Article

Contribution of ethics
education to the ethical
competence of nursing
students: Educators and
students perceptions

Nursing Ethics
2014, Vol. 21(8) 861878
The Author(s) 2014
Reprints and permission:
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10.1177/0969733014523166
nej.sagepub.com

Nancy Cannaerts, Chris Gastmans and

Bernadette Dierckx de Casterle
Catholic University of Leuven, Belgium

Abstract
Aims: To review the literature on perceptions of nursing students and/or educators on the contribution of
ethics education to ethical competence in nursing students.
Background: Nurses do not always demonstrate the competencies necessary to engage in ethical
practice. Educators continue to debate about the best ways to teach ethics to nurses so that they can
develop ethical competencies.
Data sources: MEDLINE, Embase, CINAHL, PsycINFO, and Web of Science.
Review methods: A total of 15 articles with a quantitative, qualitative, or mixed-methods design published
between January 1992 and March 2012 were analyzed.
Results: According to students and educators, ethics education increases ethical perception of nursing
students and the development of reflective and analytical skills. However, its contribution to the
development of ethical behavior was barely mentioned. The accounts of students and educators
revealed essential features of effective ethics education: active involvement of students in case study
discussions and use of ethical frameworks. The use of activating educational strategies requires a safe
learning environment where students can openly reflect on values at stake in their care practice.
Conclusion: A better understanding of how students learn to develop ethical skills and of influencing
factors can guide educators to develop ethics courses for nursing curriculum. Future research needs to
focus on the methodological accuracy of sampling and measuring instruments.
Keywords
Educators perceptions, ethics education, literature review, nursing, students perceptions

Corresponding author: Nancy Cannaerts, Department of Health and Technology, University College Leuven, Herestraat 49, 3000
Leuven, Belgium.
Email: nancy.cannaerts@khleuven.be

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Nursing Ethics 21(8)

Introduction
In daily care, nurses are continuously challenged to make decisions with the view to provide good care.
Making and performing these decisions requires not only clinical competence but also ethical competence which involves much more than understanding ethical theories. Gallagher1 defines ethical competence as the possession of ethical knowledge next to the ability to see what a situation presents (ethical
perception); to reflect critically about what nurses know, are, and do (ethical reflection); to bring out the
ethical practice (ethical behavior); and to be ethical. With these five ethical skills, Gallagher covers the
different existing narrower and broader views of the aims and purposes of nursing education as described in
previous argument-based literature about ethics education. Although ethics in nursing education has
received growing attention, research suggests that nurses do not always demonstrate the competencies necessary to engage in ethical reflection, ethical decision making, and ethical behavior. Conventions, expectations of others, uncertainty, and confusion seem to guide the ethical reasoning and decision making of
quite a few nurses.24 These concerns about the ethical preparedness of nurses raise the question whether
and how ethics education in nursing really prepares nurses to respond adequately to the ethical demands of
current healthcare.
The teaching of ethics in nursing education has become increasingly important in recent years. Despite
the availability of a lot of argument-based literature about ethics education, there still is much debate among
nurse educators concerning the best ways to teach ethics to nurses, so that they can respond fully to ethical
issues arising in their practice. A review of the studies focusing on the contribution of ethics education to the
development of ethical competence can help develop good practices in ethics teaching.
Authors state that ethics education in nursing suffers from confusion and lack of a systematic approach.57
Nurse educators face the challenge of deciding whether ethics education is best addressed through ethicsspecific courses or through ethics lectures integrated throughout the curriculum, by teaching abstract theories or by using more skills-based approaches, through lectures, or by stressing clinical experience and
reflection.5,8,9 Studies measuring the effectiveness of ethics education by using objective measures such
as the Defining Issue Test do not sufficiently support the use of any particular teaching approach.10 In
addition to objective measurement, it is equally essential to identify how students and educators perceive
ethics education. Involvement of students and educators is a vital prerequisite to course design and for
determining whether they believe ethics education contribute to the development of ethical competence
of students. Understanding of the educational features that, according to students, have value in supporting and empowering them to deal professionally with ethical problems in practice can contribute to the
development of adequate ethics teaching.

Review
Aim
The objective of this study was to thoroughly review the literature on how nursing students and/or educators
perceive the contribution of ethics education to the ethical competence of nursing students. In this review,
we specifically address the following research questions: (a) How do students and educators perceive the
general contribution of ethics education to ethical competence of nursing students? (b) How do students and
educators perceive the contribution of ethics education content to ethical competence? (c) How do students
and educators perceive the contribution of ethics education teaching methods to ethical competence? (d)
What are according to students and educators essential features of ethics education necessary to promote
the ethical competence? (e) How do students and educators perceive the examination system in ethics
teaching?
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863

Review methodology
The review was conducted by following the guidelines of the UK Centre for Reviews and Dissemination11
Guidelines for systematic reviews. One reviewer (N.C.) conducted the primary search of the literature. After
removing duplicate articles, we applied the selection criteria to the titles and abstracts generated from the
literature search. Studies were included if they met the following criteria: (a) empirical research with a
quantitative, qualitative, or mixed-methods design; (b) written in English, French, or Dutch; and (c) concerned the contribution of ethics education to ethical competence in baccalaureate- and masters-level nursing curriculum and in postgraduate courses. Systematic reviews, conference proceedings, reports, and
other non-peer-reviewed literature were not included. Relevant articles were read in their entirety
and assessed by the first reviewer (N.C.). If a candidate article was questionable, the coauthors (B.D.D. and
C.G.) screened the entire publication for appropriateness.
The quality of the articles was checked using the quality appraisal list of Hawker et al.12 This method
enabled us to evaluate the quality of both quantitative and qualitative studies. In addition, the articles
were assessed with regard to validity and reliability criteria (for the quantitative studies) and criteria
of trustworthiness (for the qualitative studies) according to Polit and Beck.13 Articles were reread, and
relevant data were isolated, compared, categorized, and related. After consultation with B.D.D. and C.G.,
concepts and themes were identified. A narrative approach was used to collate and summarize the results
of the individual studies. Microsoft Word databases were constructed for data extraction. These databases contained a set of fields for each study design, including characteristics of the study based on the
conceptual outline.

Search methods
Electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, and Web of Science) were searched for
research articles published from January 1992 until March 2012. The following MeSH terms ethics, nursing education, students, nursing, perception and free labels (with synonyms and closely related
words) ethics, education, nursing student, nursing teacher, view, perspective, and experience were used. Reference lists of the selected articles and of relevant reviews were examined for additional publications.

Quality appraisal
Most quantitative studies implemented a cross-sectional descriptive design.1417 One study used a longitudinal descriptive design to explore changes in students ethical approaches to practice over their 4 years of
training.18 One study used a randomized experimental design to compare conventional teaching and
problem-based learning in ethics education.19
Although all quantitative studies used a self-developed questionnaire, only a few studies described its
development in detail. Only the studies of Lin et al.19 and Hsu16 reported rather high scores for the internal
consistency and content validity of their scales.
In the quantitative cross-sectional studies, the sample size varied from 15 to 369 nursing students. Three
studies mentioned their response rate varying from 36.3% to 75% for the student population.14,17,18 The
study of Edward and Preece14 also used a sample of nine nurse educators with a response rate of 100%. The
sampling methods were convenience sampling,14,15,17,18 random sampling,19 and purposive sampling.16
The criteria used to purposefully select the participants in this study were not mentioned. In the longitudinal
study of Nolan and Markert,18 the convenience sample consisted of 34 students and the dropout rate was
19 of 34 students.
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Nursing Ethics 21(8)

The qualitative studies used participant observation,20 focus groups,21 and semi-structured interviews.22
Two studies used a variety of methods to enhance the trustworthiness: verbatim transcription of the interviews, maintenance of an audit trial, data triangulation, peer debriefing, reflexivity, and investigator triangulation.21,22 Only the study of Vanlaere et al.22 stated that data saturation was probably not reached.
Sample sizes varied from 15 to 110 nursing students. The study of Parsons et al.23 used the Delphi technique
to explore the views of educators on the teaching of healthcare ethics. Eight of the 25 educators participated
in the study from start to finish.
In the mixed-methods studies, studies collected data from essays,24,25 anonymized reflection
reports, formative evaluations, and tutors materials.26 Three studies developed a questionnaire.2628
To complete data collection, Numminen et al.28 added one open-ended question to the questionnaire
and Nasrabadi et al.27 interviewed nursing students. The sample size varied from 24 to 97
students.24,25,27 In the study of Numminen et al.,28 634 questionnaires were sent to educators and
800 questionnaires were sent to students. The return rate was 29% for the educators and 27% for
the students.28

Search outcome
The electronic database search produced 1783 publications, including 135 duplicates. N.C. evaluated all
publications (n 1648) by title and abstract against the inclusion criteria. A total of 25 papers were identified as potentially meeting the inclusion criteria. Four additional articles were retrieved through the suggestions of B.D.D. and C.G. and by manual searching of reference lists of relevant articles. A total of 29
articles were read in their entirety and assessed again by N.C. in consultation with the coauthors. This
resulted in 15 publications (Figure 1).
Six studies used a quantitative design1419 (Table 1), four studies used a qualitative design2023 (Table 2),
and five studies used a mixed-methods design (Table 3).2428 The quantitative study of Park et al.25 replicated the study of Cameron et al.24
Five studies were conducted in the United Kingdom;14,18,20,23,26 the remaining studies were conducted in
Taiwan16,19 (n 2), or the United States,24 Korea,25 Iran,27 Canada,21 Belgium,22 Turkey,15 Finland,28 and
Australia17 (n 1 for each country).
Six studies focused on the perceptions of students and educators on traditional ethics courses in the nursing baccalaureate curriculum.15,17,18,21,23,27 Methods used most frequently were formal lectures combined
with case discussions in small groups. The content of ethics courses included ethical theories,1619,24,25,27
ethical codes,28 ethical decision-making models,24,25 and special issues such as end-of-life decision making,
confidentiality, and truth telling.18,20,26
Six studies reported results from research on an experiential working method in ethics education: anonymized reflection,26 reflective analysis,20 empathy sessions in a care-ethics lab,22 interdisciplinary
courses,14 problem-based learning,19 and blended learning.16 Only two studies described the perceptions
of students with the examination system.15,17
In eight studies, the sample consisted of baccalaureate nursing students in different years of their training.1519,24,25,27 Other studies used a sample of postgraduate nursing students,20 care providers participating
in an empathy session in a care-ethics lab,22 and nursing educators.23 The remaining four studies consisted
of a mixed sample of students and educators,14,26,28 and of nursing students, advanced nurse practitioners,
and nurses providing direct care.21 The combined research population consisted of about 1400 students and
210 nursing educators. Only seven16,18,22,24,25,27,28 studies provided detailed information about the sample,
which consisted mostly of females (84%100%). The mean ages of all participants were between 18.6 and
27.4 years (range 1851 years).
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Cannaerts et al.

865

Records identified
through database
searching (n = 1783)

Records after
duplicates removed
(n = 1648)
Reject: philosophically oriented
articles, not considering the
perceptions of students or educators

Records meeting
inclusion criteria by
title or abstract (n = 25)

Selection of papers to
assess in their entirety
(n = 29)

Reference list of all selected studies

and of relevant reviews + suggestion
of ethics expert: +4

Reject: no empirical research, not

focusing on perceived effectiveness of
ethics education of nursing students
or educators

Review: papers
included (n = 15)

Figure 1. Flow diagram of the study selection progress.

Findings
The studies included in the present review described how, according to students and educators, ethics education contributes to the development of ethical competence. Participants reported that ethics courses
increased ethical perception of nursing students and contributed to the development of reflective, analytical,
and reasoning skills. According to students and educators, some specific teaching methods and ethics course
contents were perceived as influential sources for developing ethical competencies, while others were considered to be less influential. Students and educators also described important features of ethics education
essential for it to be effective. In the following sections, we describe the general perceived contribution of
ethics education to ethical competence, the perceived contribution of specific teaching methods and course
contents, the features of ethics education as described by students and educators being of importance to
effective ethics education and students and educators perceptions with the examination system used in
ethics education.

General contribution of ethics education to ethical competence

According to students and educators, ethics education increased awareness in nursing students of the importance of ethics in nursing and of the complexity of ethical issues in caring practice (ethical perception).14,18,23,27 Students mentioned how they learned to challenge their established practices. Students
865

866
Data collection

Data analysis

Ethical
considerations

United
Nolan and
Kingdom
Markert18

(continued)

Interdisciplinary sessions of
To establish the negative and
Descriptive: Convenience
Student survey: selfFrequency data
nursing students and medical
positive aspects of the
sample37 second-year
administered questionnaire
students
interdisciplinary sessions as
nursing students and 40
completed during the last
Small group discussion student
experienced by both
third-year medical students,
seminar; including open- and
led, with a facilitator, groups
students and facilitators, and
RR 75% (n 28 nursing
closed-questions on the
of 4/5, case studies ethical
to elicit their views
students and n 30 medical
operational aspects and sugdilemmas that students may
concerning the possibility of
students); 9 nurse lecturers
gestions to improvement
have encountered during
improving the course and
and 13 medical staff, RR
Facilitator survey: selftheir practice settings
applying it to other aspects
100% (n 9 nurse lecturers
administered questionnaire
of their training
and n 13 medical staff)
sent 1 week after the last
seminar; asking for comments on negative and positive points of the course and
suggestions to improvement
20-h ethics course as part of
To determine the views and
Descriptive: Convenience
Questionnaire developed by
Descriptive
Informed consent
nursing history and ethics
opinions of students on the
sample113 second-year
the researchers based on
statistics
course (3 credits)
content of the nursing ethics
nursing students
experience and literature
course, the testing system,
Questionnaire: 21 items on the
Methods: formal lectures,
and some educational
content subheadings of the
question and answer
characteristics of the
nursing ethics unit, the
sessions, case study
teachers
examination system, the
discussions in small groups,
educational characteristics
presentations
of the teacher
Examination:
presentation, written essays,
final multiple-choice
examination
30-h ethics course
To explore the understanding
Descriptive: Longitudinal
Questionnaire: 29 forced
Descriptive
Content: ethical reasoning,
of nursing students and
studycomparing the
choice questions on ethical
statistics;
deontology, utilitarianism,
changes in their
results with the study of
thinking, with three new
quantitative
respect for persons, truth
understanding and
1995 (study of the ethical
items to elicit developments
content
telling, informed consent,
approaches to practice over
awareness of first-year
in the students ethical
analysis
end-of-life decisions, pertheir 4 years of training
medical, dental, nursing stuthinking over the years of
sonal choice, fair distribution
dents in their first year,
their training
of healthcare resources
To identify and compare the
Nolan and Smith, 1995)34
5 vignettes presenting
presentation to the peer
ethical values and thinking of Descriptive:
healthcare dilemmas to
group of their clinical pracnursing students at the
Convenience sample
comment upon
tice and analysis from an
beginning and at the end of
34 fourth-year
ethical perspective
their professional studies
nursing students, dropout
19 from 34 nursing students
who had completed, in their
first year, a questionnaire
regarding their ethical
awareness

Design: sample, response

rate (RR)

United
Kingdom
University
School of
Nursing and
Midwifery

Aims of the study

Ethics course: organization,

content, and method

Country
setting

Turkey
Dinc and
University
Gorgulu15
School of
Nursing

Edward and
Preece14

Author

Table 1. Quantitative studies included in the literature review.

867

Australia
University
School of
Nursing and
Midwifery

Kalaitzidis
and
Schmitz17

Pretestposttest experimental
design: Random sample
142 nursing students,
experimental group n 72,
control group n 70

Design: sample, response

rate (RR)

Blended learning: 11 ethical

To study students satisfaction Descriptive, questionnaire
scenario-based sessions
and attitudes as members of
survey design: Purposive
Content: four principles,
a scenario-based learning
sample99 baccalaureate
ethical issues
process in a blended learning
second-year nursing
Method: 1-h lecture by
environment
students
instructor, group discusTo study the relationship
sions, online materials, feedbetween students satisfacback by students online
tion ratings of nursing ethics
course and their attitudes in
the blended learning
environment
5 h of lectures and another 8 h To elicit students perceptions Descriptive, questionnaire
of tutorials (discussions, case
of the usefulness or
survey: Convenience
scenarios)
relevance of the ethics
sample396 final-year bacContent: overview of ethical
teaching to their clinical
calaureate nursing students,
theories, four ethical
nursing work
RR 36.3% (n 144)
principles of autonomy,
beneficence, nonmaleficence
and justice, applications of
these principles in practice,
ethical decision models
Assessment: group
presentation on an ethical
issue taken from the
students clinical practice

TaiwanPublic
Nursing
College

Aims of the study

Hsu16

Ethics course: organization,

content, and method

Taiwan
1-h 40-min session every week To compare the educational
Department
over 8 weeks
results of peer tutor
of Nursing at Method: problem-based learnproblem-based learning and
Taipei
ing versus conventional
conventional teaching in
Medical
teaching
nursing ethics education
University
Content: virtue ethics, four
ethical principles, nurse
patient relationship, rights
and responsibilities of nurses
and patients, codes of ethics,
ethical guidelines, ethical
issues

Country
setting

Lin et al.19

Author

Table 1. (continued)

Data analysis

Questionnaire: administered 1 Descriptive

year after they had
statistics
successfully completed the
topic had undertaken two
clinical placements after the
ethics topic
Questionnaire included closed
questions containing
background information and
addressing the relative value of
various aspects of the ethical
component of the topic,
students perceived ability to
identify, describe, explain, and
justify ethical situations in the
context of clinical practice,
and open questions
addressing additional
comments about situations
where knowledge made a
difference

Pretest questionnaire
T-test; analysis
administered immediately
of variance
prior to the education
program. Posttest
questionnaires administered
immediately after the end of
the course
Pretest and posttest
questionnaire: nursing ethical
discrimination ability scale: 9
situations and 41 questions
Posttest questionnaire: the
learning satisfaction survey
Included three open-ended
questions and six closedended questions on learning
satisfaction
Demographic questionnaire:
Frequency
Case Analysis Attitude Scale
data;
(CAAS)14 items on
descriptive
attitudes of students in doing
statistics
ethical case analysis;
Blended Learning
Satisfaction Scale
(BLSS)18 items

Data collection

Approval from the

Universitys social
and behavioral
research ethics
committee

Approval of the
institutional
review board;
consent;
confidentiality

Confidentiality

Ethical
considerations

868

20

Parsons
et al.23

Durgahee

Author

United
Kingdom
nine
universities

United
Kingdom

Country
setting

Reflective diary and reflective

diary sessions: share
through storytelling, group
formation, and discussion

Ethics course:
organization, content,
and method

To discuss, elaborate, and

explore the views of
teachers of HCE
To gather qualitative data on
the teaching of HCE to
students of nursing
To test the applicability of the
Delphi technique

To explore and identify the

possible effects of reflective
analysis on the nurses
abilities in ethical decisionmaking

Aim(s) of the study

Table 2. Qualitative studies included in the literature review.

Delphi technique: Convenience

sample25 lecturers in
mental health nursing of nine
UK universities, RR: 44% in
round one (n 11); 9
lecturers in round 2; 8
lecturers continued until the
end of the study (round 3)

Illuminative evaluation and

research model: 110 nurses
working in community,
hospital and psychiatric
settings, undertaking a
diploma-level course in the
care of the dying

Sample

Data analysis

Participant observation of 60
Qualitative
reflective diary sessions:
analysis;
group discussions with 10
constant
groups of 11 nurses
comparison
exploring the learning
process that the students
felt they underwent and
what they learnt about the
ethical decision-making
process
Three rounds; postal
Comparison
questionnaire, semiand content
structured questions and
analysis
Likert statements
Round 1: questions covering the
organization, methods,
assessment, and content of
the HCE module
Round 2: role of case studies,
reasons for providing nurses
with a formal education in
HCE, value of role models,
interpretations of virtue
ethics, positive and negative
features of the fourprinciples approach
Round 3: content and timing of
HCE

Data collection

(continued)

Informed consent

Ethical considerations

869

Belgium
Careethics lab,
sTimul

Vanlaere
et al.22

Aim(s) of the study

Sample

Data collection

To explore the meaning of and 87 participant nurses, advanced Focus groups (4 with
enactment of ethical
practitioner nurses, and
nursing students, with
practice for three groups of
third- and fourth-year bac37 participants)
nurses: nurses providing
calaureate nursing students
direct care, APN, nursing
students
To understand:
 how nurses humanly
involve themselves as
ethical agents
 what helps them to
develop the knowledge
and ability to live in and
navigate their way
through the shifting
terrain of ethical
nursing practice?
Empathy sessions: two days and To gain insight into the impact Randomized sample15 care Semi-structured narrative
one night, simulation of care
of empathy sessions on the
providers: 14 women, 1
interview
providers as a patient,
empathic abilities of care
man, age range 42 years,
receiving care from nursing
providers who underwent
RN, cleaning or logistic
students, followed by
an empathy session in the
assistant, healthcare
discussion and reflection
sTimul care-ethics lab as
assistant and kinesistherapy
simulated patients

Ethics course:
organization, content,
and method

APN: advanced practice nurse; HCE: healthcare ethics; RN: registered nurse.

Canada
Number of
clinical
settings

Doane
et al.21

Author

Country
setting

Table 2. (continued)

Ethical considerations

Qualitative
analysis;
thematic
analysis

Informed consent;
anonymity;
confidentiality

Qualitative
Approval from the
analysis;
university research
independent
review committee and
coding
from each of the
agencies that
employed the nurse
participants

Data analysis

870

Nasrabadi
et al.27

Numminen
et al.28

To explore nursing students

experience of an ethical
problem involving nursing
practice
To explore nursing students
experience of using an
ethical decision-making
model
To explore nursing students
experience of an ethical
problem involving nursing
practice
To explore nursing students
experience of using an
ethical decision-making
model
To evaluate the effectiveness
of using anonymized
reflection when teaching
ethics in the Care of the
dying patient and family
module

Aim(s) of the study

Data collection

Descriptive: Purposive sample

24 students (all qualified
nurses) and 2 lecturers, RR,
postal questionnaire: 42%
(n 10); RR, assignments: 62%
(n 15)

Frequency
Ethical enquiry phenomenological Essays designed to evaluate
data;
application of the nursing
approach: Convenience
content
ethics seminar content, by
sample97 Korean female
analysis
asking how the ethical decision
baccalaureate nursing
model helped them in
students
resolving the ethical dilemma

Approval by the
research and
ethics
committee of
the university;
informed
consent;
anonymity

Approval of the
universitys
ethical
committee;
informed
consent;
confidentiality;
anonymity
Approval of the
research ethics
committee;
informed
consent;
anonymity;
confidentiality

Approval by the
ethics
committee;
consent;
anonymity

Approval by the
ethics
committee;
consent;
anonymity

Ethical
Data analysis considerations

Frequency
Ethical enquiry phenomenological Essays designed to evaluate
data;
application of the nursing
approach: Convenience
content
ethics seminar content, by
sample73 baccalaureate
analysis
asking how the ethical decision
nursing students
model helped them in
resolving the ethical dilemma

Design: sample, response

rate (RR)

Completed anonymized
Descriptive
reflection reports
statistics;
thematic
Copies of the students
analysis
theoretical assignments
Tutors concept maps
Formative evaluations
Tutors personal reflections
Postal questionnaires
Questionnaire: three structured Descriptive
634 nurse ethics educators and
Nursing codes of ethics
To describe the views of
Finland39
statistics;
questions about the need, the
800 nursing graduating
nurse educators and
nursing
inductive
application, and teaching of
students: RR, nursing
students on teaching
education
content
codes in nursing, with an
education units: 96% (n 24);
nurses codes of ethics
units from 25
analysis
opportunity to provide a
RR, educators: 29 (n 183);
polytechnics
written response; one open
RR, students: 27% (n 212)
question about how teaching
of codes should be developed
IranSchool of Traditional course: nursing history, To compare the perceptions Action research: Traditional
Perception questionnaire:
Descriptive
Nursing and
deontology and law Two unit
and behavior scores of the
course21 traditional class
Behavior checklistexam
statistics;
Midwifery
course, traditional approach,
students in the action
first-year baccalaureate nurwith multiple-choice questions
t-test;
lectures, teacher centered
study with the scores of
sing students; Innovative
and cases for decision making;
qualitathe students in the
course57 first-year baccaInterviewsone question:
tive
Innovative course: short lecture
traditional course
laureate nursing students
what do you think about the
analysis
followed by case study
nursing ethics course?
discussions, weekly 2-h sessions, for 16 weeks, 1 semester cases (TV serial All Saints)
Content: importance of ethics for
nursing, basic principles of ethics,
theories, some special issues

Care of the dying module:

anonymized reflection, small
group discussion, student led

United Kingdom

Kyle26

Three-part model nursing ethics

course: (1) integration of
ethics in the curriculum, (2)
philosophy course in ethical
theory, and (3) 4-h nursing
ethics seminar using five ethical decision models
Three-part model nursing ethics
course: (1) integration of
ethics in the curriculum, (2)
philosophy course in ethical
theory, (3) 4-h nursing ethics
seminar using five ethical
decision models

United States
Nursing
college

Cameron
et al.24

Ethics course: organization,

content and method

Park et al.25
KoreaTwo
university
(replication
nursing
of the study
colleges
of Cameron
et al.24)

Country

Author

Table 3. Mixed-methods studies included in the literature review.

Cannaerts et al.

871

felt invited to reveal their predispositions to act in a certain way and their attitudes, prejudices, and frames of
references.14,1720,22
Students also argued that ethics education contributed to the ethical reflecting and ethical beingcomponent of ethical competence.1618,20,21 Through ethics education, students became aware of their personal qualities and limitations. They discovered personal and professional values.20,21 They could state their
thoughts positively, and could conceive counter arguments.16,17,20
At the same time, students mentioned how this increased awareness and reflective attitude created uncertainty.18,20 Educators also experienced that students dogmatism was replaced by uncertainty and doubt. In
view of this uncertainty, educators stressed the importance of acquiring confidence and security as key in
ethics education.23
According to students and educators, ethics education also influenced students analytical and problemsolving skills related to ethics. Students perceived that ethics courses had an immediate impact on their ability to identify and describe ethical issues, to understand, explain, and to justify ethical issues.16,17,19,21
Only Vanlaere et al.22 mentioned how ethics education was perceived to affect the ethical behavior of
their participants. Some participants mentioned how they introduced minor changes into their own practice,
such as avoiding noise during mealtimes or not mixing various foods together, because of their own related
negative experiences as a patient in the care-ethics lab.

Perceptions of the contribution of teaching methods

Students regarded lectures as dull, impractical, not motivating, and teacher centered. Students did not feel
involved in lectures.27,28
Both students and educators considered case studies to be meaningful and appropriate.1416,23,28 Engaging in ethical case analysis provided students with a better understanding of the ethical conflicts. It made
students develop a deeper understanding of the concepts of ethics in nursing and their applications.16
According to students, case studies were also useful for helping them develop ethical decision-making
skills.15 They mentioned, however, some important drawbacks of case studies: They were too vague or
obvious,14 and time for discussing the cases was limited.15 Educators also warned of the danger of relying
too heavily on case studies. According to them, presenting cases as clear-cut scenarios may tempt students
to focus on how a certain person acted at one time in one place, causing them to act in the same way without
considering the specific context of their practice.23 Students underlined the importance of using patient
cases from their own clinical practice.2628
In addition to case studies, students also appreciated group discussions. Student participation and interaction were perceived to be important.15,16,2628 In the studies of Durgahee20 and Kyle,26 students perceived
group discussions about dilemmas as the place where learning happened. While discussing situations in
the group, students felt invited to listen to colleagues and to restrain their own views. It helped them to
affirm their thoughts positively and to express their thoughts carefully and with clarity.20
Six studies discussed the specific value of innovative teaching methods in ethics education. The study of
Hsu reported statistically significant correlations between students satisfaction with blended learning, that
is, a hybrid of traditional face-to-face classroom lectures and e-learning. By social exchange of ideas with
classmates and teachers and by using scenario instruction, students felt enabled to develop critical analysis
and problem-solving skills.16 Lin et al.19 indicated that problem-based learning was preferred by students to
conventional teaching. According to the students of the experimental (problem-based learning) group, selfmotivated learning, moral self-cultivation, understanding of nursing ethics, and critical thinking were promoted by using problem-based learning.
Durgahee20 and Kyle26 suggested that reflection, in combination with group discussions, was perceived
as an effective method for teaching ethics. Durgahee20 studied the use of reflective diary sessions where
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students were encouraged to share their notes through storytelling. Although students felt vulnerable in
reflective groups, the majority of students participating in this study felt that discussion helped them to think
about their experiences, and to question their convictions and attitudes. Kyle26 studied the method of anonymized reflection, in which reflections were anonymized, and redistributed to students, so that they never
retrieved their own scenario. The reflections were discussed in small groups. The anonymity of the students
reflections was significant to them, as anonymity prevented the students from feeling vulnerable.
Edward and Preece14 studied nursing and medical students experiences with interdisciplinary teaching.
Student-led small group discussions of cases on different ethical issues were considered to be meaningful.
Many students stated that hearing and appreciating the variety of views of others were important.
In the care-ethics lab, studied by Vanlaere et al.,22 students experienced how the rather negative experiences of being a simulation patient related, for example, to feelings of cold and pain, powerlessness and
insecurity, and not being considered as a person. According to them, these contrasting experiences exposed
self-evident beliefs, made them reflect on their own practices, and led to new insights into their view on
care. Some participants mentioned how they introduced minor changes into their own practice because
of their experiences during the sessions.

Perceptions of the contribution of ethics education content

Three studies investigated the perceived effectiveness of ethical theories in nursing ethics education.15,17,23
In the study of Dinc and Gorgulu,15 91.2% of the students stated that the teaching of ethical theories was
adequate. In the study of Kalaitzidis and Schmitz,17 38.2% of the students perceived utilitarianism as useful
in practice, and 32.6% of the students perceived deontology as relevant to their clinical nursing work. The
four-principles approach was considered useful by 52.1% of the students. According to educators, the positive features of the four-principles approach were that it widens ones thinking beyond the obvious and
provides a framework to base ones ethical thought. A negative feature of the four-principles approach mentioned by the participants was that it could become formulaic, leading to justification of action rather than to
clear ethical thought.23 In the study of Parsons et al.,23 some educators expressed uncertainty surrounding
the teaching of virtue ethics due to their limited knowledge of this area.
Numminen et al.28 investigated the views of students and educators on the teaching of ethics codes. The
majority of students and educators regarded the codes as a basis of professionalism, enhancing professional
growth and identity. Codes were perceived as a guide for ethical decision making. However, both educators
and students believed that the teaching of ethics codes should be supplemented with other ethics-related
material. Some students found the codes to be outdated, limited in scope, or too general in content. Some
students even questioned their applicability in practice, because they perceived a difference between theoretical education and nursing practice.28
Two studies examined the experiences nursing students had when attending ethics courses that included
five ethical decision-making models.24,25 Students felt supported by the models to understand ethical conflicts, to be more systematic, and to develop the ability to resolve and rationalize ethical issues. Students
mentioned how the decision-making models provided a framework, guiding them to think in a more objective way and to clarify values. They reduced stress, provided an ethical lexicon, and helped filter bias and
injustice, resulting from ones own value system.24,25

Essential features of ethics education

Features perceived to contribute to the effectiveness of ethics education in nursing were mentioned by the
participants of various studies: the combination of theory and practice, organizational elements such as time
and integration of ethics in the curriculum, and characteristics of the teacher.
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Combining theory and practice was considered to be an essential feature of good teaching. Students
argued that ethics education should be grounded in real clinical practice.20,21,2628 In two studies participants described the effective use of educational tools, such as reflection reports or diaries in which students
described cases from their own clinical practice, that provided them the opportunity to link their everyday
experience with ethical theory.20,26
Both educators and students noted that ethics education demands significant time.14,15,23,28 Students
argued that more time was needed for student discussions in an intimate classroom setting.14,15,28 As educators perceived that ethics was being taught at a superficial level, they argued that more time should be
devoted to ethics courses, so that the material could be thoroughly covered.23,28
Some studies raised the question: at what point in the curriculum should ethics be taught? In the study of
Nolan and Markert,18 students preferred ethical courses both at the beginning and at the end of their professional training. In the study of Parsons et al.,23 some educators commented that students need a certain
amount of ethical knowledge prior to clinical practice. Both students and educators proposed that nursing
ethics should be integrated into all nursing subjects and throughout all study years. However, other participants stressed the need for a separate ethics course, which would promote a more systematic
approach.23,28
Students stressed the importance of the skills of educators in ethics education. They reported that teachers should be able to stimulate students via gentle persuasion rather than via excessive theoretical commentary. Teachers needed to balance being supportive and being challenging. An educators supportive attitude
contributed to a sense of confidence and security in those students who might feel uncertain and vulnerable
during the reflection process.20,21,26 Other prerequisites mentioned by students contributing to creating a
safe learning environment were the explicit knowledge base of the educator,14,15,21,26 the ability to promote
student interaction and participation,1416,28 and the ability to create a positive group atmosphere.26,27

Examination system
Of the two studies that mentioned the presence of evaluation activities in the ethics course,15,17 only one
study15 asked for the perceptions of the students with the testing system. Group presentations on an ethical
case from the students clinical practice in combination with a written essay and a final multiple-choice
exam were perceived as adequate by more than half of the students. However, about 30% of the students
also rated these examination activities as moderate or inadequate.

Discussion
Methodological issues
The international character of this review enables us to present a broad picture of how students and educators perceive the contribution of ethics education to ethical competence of nursing students. Studies from 10
different countries were included, representing four different continents: Europe (n 7), North America
(n 2), Australia (n 1), and Asia (n 5). Our analyses of the 15 articles suggest that there is an ongoing
international discussion about teaching ethics to nursing students. However, combining data that originate
from different countries and cultures is a complex task and may impose constraints on our conclusions. Cultural differences might play an important role in comparing perceptions of students and educators about the
contribution of ethics education.
The different research settings, participants, and data collection methods as well as the inclusion of
quantitative, qualitative, and mixed-methods studies add to the diversity of this review. While the quantitative studies mostly considered the degree of student satisfaction or perceived usefulness of ethics
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education in practice, the qualitative studies provided additional insight into the meaning of some educational processes that contribute to the development of students ethical competencies according to students and educators.
When interpreting the results of this review, readers need to consider some methodological shortcomings. The variety of the included studies led to highly fragmented research material that was difficult to
integrate. In this review, we focused on self-reported assessment of ethics education. The methods used to
assess how students and educators perceive the contribution of ethics education to ethical competence
varied among the papers. Within the studies, contribution of ethics education was operationalized
as the perceived impact on ethical skills, the perceived usefulness in practice, the evaluation of positive
and negative aspects of ethics courses, and satisfaction with specific contents or methods implemented in
ethics education. Moreover, these perceived effects such as usefulness in practice, impact on ethical
skills, adequate, and enhancing professional care, growth and identity are not clarified or operationalized in the studies. These diverging approaches and this vagueness in vocabulary to describe the real
contribution of ethics education point to the complexity of examining the contribution or effects of education which is just as large and difficult as the topics of ethics and education themselves.
The included studies all used a self-developed measure. Yet, few studies provided detailed information
about the items in their questionnaire. Hence, it was difficult to compare the results. Moreover, only two
studies established the reliability and validity of their questionnaires.16,19 In addition to the limited validation of the instruments used in the studies, the large variation in sample sizes and the meager description of
the subjects in the samples can further limit the generalizability of our conclusions.
All included articles were published over a 20-year period from 1992 to 2012, during which ethics course
content and teaching methods might have evolved significantly. In addition, the small number of studies
reveals the paucity of research explicitly concerned with the perceived contribution of ethics education. Yet
when considering the argument-based literature about ethics education in nursing, a considerable number of
articles have been published. Those articles mostly deal with theoretical or philosophical discussions about
ethics education in nursing, suggesting that ethics educators are preoccupied with philosophical and substantive ethics-related topics rather than with empirical outcomes.
This review did not identify disparities between the perceptions of students and educators about the
impact of ethics education. However, there is little research available on the perceptions of educators about
the contribution of ethics education. For this review, we retrieved only one study with a single sample of
educators23 and three studies with a mixed sample of educators and students.14,26,28 Moreover, in reporting
their results, few studies explicitly differentiated between the perceptions of students and educators.

Substantive findings
Despite the methodological limitations of this review, some tentative conclusions about the contribution of
ethics education to ethical competence can be drawn. The findings of this review suggest that during training, students and educators perceive an increase in students ethical perceptive, reflective, and decisionmaking skills. However, they barely mentioned the contribution of ethics education to the development
of ethical behavior in nursing practice.
According to students and educators, reflective skills seem to be realized by stimulating students to
reflect on personal and professional values, to question their practice, and to clarify their own predispositions and convictions. By implementing ethical decision-making models, by analyzing and discussing cases
from clinical practice in a systematic way with other students and with educators, and by using tools such as
reflection reports, students feel more able to identify, to explain, and to resolve ethical issues in practice.
Only one study mentioned the value of education in the development of ethical behavior in practice. In this
study, some participants indicated that their experience not only sparked new insights but also changed their
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875

behavior in practice.22 These findings probably indicate that the whole range of ethical skills (knowing, seeing, reflecting, doing, and being) cannot be realized only by formal teaching. Much ethical learning takes
place next to the formal teaching by means of other strategies such as role modeling.1
The qualitative findings of this review allow us to formulate some tentative conclusions about teaching
methods and features relevant to students ethical development. According to students and educators,
active involvement in ethics courses contributed to the development of ethical competencies. This was
supported by the studies of Auvinen et al.29 and Numminen and Leino-Kilpi,30 which concluded that curricula emphasizing the active involvement of students in ethical decision making, as opposed to more passive lecture-type exposure to ethical problems, tend to promote the development of ethical judgment. The
use of activating teaching strategies, such as group discussions, case analysis, and reflection sessions,
enable students to apply ethical knowledge in real care situations.31 However, students and educators
emphasized that the use of activating strategies demands careful consideration.
First, although students perceived lectures as dull and not motivating, students and educators underlined
the need for lectures on basic ethical principles, as students require a certain amount of ethical knowledge
before they can apply it in practice. Educators warned against relying solely on case studies to teach ethics,
stating that separate theoretical courses should implement a more systematic approach in teaching ethics to
nursing students.6,23,28
Second, case studies, considered by students and educators as a meaningful tool for guiding reflection
sessions and group discussions, need to be detailed and not superficial. According to them, cases should
not be described as definite, and they must be consistent with students own clinical practice. Sufficient time
is needed to reflect on case studies from the students clinical practice. Previous research indicates that more
hours of ethics education is associated with higher moral reasoning in students.7
Third, students and educators believe that reflecting on practice, discussing conflicting viewpoints, and
self-examination increase the vulnerability in students, thus creating uncertainty. These findings suggest the
need for creating a safe environment. Students and educators mentioned some requisite strategies for establishing a safe learning environment. Students felt more confident when they were equipped with frameworks and systematic approachessuch as ethical decision-making models and ethical theoriesthat
permitted them to reflect in a systematic way. Students also considered experienced teachers to be important, as they acted as role models that balanced being supportive and challenging and that provided theoretical input. Other strategies such as the anonymity of cases, an intimate classroom setting, and a democratic
climate also contributed significantly to the feeling of security.
When considering the content of ethics courses examined in this review, almost all included ethical principles,1419,2325,27 ethics codes,28 and ethical theories such as the four-principles approach,16,2325,27 deontology,2427 and utilitiarism.1527 Only three studies mention virtue ethics2325 and one study22 refers to
empathy as a care ethic framework used to develop a very specific ethics course content and method. These
course contents indicate that medical and rather rationalistic approaches in nursing ethics teaching remain
influential. This finding is confirmed by other argument-based ethics literature reviews indicating the predominance of the principle-based approach rather than a care-ethics approach in nursing ethics-related
topics.32,33
Indeed, ethics courses focused very little on care ethics, virtues, and the reciprocal relationships
between a patient and a nurse. The study of Parsons et al.23 revealed that educators felt uncertain and hazy
about teaching virtue ethics, because of limited knowledge in this area and ambiguity about how to teach
virtue ethics. In contrast to the vagueness associated with teaching virtue ethics, teaching normative principles of ethics codes was more clear-cut, because these principles clearly demarcate the boundaries
within which nurses must act. They consist of postulated principles, and they result in a justifiable outcome when strictly followed.23 To develop a virtue of caring and a caring attitude next to the development
of knowledge of ethical principles and ethical theories, other strategies such as role models and critical
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reflection on behavior in clinical internship are considered more appropriate than a traditional ethics
course in a classroom setting.31 As this review is focused on ethics education in nursing curricula, the
studies retrieved concentrate on traditional ethics courses and not on the contribution of critical reflection
on behavior in clinical internship to the development of ethical competence. More research is needed to
describe the contribution of reflection on students clinical internship to the development of the different
skills related to ethical competence.
In the studies included in this review, very few studies focus on the perceptions of students with the
examination system. This finding suggests that the evaluation of ethical competence (and research about
it) might be problematic and challenging as ethical competence comprises a wide range of learning objectives. A variety of methods of evaluation might be necessary to assess ethical competence in nursing
students.1

Conclusion
This review shows that according to nursing students and educators, ethics education contributes to the ethical awareness (ethical perception) and ethical reasoning competencies (ethical reflection) of nursing students. The accounts of students and educators point to the importance of carefully considering the use of
activating and student-centered teaching strategies in addition to theoretical frameworks, a safe learning
environment, and adequate support. To develop ethical competencies, students feel invited to question their
own values and convictions, to reflect on their care practices, and to discuss these with other students.
According to students and educators, this creates a certain amount of vulnerability and uncertainty, which
they believe can only exist in a safe learning environment created by supportive educators acting as knowledgeable and competent role models, by small groups, and by providing students with tools such as theoretical frameworks and ethical decision-making models.
This review also reveals that studies on the contribution of ethics education to the goals set out by ethics
education are scarce. Consequently, there is a clear need for further research. A better understanding of
influential factors and of the learning process of nursing students who are developing ethical awareness
(perception), ethical reasoning (reflection), and specifically ethical behavior can guide the development
of ethics education in the nursing curriculum. In addition, researchers must pay more attention to the methodological accuracy of sampling and measuring instruments and to assessing their validity and reliability.
Instruments should be designed to measure the impact of ethics education on reflective and analytical skills
as well as on behavioral competencies.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not for profit
sectors.
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