Progress in the moral reasoning of baccalaureate nursing students between program entry and exit

The effect and comparison of training in ethical decision-making through lectures and group discussions on moral reasoning, moral distress and moral sensitivity in nurses: a clinical randomized controlled trial

BACKGROUND

Ethical decision‑making and behavior of nurses are major factors that can affect the quality of nursing care. Moral development of nurses to making better ethical decision-making is an essential element for managing the care process. The main aim of this study was to examine and comparison the effect of training in ethical decision-making through lectures and group discussions on nurses' moral reasoning, moral distress and moral sensitivity.

METHODS

In this randomized clinical trial study with a pre- and post-test design, 66 nurses with moral reasoning scores lower than the average of the community were randomly assigned into three equal groups (n = 22) including two experimental groups and one control group. Ethical decision-making training to experimental groups was provided through the lectures and group discussions. While, the control group did not receive any training. Data were collected using sociodemographic questionnaire, the nursing dilemma test (NDT), the moral distress scale (MDS) and the moral sensitivity questionnaire (MSQ). Unadjusted and adjusted binary logistic regression analysis was reported using the odds ratio (OR) and 95% confidence intervals.

RESULTS

Adjusted regression analysis showed that the probability of increasing the nursing principle thinking (NPT) score through discussion training was significantly higher than lecture (OR: 13.078, 95% CI: 3.238-15.954, P = 0.008), as well as lecture (OR: 14.329, 95% CI: 16.171-2.005, P < 0.001) and discussion groups compared to the control group (OR: 18.01, 95% CI: 22.15-5.834, P < 0.001). The possibility of increasing moral sensitivity score through discussion training was significantly higher than lecture (OR: 10.874, 95%CI: 6.043-12.886, P = 0.005) and control group (OR: 13.077, 95%CI: 8.454-16.774, P = 0.002). Moreover, the moral distress score was significantly reduced only in the trained group compared to the control, and no significant difference was observed between the experimental groups; lecture group vs. control group (OR: 0.105, 95% CI: 0.015-0.717, P = 0.021) and discussion group vs. control group (OR: 0.089, 95% CI: 0.015-0.547, P = 0.009).

CONCLUSIONS

The results of this study indicate that ethical decision-making training is effective on empowerment of ethical reasoning. Whereas the group discussion was also effective on increasing the ethical sensitivity, it is recommended the training plan provided in this study to be held as workshop for all nurses in health and treatment centers and placed in curricular plan of nursing students.

REGISTRATION

This randomized clinical trial was registered in Iranian Registry of Clinical Trials under code (IRCT2015122116163N5) in 02/07/2016.

The effects of an ethics laboratory program on moral sensitivity and professional values in nursing students: A randomized controlled study

BACKGROUND

Recently, moral sensitivity and professional values have become increasingly important in nursing education and have been tried to be improved.

OBJECTIVES

To investigate the effects of an ethics laboratory program integrated with the fundamentals of nursing course on the moral sensitivity and professional values of nursing students.

DESIGN

The present study was designed as a randomized controlled study. The 8-week ethics laboratory program was applied to the students in the intervention group. In the ethics laboratory program, interactive education methods, such as ethical scenarios, case studies, roleplay, group discussions, project papers and watching movies, were applied. Control group received the standard fundamentals of nursing curriculum.

PARTICIPANTS

The sample size was determined using stratified block randomization method, and 100 nursing students were assigned to intervention (n = 50) and control group (n = 50).

RESULTS

There was no baseline difference between the groups. The moral sensitivity average of the students in the intervention (82.66 ± 12.57) was lower than the average of the control group (85.64 ± 16.83) after the ethics laboratory program; however, the difference was not statistically significant (p > .05). Similarly, there were no significant differences between the intervention (132.32 ± 16.83) and the control group (131.81 ± 20.55) regarding the average score of professional values. In the responsibility sub-dimension of professional values, there was a statistically significant increase in the intervention group (p < .05).

CONCLUSION

The findings suggest that the ethics laboratory program for nursing students is effective in promoting responsibility sub-dimension of professional values. However, there was no significant effect on students' moral sensitivity and other dimensions of professional values. Further refinements of interventional research in ethics education and measurement of learning outcomes should be developed.

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.

Moral reasoning as a catalyst for cultural competence and culturally responsive care

The importance of developing cultural competence among healthcare professionals is well recognized. However, the widespread reports of insensitivity and deficiencies in care for culturally diverse patients illuminate the need to review how cultural competence development is taught, learnt and applied in practice. Unless we can alter the 'hearts and minds' of practising nurses to provide the care that they know they should, culturally insensitive care will continue operating in subtle ways. This paper explores the ideas behind nurses' actions and omissions when caring for culturally diverse patients and proposes the need to examine cultural competence development through a moral reasoning lens. Examining cultural competence development through a moral reasoning lens can help empower nurses, whilst nurturing commitment and courage to providing quality care that meets the needs of culturally diverse patients. The model of morality provides a framework that explores how moral motivation and behaviour occur and can provide a vehicle for critically examining the knowledge, skills and attitudes required to provide culturally responsive care.

Hypothesis: the hospital learning environment impedes students' acquisition of reflectivity and medical professionalism

Undergraduate clinical education follows the "bedside" tradition that exposes students to inpatients. However, the hospital learning environment has two main limitations. First, most inpatients require acute care, and students may complete their training without seeing patients with frequent non-emergent and chronic diseases that are managed in outpatient settings. Second, students rarely cope with diagnostic problems, because most inpatients are diagnosed in the community or the emergency room. These limitations have led some medical schools to offer longitudinal integrated clerkships in community settings instead of hospital block clerkship rotations. In this paper, I propose the hypothesis that the hospital learning environment has a third limitation: it causes students' distress and delays their development of reflectivity and medical professionalism. This hypothesis is supported by evidence that (a) the clinical learning environment, rather than students' personality traits, is the major driver of students' distress, and (b) the development of attributes, such as moral reasoning, empathy, emotional intelligence and tolerance of uncertainty that are included in the definitions of both reflectivity and medical professionalism, is arrested during undergraduate medical training. Future research may test the proposed hypothesis by comparing students' development of these attributes during clerkships in hospital wards with that during longitudinal clerkships in community settings.

Moral reasoning explained by personality traits and moral disengagement: A study among Dutch nurse practitioners and physician assistants

AIM

To explore the direct and indirect effect of the personality meta-traits 'Stability' and 'Plasticity' on moral reasoning among nurse practitioners (NPs) and physician assistants (PAs).

BACKGROUND

Moral reasoning is influenced by being prone to moral disengagement and personality traits. Moral disengagement is observed among professionals in many fields, including healthcare providers. Moral disengagement is known to be provoked by environmental stressors and influenced by certain personality traits.

DESIGN

A cross-sectional approach was used including self-report questionnaires.

METHODS

A convenience sample of Dutch NPs (N = 67) and PAs (N = 88) was surveyed via online questionnaires between January and March 2015, using (a) the Defining Issues Test; (b) the BIG five inventory; and (c) the Moral Disengagement Scale. Structural equation modelling (SEM) was employed for estimating the construct validity of two meta-traits of personality and to test unidirectional influences on moral reasoning.

RESULTS

Only the Stability trait was a direct predictor of moral reasoning whereas both Stability and Plasticity were precursors of moral disengagement. Both personality meta-traits had statistically significant indirect effects on moral reasoning through a low level of moral disengagement. The influence of both personality traits on the level of moral reasoning was increased by strong self-censure on entering into morally disengaged interactions.

CONCLUSION

The personality meta-trait 'Stability' is an indicator of moral reasoning and is explained by a lower propensity to morally disengage among highly stable people. Although the meta-trait Plasticity exerts an indirect effect through moral disengagement on moral reasoning, it is not a direct indicator of moral reasoning.

The relationship amongst ethical position, religiosity and self-identified culture in student nurses

Background/purpose:

Research from other disciplines demonstrates that ethical position, idealism, or relativism predicts ethical decision-making. Individuals from diverse cultures ascribe to various religious beliefs and studies have found that religiosity and culture affect ethical decision-making. Moreover, little literature exists regarding undergraduate nursing students’ ethical position; no studies have been conducted in the United States on students’ ethical position, their self-identified culture, and intrinsic religiosity despite an increase in the diversity of nursing students across the United States.

Participants and Research Context Objectives:

The study’s two aims were to determine the relationship of self-identified culture, religiosity, and ethics position of undergraduate nursing student and whether students’ level of education and past ethics courses taken related to idealism. Two hundred and twelve volunteer undergraduate students participated.

Research design:

A descriptive cross-sectional study was designed for participants who completed the Ethical Position Questionnaire, The intrinsic subscale of the Religious Orientation Scale, and a Demographic, Cultural, Ethnicity Form. To test the five hypotheses, analyses included t-tests, correlations, and ANOVA.

Ethical Considerations:

The study was approved by the Institutional Review Board at Adelphi University.

Results:

Idealism and intrinsic religiosity were significantly related. Differences were observed for intrinsic religiosity and idealism for cultural identity and cultural dimensions such as parents’ place of birth, and if participants were US born. Students’ level of education or participation in past courses on ethics did not influence idealism.

Conclusions:

The study’s findings were similar to most of the research from other disciplines on culture, ethics position, and religiosity. Generic courses on ethics taken prior to clinical work may not assist nursing students in integrating principles into complex ethical dilemmas. Self-identified culture, religion, and intrinsic religiosity related to ethics position; completing ethics courses and level of education, juniors compared with seniors, did not influence idealism. Faculty should consider integrating students’ culture, religious orientation, and ethics position into teaching ethics for all levels of nursing education.

Development of critical thinking in health professions education: A meta-analysis of longitudinal studies

INTRODUCTION

While reports of critical thinking exist in the health professions literature, development of critical thinking across a broad range of health-professions students has not been systematically reviewed.

METHODS

In this meta-analysis, multiple databases and journals were searched through February 2016 to identify longitudinal studies using standardized tests of critical thinking [California Critical Thinking Skills Test (CCTST), Health Science Reasoning Test (HSRT), and Defining Issues Test (DIT)] in any language. Two reviewers extracted information and collected information regarding primary author, publishing journal, health profession, critical thinking test, and time1/time2 means and standard deviations. Standardized mean differences (SMD) with 95% confidence intervals (CI) were reported using a random-effects model.

RESULTS

Four hundred sixty-two studies were screened, and 79 studies (representing 6884 students) were included. Studies contained 37 CCTST, 22 DIT, and 20 HSRT. Health professions comprised nursing, pharmacy, physical therapy, occupational therapy, dentistry, medicine, veterinary medicine, dental hygiene, clinical laboratory sciences, and allied health. Cohen's kappa was strong (0.82) for inter-reviewer agreement. Both the CCTST (SMD = 0.37, 95% CI = 0.23-0.52) and DIT (SMD = 0.28, 95%CI = 0.18-0.39) demonstrated significant increases in total scores, but the HSRT (SMD = 0.03, 95%CI = -0.05-0.12) did not show improvement.

DISCUSSION/CONCLUSIONS

In this meta-analysis, students from the majority of health professions consistently showed improvement in development of critical thinking. In this diverse population, only the CCTST and DIT appeared responsive to change.

Lecture-based versus problem-based learning in ethics education among nursing students

BACKGROUND

Moral reasoning is a vital skill in the nursing profession. Teaching moral reasoning to students is necessary toward promoting nursing ethics.

OBJECTIVES

The aim of this study was to compare the effectiveness of problem-based learning and lecture-based methods in ethics education in improving (1) moral decision-making, (2) moral reasoning, (3) moral development, and (4) practical reasoning among nursing students.

RESEARCH DESIGN

This is a repeated measurement quasi-experimental study.

PARTICIPANTS AND RESEARCH CONTEXT

The participants were nursing students in a University of Medical Sciences in west of Iran who were randomly assigned to the lecture-based (n = 33) or the problem-based learning (n = 33) groups. The subjects were provided nursing ethics education in four 2-h sessions. The educational content was similar, but the training methods were different. The subjects completed the Nursing Dilemma Test before, immediately after, and 1 month after the training. The data were analyzed and compared using the SPSS-16 software.

ETHICAL CONSIDERATIONS

The program was explained to the students, all of whom signed an informed consent form at the baseline.

FINDINGS

The two groups were similar in personal characteristics (p > 0.05). A significant improvement was observed in the mean scores on moral development in the problem-based learning compared with the lecture-based group (p < 0.05). Although the mean scores on moral reasoning improved in both the problem-based learning and the lecture-based groups immediately after the training and 1 month later, the change was significant only in the problem-based learning group (p < 0.05). The mean scores on moral decision-making, practical considerations, and familiarity with dilemmas were relatively similar for the two groups.

CONCLUSION

The use of the problem-based learning method in ethics education enhances moral development among nursing students. However, further studies are needed to determine whether such method improves moral decision-making, moral reasoning, practical considerations, and familiarity with the ethical issues among nursing students.

Impacts of Socratic questioning on moral reasoning of nursing students

Background:

Nurses are often faced with complex situations that made them to make ethical decisions; and to make such decisions, they need to possess the power of moral reasoning. Studies in Iran show that the majority of nursing students lack proper ethical development. Socratic teaching is a student-centered method which is strongly opposed to the lecturing method.

Objectives:

This study was conducted to evaluate the impacts of Socratic questioning on the moral reasoning of the nursing students.

Research design:

In a quasi-experimental study, Crisham’s Nursing Dilemma Test was used to evaluate the results of three groups before, immediately after, and 2 months after intervention. The data were analyzed using the SPSS statistical software (v 15).

Participants and research context:

Through random allocation, 103 nursing students were divided into three groups. In experiment group 1 (37 students), intervention consisted of Socratic questioning-based sessions on ethics and how to deal with moral dilemmas; experiment group 2 (33 students) attended a 4-h workshop; and the control group (33 students) was not subject to any interventions.

Signed informed consent forms:

This research was approved by the Ethics Committee of the University. All the participants signed written informed consents.

Findings:

There were significant differences between experiment group 1 and experiment group 2’s pre-test and post-test scores on moral reasoning (p ≤ 0.001, p ≤ 0.001), nursing principled thinking (p ≤ 0.001, p ≤ 0.001), and practical considerations (p ≤ 0.001, p ≤ 0.031).

Discussion:

Both the teaching approaches improved the subjects’ moral reasoning; however, Socratic questioning proved more effective than lecturing. Compared to other similar studies in Iran and other countries, the students had inadequate moral reasoning competence.

Conclusion:

This study confirms the need for the development of an efficient course on ethics in the nursing curriculum. Also, it appears that Socratic questioning is an effective method to teach nursing ethics and develop nursing students’ competence of moral reasoning.

Moral Professional Personhood: ethical reflections during initial clinical encounters in nursing education

Moral agency is an important constituent of the nursing role. We explored issues of ethical development in Greek nursing students during clinical practice at the beginning of their studies. Specifically, we aimed to explore students’ lived experience of ethics, and their perceptions and understanding of encountered ethical conflicts through phenomenological analysis of written narratives.

The process of developing an awareness of personal values through empathizing with patients was identified as the core theme of the students’ experience. Six more common themes were identified. Development of the students’ moral awareness was conceptualized as a set of stages, commencing with empathizing with patients and nurses, moving on to taking a moral stand and, finally, concluding by becoming aware of their personal values and showing evidence of an emerging professional moral personhood. The notions of empathy, caring and emotion were in evidence throughout the students’ experience. Implications for practice and nurse education are discussed.

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.

Evaluation of School of health students' ethics position in Turkey

BACKGROUND

The advances in science and technology increasingly lead to the appearance of ethical issues and to the complexity of care. Therefore, it is important to define the ethics position of students studying in health departments so that high quality patient care can be achieved.

OBJECTIVES

The aim of this study was to examine the ethics position of the students at Shool of Health of an University in western Turkey.

METHODS

The study design was descriptive and cross-sectional. The study population included 540 first, second, third, and fourth year students from the Departments of Nursing, Midwifery, and Rescue and Disaster Management in the 2013-2014 academic year. Data were collected with a Personal Identification Form and The Ethics Position Questionnaire. Obtained data were analyzed with Chi-square test, Confirmatory Factor Analysis, and Nested Analysis of Variance. Ethical considerations: Before conducting the research, approval was obtained from Ege University Clinical Research Ethics Committee in İzmir and written informed consent was taken from all the participants.

FINDINGS

There was no significant difference in the mean scores for the Ethics Position Questionnaire between the students in terms of years and fields of study. Although the mean scores for the subscale idealism did not differ between fields of study, the mean scores significantly differed between years of study. However, the mean scores for the subscale relativism did not differ in terms of years and fields of study.

DISCUSSION

Whether students are idealistic or relativistic in terms of ethical judgment will be effective in ethical decision-making skills during patient care. Therefore, we need to define the factors that influence students' ethics position in the future.

CONCLUSION

It is suggested that the courses and practices that teach students to be aware of their ethics position to create an ethical outlook can be placed in the curriculum in health schools.

A Mixed-Methods Analysis in Assessing Students' Professional Development by Applying an Assessment for Learning Approach

Objective. To describe an approach for assessing the Accreditation Council for Pharmacy Education's (ACPE) doctor of pharmacy (PharmD) Standard 4.4, which focuses on students' professional development. Methods. This investigation used mixed methods with triangulation of qualitative and quantitative data to assess professional development. Qualitative data came from an electronic developmental portfolio of professionalism and ethics, completed by PharmD students during their didactic studies. Quantitative confirmation came from the Defining Issues Test (DIT)-an assessment of pharmacists' professional development. Results. Qualitatively, students' development reflections described growth through this course series. Quantitatively, the 2015 PharmD class's DIT N2-scores illustrated positive development overall; the lower 50% had a large initial improvement compared to the upper 50%. Subsequently, the 2016 PharmD class confirmed these average initial improvements of students and also showed further substantial development among students thereafter. Conclusion. Applying an assessment for learning approach, triangulation of qualitative and quantitative assessments confirmed that PharmD students developed professionally during this course series.

Assessing development in critical thinking: One institution's experience

OBJECTIVE

Enhancing critical and moral thinking are goals of higher education. We sought to examine thinking development within a Doctor of Pharmacy (Pharm.D.) program.

METHODS

The California Critical Thinking Skills Test (CCTST), Health Sciences Reasoning Test (HSRT), and the Defining Issues Test (DIT2) were administered to Pharm.D. students over four sessions throughout their didactic studies. Students took tests in their P1 Fall, P1 Spring, P2 Spring, and P3 Spring. While CCTST and HSRT are similar for assessing foundational critical thinking, the DIT2 assesses complex moral thinking. Each thinking test was correlated with academic success by undergraduate and graduate grade-point averages (GPAs).

RESULTS

The CCTST was administered in P1 Fall (20.1 ± 5.0). For HSRT, mean ± S.D. was P1 Spring: 22.7 ± 3.5, P2 Spring: 22.6 ± 4.8, and P3 Spring: 23.8 ± 4.5. After converting P1-CCTST and P2-HSRT scores using user-manual interpretations, there was no difference on paired comparison (P = 0.22, 0.1 Cohen's d). There was a small difference between P1-HSRT and P3-HSRT (P < 0.01, 0.2 Cohen's d). Also administered each time, the DIT2 was P1 Fall: 40.4 ± 12.6, P1 Spring: 36.3 ± 13.7, P2 Spring: 44.9 ± 13.6, and P3 Spring: 43.4 ± 15.4. For DIT2, both P1 Fall to P2 Spring and P1 Spring to P3 Spring were significant with small and medium effect-sizes (both P < 0.01, 0.4 and 0.5 Cohen's d respectively). Importantly, multiple HSRT, and DIT2 assessments correlated with undergraduate and graduate GPAs.

CONCLUSIONS

During a Pharm.D. program of study, students developed substantially in moral reasoning though minimally in foundational critical thinking. Both foundational and moral reasoning correlated with academic success. Showing responsiveness to change, the DIT2 appears helpful as a measure of cognitive development for pharmacy education.

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.

The changing landscape of care: does ethics education have a new role to play in health practice?

BACKGROUND

In the UK, higher education and health care providers share responsibility for educating the workforce. The challenges facing health practice also face health education and as educators we are implicated, by the way we design curricula and through students' experiences and their stories. This paper asks whether ethics education has a new role to play, in a context of major organisational change, a global and national austerity agenda and the ramifications of disturbing reports of failures in care. It asks: how would it be different if equal amounts of attention were given to the conditions in which health decisions are made, if the ethics of organisational and policy decisions were examined, and if guiding collaborations with patients and others who use services informed ethics education and its processes?

DISCUSSION

This is in three parts. In part one an example from an inspection report is used to question the ways in which clinical events are decontextualised and constructed for different purposes. Ramifications of a decision are reflected upon and a case made for different kinds of allegiances to be developed. In part two I go on to broaden the scope of ethics education and make a case for beginning with the messy realities of practice rather than with overarching moral theories. The importance of power in ethical practice is introduced, and in part three the need for greater political and personal awareness is proposed as a condition of moral agency.

SUMMARY

This paper proposes that ethics education has a new contribution to make, in supporting and promoting ethical practice - as it is defined in and by the everyday actions and decisions of practitioners and people who need health services. Ethics education that promotes moral agency, rather than problem solving approaches, would explore not only clinical problems, but also the difficult and contested arenas in which they occur. It would seek multiple perspectives and would begin with places and people, and their priorities. It would support students to locate their practice in imperfect global contexts, and to understand how individual and collective forms of power can influence healthcare quality.

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.

Evaluating moral reasoning in nursing education

Evidence-based practice suggests the best approach to improving professionalism in practice is ethics curricula. However, recent research has demonstrated that millennium graduates do not advocate for patients or assert themselves during moral conflicts. The aim of this article is the exploration of evaluation techniques to evaluate one measurable outcome of ethics curricula: moral reasoning. A review of literature, published between 1995 and 2013, demonstrated that the moral orientations of care and justice as conceptualized by Gilligan and Kohlberg are utilized by nursing students to solve ethical dilemmas. Data obtained by means of reflective journaling, Ethics of Care Interview (ECI) and Defining Issues Test (DIT), would objectively measure the interrelated pathways of care-based and justice-based moral reasoning. In conclusion, educators have an ethical responsibility to foster students' ability to exercise sound clinical judgment, and support their professional development. It is recommended that educators design authentic assessments to demonstrate student's improvement of moral reasoning.

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.

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.

Preparing occupational therapy students to make moral decisions

ABSTRACT There is growing awareness that moral distress has negative consequences for health care practitioners. The preparedness of future occupational therapists to make moral decisions needs to be addressed. The purpose of this exploratory study was to examine how moral reasoning changes during occupational therapy education. A repeated cross-sectional design was used to collect data from students enrolled in a 5-year entry-level professional program. For students in this study, a type of moral reasoning based on rules and social order was preferred over a type of moral reasoning based on abstract ideals. The consequences for moral distress and implications for occupational therapy education were discussed.

Moral reasoning among physical therapists: results of the Defining Issues Test

BACKGROUND AND PURPOSE

Although there is extensive literature in other health care fields about the ability to make ethical judgements (moral reasoning), there is a paucity of research addressing the moral reasoning of practising physical therapists. The purposes of this research were to 1) identify the types of moral reasoning used by practising physical therapists as measured by the Defining Issues Test; 2) identify differences in moral reasoning among physical therapists based on educational background, demographic variables, clinical experience, practice setting or expertise in ethics; and 3) compare the moral reasoning of physical therapists with that of other professional groups.

METHODS

The Defining Issues Test of James Rest was used to evaluate moral reasoning. Five hundred thirty-seven physical therapists responded to a mail survey sent to a random sample of 2,000 American Physical Therapy Association members. Twelve physical therapists with expertise in ethics or professionalism completed the same survey.

RESULTS

The mean postconventional score for the random sample was 41.93. This score was lower than the mean scores of physicians, nurses, medical students, nursing students and dental students established in previous research. Females, ethics experts and those in academic settings had higher postconventional scores.

CONCLUSIONS

Physical therapists scored lower in postconventional moral reasoning than some other professional groups with similar educational background. Factors that may inhibit or enhance the development of moral reasoning among physical therapists and possible consequences of high or low moral reasoning scores in physical therapy require further research. These findings may raise concerns about the entry-level educational curriculum and professional development opportunities in the area of ethics and moral reasoning. Results of this research may also highlight the challenges of evaluation, scholarship and research in physical therapy ethics. Further research and theory development is needed to address the relationships between moral theory and descriptive or empirical research within physical therapy.

A Meta-Analysis of Ethics Instruction Effectiveness in the Sciences

Scholars have proposed a number of courses and programs intended to improve the ethical behavior of scientists in an attempt to maintain the integrity of the scientific enterprise. In the present study, we conducted a quantitative meta-analysis based on 26 previous ethics program evaluation efforts, and the results showed that the overall effectiveness of ethics instruction was modest. The effects of ethics instruction, however, were related to a number of instructional program factors, such as course content and delivery methods, in addition to factors of the evaluation study itself, such as the field of investigator and criterion measure utilized. An examination of the characteristics contributing to the relative effectiveness of instructional programs revealed that more successful programs were conducted as seminars separate from the standard curricula rather than being embedded in existing courses. Furthermore, more successful programs were case-based, interactive and allowed participants to learn and practice the application of real-world ethical decision-making skills. The implications of these findings for future course development and evaluation are discussed.

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.

The development of moral judgment during nursing education in Finland

This study describes moral judgment among first- and last-year nursing students in Finland and examines the effects of ethics teaching on the development of moral judgment. The data for this quantitative cross-sectional study were collected using the Defining Issues Test (DIT), which is based on Kohlberg's theory of moral reasoning stages. The questionnaires were sent to four polytechnics, which offer nursing education in southern Finland. A total of 52 first-year students and 54 last-year students participated. The results showed that students who had had to deal with ethical dilemmas in their practical training had higher moral judgment than students who did not. Last-year students had higher moral judgment than first-year students. Last-year students resorted to principle-based thinking more often than first-year students in resolving DIT dilemmas. The differences between the two groups were statistically significant. The results indicate that nursing education may has an effect upon students' moral judgment.

Professional Values Held by Baccalaureate and Associate Degree Nursing Students

PURPOSE

To determine the congruency in value orientation of graduating students in baccalaureate and associate degree programs.

DESIGN AND METHODS

A survey design with a convenience sample of 1,450 graduating nursing students from all baccalaureate and associate degree nursing programs in Texas. Data were collected using the Nurses Professional Values Scale (NPVS). Descriptive and parametric statistics were used for analysis.

FINDINGS

ADN and BSN students did not differ significantly on the NPVS total score, however, ADN student scored higher on 5 of the 11 subscales than did their BSN counterparts. Men from both programs scored significantly lower than did women on the total scale and all subscales. Ethnic groups differed on the responses to three of the subscales representing nurses' values: respect for human dignity, safeguarding the client and public, and collaborating to meet public health needs.

CONCLUSIONS

Professional values in graduating nursing students were significantly related to sex and ethnicity, regardless of educational program. Nursing faculty members are challenged to address these differences during the educational process and mentoring of students.

Principled Thinking: A Comparison of Nursing Students and Experienced Nurses

BACKGROUND

A descriptive study was used to compare ethical reasoning abilities in senior baccalaureate nursing students and experienced registered nurses. The effects of environmental factors and previous experience with ethical dilemmas in regard to nursing principled thinking were also examined.

RESULTS

Findings on the Nursing Dilemma Test indicated a significant difference in the level of nursing principled thinking in the two groups, with nursing students scoring higher than experienced nurses. There was a significant negative correlation between years of experience and level of nursing principled thinking. The level of nursing education (e.g., associate degree of nursing, diploma, bachelor of science in nursing, masters degree, or doctorate) did not appear to have an effect on nursing principled thinking. In addition, subjects who were most affected by practical considerations demonstrated less use of higher level moral reasoning. The effect of previous experience with ethical dilemmas on nursing principled thinking was found to be nonsignificant.

CONCLUSION

Ethical dilemmas continue to create much confusion and uncertainty for practicing nurses. Suggestions are made regarding individual analysis of personal and professional values in nurses. In addition, recommendations include ongoing educational offerings and nursing administration support to assist nurses during times of moral distress.

A holistic model of advocacy: factors that influence its use

Although advocacy is embraced by nursing as an essential component of holistic philosophy, its scope is often limited in practice. In this article, a research study that examined the use of an expanded definition of advocacy is described. A link to the role of advocacy as a complementary therapy and in relation to facilitating the use of complementary therapies by patients is provided. Fifty-two registered nurses completed a researcher developed advocacy research instrument that assessed the use of moral-ethical, legal, political, spiritual, and substitutive advocacy along with various factors thought to influence the use of advocacy including moral development, perceived assertiveness, and perceived job security. An additional 40 RN-BSN students generated case studies of advocacy enacted in practice that were used as examples of the five categories of advocacy and to support the findings of the survey. Results indicated that moral-ethical advocacy was used more often than the other four categories. Moral stage development had a significant effect on substitutive advocacy but assertiveness and job security were not significant factors influencing any category of advocacy.

The defining issues test and the four component model: contributions to professional education

This article reviews studies examining the effect of professional education on ethical development. Most studies limit assessment to the measurement of moral judgement, observing that moral judgement plateaus during professional school unless an ethics intervention is present. Whereas interventions influence the shift to postconventional reasoning (the DIT P score), a more illuminating picture of change may emerge if researchers examined DIT profiles. More importantly, limiting assessment to measures of moral judgement ignores important aspects of moral functioning suggested by the Four Components Model. Assessment methods have been validated for sensitivity, role concept and ethical implementation that could be adapted to provide individuals in a particular profession with a more complete picture of abilities needed for real-life professional practice.