Journal of Nursing Education

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Wrestling with the Larger Picture: Placing Ethical Behavior in Clinical Situations in Context

Muriel B Ryden, PhD, RN; Mary Ellen Waithe, PhD; Patricia Crisham, PhD, RN; Arthur Caplan, PhD; Laura Duckett, PhD, RN



This article provides an account of the use of a modelbuilding process as an educational strategy for the teaching of ethics. Designed to integrate students' growing knowledge and skill in nursing with their intellectual and professional development, this model-building process has its theoretical foundations in cognitive moral development theory, and in an integrative approach to nursing education called Multi-Course Sequential Learning (MCSL).



This article provides an account of the use of a modelbuilding process as an educational strategy for the teaching of ethics. Designed to integrate students' growing knowledge and skill in nursing with their intellectual and professional development, this model-building process has its theoretical foundations in cognitive moral development theory, and in an integrative approach to nursing education called Multi-Course Sequential Learning (MCSL).


This article describes an active learning experience used in an ethics unit in the first nursing course at the University of Minnesota School of Nursing. The educational experience was developed as part of a three-year project for integrating ethics education in the curriculum of the undergraduate program in nursing. (Ryden, Duckett, Crisham, Caplan, and Schmitz, 1989). The project has enabled the development of teaching strategies and evaluation measures.

During the first ethics class, a student posed the question: "But don't we have rules to tell us what to do?" This question reinforced our view that students need to understand relationships among components that influence moral action in a clinical setting- They need to recognize that "rules," such as institutional policies, are useful, but are not in themselves sufficient guides to moral conduct. The purpose of the active learning experience we constructed for students was to help them understand that ethical behavior in a clinical situation is influenced by a number of factors.

Theoretical Framework

As a way of visualizing the theoretical underpinnings for this educational strategy, Figure 1 depicts interrelationships among nursing, ethics, and moral psychology. The intersection of these three domains represents ethical decision making and moral action in nursing situations. Because students are learning the professional practice of nursing, all ethical decisions by nurses occur within the domain of knowledge in the discipline of nursing. The domain of ethics provides moral knowledge derived from ethical theories about principles and virtues.

In the domain of moral psychology, the cognitive development theory articulated in 1932 by Piaget (1965) gave rise to the stage-theory of moral development enunciated by Kohlberg (1969). Kohlberg identified a hierarchy of six stages of moral reasoning: obethence to authority, selfinterest, interpersonal concordance, law-and-order, social consensus about rights, and universal principles of justice and fairness. Ethical decisions are made by nurses who are at different stages of moral development, and who apply theory to practice through their individual understanding of ethical principles and virtues. The active learning experience we created for our nursing students required them to incorporate components of the domain of ethical decision making into a model.


In the model-building task, we challenged students to place ethical behavior in clinical situations in context: to wrestle with the "larger picture" by considering the multiple influences on moral action in a clinical situation. Working together in small groups, students constructed a conceptual model that depicted their view of the relationships among a given set of components. These components included: 1) universal ethical principles, 2) personal beliefs, attitudes, and values, 3) formal codes, 4) institutional and professional guidelines and procedures, 5) law (case and legislation), 6) a systematic process, 7) a clinical situation, and 8) ethical behavior. We recognized that before students could do the synthesizing required by this assignment, they would have to meet other lower level learning outcomes (e.g., learn the definitions of the components, comprehend the components, and recognize specific examples of each component).




To stimulate students to meet the lower level learning outcomes, they had available to them prior to the class a handout that defined each of the components and other resources included in their course materials (American Nurses' Association, 1985; University of Minnesota School of Nursing, 1987; University of Minnesota, 1974; University of Minnesota, 1984; and State of Minnesota Statutes).

The students were divided into randomly selected groups of six or seven. Each group was provided an envelope containing the names of the components (each printed on a separate, small piece of transparency), a case situation, colored markers, tape, and a blank transparency for use with an overhead projector. Students were instructed to decide as a group how to order the various components into a model depicting their interrelationships. Although the materials students had read included definitions and examples of the components, these resources did not describe the relationships among them and the way the components together constitute the domain of nursing ethics.

As an abstraction in the model, the component "clinical situation" would be applicable to any nursing encounter. However, in the belief that students needed a concrete example of a clinical situation as a stimulus for their thinking, we provided the short case shown in Figure 2. In an attempt to develop moral sensitivity, we chose an "everyday" situation where a nurse was the decision maker. The focus was on ethics with a little "e," not a dramatic, headline-grabbing dilemma (ethics with a big "E"). Since the students would have their first clinical experience the next quarter in a long-term care facility, we chose an ethical problem regarding a resident in that setting.

We gave students clear directions for proceeding: 1) read the case situation; 2) discuss how the components relate to each other, 3) use the transparency to show these relationships visually in a model that could be used to analyze the case; 4) consider likely objections that another group might raise to your model; 5) address those objections; and 6) designate someone in the group to record a description of the model, as well as the rationale offered for building the model in the way you ultimately decide to build it. We informed students that a presenter for each group would be selected at random; therefore everyone in the group was to take responsibility for each group members learning and preparedness (Johnson, Johnson, & Holubec, 1986, pp. 59-85).

Faculty members circulated among the groups, urging students to question their assumptions, and encouraging them to avoid making premature decisions and to consider objections to their view. Faculty served as facilitators, not as providers of answers. For twenty minutes, students engaged in animated discussion as they constructed their models. Then each group was called upon in random order, and a member selected at random presented the transparency of the groups model and described their rationale for ordering the components as they did.

Analysis of Models

There was no duplication of models among the seven groups, although there were similarities which enabled us to cluster models into three representative groups according to relative degree of sophistication. One of the least sophisticated models was presented by Group C (see Figure 3). In their oral presentation, this group indicated that clinical situations were the consequence of a systematic process, although that process was not identified. The group was able to identify that relationships existed between law and institutional and professional guidelines/procedures, as well as between the latter and ethical behavior, which, in turn, they said, was directly influenced by personal beliefs and values.

A somewhat more sophisticated model was offered by Group B (see Figure 4). In their verbal presentation, Group B indicated that formal codes develop from laws and from institutional guidelines. They said that personal beliefs and values should develop from universal ethical principles. In their view, ethical behavior was the result of applying those beliefs in a systematic process. The clinical situation, they said, is where ethical development and imminent behavior come into focus for a specific outcome.




The most sophisticated model was that presented by Group E (see Figure 5). After some opening remarks, their presenter uncovered the left third of the model, the portion labeled "Input." This group identified the following as input: universal ethical principles, they said, gave rise to 1) an individual's beliefs and values; and 2) a tripartite set of what they called "corporate beliefs" including institutional and professional guidelines and procedures, formal codes, and case and legislative law.

Next, the presenter uncovered the center third of the model which is labeled "process," and identified a systematic process that a nurse goes through. Personal beliefs and corporate beliefs interact with and modify each other. In their modified forms, individual beliefs and values and corporate beliefs function as filters through which clinical situations are understood and systematically processed by a nurse, leading to output. At this point, the presenter uncovered the right third of the model, labeled "output." Ethical behavior as a student and as a nurse was viewed as behavioral output.


The least sophisticated group, Group C (see Figure 3), did not clearly recognize the relationship between universal ethical principles and law or that between codes and guidelines. They saw those universal principles as an equal partner to ethical behavior as informed by their personal beliefs and values. The perspective they took was their own personal perspective as nurses. This model may be a realistic representation both of the approaches to ethical decision making actually taken by practicing nurses and of the approach that some student nurses actually will take. In this model, ethical behavior as a student and as a nurse was going to be affected as much by a nurse's personal beliefs and values as by any other component of the process.

The somewhat more sophisticated model offered by Group B incorporated written-in explanations and qualifications. The model evidences awareness of the concept of reusability: that codes and institutional guidelines should always be révisable in light of our understanding of those original basic ideas. In Kohlbergs scheme, this is an ability that characterizes Stage 5 moral reasoning. This model indicated some awareness that professionals have a duty to act on an informed conscience: they must go through this systematic process and adopt tentative behavioral decisions which are then further processed in light of an understanding of legal requirements in particular clinical situations. In Kohlbergfc scheme, this is a Stage 5 social consensus perspective insofar as it calls for an interpretation of the clinical situation in light of the law, and in light of all of the other components. The perspective is idealistic, yet realistic in that it evidences a commitment to the process.

The presentation of the most sophisticated group, Group E, demonstrated a clear understanding of the theoretical relationship of principles to laws, codes, and individual belief systems. In attempting to achieve a balance among universal ethical principles, corporate beliefs, and personal beliefs and values, Group E's model comes closest to reflecting an awareness of the highest level of moral reasoning, Kohlbergs Stage 6. This model was the most coherent and the most logically organized. This group's approach to the entire activity appeared to be the most methodical. Their presentation was also the most coherent and the most concise.

The entire class was impressed by this groups ability to organize their model based on the Roy (1984) model which had been used in the course. Group E's presentation drew enthusiastic applause. Other students intuitively recognized a clear and appropriate model. It is possible that other students recognized the leadership potential of those who organized abstract concepts in a methodological, meaningful way, and who presented those concepts by building on previously learned material with which the authence was familiar.


According to contemporary moral theory, the ability to value the perspective of another is a mark of moral objectivity. Similarly, the ability to anticipate objections others might raise to one's position, as well as the disposition to entertain challenges to one's viewpoint marks a rejection of ethical egotism. The ability to reconsider and perhaps revise one's position is an important indicator of principled reasoning which characterizes the highest levels (Stages 5 and 6) of moral development.

One result that we expected, but which did not materialize, was that the groups would anticipate objections to the way in which their model was constructed, and to their rationale for constructing their model as they ultimately did. No one challenged any of the models presented. This perhaps indicated that we as faculty either expected too much from this group of sophomore nursing students or needed to help students to challenge each others' models and to discuss each others' objections.

Faculty and students learned that some models are clearly more sophisticated than others. This variability may reflect differences in ability to think abstractly, as well as dissimilarity in individual students' commitment to doing background readings, and to contributing to a group effort. One important thing faculty learned is that students welcome opportunities to work collectively, to take responsibility for group endeavors, and to assume new challenges. We also verified that students can learn by experience that professional ethics is not simply a matter of acting on the personal values learned in childhood.

Students discovered through an active learning method that professional ethics requires more than obeying laws, codes, guidelines, and regulations. They learned that it is not only the outcome of their decision making process that is important but also the appropriateness of the component parts of that process, the rigor and care with which that process is completed, and the need to involve peers in that process.


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