A Longitudinal Study on the Development of Moral Judgement in Korean Nursing Students

Problem-based learning versus reflective practice on nursing students' moral sensitivity

BACKGROUND

Moral sensitivity is one of the prerequisites for nurses' professional competency and patient care. It is critical to teach professional ethics in a student-centered manner in order to increase students' moral sensibility. This study evaluated the effects of professional ethics education via problem-based learning and reflective practice on nursing students' moral sensitivity.

METHODS

This experimental study was performed on 74 nursing students who were randomly divided into three groups of problem-based learning, reflective practice and control. Principles of professional ethics were presented for the two intervention groups in four 2-hour sessions using ethical dilemmas scenarios. Participants completed the Moral Sensitivity Questionnaire before, immediately, and three months after the intervention. Data were analyzed using SPSS₁₆.

RESULTS

Demographic characteristics of the three groups were similar (p > 0.05). The total moral sensitivity score significantly differed between the groups immediately and three months after the intervention (p < 0.001). The total mean score for moral sensitivity was significantly different between the two groups of problem-based learning and reflective practice, with the mean scores in the problem-based learning group being higher (p = 0.02). The mean score of moral sensitivity decreased statistically significantly in both experimental groups three months after the intervention as compared to immediately after the intervention (p < 0.001).

CONCLUSION

Nursing students' moral sensitivity can be increased through reflective practice and problem-based learning. While the results indicated that problem-based learning was more successful than reflective practice, additional research is recommended to confirm the influence of these two strategies on moral sensitivity.

Development of a questionnaire to measure the moral sensitivity of nursing students

Moral sensitivity is important for both, qualified nurses and nursing students. Currently, however, the instruments to measure moral sensitivity exist for qualified nurses only. The objective of this study is to develop a valid and reliable instrument to assess moral sensitivity of nursing students and to examine the development and differentiation of this sensitivity by school year, clinical training, and other educational variables. The study comprised semi-structured focus group interviews and a survey using a self-administered questionnaire. The questionnaire was developed using data obtained from the focus groups and distributed to 1,995 nursing students in three Bachelor of Science in Nursing programs (BScN) and eight Nursing Diploma programs. Completed questionnaires were obtained from 473 nursing students. An exploratory factor analysis indicated that 11 items and 3 factors were extracted: “Moral Strength,” “Sense of Moral Burden,” and “Moral Responsibility.” The factors each demonstrated acceptable content- and criterion-related validity with the Resilience Measurement Scale for University Students. This three-factor structure was consistent with that of the Japanese version of the revised Moral Sensitivity Questionnaire. The mean score of each item ranged from 2.75 to 4.74 (SD = 1.04 – 1.34). A comparison of inter-year scores showed that third-year students had significantly higher Moral Strength scores in both the BScN and Nursing Diploma programs. The 11-item questionnaire developed for this study was consistent with a three-factor structure of registered nurses’ moral sensitivity and successfully identified differences in moral sensitivity among nursing students. Using this type of questionnaire will allow nursing programs to improve the moral sensitivity of nursing students by allowing lecturers to develop tailored moral sensitivity programs.

Bioethics education and the development of nursing students' moral competence

BACKGROUND

The nurse accompanies individuals throughout their lives and, when in the hospital environment, provides care to those who face illness or injury. Nurses witness numerous situations involving ethical dilemmas that require a prompt and effective response based on ethical and moral principles.

OBJECTIVES

This study aimed to determine whether bioethics education in nursing influences the level of moral competence and opinion of nursing students about three ethical dilemmas.

METHODS

A longitudinal study was conducted through the application of the MCTxt (Moral Competence Test extended) questionnaire, composed of three ethical dilemmas (worker, doctor and judge), on two separate occasions (before and after students completed the Bioethics and Nursing Ethics curricular unit, which covered a total of 32 h).

PARTICIPANTS

122 s-year students from a Portuguese nursing school.

RESULTS

Nursing students showed a moral competence stagnation (1.2-point difference between the two assessments), although this did not reach statistical significance (p = 0.268). Regarding performance for each of the dilemmas, students showed an increase in performance for the worker's and judge's dilemmas and a sharp decrease in performance for the doctor's dilemma.

CONCLUSIONS

The support of students by morally competent teachers and monitors, the development of methods that provide the development of critical judgement and decision-making ability, and the increase of hours for the Bioethics course unit seem crucial factors to develop nursing students' moral competence.

A scoping review of the integration of ethics education in undergraduate nursing high-fidelity human simulation-based learning

AIMS AND OBJECTIVES

To systematically assemble, examine and map the extant literature pertaining to the integration of ethics education in high-fidelity simulation-based learning experiences in nursing undergraduate programmes.

BACKGROUND

The value of ethics education for undergraduate nursing students is well established in the literature. Whether high-fidelity human simulation (HFHS) supports the development of ethical reasoning or positively impacts the acquisition of ethical knowledge and reasoning skills in undergraduate nursing students is inconsistently addressed.

DESIGN

A scoping review was conducted using the Arksey and O'Malley framework.

METHOD

CINAHL, ProQuest Nursing & Allied Health Source, ProQuest Dissertations & Theses A&I, MEDLINE, Web of Science, ERIC, Scopus, PsycINFO, and the Joanna Briggs Institute EBP databases were searched for English-language manuscripts published between 2012 and 2020. The PRISMA-ScR was used.

RESULTS

Eight papers that met the inclusion criteria were extracted for this review. Three broad categories were identified: the 'what' in ethics education, the 'how' of ethics education and the 'when' of ethics education in high-fidelity human simulation.

CONCLUSION

The integration of ethics education into simulation-based learning has the potential to positively promote nursing students' ability to develop knowledge of and skills in ethical practice. However, the inclusion of ethics education scenarios in HFHS is a relative new teaching innovation in undergraduate nursing education. As such, there continues to be no consensus on the 'what', 'how' or 'when' of ethics education for best practice in ethics education for undergraduate nursing programmes.

RELEVANCE TO CLINICAL PRACTICE

Quality improvement processes and research studies are needed to determine: the types of ethical dilemmas and debriefing sessions and optimal timing of HFHS ethics simulation in undergraduate nursing education, student support needed for running HFHS, and the learning needs of nurse educators seeking to incorporate ethics within HFHS.

The Teaching of Ethics and the Moral Competence of Medical and Nursing Students

In a time marked by the development of innovative treatments in healthcare and the need for health professionals to deal with resulting ethical dilemmas in clinical practice, this study was developed to determine the influence of the bioethics teaching on the moral competence of medical and nursing students. The authors conduct a longitudinal study using the Moral Competence Test extended version before and after attending the ethics curricular unit, in three nursing schools and three medical schools of Portugal. In this questionnaire the participant is confronted with three ethical dilemmas (related to theft, euthanasia and the torture of a terrorist) and asked to evaluate arguments for and against the attitude of the main character (Worker, doctor and judge). For both nursing and medical students, C-score was lower after the attendance of the ethics curricular units, with a statistically significant decrease in the total score (from 21 to 19.5 on average; p = 0.046) for nursing students and a decrease not statistically significant for medical students (from 23.2 to 22 on average; p = 0.358). A multivariate analysis did not find any association between this decrease and gender, course, or age. The phenomenon of moral segmentation was observed, with better performance in the worker and judge dilemma, than in the doctor dilemma. These results highlight the need to reflect on the curricular strategies that can be implemented for health professionals to better develop moral competence and decision-making, allowing for the provision of humanized health care.

Effects of using standardized patients on nursing students’ moral skills

Background:

Nurses and nursing students increasingly confront ethical problems in clinical practice. Moral sensitivity, moral reasoning, and ethical decision-making are therefore important skills throughout the nursing profession. Innovative teaching methods as part of the ethics training of nursing students help them acquire these fundamental skills.

Aim:

This study investigated the effects and potential benefits of using standardized patients in ethics education on nursing baccalaureate students’ moral sensitivity, moral reasoning, and ethical decision-making by comparing this method with in-class case analyses.

Research design:

This is a quasi-experimental study.

Participants and research context:

The sample comprised 89 students in Hacettepe University’s Faculty of Nursing. Following lectures describing the theoretical components of ethics, students were randomly assigned to two working groups, one using standardized patients and the other using in-class case analyses. Data were collected using the Moral Sensitivity Questionnaire, Rest’s Defining Issues Test, and the Nursing Dilemma Test. All data were analysed using IBM SPSS Statistics Version 23.

Ethical considerations:

Ethical approval and official permission were obtained. All participating students completed informed consent forms.

Findings:

According to the results, the moral sensitivity of students in the standardized patient group significantly improved over time compared to those in the case analysis group, while the mean scores of students in both groups for moral reasoning and ethical decision-making were not statistically significant.

Conclusion:

Based on our results, we recommend the use of both standardized patients and case analysis as appropriate teaching methods in ethics education.

Differences in Moral Judgment Between Nursing Students and Qualified Nurses

This longitudinal study examined how nursing students' moral judgment changes after they become qualified nurses working in a hospital environment. The sample used was a group of 80 nursing students attending a university in Suwon, Korea, between 2001 and 2003. By using a Korean version of the Judgment About Nursing Decisions questionnaire, an instrument used in nursing care research, moral judgment scores based on Ketefian's six nursing dilemmas were determined. The results were as follows: (1) the qualified nurses had significantly higher idealistic moral judgment scores than the nursing students; (2) the qualified nurses showed significantly higher realistic moral judgment scores than the nursing students; and (3) when comparing idealistic and realistic moral judgment scores, both the qualified nurses and the nursing students had higher scores for idealistic moral judgment. Further study is recommended to examine changes in moral judgment.

Ethics in Turkish Nursing Education Programs

This descriptive study investigated the current status of ethics instruction in Turkish nursing education programs. The sample for this study comprised 39 nursing schools, which represented 51% of all nursing schools in Turkey. Data were collected through a postal questionnaire. The results revealed that 18 of these nursing schools incorporated an ethics course into undergraduate and three into graduate level programs. Most of the educators focused on the basic concepts of ethics, deontological theory, ethical principles, ethical problems in health care, patient rights and codes of ethics for nurses. More than half of the educators believed that students' theoretical knowledge of ethics is applied to their clinical experiences. The teaching methods used included discussion in class, lectures, case studies, small group discussion, dramatization and demonstration. Assessment was carried out by means of written essays and written examinations.

Effects of ethics education on moral sensitivity of nursing students

BACKGROUND

While nursing ethics education is commonly provided for undergraduate nursing students in most nursing colleges, consensus on the content and teaching modules for these ethics courses have still not been established.

OBJECTIVES

This study aimed to examine the effects of nursing ethics education on the moral sensitivity and critical thinking disposition of nursing students in Korea.

RESEARCH DESIGN

A one-group pre- and post-test design was used. Moral sensitivity was measured using the Korean version of the Moral Sensitivity Questionnaire. Critical thinking disposition was measured using the Critical Thinking Disposition Questionnaire. Participants and research context: Participants were 70 undergraduate nursing students who were attending a university located in Seoul, Korea. The nursing ethics education was provided 7 times, from September to December 2010, and comprised 90-min sessions each week. Ethical considerations: This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines.

FINDINGS

After the education, the levels for the patient-oriented care, a sub-domain of moral sensitivity, and inquisitiveness, a sub-domain of critical thinking disposition, significantly improved. There were no changes in overall scores for moral sensitivity and critical thinking disposition. There were significant positive correlations between moral sensitivity and critical thinking disposition both pre- and post-intervention.

CONCLUSION

These results reflect the need for ongoing efforts to develop innovative content, structure, and instructional methods for undergraduate nursing ethics education programs.

Becoming a nurse as a moral journey: A constructivist grounded theory

BACKGROUND

Nursing students, during their study, experience significant changes on their journey to become nurses. A major change that they experience is the development of their moral competency.

OBJECTIVE

The purpose of this study is to explore the process of moral development in Iranian nursing students.

RESEARCH DESIGN

A constructivist grounded theory method was adopted. Twenty-five in-depth, semi-structured, face-to-face intensive interviews with 22 participants were conducted from September 2013 to October 2014. All interviews were audio-taped, transcribed, and analyzed using writing memos and the constant comparative method. Participants and research context: The setting was three major nursing schools within Tehran, the capital of Iran. Nineteen nursing students and three lecturers participated in the study. Ethical considerations: The study was approved by the Tehran University of Medical Sciences Committee for Medical Research Ethics (92/D/130/1781). It was explained to all participants that their responses would be treated with confidentiality and that they would not be identified in any way in the research and any publication ensuing from the research. All participants agreed to be interviewed and signed written consent forms agreeing to the recording and analyses of the interview data gathered.

FINDINGS

Findings indicated three levels of moral development along with the formation of professional identity. The three levels of moral development, getting to know the identity of nursing (moral transition), accepting nursing identity (moral reconstruction), and professional identity internalization (professional morality), were connected to the levels of professional identity formation.

DISCUSSION

The proposed model added a new insight to professionalism in nursing.

CONCLUSION

From the findings, it was concluded that to enhance higher moral practice, nursing instructors should promote the professional identity of nursing students. Reinforcement of moral characteristics and professional identity within registered nurses occurs over a series of phases and, once fully integrated into the identity of nursing students, the moral characteristics that they acquire become part of their both professional and personal identities.

Effectiveness of ethics education as perceived by nursing students

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.

Moral judgment competence of nursing students in the Czech Republic

The aim of this cross-sectional study was to determine the level of moral judgment competence in students of nursing at the University of Ostrava Faculty of Medicine, and whether it is influenced by the field of study, type of study, current year of study and age. The design of the study was cross-sectional. The survey sample comprised 662 full-time and part-time students of General Nursing and Midwifery. To measure ethical competence, Lind's Moral Judgment Test (MJT, 1995) was used. The nursing students showed low C-index scores (the mean C-index was 14.24 ± 9.56). The C-index was significantly influenced only by the type of study and age (p<0.05). Part-time students and those over 30 years of age had the lowest C-index scores. On average, the students preferred stages 5 and 6 of moral judgment, that is the post-conventional level. Due to the nursing students' lower C-index scores, methods developing ethical argumentation should be introduced into nursing ethics courses.

Moral sensitivity and critical thinking disposition of nursing students in Korea

This study aimed to examine the level of moral sensitivity and critical thinking disposition among baccalaureate nursing students in Korea. A convenience sample of 142 undergraduate nursing students was surveyed on moral sensitivity using the Korean version of the Moral Sensitivity Questionnaire (K-MSQ) and on critical thinking disposition using the Critical Thinking Disposition Questionnaire (CTDQ). Data were collected from June 2009 to July 2010. Mean score was 2.83 out of 7 on the K-MSQ (relatively low) and 3.70 out of 5 on the CTDQ (relatively high), indicating the need for nursing educators to continue to develop and incorporate strategies that enhance moral sensitivity into ethics courses in undergraduate nursing programs in Korea. Nursing students who regarded nursing as a lifelong career exhibited stronger critical thinking disposition than did students who considered nursing to be a temporary or premarital job. Moral sensitivity should be further emphasized in nursing ethics courses in undergraduate nursing programs in Korea.

The development and implications of a case-based computer program to train ethical decision-making

To effectively train ethical decision-making of nursing students, a case-based computer program was developed using Flash animation. Seven ethical cases collected from practicing registered nurses’ actual clinical experiences and a six-step Integrated Ethical Decision-Making Model developed by the author were employed in the program. In total, 251 undergraduate students from three nursing schools used the program in their nursing ethics course. The usability of the program and its usefulness in improving 11 abilities needed in ethical decision-making were measured; it scored higher than 4 on a 5-point scale. Of the students, 82% recommended the program as a valuable complementary tool in the teaching of a nursing ethics course. A variety of encouraging and positive experiences were reported by the students. The computer program is likely to be usefully practical in the training of abstract skills to nursing students, though certain challenges remain, such as the precise understanding of cognitive or affective responses to ethical issues.

The relationship of ethics education to moral sensitivity and moral reasoning skills of nursing students

This study described the relationships between academic class and student moral sensitivity and reasoning and between curriculum design components for ethics education and student moral sensitivity and reasoning. The data were collected from freshman ( n = 506) and senior students ( n = 440) in eight baccalaureate nursing programs in South Korea by survey; the survey consisted of the Korean Moral Sensitivity Questionnaire and the Korean Defining Issues Test. The results showed that moral sensitivity scores in patient-oriented care and conflict were higher in senior students than in freshman students. Furthermore, more hours of ethics content were associated with higher principled thinking scores of senior students. Nursing education in South Korea may have an impact on developing student moral sensitivity. Planned ethics content in nursing curricula is necessary to improve moral sensitivity and moral reasoning of students.

Construction and testing of the Moral Development Scale for Professionals (MDSP)

Moral development among students is central for nursing education, because nursing is informed by moral ends, and it is essential that professional nurses have a well developed ability for moral behaviour, ethical reasoning and decision making. The aim of this study was to construct a new instrument for measuring moral development according to Kohlberg's theory of moral development among students and professionals, and initially test it for reliability and validity among students in professional education. Thirty-two items following the conventional and postconventional stages in the theory were developed. Different actions for reducing the items were implemented. The final version of the instrument with 12 items was tested for reliability and validity among 326 conveniently chosen students. A Cronbach's alpha coefficient of 0.67 and support for construct validity was obtained.

"Whatever it takes": nursing students' experiences of administering medication in the clinical setting

This research was conducted to examine experiences of nursing students in administering medication in the clinical setting. Grounded theory was utilized, involving in-depth interviews with 28 final-year students. In this article, we examine the importance participants attached to conforming to the prevailing culture, and their responses when offered what they considered inadequate supervision. Three main categories emerged: norming for the survival of self, conforming and adapting for benefit of self and others; and performing with absolute conscience. Subsequently, the model of contingent reasoning was developed to explain the actions of students. Contingent reasoning was influenced by the relationship with the registered nurse and individual characteristics of the students. Contingent reasoning was validated by participants and is discussed in relation to Kohlberg's theory of moral reasoning and other relevant nursing literature. This model has the potential to enhance understanding of how students make decisions, and ultimately to positively influence this process.

Encompassing multiple moral paradigms: A challenge for nursing educators

Providing ethically competent care requires nurses to reflect not only on nursing ethics, but also on their own ethical traditions. New challenges for nurse educators over the last decade have been the increasing globalization of the nursing workforce and the internationalization of nursing education. In New Zealand, there has been a large increase in numbers of Chinese students, both international and immigrant, already acculturated with ethical and cultural values derived from Chinese Confucian moral traditions. Recently, several incidents involving Chinese nursing students in morally conflicting situations have led to one nursing faculty reflecting upon how moral philosophy is taught to non-European students and the support given to Chinese students in integrating the taught curriculum into real-life clinical practice settings. This article uses a case study involving a Chinese student to reflect on the challenges for both faculty members and students when encountering situations that present ethical dilemmas.

Ethical problems observed by student nurses

This descriptive study was conducted to determine nursing students' observation of ethical problems encountered in their clinical practice. Data were collected through a questionnaire from 153 volunteer nursing students at a university-based nursing school in Ankara, Turkey. The students reported that some patients are either physically or psychologically mistreated by doctors and nurses; they were not given appropriate information; they were subjected to discrimination according to their socio-economic situation; and their privacy was ignored. The findings reveal that nurses' own unethical behaviors contribute to a rise in ethical problems. It is argued that nurses should internalize their professional and ethical roles in order to provide safe and ethical care and be good role models for students.

Nursing students' ethical decision-making: a review of the literature

Research into education in ethical decision-making in nursing is scarce. This review is an overview of empirical literature published between 1980 and September 2006. The literature was retrieved from the Medline and CINAHL databases. The focus is on the methodology and findings of these studies for identifying knowledge gaps for further research. The methodological approaches and foci of the studies varied rendering the comparison and generalization of the findings difficult. The findings indicate that education has a positive impact on students' moral development. Future research should focus on educators and clinical instructors, and on the cooperation between theoretical and clinical instruction. A review of the theoretical scientific literature would provide valuable knowledge as well. Research in this area might also benefit from more context appreciating qualitative research as well as from the use of longitudinal research designs. Research projects at national and international level should be considered.