Bangladesh Journal of Medical Science Vol. 21 No.

04 October’22

Original article
The Reflection of Ethics Education on Clinical Practices in Undergraduate Nursing Education: A
Qualitative Study
Fatma Tanrıkulu1, Handenur Gündoğdu2, Nasibe Yağmur Ziyai3, Funda Erol4, Yurdanur Dikmen5
Abstract
Aim:This research aims to reveal the reflections of ethics education given to nursing students in
undergraduate education on clinical practices. Method: A focus group interview from qualitative
methods was held to obtain and interpret information regarding the reflections of ethics courses.
Fifteenvolunteernursing students studyingatthe faculty of health sciences ofa public university
in Turkey were included in the research. For the data analysis, the method used to code and
categorizefocus group data were adapted from approaches to qualitative data analysis. Results:
Six main themes emerged from the data: (1) opinions about ethics courses; (2) ethical issues;
(3) the factors that cause ethical issues; (4) the effects of ethics courses on the approach towards
ethical problems; (5)contradictory situations between the ethics course and clinical practices;
(6) recommendationsabout the ethics course and educators. Conclusion:According to the data
obtained in this study, the researcher concluded that the lecturers and teaching methods used are
important in ethics education in nursing.
Keywords: Nursingeducation, Ethicseducation, Clinicalpractices, Qualitative.

Bangladesh Journal of Medical Science Vol. 21 No. 04 October’22 Page : 711-718

DOI: https://doi.org/10.3329/bjms.v21i4.60274

Introduction and high-quality ethics education during the

Nursing ethics is the thinking activity of nurses undergraduate periodin order to get integrated into
abouttheir actions during nursing practices; it the professional ethical decision-making process and
can also be defined as the examination of the to gain ethical sensitivity bylearning professional
moral responsibilities felt by nurses, as well asthe ethical principles4.
analytical thinking in nursing practices1,2. In this Ethics education is indispensablefor nursing students
context, nurses are responsible for fulfilling ethical to make ethical decisions andto actualize care
and moral obligations towards patients/healthy practices by acting according to ethical principles
individuals. Nursescan be deemed to have acted and codes in their professional lives5. Thus, ethics
in a “good” and“right” manneronly if theyact in education should be deliveredwith contentsand
a way that protects the dignity of individuals with methods that will ensurethe development of clinical
whomthey have an ethical relationship3. In light of decision-making, critical thinking, and problem-
this information, nursesrequire to take an extensive solving skills of nursing students2. When the relevant

1. Fatma Tanrıkulu, Ph.D., Sakarya University of Applied Sciences, Faculty of Health Sciences, Nursing
Department, Sakarya, Turkey. e-mail: ftanrikulu@subu.edu.tr https://orcid.org/0000-0003-1203-5852
2. Handenur Gündoğdu, MSc, Sakarya University of Applied Sciences Faculty of Health Sciences, Nursing
Department, Sakarya, Turkey.e-mail: handenur@subu.edu.tr https://orcid.org/0000-0001-9058-6057
3. Nasibe YağmurZiyai, MSc, Sakarya University Faculty of Health, Nursing Department, Sakarya, Turkey.
e-mail: nasibef@sakarya.edu.tr https://orcid.org/0000-0003-0175-2303
4. Funda Erol, Ph.D. Sakarya University of Applied Sciences, Vocational School of Health Services, Sakarya,
Turkey. e-mail: fundaerol@subu.edu.tr http://orcid.org/0000-0002-0222-8725
5. Yurdanur Dikmen, Professor, Sakarya University of Applied Sciences Faculty of Health Sciences, Nursing
Department, Sakarya, Turkey. e-mail: nurdem35@gmail.com http://orcid.org/0000-0002-4017-4916

Correspondence: Fatma Tanrıkulu, Lecturer, Sakarya University of Applied Sciences, Faculty of Health
Sciences. Akyazı/Sakarya/Turkey. E-mail :ftanrikulu@subu.edu.tr

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 Bangladesh Journal of Medical Science Vol. 21 No. 04 October’22

literature is reviewed, different techniques are seen practices.

to be used in ethics courses such as the traditional Method
narratingmethod, case analysis method, small
group discussions, problem-based learning, and Research Design and Sample
reflection6-8,4. The study of Milton1 (2004), which Afocus group interview from qualitative
includes the views of ethics experts, reports that methodswasheld to obtain and interpret
ethics education should be different ateachlevel informationregarding the reflections of ethics
of nursing education and distributed to the entire coursesreceived in undergraduate education on
curriculum instead of being delivered as a separate clinical practices.Fifteen voluntary nursing students
course. Even though there is a consensus about studying atthe faculty of health sciences ofa public
the importance of ethics education in nursing, in university in Turkey wereincludedin the research.
Turkeycertain differences are observed regarding There areplenty of different opinions in the literature
howethics education is delivered9,2. about the ideal number of participants for a focus
Although there are not any standards in ethics group interview, but the common opinion is to
perform it with a small number of participants, and
education in Turkey, ethics-related issuesare handled
this number is approximately between 4-10 people14.
within the scope of The History of Nursing and
In the study, two focus group interviewswere held,
Deontology Coursein many colleges. In order for
and groups were made up 7-8 people.
ethics education to achieve its goal, students must gain
ethical thinking and analysis skills, as well as ethical Data Collection
sensitivity. In this regard, the content anddelivery A moderatorand reporter,who wereinformed about
method of ethics education gains importance. the topic of the research, collected the data using
However, Nolan and Markert10(2002) state that there a semi-structured interview formin April and May
is still a problem inplanning and implementing ethics 2017. The semi-structured questionnaire prepared
courses, and there is a small number of publications for the focus group interviewincludes open-ended
about theissue. Although ethics course has been a questions that are created byscreeningthe literature
part of the nursing curriculum for a long time, a lot of with regard tothe topic of the research2-5,9. These
nurses today do not considerthemselves qualified in questions are as follows:
terms of ethics knowledge and skills10,11. In a research
• How do you evaluate the courses you have
conductedin Turkey by Aydın Er12 (2012) on nursing
receivedonethics during your undergraduate
students, ethics education in nursingwas determined
education?
to be not able to develop certain attitudes regarding
patient rights on a sufficient level. In another study • What do you think the content of an ethics
conducted on nurses by Aksu and Akyol13 (2011) in course should be?
Turkey, 61.1% of the nurses who participated in the • What kind of problems do you face while
study was determined to get no education onethics, providingcare to your patients in clinical
whereas 65.0% of the participants receiving such practices?
education was found to receive it at college and have
• Which of these problems that you have faced
a moderate level of ethical sensitivity. This situation
do you think are ethical issues?
reveals the need to raise nursing students in a qualified
manner regarding their approaches to ethical issues. • What kind of an impact do you think the
Necessary foundations are laid during undergraduate courses that you received about professional
education to render the nurses, who provide care to ethics have on evaluating suchethical issues?
healthy and sick individuals, trustworthy, honest, and In the pre-interview held before the focus group
adhering to ethical principles. Today, in Turkey,in 124 interview, students were informed about “what a focus
nursing undergraduate education programs, ethics group is” and “the research in general”. They were
education is deliveredwithincompulsory courses.Yet, also notified that “the interviews would be recorded
it is delivered rather theoretically, and its reflections with an audio recorder.”The data were collected in an
on clinical practices have not been evaluated to a interview room where all participants were seated in
sufficient degree. This research aims to revealthe a way that they could see each other. Eachinterview
reflections of ethics education deliveredto nursing lasted for approximately 45-60 minutes, and they
students in undergraduate education on clinical were recorded with an audio recorder. Participants
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Fig. 1. Content Analysis Process

were provided with tags numbered between 1-8 5. Named codes were categorized according to
that they would pin to their collars. The seating their similaritiesand differences.
arrangement was made according to these numbers. 6. Themes and subthemes were formed by
Moderator ensured the group members revealtheir linking the meanings of categories to each
opinions about the topic of the research by asking the other.
questions in the questionnaire. As for the reporter, s/
The process of the content analysis is given in Figure 1.
he observed the emotional reactions (angry, cheerful,
tense, etc.) of the group members bytaking short Results
notes during the interview. A total of 15 (13 female, 2 male) studentshave
Data Analysis participated in the study. The main themes and
subthemes were determined after the data analysiswas
Interview recordings obtainedthrough focus made. The data relatingto these themes are given
group interviews were reported to be analyzed below:
by researchers. Later on, a content analysis was
performed by the researchers on the data obtained Theme 1: Opinions about ethics courses
from the focus group interviews to attainexplanatory All nursing students participating in the research
concepts and relations. weredetermined to have received a course about
professional ethics and have knowledge regarding
For the content analysis;
the issue. Most of the students emphasized the
1. Statements of the participants wereread once fact that the ethics course they have taken during
more after transcribingthe recordings in a undergraduate education is delivered through the
computer environment. theoretical narrationmethod. Students stated that
2. The statements in the interview text were within the scope of this course they were informed
“coded” by assigning names. about subjects such as professional roles and
responsibilities of nurses, professional values,
3. The data were organized by associating the
professional ethical principles (providing benefits,
codes that show similarities. respect to autonomy, keeping secrets, and honesty),
4. After all the data were coded in this way, a as well asunethical behaviors. Also, some of the
code list was formed. students stated that some partsof thelectureswere
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deliveredbygiving case examples and the lectures give the same care to every human being regardless
containing case examples have been more instructive of their language, religion, race, political opinion,
for them. Some of the statements of nursing students facing suchkind of problem is [an example for]
about the ethics courses are given below: unethical behavior.” (Group 1, Student 2)
“During our undergraduate education, we have “At the ward, patients stay in the rooms as two men
taken courses that includeethics. In thesecourses, ortwo women. There was a richer patient, and s/he
topics such as the roles of a nurse, ethical codes, and was taken to a single room. Also, a different treatment
unethical behaviors were explained. The lectureswere was applied and there was more involvement. It felt
usually delivered theoretically.” (Group 1, Student 1) very weird to me. I think patients are not treated
“…our teacher deliveredthe ethics course under equally.” (Group 1,Student 6).
several topics. S/he has given some case examples Below are the statements of the nursing students
while explaining each topic. In this way, the course on the ethical issues they faced about the self-
has become more memorable.” (Group 2, Student 1). determination/respect to individuals principle:
Students in the research drew attention to some “…during our internship, when we go to the clinic,
negative situations about ethics lectures. These patients wait for an operation in a hospitalized
wereexpressed asthe excessive number of students in condition. They ask a lot of questions about
the class, inadequate teaching methods used in the themselves. Actually, they want to get informed. They
course, and the low amount of examples given in don’t know what kind of treatment they will receive,
the lectures. Below are some expressions of students they don’t know the process. In such a case, we, the
about the topic: students, becomethe first people that they can ask
questions related to such issues. This condition is a
“…the fact that the lectures were delivered in a
big ethical problemfor me…” (Group 1,Student 1).
crowded class made it hard for us to understand.
I think,taking the course with approximately 100 Below are the statements of the nursing students
people in a class makes it hard for us [to learn].” on the ethical issues they faced about the privacy/
(Group 2, Student 3). keeping secrets principle:
“Delivering the ethics course theoretically causes “I’m not sureif the reason isthat,but health care
us to learn by rote. Thus, our knowledge becomes personnel are usually busy, sothey do not care about
mechanical. Of course, this ends up being a the privacy of patients in order to complete the job
troublesome situation professionally. (Group 2, [in time]. Ultimately, there is such a thing as privacy;
Student 4). you need to protect privacy to the utmost degree…”
(Group 2, Student 5).
Theme 2: Ethical issues
Theme 3: The factors that cause the ethical issues
Most of the nursing students reportedthat they faced
many ethical issues in clinical practice. The ethical Nursing students indicated that the factors that cause
issues that are faced are grouped according to the the ethical issues are usually the insufficient number
Code of Ethics Standardof The International Council of nurses working at clinics, the excessive workload
of Nurses,of whichthe Turkish Association of Nurses of nurses, lack of materials used at clinics; limited
is also a member. The nursing studentsindicated that task, authority, and responsibilityof nursing students
these ethical issues weremainly about ethical codes compared to regular nurses; and communication
such as justice and equality, self-determination/ problems experienced with patients/patients’
respect to individuals, privacy, and keeping secrets. relatives/health care personnel. Below are the
Below are the statements of the nursing students statements of the nursing students about this topic:
on the ethical issues which they faced regardingthe “Althoughwe want to provideproper care for
justice/equality principle: thepatients, necessary materials canbe lacking.
“As you know, there are so many people who come to Thiscancause ethical issues.” (Group 1, Student 4)
our country as a refugee. When these patients come “Behaviors and attitudes of patients to the staff affect
to the hospital, mostly, practices applied for such the ethical approach. For example, when the patient
people are not the same as those for Turkish citizens; talks rudely bygiving orders such as “Remove my
the staff can behavefar harsher to them. Since, in vascular access,” manners towards the patient
accordance with our profession, we are requiredto maychange.” (Group 2, Student 2).

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Theme 4: The effects of ethics courses on approach undergraduate education should be delivered
towards ethical problems withsmall groups and bysupporting the theoretical
Most of the nursing students that participated in content with case examples. Moreover, they stated
the study emphasized the importance of the ethics that the content of the course should be customized to
education they took in undergraduate education. nursing. Also, students indicated that they can learn
However, students also indicated that it was difficult better if case examples are given about the ethical
for them to applywhat they have learned to clinical issues that are facedin the units at whichnurses work.
practice. Below are some expressions of the students about
this topic:
“I believe that ethics courses helpedus make the right
decision while evaluating ethical problems.” (Group “To me, the content should be broader in scope and
1, Student 1) becustomized to nursing.” (Group 2, Student 6)
“First of all, I think, in order to evaluate such “It would be better if the ethics course were not just
[ethical] problems, courses that we have taken on an ordinary course, but a course that prompts us
professional ethics need to be understood well. In as students toponder uponcertain issues. Moreover,
that way, I think, we can solve ethical problems that it [the content of the course] should be developed
we encounter at the clinic.” (Group 1, Student 2). according to nursing ethics. For example, adapting
medical ethics into nursing does not make that
Theme 5: Contradictory situations between the
lecturesufficient. By reexamining and working on
ethics course and clinical practices
medical ethics, separate nursing ethics should be
Nursing students that participated in the research think formed and systematized.” (Group 1, Student 6)
that the theoretical knowledge they have learned from
the ethics course isnot applied correctlyto theclinical Nursing students that participated in the study
practice. Students indicated the fields in which they emphasized that lecturersgiving the ethics course
have experienced most conflict between what they should be experts in thearea andwell-equipped in
have learned to be the right behavior in the ethics professional ethics for nurses, and should use modern
course and the actual situation within the clinic as education methods. Students also suggestthat if the
follows: malpractice, relationships within the team, ethics coursewasgiven by a lecturer who hadnursing
end-of-life practices, and respect to individuals. experience, it would be more helpful for reinforcing
Below are the expressions of the students about this the lecture. Below are the statements of nursing
topic: students about the topic:
“What I have learned as the right behavior is to “I think the lecturer that deliversthe ethics course is
intervene when the heart of the patient stopped. important. In my opinion, s/he needs to have enough
However, I saw that it was not like that in the intensive level of knowledge.” (Group 1, Student 3)
care unit. The patient died, and they did not even felt “To me, the lectures should be deliveredby a lecturer
the need to give him/her a heart massage.” (Group who is well-equippedand who has clinical experience.
1, Student 3) It willbe more beneficial if it is delivered by one who
“I think, what I have learned to be right in ethics hasa nursing background.” (Group 1, Student 5)
education and things that are applied at the clinic Discussion
contradict entirely. During my internship, a blue code
In this research, when the opinions of the students
had been given from one of the wards. We went there.
about the ethics coursethat they have taken during
The patient was treated by administeringadrenaline.
their undergraduate education are examined, lectures
However, they showed us that they administered a
are determined to be mostly delivered using the
differentdose [than the required].” (Group 1, Student
theoretical narratingtechnique. It was determined
4)
that the lectures delivered along with case examples
Theme 6: Suggestions about the ethics course and were found more understandable by the nursing
educators students. Some students also gave negative
The nursing students gave suggestions regarding the feedbacks about the excessive number of students
content,teaching style and methods, and lecturers of in the class andinadequate teaching methods. Also,
the ethicscourse that they take during undergraduate they complained that lectures are mostly delivered
education.They emphasized that ethics coursesin theoretically, and case examples are not enough.

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When the literature about the topic is reviewed, 18

. In this study, students stated that the knowledge
even though a consensus is observedregarding they gainedin ethics lectures was hard to apply
the necessity and importance of ethics education toclinical practice, which is the crucial dimension of
in nursing, disagreements are seen regarding the ethics education. Findings from different researches
teaching methods to be used in ethics education2,9,11. support that ethics education has an important effect
There are different teaching techniques used in ethics on the moral acts of nurses, and it develops the
education. Researches show that there are techniques ethical awareness and ethical decision-making skills
like the traditional teaching method, case analysis of students by ensuring them to gain the attitude and
method, small group discussions, and problem-based behaviors indispensable for a nurse2,19,20. When all
learning and reflection3,4,6-8. Especially the use of the of these are taken into consideration, it is essential
case analysis method was found to contributetothe to rearrange the ethics education programso that it
development of ethical behaviors and ethical containsclinicalethicsissuesand practice.
decision-making of students in nursing practices 4,6. Students who participated in the study stated that
Hence, Gastmans15 (2002) emphasized that the ethics there were many situations in which they experienced
course must develop the ethical sensitivity of nurses, a conflict between the actual situation in the clinical
and more comprehensive content and methods should practice and what they had learned as the right
be usedrather than beingrestrictedby certain concepts behavior according to the ethical principles. Most
and rules (ethical principles, ethical decision-making, of the students stated that these situations wereabout
etc.). When all these results are evaluated together, malpractice, relationshipswithin the team, end-of-life
enriching the ethics course with active learning practices, and respect forindividuals. In the previous
methods (analyzing real-life cases, concept maps, researches, ethical dilemmasthat nursing students
group discussions, role-play exercises) is thought to often come across were determined to be about
contributeto the acquisition of ethical thinking skills giving patients false information, givingup treatment,
and ethical sensibility by students. end-of-life care practices, not caring about patient’s
In our study, nursing students were determined privacy enough, and erroneousapplicationsregarding
to face ethical issues inthe clinical practice, and patient safety10,17.
these issues are about certain nursing ethicalcodes Students participating in our study suggested that
such as justice and equality, self-determination/ the content of ethics lectures should be specific
respect to individuals, privacy, and keeping secrets. to the nursing profession. When the literature on
Furthermore, students indicated that several factors the topic was examined, no standard approach
that cause ethical issues, which are the insufficient was foundregarding professional ethics courses in
amount of nurses, excessive workload, and nursing, and in some nursing schools, ethics was
communication problems. In their study with senior found to betaughtwithin medical ethics lectures21. In
nursing students,Kalaitzidis and Schmitz16(2012) their study with nursing students who had not taken
have reported many examples regarding ethical any ethics course,Can et al. 21(2014) reported that the
issues mentioned by studentssuch as the honesty participants wanted the topics covered in the course
principle, patient’s right to refuse, and getting the to be related toconditions that might be encountered
permission of patients. In another study,nursing in nursing practices.Nolan and Markert10(2002)
students have indicated that there is psychological stated that ethics lecturesshould be related to nursing
maltreatment towards patients in clinical practices, practices and situations that students expect to come
and most of the violated ethical principles are related across throughout their careers.As tothe teaching
to self-determination of individuals (30.0%), respect style, students indicated that ethics lectures should
to privacy (22.0%), and no harming (16.0%). This be delivered to small groups and bygiving real-
studyhas also determined that the ethical issues arose life case examples. Cannaerts et al.19(2014) drew
fromthe lack of the use of adequatecommunication attention to the need for providing ethics education in
techniques when communicating with patients/ a safe learning environment, where there is adequate
patient relatives/hospital directors17. These findings support and student-centered teaching techniques are
are similar to the results of our study. actively used. The abovementioned study results are
The aim of the ethics course given in nursing education in parallel with our findings.
is to render students capable of acting ethically and Another suggestion reportedby the students concerns
making ethical decisions in their professional life the lecturers. Nursing students emphasized that

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the lecturers that deliver the ethics lectures should experiences of students. Besides, the arrangement
be an expert in thefield, well-equippedonthe of the ethics education in a way to reduce the moral
professional ethics of nursing, and should use active stress of nursing students and to enable them to
teaching methods.Students also stated that it will be gain insight into their experiences, emotions and
appropriate if the professional ethics course is given perspectives regarding ethical problems in clinical
by a clinically experienced lecturer in nursing.In the practice is thought to increase the effectiveness of
literature, there are different viewsabout lecturers the lectures.Along with teaching nursing ethics as a
who teach ethics. Akbaş et al.2(2014) stated that, separate course within the curriculum, mentioning
along with other qualities, the lecturers, who teach ethical dimensions of the topics handled in practical
ethics/deontology, should have clinical experience. courses, evaluating the cases from an ethical
Baykara et al.3 (2014) emphasized that in order to perspective, discussing and analyzing interesting
achieve the purpose of the ethics course, student- cases are also important. Another important pointin
centered education techniques and methods should education of nursing ethics according to the results
be implemented. Jahromi et al22. (2018) stated that of the presentstudy is the quality of lecturers.
educators should develop and implement effective Therefore, in order to increase the quality of
training programs in order to increase awareness and lecturers, the researcher recommendssupporting their
commitment to nursing professional values.In line participation in activities about ethics, ensuring them
with this information, although suggestions of the to follow closely current publications in the ethics
students should not be deemed to be theone and main education field, andregularly organizing professional
determinant in ethics courses, it willbe soundto think development programs about ethics education for all
that lecturesmay become more effective if the student lecturers who take part in nursing education.
feedbacks are considered.
Acknowledgments
Limitations of the Study
The authors thank volunteer nursing students who
The study was conducted in a nursing school in the devoted their time tothe implementation of this
northwestern region of Turkey. Findings obtained research.
from the study apply tothe nursing school where
the research wasconducted. Therefore, the findings Conflict of interests
cannot be generalized to students of all nursing The authors declare no potential conflicts of
schools in Turkey. Another limitation of this study interest concerning the research, authorship and/or
is that it depends on the judgments of the nursing publication of this article.
students participating in the research. Therefore, the
Ethical Clerance
results are limited to answers given by the nursing
students in the research. In order to perform this study within the framework
of ethical principles, 03.23.2017 dated and
Conclusion and Recommendations
34671234/044 numbered written permission was
According to the data obtained in this study, the received from the institution of Sakarya University
researcher concludes that lecturers and teaching Faculty of Health Sciences where the research
methods used in the lectures are important in was conducted. The verbal and written consent of
ethics education in nursing. Students emphasized the students that constitute the sample group was
especially that the course will bemore instructive received by explaining the aim of the study, their
case examples are given. However, students are roles in the study, and that the interviews would be
observed to experience difficulties and contradictions recorded with an audio recorder. The study was
in applying their knowledge to solve ethical issues realized in accordance with the Helsinki Declaration
that they come across in clinical practice. The use of principles.
active teaching methods is among the most important
factors that should be consideredto increase Authors’s contribution:
the ethical awareness and sensitivityof nursing FT is data gathering and idea owner of this study. YD
students. In this regard, the ethics lectures shouldbe designed the study, HG collected data, FT and FE
developed to enable students to participate actively performed data analysis. NYF and HG completed the
in the lectures and rearrangedto contain the clinical final draft of this manuscript.

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