Nursing codes of ethics provide nurses and nursing students with a framework for the standards of conduct related to ethical dilemmas that arise in everyday practice (Canadian Nurses Association, 2017; International Council of Nurses, 2012). Given that ethics is a foundational component of nursing practice (Kunyk & Austin, 2012), it is an essential part of undergraduate nursing education (Canadian Association of Schools of Nursing, 2015; Lechasseur, Caux, Dollé, & Legault, 2018; McLeod-Sordjan, 2014). Yet, under-graduate nursing students report feeling frustrated and unprepared when encountering ethical dilemmas during practicum experiences (Krautscheid, 2017). To assist learners in moving from comprehension to application of ethical concepts, nurse educators have turned to simulation-based learning (Buxton, Phillippi, & Collins, 2015). The aim of this study was to explore undergraduate nursing students' experience of situational microethical dilemmas in patient encounters in a simulated learning environment.
Everyday Ethics (Microethics)
Complex contemporary health care environments create situations where ethical principles may conflict. These conflicts are frequently the focus of traditional bioethics courses (Truog et al., 2015; Zizzo, Bell, & Racine, 2016). However, ethical dilemmas have the potential to exist in every nurse–patient encounter (Milliken, 2018; Milliken, Ludlow, DeSanto-Madeya, & Grace, 2018). Often unrecognized, microethical issues arise within the context of routine clinical practice where individual nurses' decisions have the potential to cause harm and create uncertainty and conflict (Austin, 2007; Milliken, 2017, 2018; Milliken & Grace, 2017).
With limited empirical evidence to determine best practice for nursing ethics education, specific ethics content may vary across programs (Iacobucci, Day, Lindell, & Griffin, 2013; Laabs, 2015). As a result, some nursing programs offer courses in nursing ethics or require courses in moral philosophy, whereas other nursing programs integrate ethics content throughout their program (Milton, 2004). A common approach to teaching ethics has been the use of classroom case review and discussion. A limitation of this teaching approach is that the fictional problems presented may seem straightforward (Thiel et. al., 2013). According to Rutherford-Hemming (2012) and Milliken (2018), using a more realistic setting may assist learners in moving from comprehension to application.
Some researchers suggest simulation-based learning activities that focus on ethics offer safe environments for students to implement ethics in practice, develop professional communication skills needed in negotiating complex patient situations, and gain competence with high-stress patient care situations (Buxton, Phillippi, & Collins, 2015; Duphily, 2014). Although high-fidelity simulation may be ideal to teach biomedical ethics (Greenawalt, O'Harra, & Little, 2017; Gropelli, 2010; Smith, Witt, Klaassen, Zimmerman, & Cheng, 2012), we suggest the scenarios used in these studies do not reflect everyday events nursing students encounter during routine nurse–patient interactions.
Two studies were located that described a simulated learning environment in which microethical dilemmas were intentionally embedded in common scenarios. In Krautscheid's study (2017), high-fidelity simulation scenarios included microethical dilemmas related to infection control breaches, violating patient confidentiality, and unsafe medication administration practices. In the second study (Buxton, Phillippi, & Collins, 2015), microethical dilemmas for student midwives considered drug-seeking behavior, a patient's refusal to provide health history information, and an on-call physician's refusal to provide a medication order for a patient unknown to them. Although the findings of these studies suggest simulation can extend ethics education, it is unknown whether undergraduate nursing students are able to recognize and respond to organic microethical dilemmas—that is, ethical dilemmas that arise naturally and are situationally dependent—in simulated scenarios that emphasize pathophysiological conditions and psychomotor skills.
Defining Moral Sensitivity
According to Robichaux (2012), recognizing the ethical importance of events and interactions and the development of the skills of sensitivity and interpretation are essential to the implementation of justifiable actions. Rest (1986) suggested that the first step to reaching a justifiable course of action within the context of an ethical dilemma is recognizing that a morally important situation exists. Consequently, the first step of Rest's Four Component Model involves the skill or ability to interpret the reactions and feelings of others, to be moved by others and to identify with other peoples' distress, and to be aware of how ones' action or inaction may affect others. This is referred to as ethical sensitivity.
Moral sensitivity requires the ability to recognize and attend to the moral values involved in a conflict-laden situation and self-awareness of one's own role and responsibility in the situation (Lützén, Dahlqvist, Eriksson, & Norberg, 2006). Thus, moral sensitivity is composed of three main dimensions: moral burden, moral strength, and moral responsibility. Moral burden occurs when a problem or situation involves moral values. Awareness of competing or contradicting moral imperatives but not being able to resolve them leaves nurses feeling burdened and perhaps even having a troubled conscience. Moral strength is having the courage to act and the ability to provide arguments with the intention of justifying these actions on behalf of another instead of defending oneself. Moral responsibility comprises two factors: a moral obligation to work according to rules and regulations and insight into their purpose, and to know what the moral problem is from the perspective of the individual patient.
A mixed-methods study with a convergent parallel design (Creswell & Plano Clark, 2011) was completed; ethics approval was received.
Study Setting and Scenario
In a fully simulated learning environment, small groups of students worked through one of three scenarios common to medical nursing practice: patients experiencing diabetic ketoacidosis, sepsis, or congestive heart failure. Microethical dilemmas arose organically.
Sixty-eight undergraduate senior nursing students (response rate = 60.7%) enrolled in a medical–surgical course in 2017 returned the completed Modified Moral Sensitivity Questionnaire for Student Nurses [MMSQ-SN] (Comrie, 2012). Participants were predominantly female (n = 54, 79.4%). Ten female and two male participants also completed a semistructured qualitative interview. Most participants were between 20 and 25 years of age (n = 21, 78%). The majority of participants self-identified as Canadian (91%). The remaining 9% self-identified as First Nations, African, Australian, or Chinese. Most participants described themselves as Christians (50%), whereas 35% indicated they were atheist. Fifteen percent of the students choose not to answer the religiosity question.
At the end of the simulation and debriefing session, a research assistant invited the students to complete the MMSQ-SN (Comrie, 2012). The questionnaire consists of 14 Likert-type questions with a 7-point scale. Its statements represent five categories: structuring moral meaning, interpersonal orientation, expressing benevolence, moral conflict, and modifying autonomy. Cronbach's alpha was .652, which is similar to the Cron-bach's alpha of .64 reported in the literature (Comrie, 2012).
We conducted individual audiorecorded semistructured interviews with participants within 2 weeks of completing the simulation. Each recorded interview lasted between 35 and 60 minutes. Typical of an emergent approach where analysis begins with the first interview, as the study progressed, in additional to the original questions we developed, we also asked new questions. For example, an original question was “Based on your experience with clinical simulation in Nursing [course number], please describe an experience you had of having difficulty knowing what nursing action was ethically right.” As our analysis progressed, we added the question “What role does the instructor have in identifying and working through an ethical dilemma during simulation?”
Quantitative Data Analysis
We used SPSS® version 24 to determine the mean and standard deviation on key concepts within the questionnaire. Mean scores between 5.9 and 7.0 reflected agreement that the moral issue was very important; 5.0 to 5.8 reflected agreement that the moral issue was important; 3.1 to 4.9 reflected neutral scores; and mean scores below 3.1 indicated disagreement or strong disagreement with the moral issue (Comrie, 2012). T tests assessed within-group differences by age, gender, and religiosity.
Qualitative Data Analysis
Interviews were transcribed verbatim, checked for accuracy, and entered into NVivo 12. For each interview, the lead researcher read each line of the transcript for key words or parts of sentences that became codes. Codes pertaining to doing the right thing became part of the category of moral strength. Codes that seemed to capture some type of conflict became part of the moral burden category and codes that addressed rules of professional conduct became part of the moral obligation category. We then met to determine whether the codes and categories aligned. We compared statistical findings for each questionnaire statement and groupings of statements within the domains of moral burden, moral strength, and moral obligation with the qualitative codes and categories.
Overall, mean scores on the questionnaire measuring moral sensitivity suggest that students in this study believed they could identify and work through moral dilemmas. During the interviews, many students identified a wide range of microethical dilemmas within their simulated learning experience and were able to come to justifiable courses of action. Some students though believed ethical dilemmas were deliberately inserted into the scenario. This might suggest that students believe typical nurse–patient interactions in real-life practice settings do not have the potential for producing ethical dilemmas. One student said:
I feel like in simulation, all the ethical decision dilemmas are just thrown in as a distraction to cause a bit of anxiety within the group and see how we do with that anxiety.
Moreover, many students reported feeling uncertain in their ability to identify and work through ethical dilemmas in their nursing practice. Indeed, half of the students interviewed indicated they had not yet encountered ethical dilemmas in their clinical experience. This belief seemed to be supported by their clinical instructor during clinical evaluations, as evidenced in this student quotation:
I feel like I have had limited opportunity because every time we do the evaluations me and my teachers agree, “Oh I don't think we've had any ethical dilemmas.”
Comparing the variables of age, gender, and religiosity and the questions associated with moral burden, moral strength, and moral obligation produced statistically significant findings for gender but not age or religiosity (p ≤ .05). Female participants were more likely to experience moral conflict during simulation (female, M = 4.83; male, M = 3.86; t = 2.464, p = .016 [two-tailed, equal variances assumed]) and expressed a greater degree of moral burden during the interviews. Having their concerns dismissed by the instructor had the potential to amplify students' experience of moral burden, as indicated in these student comments:
- So when you're drawing up medication, you're like, “Okay I touched that and that's not sterile anymore or that's not clean” or like “I did not draw up the full amount so I'm going to re-draw it.” I know that sometimes people were like “I can't get the full like 4 mLs drawn up, I'm just going to give two,” but you wouldn't do that in practice, so what's the issue?
- A couple of us did bring it up [an ethical issue] and our instructor dismissed it as we were in the [simulation laboratory]. That's difficult.
Both male and female students coped with moral conflict through avoidance. This strategy may help students mitigate moral burden. A male student commented:
In the end, I just gave up and just did it and continued with the procedure instead of trying to fight or argue with her [another student] about it.
All students were keenly aware of rules or regulations for the provision of safe care and reported applying them during simulations. Female participants though were more likely to feel compelled to comply with the rules and regulations guiding nursing actions or to express insight into the purpose of these rules and the moral problem from the patient's perspective (female, M = 5.09; male, M = 3.93; t[15.592] = 2.192, p = .044 [two-tailed, equal variances not assumed]). Indeed, female students seemed to express a higher degree of moral obligation toward engaging in professional nursing practice and meeting the patient's needs. One female student said:
It was my duty to fulfill that role, and regardless of how uncomfortable it made me feel in certain moments it was, “Well, just forget about yourself because this is the main priority and you can kind of debrief after if you need to.” It felt like a priority of mine to address those concerns and to be with him.
Some students expressed some uncertainty in their future ability to identify microethical dilemmas and so they would seek guidance from their coworkers to work through dilemmas:
I feel more confident in my abilities to lay it out and kind of analyze it but it's not something that I'd want to do on completely on my own. It'd be nice to talk to your colleagues and get help with your ethical dilemma and not just handle it completely on your own.
Discussion and Recommendations
The findings of this pilot study suggest that many students have a high degree of ethical sensitivity toward microethical dilemmas during simulated learning experiences. Consistent with Comrie's findings (2012), some students were uncertain if what they experienced was in fact an ethical dilemma. It may be that these students forgot the ethical instruction they received earlier in their program and thus were unable to apply ethical principles during simulation.
Students in this study also seemed to suggest that some instructors did not want work through ethical dilemmas during simulation. Perhaps because of time constraints or because nurse educators lack ethical knowledge, unintentionally teaching inaccurate or incomplete information is possible (Laabs, 2015). Consequently, nurse educators must embrace their role as moral agents in order to facilitate resilience and students' ability to learn and grow from challenging clinical situations (Liaschenko & Peter, 2016; Milliken, 2018).
To help students develop and enhance their ethical sensitivity, nurse educators could also incorporate reflective questioning followed by questions that deconstruct the dilemma, ending with forward questions (Johnston, Coyer, & Nash, 2017). Asking questions regarding fairness, outcomes, responsibilities, liberty, empathy, and authority can also help students develop ethical sensitivity (Greco et al., 2019; The Madison Collaborative, 2013).
Another key finding in this study is that some students anticipated they might have difficulty applying ethical reasoning in their future clinical practice. According to Miles (2018), to transfer their knowledge of how nurses act and what they need to know to practice, students need to take on the role of practicing nurses during simulated learning experience. We suggest nurse educators consciously involve students in discussions that focus on identifying interactions that produce microethical dilemmas and strategies for working through these dilemmas that are justifiable for the patient and clinical context during both simulation and clinical experiences.
This study was conducted at one university with a small sample of nursing students. Conducting a multisite study with a larger sample size may help identify different experiences and levels of moral sensitivity.
Many nursing students were able to identify microethical dilemmas during simulated learning experiences, although they also expressed some uncertainty in being able to transfer this skill to real-life clinical practice. The inconsistent opportunity to identify and work through microethical dilemmas that reside within nurse–patient interactions during simulation does little to help students transfer learning from the simulated learning environment to nursing practice situations. Findings of this study highlight the need for nurse educators to act as moral agents by creating student opportunities to deconstruct microethical dilemmas and debrief on strategies to resolve them.
- Austin, W. (2007). The ethics of everyday practice: Healthcare environments as moral communities. Advances in Nursing Science, 30(1), 81–88. doi:10.1097/00012272-200701000-00009 [CrossRef] PMID:17299287
- Buxton, M., Phillippi, J.C. & Collins, M.R. (2015). Simulation: A new approach to teaching ethics. Journal of Midwifery & Women's Health, 60(1), 70–74. doi:10.1111/jmwh.12185 [CrossRef] PMID:25141791
- Canadian Association of Schools of Nursing. (2015). National Nursing Education Framework. Retrieved from http://www.casn.ca/competency-guidelines/national-nursing-education-framework/
- Canadian Nurses Association. (2017). 2017Edition Code of Ethics for Registered Nurses. Retrieved from https://www.cna-aiic.ca/-/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive.pdf
- Creswell, J.W. & Plano Clark, V.L. (2011). Designing and conducting mixed methods research (2nd ed.). Los Angeles, CA: Sage.
- Comrie, R.W. (2012). An analysis of undergraduate and graduate student nurses' moral sensitivity. Nursing Ethics, 19(1), 116–127. doi:10.1177/0969733011411399 [CrossRef] PMID:22183964
- Greenawalt, J.A., O'Harra, P. & Little, E. (2017). Undergraduate nursing students' ability to apply ethics in simulated cases. Clinical Simulation in Nursing, 13(8), 359–379. doi:10.1016/j.ecns.2017.04.007 [CrossRef]
- Greco, S., Lewis, E.J., Sanford, J., Sawin, E.M. & Ames, A. (2019). Ethical reasoning debriefing in disaster simulations. Journal of Professional Nursing, 35(2), 124–132. doi:10.1016/j.profnurs.2018.09.004 [CrossRef] PMID:30902404
- Gropelli, T.M. (2010). Using active simulation to enhance learning of nursing ethics. The Journal of Continuing Education in Nursing, 41(3), 104–105. doi:10.3928/00220124-20100224-09 [CrossRef] PMID:20229959
- Duphily, N.H. (2014). Simulation education: A primer for professionalism. Teaching and Learning in Nursing, 9(3), 126–129. doi:10.1016/j.teln.2014.03.003 [CrossRef]
- Iacobucci, T.A., Daly, B.J., Lindell, D. & Griffin, M.Q. (2013). Professional values, self-esteem, and ethical confidence of baccalaureate nursing students. Nursing Ethics, 20(4), 479–490. doi:10.1177/0969733012458608 [CrossRef] PMID:23166146
- International Council of Nurses (2012). The ICN Code of Ethics for Nurses. Retrieved from https://journals.sagepub.com/doi/pdf/10.1177/0969733012458608
- Johnston, S., Coyer, F. & Nash, R. (2017). Simulation debriefing based on principles of transfer of learning: A pilot study. Nurse Education in Practice, 26, 102–108. doi:10.1016/j.nepr.2017.08.002 [CrossRef] PMID:28797933
- Krautscheid, L.C. (2017). Embedding microethical dilemmas in high-fidelity simulation scenarios: Preparing nursing students for ethical practice. The Journal of Nursing Education, 56(1), 55–58. doi:10.3928/01484834-20161219-11 [CrossRef] PMID:28118477
- Kunyk, D. & Austin, W. (2012). Nursing under the influence: A relational ethics perspective. Nursing Ethics, 19(3), 380–389. doi:10.1177/0969733011406767 [CrossRef] PMID:21646324
- Laabs, C.A. (2015). Toward a consensus in ethics education for the doctor of nursing practice. Nursing Education Perspectives, 36(4), 249–251. doi:10.5480/13-1195 [CrossRef] PMID:26328294
- Lechasseur, K., Caux, C., Dollé, S. & Legault, A. (2018). Ethical competence: An integrative review. Nursing Ethics, 25(6), 694–706. doi:10.1177/0969733016667773 [CrossRef] PMID:27694548
- Liaschenko, J. & Peter, E. (2016). Fostering nurses' moral agency and moral identity: The importance of moral community. The Hastings Center Report, 46(Suppl. 1), S18–S21. doi:10.1002/hast.626 [CrossRef] PMID:27649913
- Lützén, K., Dahlqvist, V., Eriksson, S. & Norberg, A. (2006). Developing the concept of moral sensitivity in health care practice. Nursing Ethics, 13(2), 187–196. doi:10.1191/0969733006ne837oa [CrossRef] PMID:16526152
- McLeod-Sordjan, R. (2014). Evaluating moral reasoning in nursing education. Nursing Ethics, 21(4), 473–483. doi:10.1177/0969733013505309 [CrossRef] PMID:24225058
- Miles, D.A. (2018). Simulation learning and transfer in undergraduate nursing education: A grounded theory study. The Journal of Nursing Education, 57(6), 347–353. doi:10.3928/01484834-20180522-05 [CrossRef] PMID:29863735
- Milliken, A. (2018). Ethical awareness: what it is and why it matters. Online Journal of Issues in Nursing, 23(1), Manuscript 1. doi:10.3912/ojin.vol23no01man01 [CrossRef]
- Milliken, A. (2017). Toward everyday ethics: Strategies for shifting perspectives. Ethics in Critical Care, 28(3), 291–296. doi:10.4037/aacnacc2017406 [CrossRef] PMID:28847865
- Milliken, A. & Grace, P. (2017). Nurse ethical awareness: Understanding the nature of everyday practice. Nursing Ethics, 24(5), 517–524. doi:10.1177/0969733015615172 [CrossRef] PMID:26659025
- Milliken, A., Ludlow, L., DeSanto-Madeya, S. & Grace, P. (2018). The development and psychometric validation of the Ethical Awareness Scale. Journal of Advanced Nursing, 74(8), 2005–2016. doi:10.1111/jan.13688 [CrossRef] PMID:29672907
- Milton, C.L. (2004). Ethics content in nursing education: Pondering with the possible. Nursing Science Quarterly, 17(4), 308–311. doi:10.1177/0894318404268813 [CrossRef] PMID:15359028
- Robichaux, C. (2012). Developing ethical skills: from sensitivity to action. Critical Care Nurse, 32(2), 65–72 doi:10.4037/ccn2012929 [CrossRef]
- Rutherford-Hemming, T. (2012). Learning in simulated environments: Effect on learning transfer and clinical skill acquisition in nurse practitioner students. The Journal of Nursing Education, 51(7), 403–406. doi:10.3928/01484834-20120427-04 [CrossRef] PMID:22533500
- Smith, K.V., Witt, J., Klaassen, J., Zimmerman, C. & Cheng, A.L. (2012). High-fidelity simulation and legal/ethical concepts: A transformational learning experience. Nursing Ethics, 19(3), 390–398. doi:10.1177/0969733011423559 [CrossRef] PMID:22323395
- The Madison Collaborative (2013). The eight key questions handbook. Retrieved from https://www.jmu.edu/ethicalreasoning/Docs/131101%208KQ%20Handout%20Revision.pdf
- Thiel, C.E., Connelly, S., Harkrider, L., Devenport, L.D., Bagdasarov, Z., Johnson, J.F. & Mumford, M.D. (2013). Case-based knowledge and ethics education: Improving learning and transfer through emotionally rich cases. Science and Engineering Ethics, 19(1), 265–286. doi:10.1007/s11948-011-9318-7 [CrossRef] PMID:22038062
- Truog, R.D., Brown, S.D., Browning, D., Hundert, E.M., Rider, E.A., Bell, S.K. & Meyer, E.C. (2015). Microethics: The ethics of everyday clinical practice. The Hastings Center Report, 45(1), 11–17. doi:10.1002/hast.413 [CrossRef] PMID:25600383
- Zizzo, N., Bell, E. & Racine, E. (2016). What is everyday ethics? A review and a proposal for an integrative concept. The Journal of Clinical Ethics, 27(2), 117–128 PMID:27333062