
environmental factors are influential on their decisions. In our study, ethical decision making
process of the students was found to be affected by sex, class level and the students’
knowledge of the definition of ethical dilemma. In order to improve nursing students’ critical
thinking and ethical decision making skills, ethics courses must be included in the nursing
curriculum and students need to discuss ethical dilemmas with their instructors during clinical
practices. Ethics classes should be based on sample cases instead of explanation through
traditional method to increase course efficiency and help students internalize them better.

Authors’ Contribution
DS, EB & GGC: Designed the study, data collection and manuscript writing.
DS & IE: Designed the study, editing of manuscript, review and final approval of
manuscript.
Go to:

Footnotes
Grant Support & Financial Disclosures: There is no financial support.

Conflict of Interest: No conflict of interest has been declared by the authors.

Go to:

REFERENCE
1. Baykara ZG, Caliskan N, Karadag A. Effect of the case analysis method on nursing
students'assessment skills of ethical problems. J Human Sci. 2014;11:236–254. [Google
Scholar]
2. Numminen OH, Leino KH. Nursing students'ethical decision-making:a review of the
literature. Nurse Educ Today.  2007;27:796–807. doi:10.1016/j.nedt.2006.10.013.
[PubMed] [Google Scholar]
3. Berggren I, Begat I, Severinsson E. Australian clinical nurse supervisors'ethical
decisionmaking style. Nurs Health Sci.  2002;4:15–23. [PubMed] [Google Scholar]
4. Han SS, Ahn SH. An analysis and evaluation of student nurses'participation in ethical
decision making. Nurs Ethic. 2000;7:113–123. [PubMed] [Google Scholar]
5. Kurt FY, Atay S, Arikan D. The level of ethical decision-making of nursing
students. Turkiye Klinikleri J Med Ethics-Law History.  2013;21:79–87. [Google Scholar]
6. Park HA, Cameron ME, Han SS, Ahn SH, Oh HS, Kim KU, et al. Korean nursing
students'ethical problems and ethical decision making. Nursing Ethics. 2003;10:638–
653. doi:10.1191/0969733003n.e653oa. [PubMed] [Google Scholar]
7. Cameron ME, Schaffer M, Park HA. Nursing students'experience of ethical problems and
use of ethical decision-making models. Nurs Ethics. 2008;8:432–
447. doi:10.1177/096973300100800507. [PubMed] [Google Scholar]
8. Cerit B. A study of validity and reliability of nursing dilemma test and nurses'level of
ethical decision-making. Hacettepe Uni Facu Health Sci Nurs J. 2010:47–67. [Google
Scholar]
9. Cerit B, Dinc L. Ethical decision-making and professional behaviour among nurses:a
correlational study. Nurs Ethics.  2013;20:200–212. doi:10.1177/0969733012455562.
[PubMed] [Google Scholar]
10. Erdil F, Korkmaz F. (2009) Ethical problems observed by student nurses. Nurs
Ethics.  2009;16:589–598. doi:10.1177/0969733009106651. [PubMed] [Google Scholar]
11. Nolan PW, Markert D. Ethical reasoning observed:a longitudinal study of nursing
students. Nurs Ethics. 2002;9:243–258. doi:10.1191/0969733002n.e507oa.
[PubMed] [Google Scholar]
12. Yurttas A, Kasikci MK, Agacdiken S, Kavurana E, Sirin M. Comparison of levels of
nurses and nursing students'ethical decision making. Turkiye Klinikleri J Med Ethics-Law
History.  2014;22:1–8. [Google Scholar]
13. Torun S. A group of master degree students'assessment of ethical dilemmas and their
familiarity status. The Interdisciplinary J Law Forensic Sci. 2016;1:81–92. [Google Scholar]
14. Gul S, Asiret GD, Kahraman BB, Devrez N, Buken N. Investigating ethical decision-
making levels of nursing students who did and did not take ethics courses. HEMAR-
G. 2013;1:23–31. [Google Scholar]
15. Küçük S, Uysal N, Çalbayram NÇ, Kahraman İ, Altundağ S, Gönenç İ, et al.
Determination the ethical decision making process levels of nursing students and the factors
that effect them. Acıbadem Uni J Health Sci. 2017;8:157–162. [Google Scholar]
16. Karataş N. Erefe İ., editor. Sample in research:research principles, processes and methods
in nursing. Association of Research and Development in Nursing, Odak offset. 2004;17:216–
223. [Google Scholar]
17. Sümbüloğlu K, Sümbüloğlu V. Kesici T, Kocabaş Z, editors. Biostatistics. Ankara
University Faculty of Pharmacy. 1997:79. [Google Scholar]
18. Ham K. Principled thinking:a comparison of nursing students and experienced nurses. J
Cont Educ Nurs. 2004;35:66–73. [PubMed] [Google Scholar]
19. Crisham P. Measuring moral judgement in nursing dilemmas. Nursing Res.  1981;30:104–
110. [PubMed] [Google Scholar]
20. Hatfield PG. Doctoral Dissertation. Michigan: Michigan State University; 1991. The
relationship between levels of moral/ethical judgement, advocacy and autonomy among
community health nurses. [Google Scholar]
21. Cerit B, Dinc L. Ethical decision-making and professional behaviour among nurses:a
correlational study. Nursing Ethics. 2013;20:200–212. doi:10.1177/0969733012455562.
[PubMed] [Google Scholar]
22. Burkhardt MA, Nathaniel AK. In: Ethics in contemporary nursing:Ethical decision
making. 3rd Edition. Alpar Ş, Bahçecik N, Karabacak Ü., editors. Istanbul Medical Publisher;
2013. pp. 117–118. [Google Scholar]
23. Pinch W. Ethical dilemmas in nursing:the role of the nurse and perceptions of
autonomy. J Nurs Educ. 1985;24:372–376. [PubMed] [Google Scholar]

Articles from Pakistan Journal of Medical Sciences are provided here courtesy of Professional

Medical Publications