Journal of Nursing Education

Major Article 

Effectiveness of a Case-Based Computer Program on Students’ Ethical Decision Making

Eun-Jun Park, PhD, RN; Mihyun Park, PhD, RN



The aim of this study was to test the effectiveness of a case-based computer program, using an integrative ethical decision-making model, on the ethical decision-making competency of nursing students in South Korea.


This study used a pre- and posttest comparison design. Students in the intervention group used a computer program for case analysis assignments, whereas students in the standard group used a traditional paper assignment for case analysis.


The findings showed that using the case-based computer program as a complementary tool for the ethics courses offered at the university enhanced students’ ethical preparedness and satisfaction with the course.


On the basis of the findings, it is recommended that nurse educators use a case-based computer program as a complementary self-study tool in ethics courses to supplement student learning without an increase in course hours, particularly in terms of analyzing ethics cases with dilemma scenarios and exercising ethical decision making. [J Nurs Educ. 2015;54(11):633–640.]



The aim of this study was to test the effectiveness of a case-based computer program, using an integrative ethical decision-making model, on the ethical decision-making competency of nursing students in South Korea.


This study used a pre- and posttest comparison design. Students in the intervention group used a computer program for case analysis assignments, whereas students in the standard group used a traditional paper assignment for case analysis.


The findings showed that using the case-based computer program as a complementary tool for the ethics courses offered at the university enhanced students’ ethical preparedness and satisfaction with the course.


On the basis of the findings, it is recommended that nurse educators use a case-based computer program as a complementary self-study tool in ethics courses to supplement student learning without an increase in course hours, particularly in terms of analyzing ethics cases with dilemma scenarios and exercising ethical decision making. [J Nurs Educ. 2015;54(11):633–640.]

The goal of undergraduate nursing ethics education is to ensure that students, as future nursing professionals, are prepared to cope with ethical issues in nursing in a manner that is consistent with a professional nurse’s role. To achieve this goal, ethical decision making is recognized as a core skill for students to achieve in ethics courses, and an effective pedagogical approach to teaching this skill is a concern of nurse educators. The use of ethical decision-making models, case analyses, or group discussion with clinical vignettes is effective in ethics education (Cannaerts, Gastmans, & de Casterlé, 2014). However, there are constraints on students’ time regarding the adoption of diverse pedagogical approaches in an ethics course. Technology-based computer programs are emerging in education, with merits such as greater accessibility due to being offered anywhere and anytime and the possibility for alignment to the learner’s needs and pace, thus providing a solution to students’ lack of time (Hwang & Wu, 2014). The current study describes the effects of the use of a case-based computer program, which is based on the integrative ethical decision-making model (IEDM; Park, 2012, 2013), on students’ ethical decision-making competency.

Integrative Ethical Decision-Making Model

A structured ethical decision-making model is usually introduced to guide students, and the IEDM (Park, 2012) is an exemplar of such a model. The IEDM was developed by critically reviewing and integrating 20 ethical decision-making models. The IEDM consists of the following six steps:

  • Identification of an ethical problem.
  • Collection of additional information to identify the problem and develop solutions.
  • Development of alternatives for analysis and comparison.
  • Selection and justification of the best alternatives.
  • Development of diverse, practical ways to implement ethical decisions and actions.
  • Evaluation of effects and the development of strategies to prevent a similar occurrence.

The IEDM provides not only a decision-making procedure but also scaffolding questions and considerations to guide each step. For example, when applying the model to a case, students were asked to evaluate the temporal urgency and magnitude of consequences after stating an ethical problem in step 1, or to answer the five questions (Edgar, 2002)—legal test, front-page test, gut-feeling test, role-model test, and professional standard test—to reexamine the resolution selected in step 4.

A Case-Based Computer Program

Anticipating better effects of case analysis in nursing ethics education, a case-based computer program was developed using the IEDM and Flash animation (Park, 2013). The seven ethics cases presented in the computer program were real stories collected from practicing nurses and were closely related to the bioethical principles outlined by Beauchamp and Childress (2013), including surrogate decision making, self-determination, the right to know, distributive justice, conflict between distributive justice and nonmaleficence, conflict between fidelity and nonmaleficence, and conflict between veracity and fidelity. Using the audio and graphic functions of computer technology, vignettes were presented with contextual reality, stimulating students’ curiosity and interest. In addition, unlike students using the IEDM with a traditional paper-and-pencil approach, students using the computer program were able to enter and electronically save their answers using a NOTE function. They were also able to follow up with possible consequences of their solution shown in the computer program, which has the potential to encourage reflection on their decisions made.

Nursing students reported positive experiences when the IEDM (Park, 2012) or the computer program (Park, 2013) was applied in a nursing ethics course. However, the effectiveness of these approaches on ethical decision-making competency needed to be tested by comparing the computer program with a traditional, standard text-based approach using the IEDM (standard method). Therefore, the research questions in the current study were as follows:

  • Do students improve their perceived preparedness to cope with ethical issues and principled thinking after taking the nursing ethics course?
  • Is a case-based computer program more effective in improving the perceived preparedness or principled thinking than the standard method?
  • How different are the types of solutions and justification for selected ethics vignettes prior to and after taking the ethics course? Is there any difference in these variables between students who use the computer program and those who use a standard method for case analysis?
  • Is satisfaction with the ethics course higher among students who use the computer program than it is among those who use a standard method for case analysis?



The current study evaluated the effectiveness of a case-based computer program, using a quasi-experimental design according to the nonequivalent control group pretest–posttest method. The sample consisted of 158 students from four courses. Two courses for fourth-year students (n = 81) and two courses for second-year students (n = 77) were sampled from different nursing schools, as it has been found that educational grade can influence the effectiveness of ethics education (Park, Kjervik, Crandell, & Oermann, 2012). The ethics courses were taught in undergraduate nursing schools of private universities located in an urban area of South Korea during the 2011 spring or fall semester by the same instructor, following the same syllabus as a stand-alone 2-credit nursing ethics course during a 15-week semester. The instructor reviewed the program and voluntarily decided to use either the computer program or the IEDM for case analysis (a regular learning activity in the ethics course). The contents of the ethics course are presented in Table 1. The contents are consistent with the learning objectives of other ethics courses in South Korea (Korean Academy of Nursing Administration, 2000, 2012).

Content of Nursing Ethics Courses

Table 1:

Content of Nursing Ethics Courses


Each of two fourth-year courses and two second-year courses were assigned to either a computer group (n = 69) or a control group (n = 89). Both groups analyzed the same ethics cases, applying the same ethical decision-making model (the IEDM), but differed in whether they used the computer program or a paper-and-pencil method. The computer group students used the case-based computer program by downloading it through Webhard ( and watching an orientation session to learn how the computer program operates. The students were able to save their input in free text throughout the decision-making process by using the embedded NOTE function. The students in the control group learned about the IEDM from relevant handouts in the classroom and were able to access the relevant slides and an audio file explaining the IEDM through Webhard. The control group students wrote their responses to the questions included in the IEDM on an answer sheet. Case analysis was introduced as a mandatory individual home assignment after students learned the theoretical knowledge and codes of ethics for nurses in approximately the ninth week of the course. Students in both groups were evenly assigned to three of seven ethics cases by the instructor. Students in both groups submitted their case analysis results to the instructor to ensure they completed the assignment and then participated in a 20 to 30-minute, in-class, small-group discussion of three to four students per group who analyzed the same three cases. The discussion was mainly intended to allow students to learn diverse perspectives and ways to justify these perspectives.

Ethical Consideration

The current study was approved by the institutional review board. The students enrolled in the nursing ethics courses voluntarily participated in this study and received $12 (USD) cash after signing the informed consent form. To protect the anonymity of the students, both surveys were conducted in the absence of the instructor, and the names of survey participants or any other information obtained from the survey were not shared with the instructor. No identifiable information, other than a student identification number to match the pretest and post-test, appeared on the survey.

Data Collection

Data were collected using a self-administered questionnaire. A pretest was administered in the first or second week, and a posttest was administered in the 13th or 14th week of the 15-week course. The current study measured ethical decision-making competency from the following variables: (a) perceived ethical preparation to cope with ethical issues (Lu, 2007); (b) moral reasoning, using the P% score of the Korean version of the Defining Issues Test (KDIT); (c) analysis of hypothetical ethics cases in the pre- and posttest; and (d) satisfaction with the ethics course around the ability to cope with ethical issues. Individual characteristics, including age, gender, educational grade, grade point average, and any previously achieved academic degree, were collected in the pretest.

Perceived ethical preparation was measured with seven items (Lu, 2007):

  • Understanding of ethical principles or theories.
  • Ability to identify and address ethical issues.
  • Ability to resolve ethical issues.
  • Frequency of thinking about ethical dilemmas or conflicts.
  • Adequacy of ethics training received to date.
  • Helpfulness of nursing education received to date in managing ethical dilemmas or conflicts.
  • Overall ethical decision-making ability.

Responses were rated on a 9-point scale (ranging from 1 = limited to 9 = excellent), with higher scores representing higher levels of perceived ethical preparation. Cronbach’s alpha was .80 in the pretest and .86 in the posttest.

The KDIT (Moon, 2011) was used to evaluate students’ principled thinking, along with the P% score, reflecting Kohlberg’s postconventional moral stages. The KDIT was developed based on a short form of the original Defining Issues Test (Rest, 1979), using three of six ethical dilemmas, including the sick woman’s husband and the drug, the escaped prisoner, and the doctor and euthanasia. The Defining Issues Test was developed based on Kohlberg’s moral development theory that one’s moral reasoning proceeds to higher stages (from the first stage to the sixth stage) over time (Rest, 1979). According to Kohlberg and Hersh (1977), at each stage, one is likely to make a moral decision based on specific reasons. The reasoning of stages 1 and 2 at the preconventional level is based on the physical consequences of actions (e.g., punishment or reward) and satisfying one’s own needs, respectively. The reasoning of stages 3 and 4 at the conventional level is based on pleasing others or gaining others’ approval and doing one’s duty to the social order, respectively. The reasoning of stages 5 and 6 at the postconventional level is based on the arrangements agreed on by society (a social contract) and on universal principles such as justice or respect for human dignity, respectively. For each dilemma in the KDIT, 12 statements, reflecting Kohlberg’s moral stages, are rated on a scale from 1 = very important to 5 = not at all important in defining the main issue, and the most important four items of the 12 are ranked. The P% score ranges from 0 to 95 and is a strong and standard index for the KDIT (Moon, 2011). P% score represents the percentage of moral reasoning (principled thinking) in the postconventional stage preferred by the respondent.

A further assessment of ethical reasoning was conducted using three ethics vignettes. Two nurse researchers and one nurse manager reviewed the ethics cases in relevant books and articles (Fry, Veatch, & Taylor, 2011; Han et al., 2008; Lu, 2007) and selected the following vignettes that nursing students are likely to confront as clinical nurses:

  • Case A. An RN develops symptoms of an upper respiratory infection while caring for a patient with leukemia, who is vulnerable to infection, in a nursing unit with high patient acuity and an insufficient staffing level.
  • Case B. A 65-year-old man has metastatic colon cancer and a history of depression and his family members do not want him to know the truth about his prognosis; therefore, his physician is keeping this information from him.
  • Case C. The husband of a 37-year-old woman with recurrent breast cancer, who had previously requested a Do Not Resuscitate order, insists on implementing cardiopulmonary resuscitation on signs of impending respiratory failure, despite his previous agreement with the Do Not Resuscitate order.

After reading each vignette, the students, as nurses, were asked to make their own decisions and to justify their decisions:

Finally, satisfaction with the ethics course was measured with responses to the following eight statements (Lu, 2007):

  • The ethics course has contributed to my development in considering ethical issues.
  • The case analysis has contributed to my awareness of the need to make an ethical decision.
  • The case analysis has stimulated awareness of my ethical reasoning processes.
  • I have gained further insight into my approach to ethical reasoning.
  • The knowledge and skills gained through the ethics course are directly applicable to my future nursing practice.
  • This learning experience should result in changes to my approaches in coping with ethical dilemmas and issues.
  • I will use what I have learned about ethical decision making in my future nursing practice.
  • The case analysis provided a useful guide for me to make decisions regarding ethical dilemmas and issues.

Responses were rated on a 5-point scale from 0 = strongly disagree to 5 = strongly agree. Cronbach’s alpha was .95.

Data Analysis

SAS® version 9.3 software was used to analyze the quantitative data in the current study. Descriptive statistics and a chi-square test or Fisher’s exact test were conducted to examine homogeneity between the two groups. For perceived ethical preparation and P% score of the KDIT, a repeated measures analysis of variance was applied to examine an interaction effect between testing time and program type. Satisfaction with the ethics course was compared using analysis of variance, with program and educational grade as independent variables. A statistical significance of 0.05 (type I error) and pairwise deletion was applied in the data analysis.

Qualitative data obtained from the open-ended questions about the ethics vignettes were evaluated independently by the authors, using a checklist of the type and justification of the resolution for each of the three vignettes. The checklist was developed with possible responses prior to the test and was completed retrospectively based on the students’ responses in both the pre- and posttest. Originally, it was planned to count the number of justifications for the decisions made, assigning a higher score for explicit responses than for implicit ones, similar to Lu’s (2007) scoring method. However, changes in ethical reasoning between the pre- and posttests could be biased if the number of justifications was simply counted. Although the survey questions solicited all possible justifications for a resolution, several students in the posttest often omitted some of the valuable justifications mentioned in the pretest. Simultaneously judging responses as explicit or implicit was not only complicated but also unlikely to indicate a different level of ability to provide justification for their ethical decisions, as slightly different expressions in Korean are considered to have a similar meaning or intention. Therefore, the evaluation of open-ended responses for ethics vignettes focused on the changes between testing times regarding whether students were able to make a decision or not, what type of resolutions they made, and what kind of justifications they provided, depending on the resolution. Agreement between the two nurse researchers ranged from 94% to 96%, depending on the case. Disagreements were resolved through discussion until 100% agreement was reached.


The computer and control groups were homogeneous in gender (92% and 96% women, respectively), grade point average (75% and 73%, ⩽3.0 and <4.0, respectively), and year in school (46% and 52% second year students, respectively) but were heterogeneous in mean age (23.4 ± 3.97 and 22.2 ± 1.31, respectively) and whether they held a bachelor’s degree in a nonnursing major (yes, 12% and 2%, respectively). Although differences were noted in age and tertiary education between groups, these variables were excluded from the analysis of the program effects because they did not significantly affect the results. Results concerning ethical decision-making competency are described in the order of perceived ethical preparation score, P% score of principled thinking, and findings of the case analyses. In addition, satisfaction level with the nursing ethics course is compared between the programs.

Perceived Ethical Preparation

Regarding perceived ethical preparation, a significant interaction was noted between testing time and program type (F = 26.95, p < .001, ηp2 = .09) and between testing time and educational grade (F = 21.39, p < .001, ηp2 = .07). In other words, the effects of testing time on perceived ethical preparation was likely to be different, depending on the program type and educational grade. Accordingly, the simple effects for both variables were examined. As shown in Table 2, the ethical preparation score of the computer group was significantly lower than the control group at pretest (F = 5.89, p = .015), but it was significantly higher at posttest (F = 10.21, p < .001). In addition, the ethical preparation score of the fourth-year students did not differ from the second-year students at pretest (F = 0.25, p = .62), but it was significantly higher than the second-year students at posttest (F = 21.49, p < .001).

Ethical Preparation and Principled Thinking in Study Participants

Table 2:

Ethical Preparation and Principled Thinking in Study Participants

Principled Thinking

Means and standard deviations of the P% score of the KDIT are presented in Table 2. No interaction effect on P% score was noted between testing time and program type (F = 0.44, p = .509) or between testing time and educational grade (F = 0.01, p = .937). Regardless of the group, the P% score of all students was reduced after taking the course (F = 5.93, p = .016).

Ethics Case Analyses

Table 3 presents a summary of case analyses, with ethical decisions and major justifications for three cases in the pre- and posttests for both groups. Although the students’ decisions were never agreed upon, the most common ethical decision was distinct at both the pretest and posttest in both groups, depending on the case. Case B (telling the truth of a patient’s diagnosis), showed the highest agreement—92.8% of participants in the computer group and 82% of participants in the control group—among the three cases at posttest. Case A (the resolution of requesting sick leave), showed the lowest agreement—69.6% of participants in the computer group and 57.3% of participants in the control group—at posttest. Although the proportion of nondecision makers before starting the courses ranged from 5.8% to 18%, it ranged from 1.5% to 12.5% after completing the courses. The largest drop (14.5%) was found in Case A of the computer group. However, group differences were not evident in terms of decreasing the proportion of nondecision makers. Table 3 includes the frequency (percentage) of the major justifications to help demonstrate nursing students’ perspectives. At pretest, the students tended to express a variety of reasons, including personal values or common sense, for their decision as a layperson; however, at posttest, they tended to respond with fewer justifications and instead referred to a theoretical framework, such as ethical theories or ethical principles, learned in an ethics course. In both groups, the major justifications for each decision were common, including “do no harm to patients (principle of nonmaleficence),” “patients have a right to know the truth (principle of autonomy),” and “patients have a right to self-determination (principle of autonomy).” After completing the course, the frequency of major justification for the first key decision in each case increased, regardless of group.

Summary of Case Analyses for the Computer Group (n = 69) and the Standard Group (n = 89)

Table 3:

Summary of Case Analyses for the Computer Group (n = 69) and the Standard Group (n = 89)

Satisfaction With the Ethics Course

The means and standard deviations of the course satisfaction scores and the analysis of variance results are presented in Table 4. The computer group students reported a higher satisfaction score with their nursing ethics course in enhancing ethical decision-making competence, compared with the control group (F = 46.1, p < .001, ηp2 = .23). Satisfaction with the nursing ethics course did not differ between the second- and fourth-year students (F = 0.76, p = .38).

Students’ Satisfaction With the Ethics Course

Table 4:

Students’ Satisfaction With the Ethics Course


Nursing ethics education helps students to make well-justified ethical decisions, through which ethical nursing practice is guided. In the current study, the students’ perception of preparedness to cope with ethical conflicts improved after taking the ethics course. This progress was significantly greater among students who used the computer program for case analysis than it was for those in the control group. In addition, progress was greater in the fourth-year students than in the second-year students, regardless of program type. Therefore, the computer program can be expected to give students more confidence in their ethical decision-making competency. Furthermore, satisfaction with the ethics course was higher among the computer group students than the control group students; however, it did not differ between the second- and fourth-year students.

Although this study cannot clearly link specific characteristics of the computer program with the higher level of ethical preparedness and satisfaction, these measures can be attributed to some distinct features of the computer program, which is consistent with the positive feedback received in a previous study (Park, 2013). Above all, students reported that studying ethics using computer animations provoked their curiosity and interest in solving ethical issues, attracted their attention to learning ethics, and helped them to better understand the ethical conflicts or different positions of stakeholders in real life. Even for the same scaffolding questions, students may find it more attractive when those questions are presented with audio and graphics on a computer, rather than as black-and-white text. In addition, feedback on their responses was delivered by the computer program. As a reference, students can refer to the example opinions of an expert nurse or watch simulated stories of all possible resolutions, thus being exposed to different values and perspectives. Educational outcomes tend to be better when students have a positive attitude toward ethics learning (Chin, Voo, Karim, Chan, & Campbell, 2011), as shown in the current study. In addition, authentic clinical situations that present ethical issues, which in the current study were better experienced by the computer group than by the control group, are likely to result in these encouraging outcomes.

On the other hand, the ethical preparation level, based on a 9-point scale, after completing an ethics course was not high in either the computer group (6.19 ± 1.01) or among the fourth-year students (6.25 ± 1.11). Therefore, room for improvement remains. The use of only three ethics cases is unlikely to be enough experience for students to have high confidence in their ethical preparedness. More opportunities to apply theoretical knowledge to practical ethics issues are needed, and individual feedback for case analyses may prompt reflection in an ethics curriculum.

The current study findings suggest that a nursing ethics course should be provided in the students’ fourth year of study, after they have had clinical practice, rather than in the second year of their preclinical period. Students’ reflections on clinical experience may encourage their learning. However, others believe that ethical education should be provided early, before students’ clinical experiences, because students’ ethical knowledge and understanding at the beginning of professional training is influential in the development of ethical competency (Cannaerts et al., 2014). As a result, ethics content may be used throughout a 4-year nursing curriculum to facilitate students’ learning.

Students’ P% score, which is a degree of principled thinking at the postconventional stage for ethical judgment, decreased after taking the nursing ethics course. This finding is disappointing, although the P% score is similar to that reported in previous nursing studies (Cho, 2009; Lee, 2008, 2013; Park et al., 2012) and to the Korean norm of college students, which is 43.2. Few Korean nursing or medical studies have found that P% scores increased after completing a semester-long ethics course or even after 4 years of undergraduate education (Kim et al., 2005; Lee, 2008, 2013). Even internationally, professional school curricula often fail to show positive effects by the P% score (Murrell, 2014).

Because of the increasing responsibility and accountability of the nursing profession and the complexity of health care systems, nurses are confronting newly emerging ethical issues, in addition to recurrent ones, and strong ethical reasoning ability at the postconventional stage is essential. Nevertheless, a semester-long ethics course may be too short to expect students’ growth in principled thinking. Acquiring ethical reasoning ability at the postconventional stage may be more difficult and may take more time, compared with acquiring this ability at the conventional or preconventional stage. Moreover, a large lecture-centered ethics curriculum and a school climate that stresses test-oriented, right/wrong answers in Korea are unlikely to stimulate the critical thinking and reflection needed for postconventional judgment. Nursing ethics educators may emphasize social systems and common expectations and may not encourage and support individual diversity and the practice of thinking about ethical issues separately from social laws and systems. Nursing students may feel pressure to choose a socially agreed upon and acceptable resolution from conventional judgment while taking an ethics course, even if this is not the educator’s intention. As a result, the students may lose the motivation to inquire and insist on their own personal principles and perspectives, separate from social systems and rules.

Although the Defining Issues Test is a multiple choice format that presents a limited number of predetermined issues and does not focus on nursing ethics issues, the case analyses in this study were in an open-ended format in which students are able to show their own cognitive reactions to nursing dilemmas, thus assuming a nurse’s role. Ethical issues in professional practice often have suggested resolutions. The high levels of agreement in cases B and C indicate that patients’ right to know and self-determination and health professionals’ duty to respect patient autonomy, rather than family concerns, are now widely accepted among nursing students. In case A, students showed relatively low agreement, with priorities differing between requesting sick leave to protect a leukemia patient at risk of possible infection and continuing to work to protect patients who were unlikely to be properly cared for due to insufficient staffing, as well as responsibility for a patient as a professional nurse and fidelity to an organization or colleagues. Agreement on a resolution may be more difficult as the number of stakeholders increases or as work colleagues become involved, as seen in case A (i.e., requesting sick leave). Non-decision makers existed, even at the posttest, which is an important point requiring the attention of nursing ethics educators, as these students may be dependent on others’ decisions and may be vulnerable to criticism.

In terms of the justification of case analyses, students are expected to be able to show improved thought processes in the justification of ethical decisions, even without changes in the final decision, after taking a nursing ethics course; that is, to make a decision not by intuition but by reasoned arguments based on theoretical knowledge and professional values. Although the total number of justifications per individual was not counted, it tended to be stable or even slightly decreased at posttest. The IEDM used in both groups aims to stimulate thinking about relevant ethics principles and professional standards, which may explain the finding that fewer justifications stressed ethical principles and professional values at posttest, compared with pretest. Students may feel confident when they are able to justify their decisions, based on ethics theories and principles, rather than relying on personal thoughts and values as a layperson. Qualitative or quantitative differences in the justification of case analyses between the computer and control groups were not obvious.

Although written responses in ethics case analysis are recommended to better assess ethical decision making (Bebeau, 2006), their evaluation is time consuming and challenging. A measurement tool using ethics cases in nursing-specific contexts would be more appropriate to assess the effects of professional ethics education (Bebeau, 2006). An ethics measurement tool should be developed or validated in a target society, as ethical values are closely linked to sociocultural systems and values. Few measurement tools are available for nursing ethics in Korea, which considerably constrains evidence-based progress in nursing ethics education. The trial-and-error learning that occurs from exploring the written responses to ethics cases may be helpful in developing a new measurement tool.


The current study has some limitations. A control group that did not use a structured decision-making model for case analysis was not included because it was not possible to find an ethics course that does not introduce any structured ethical decision-making models. This study measured ethical decision-making competency, focusing on moral reasoning from both an objective and a subjective approach, in accordance with the main purpose of the case analysis. However, other critical components, such as moral sensitivity, moral motivation, and moral character, according to Rest and Narváez (1994), may change due to ethics education, especially when using a computer program.

Also, the current study assessed only short-term outcomes, and it would be desirable to assess long-term effects on decision-making processes, justification, and the ability to lead with ethical behaviors in clinical settings after graduation.


Implementing the case-based computer program is highly likely to be more successful in enhancing the ethical preparation level of students and their satisfaction with an ethics course than a standard method that adopts only a structured ethical decision-making model such as the IEDM. However, neither a case-based computer program nor a paper-and-pencil method could improve principled thinking of nursing students.

The expectation that students would cite more justifications for their decisions after taking an ethics course was not met. Nursing students tended to rely on theoretically proven principles or professional values, which may eliminate the necessity to add personal values for justification. Evaluating ethical reasoning based on students’ case analysis needs to be carefully designed to obtain meaningful information, and its scoring method warrants further investigation. At the same time, more diverse and sensitive measures need to be developed to assess the effects of nursing ethics courses that reflect Korean society’s systems and values.

Despite the popularity of computer technology in various education fields, few examples are found in nursing ethics education. The preliminary evidence of the current study on the effectiveness of a case-based computer program supports its adoption as a complementary self-study tool in nursing ethics courses, without increasing course hours. Nevertheless, it is suggested that Korean nurse educators critically evaluate the current ethics curriculum to achieve better outcomes: For example, it may be necessary to allocate more hours for case analysis or group discussion and to stimulate individuals’ reflective thinking and critical judgment, rather than simply following codes of ethics or ethical principles.


  • Beauchamp, T.L. & Childress, J.F. (2013). Principles of biomedical ethics (7th ed.). New York, NY: Oxford University Press.
  • Bebeau, M.J. (2006). Evidence-based character development. In Kenny, N. & Shelton, W. (Eds.), Lost virtue: Professional character development in medical education (Vol. 10, pp. 47–86). Oxford, UK: JAI Press. doi:10.1016/S1479-3709(06)10004-7 [CrossRef]
  • Cannaerts, N., Gastmans, C. & de Casterlé, B.D. (2014). Contribution of ethics education to the ethical competence of nursing students: Educators’ and students’ perceptions. Nursing Ethics, 21, 861–878. doi:10.1177/0969733014523166 [CrossRef]
  • Chin, J.J., Voo, T.C., Karim, S.A., Chan, Y.H. & Campbell, A.V. (2011). Evaluating the effects of an integrated medical ethics curriculum on first-year students. Annals of the Academy of Medicine, Singapore, 40 (1), 4–18.
  • Cho, M. (2009). A study of the moral judgments of nursing and non-nursing students using a DIT test. Korean Journal of Medical Ethics, 12, 377–390.
  • Edgar, P.H. (2002). Resolving ethical dilemmas: Applying the Institute for Global Ethics’ ethical fitness model to occupational and environmental health practice issues. AAOHN Journal, 50, 40–45.
  • Fry, S.T., Veatch, R.M. & Taylor, C. (2011). Case studies in nursing ethics (4th ed.). Sudbury, MA: Jones & Bartlett.
  • Han, S.S., Um, Y.R., Ahn, S.H., Kim, C.H., Kwon, B.K., Ku, I.H. & Koo, Y.M. (2008). Nursing ethics (3rd ed.). Seoul, Korea: Korean Nurses Association.
  • Hwang, G.-J. & Wu, P.-H. (2014). Applications, impacts and trends of mobile technology-enhanced learning: A review of 2008–2012 publications in selected SSCI journals. International Journal of Mobile Learning and Organisation, 8, 83–95. doi:10.1504/IJMLO.2014.062346 [CrossRef]
  • Kim, I.J., Sung, N.J., Jung, K.H., Bae, G.R., Park, K.U., Kim, J.P. & Hong, S.H. (2005). Effect on the medical ethics education evaluated by DIT. Korean Journal of Medical Ethics Education, 8, 95–104.
  • Kohlberg, L. & Hersh, R.H. (1977). Moral development: A review of the theory. Theory into Practice, 16, 53–59. Retrieved from doi:10.1080/00405847709542675 [CrossRef]
  • Korean Academy of Nursing Administration. (2000, 2012). Learning objectives of nursing management courses. Seoul, Korea: Korean Nurses Association. Retrieved from
  • Lee, M. (2008). Longitudinal DIT study of the moral judgments of student nurses at one university in Korea. Korean Journal of Medical Ethics Education, 11, 139–152.
  • Lee, M.-A. (2013). Changes in nursing students’ moral judgment and ways to evaluate the effect of ethics education. Journal of Korean Academy of Nursing Administration, 19, 351–360. doi: doi:10.11111/jkana.2013.19.3.351 [CrossRef]
  • Lu, W.-H. (2007). Understanding the effect of computer-supported, case-based instruction on third-year medical students’ ethical reasoning (Doctoral dissertation). Available from ProQuest Dissertations and Theses database. (UMI No. 3349041)
  • Moon, Y. (2011). Measuring moral development through Defining Issues Test in Korea. Seoul, Korea: Jipmoondang.
  • Murrell, V.S. (2014). The failure of medical education to develop moral reasoning in medical students. International Journal of Medical Education, 5, 219–225. doi:10.5116/ijme.547c.e2d1 [CrossRef]
  • Park, E.J. (2012). An integrated ethical decision-making model for nurses. Nursing Ethics, 19, 139–159. doi:10.1177/0969733011413491 [CrossRef]
  • Park, E.J. (2013). The development and implications of a case-based computer program to train ethical decision-making. Nursing Ethics, 20, 943–956. doi:10.1177/0969733013484489 [CrossRef]
  • Park, M., Kjervik, D., Crandell, J. & Oermann, M.H. (2012). The relationship of ethics education to moral sensitivity and moral reasoning skills of nursing students. Nursing Ethics, 19, 568–580. doi:10.1177/0969733011433922 [CrossRef]
  • Rest, J.R. (1979). Development in judging moral issues. Minneapolis: University of Minnesota Press.
  • Rest, J.R. & Narváez, D. (1994). Moral development in the professions: Psychology and applied ethics. Hillsdale, NJ: Lawrence Erlbaum.

Content of Nursing Ethics Courses

Definition and concept of ethics and nursing ethics
Ethical theories: Utilitarianism and deontology
Ethical development theories: Kohlberg’s and Gilligan’s stages of moral development
Bioethical principles of Beauchamp and Childress
Major issues in bioethics
Ethical codes for nurses
Ethical reasoning and decision making
Ethical issues in nursing with patients or coworkers

Ethical Preparation and Principled Thinking in Study Participants

VariablenaEthical PreparationnaPrincipled Thinking

Pretest Mean (SD)Posttest Mean (SD)Pretest Mean (SD)Posttest Mean (SD)
Computer group684.75 (1.1)6.19 (1.01)6650.95 (13.91)46.82 (17.18)
Standard group895.2 (1.14)5.62 (1.18)8346.07 (13.09)43.7 (14.73)
Second-year students765.06 (1.08)5.45 (1.04)7046.76 (4.36)43.52 (16.81)
Fourth-year students814.95 (1.2)6.25 (1.11)7949.54 (12.91)46.46 (14.97)

Summary of Case Analyses for the Computer Group (n = 69) and the Standard Group (n = 89)


Computer (n [%])Standard (n [%])ReasonaComputer (n [%])Standard (n [%])

ARequest sick leave34 (49.3)48 (69.6)47 (52.8)51 (57.3)Principle of nonmaleficence: Do no harm to patients31 (44.9)45 (65.2)38 (42.7)45 (50.6)
Professional responsibility: Nurses should cooperate with colleagues8 (11.6)7 (10.1)
Professional values: Patients’ lives are the most important value for nurses to uphold7 (10.1)
Professional responsibility: Nurses should take care of their own health13 (14.6)9 (10.1)
Continue to work24 (34.8)20 (29)28 (31.5)26 (29.2)Principle of benevolence: Nurses should provide quality of care (necessary care)15 (21.7)12 (17.4)21 (23.6)18 (20.2)
Professional responsibility: Nurses should cooperate with colleagues11 (15.9)
Employee’s duty: Fidelity to one’s organization/group16 (18)14 (15.7)
BTell the truth58 (84.1)64 (92.8)54 (60.7)73 (82)Principle of autonomy: Patients have a right to know the truth42 (60.9)56 (81.2)42 (47.2)59 (66.3)
Principle of benevolence: Nurses should help patients to make decisions and preparations regarding their end-of-life care15 (21.7)20 (22.5)25 (28.1)
Principle of autonomy: Patients have a right to self-determination23 (33.3)
Do not tell the truth7 (10.1)3 (4.4)29 (32.6)7 (7.9)Principle of nonmaleficence: Telling the patient the truth will have a depressing effect26 (37.7)2 (2.9)7 (7.9)6 (6.7)
Professional responsibility: Keeping a promise to a patient’s family11 (15.9)2 (2.9)
CFollow DNR order45 (65.2)48 (69.6)59 (66.3)64 (71.9)Principle of autonomy: Patients have a right to self-determination40 (58)46 (66.7)45 (50.6)56 (62.9)
Principle of benevolence: Withholding life-sustaining treatments could reduce unnecessary suffering and prevent prolonged dying11 (15.9)12 (17.4)10 (11.2)12 (13.5)
Provide active treatment18 (26.1)14 (20.3)14 (15.7)15 (16.9)A durable power of attorney: The spouse and family members can play a role as a surrogate9 (13)9 (13)9 (10.1)8 (9)
Principle of nonmaleficence: Do no harm to patients9 (13)5 (7.2)
Principle of autonomy: Patients suffering from illness are unable to make decisions4 (4.5)

Students’ Satisfaction With the Ethics Course

VariablenMean (SD)Fp
Computer group693.8 (0.42)46.1<.0001
Standard group893.21 (0.62)
Second-year students773.49 (0.57)0.76.38
Fourth-year students813.44 (0.65)

Dr. Eun-Jun Park is Associate Professor, Department of Nursing, Konkuk University, Chungju-si; and Dr. Mihyun Park is Assistant Professor, College of Nursing, The Catholic University of Korea, Seoul, South Korea.

This research was supported by the Basic Science Research Program through the National Research Foundation of Korea, funded by the Ministry of Science, ICT & Future Planning (2009-0064667). The supporting source did not have any involvement in the current study.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Mihyun Park, PhD, RN, Assistant Professor, College of Nursing, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea; e-mail:

Received: September 14, 2014
Accepted: July 08, 2015



Sign up to receive

Journal E-contents