Methodology

This is an action research. Action research (AR) is a process of inquiry that describes, interprets, and explains social situations by intervening to bring about improvement and involvement (11). AR is a critical social activity relying on participation and collaborative working to generate change and new knowledge (12). Action researchers usually use a mixture of the two predominant paradigms, quantitative and qualitative approaches to research. Action research proceeds through several stages to bring about change and development. This spiral movement is continued until the problem is either solved or redefined (13). Action research focuses on working with people to identify problems in practice, implement solutions, and monitor the process and outcomes of change (11)

In this study we went through the stages suggested by Meyer. She describes these stages as negotiation, assessment, planning, action and evaluation. Finally she explains how, despite the open-ended nature of action research, the research should go to the withdrawal stage (12).

Negotiation phase

Discussing the perceived problem with some concerned colleagues and convincing the dean of the nursing faculty and curriculum planning department of the need for change was a challenging part of this action research. The researchers’ experiences in working with students, the responses of students to this course, their general dissatisfaction with the traditional course that was reflected in their daily clinical activities – all this formed part of the informal qualitative documents that were a starting point for convincing decision makers in the nursing faculty of the need to co-operate in the study.

Assessment phase

It was necessary to make a detailed assessment of the concerns of first year students, their final scores and their behaviour (as regards ethics) during their clinical experience, when attending the ethics course. This was done through a perception questionnaire, a behaviour checklist, as well as interviews with some of the students and interpreting their stories about their experiences of attending traditional nursing ethics classes.

The qualitative findings are presented in themes captured from the students’ answers to open-ended questions in a perception questionnaire as well as the transcribed interview texts. They were asked to answer the question “What do you think about the nursing ethics course?” The written answers and transcribed interviews were then analysed. This analysis was done by reading and re-reading the texts, capturing the whole meaning, highlighting the important words and phrases and categorising them. The most common themes that emerged in traditional teaching groups were:

• Content overlaps with some other courses
• Content is boring and useless
• There are no clearly defined aims and applications
• Content is not realistic and practical
• Lecture-based class sessions are boring
• Students do not feel involved in the process
• Content is not motivating
• The teaching method is not attractive and motivating

As shown above, the themes mainly related to both the “course content” and “teaching method”.

The findings at the assessment stage indicated that students have a negative perception of the “Nursing history, deontology and law” course and also the nursing ethics part of it. They stated that they attended this class only to pass the course, as a means to an end.

Planning phase

The next stage was planning for the new programme. The content for the new nursing ethics course and the teaching methods were prepared by the researchers with the support of ethics teachers and the nursing faculty’s decision makers.

The content of the course was prepared from textbooks on nursing ethics and supplemented with the researchers’ experiences, and student feedback. Each class session started with a short lecture followed by case study discussions. The lectures discussed the importance of ethics for the nursing profession and covered the basic principles of ethics, theories, and some special ethical issues in contemporary health care. Classes were conducted in weekly two-hour sessions for 16 weeks, or one academic semester.

Case studies were drawn from various sources including the Australian TV serial “The Nurses” (originally named “All Saints”) which was broadcast on national TV in Iran from 2004. This serial was about the daily professional practices of nurses and physicians in a hospital setting. A number of case studies were presented in the episodes. The serial was consistent with the basic ethical beliefs of the Iranian healthcare delivery system despite some cultural differences. The first researcher watched the episodes to capture and write down the ethical themes of each case.

Action phase

The participants were all the first year students during four consecutive academic semesters (N=78). Most of them were female (84%), and between 18 and 20 years old (70%). More than half of them (55%) had previous experience of nursing. Interestingly, most did not like nursing at all (52%).

Twenty one students chose to stay in the traditional class in the first semester. In the following semesters all the students chose to attend the new teaching method classes and participated in our action research. A total of 57 students attended the new class over the four consecutive academic semesters.

The new model for teaching ethics showed parts of “The Nurses” after a short lecture on the general principles and terminology of nursing ethics.

Evaluation and reflection went on concurrently and the intervention was continuously refined as is expected in an action research. The evaluation consisted of a perception questionnaire, a behavioural check list and an exam with some multiple choice questions on some ethical cases for decision making. One of these cases is presented below:

The mother of two young children is recently diagnosed with breast cancer. Though she has been put on treatment, she has not been properly informed of her diagnosis and believes that there is nothing wrong with her. So she refuses to follow the treatment schedule, saying that she has many other important things to do rather than coming for treatment sessions. What should you do as a nurse to help this patient?

1. I think it’s better to do nothing because she prefers to continue her usual life.
2. I will try to talk to her doctor.
3. I will tell her the truth directly in the next visit session.
4. It’s not my business. Her doctor has the duty to inform her.

Ethical considerations

After getting the proposal approved by the Research and Ethics Committee of Tehran University of Medical Sciences we provided the students with information about the study in a preliminary session. We explained to them that the dean of the faculty had agreed to our conducting the project with this group. We would try to protect their anonymity. We assured them that they were free to be in either the action research or traditional group. We also told them that if they decided not to participate in the action research this would not affect their right to attend the final examination. The students’ verbal and written consent was obtained before proceeding.

Results

The findings of the study included two complementary sets of quantitative and qualitative data. The main purpose of the quantitative section was to compare the perception questionnaire scores and behaviour checklist scores of the students in the action study with the scores in the traditional teaching group. This would help to identify how the new approach might affect the students’ perceptions regarding the ethics course as well as their ethical behaviour in an ethical setting.

The maximum score for perception was 46. The average perception scores for those using the traditional training module and those undergoing the new teaching methods were calculated.

The independent test results showed the mean score of the action group was significantly higher than that of the traditional group.

The maximum possible score for students’ ethical behaviour checklist was 10. The average behavioural checklist score for both groups was calculated. The difference in these scores was statistically evaluated to determine if there was indeed a difference in the ethical behaviour scores across the two groups. The mean scores are shown in Table II.

The independent test results showed a significant difference between students’ behaviour checklist mean scores in the two teaching groups. The mean score of the action group was significantly higher than that of the traditional group.

The new materials and methods for the ethics course were established according to the themes that emerged in the first stage. This content and this method were revised and developed during the process of teaching and learning across the study.

After using the new method for teaching in the action group, students were asked if they would be interviewed to obtain their views on this method. Those students who showed an interest in giving their opinions were interviewed. The interviews were then transcribed verbatim and analysed. The themes that emerged were placed in three categories: content related, teaching method related and both content and teaching method related. Table III shows some of the themes under these categories.

The following are excerpts from students who received the new content via the new teaching method:

• “I couldn’t believe that this course could be presented in such a practical way in daily works of the nurses. This class is very attractive. I wish the other classes could be so practical”.

The students were very satisfied with the new way of teaching. They explained how this would encourage them to engage more in class discussions:

• “The things that I see make me so interested. I fully understand how important these issues (ethical issues) are in daily nursing work. Simple and very important”.

Discussion

Ethical practice is the responsibility of all nurses, so teaching nursing ethics can play an important role in understanding the meaning and practical applications of ethics for nurses.

What do we teach students as “nursing ethics” and how? Who is teaching them? Why should we expect them to be able to consider ethical situations and find the best way to deal with ethical issues when our course content and teaching styles do not prepare them for playing these roles? We realised that something is wrong and this was the starting point for change.

As was found in this action research, the perceptions of the two groups (traditional teaching and the action group with new teaching method) during and after classes were very different. The students in the traditional teaching group had a negative perception of “nursing ethics”, while the new teaching method group gave positive and encouraging feedback which led to the programme being continued. Gaul emphasises the influence of ethics education on nurses’ ethical perception and action (14).

All the students in both groups said that they did not like those courses that were very theoretical and subjective and preferred to learn concepts that could be immediately applied in their work.

Some studies have found that in many schools, nursing ethics is taught as a subjective course and nurses do not usually have a clear understanding of the importance of ethics in their daily work (15). Many texts and research findings emphasise the importance of teaching ethics through more flexible and realistic approaches than the traditional theory-based routes (4). The findings of Doane et al showed that the education experience influences nurses’ knowledge and ability to confront complex ethical issues in nursing practice (16). It was also suggested by Riesch et al that educational experiences which allow nursing students to develop skills in analysing the issues, consequences, and obligations inherent in a moral dilemma may help to improve their moral perception and performance during graduate education and in professional practice (17).

In Iran, despite the recent activities in the field of ethics by the ministry of health and medical education, ethics has not been taught in an active practical way in nursing faculties (2). It has been a small part of the “Nursing history, deontology and law” course that is taught through lectures.

The students in the new teaching method group reported that these classes gave them the opportunity to encounter real life situations. They stated that in this way they could understand what nursing ethics was really about and how significant it can be in a nurse’s daily work. They described the experience as an opportunity for participating and learning in a democratic climate. Dinc and Gorgülü support the active participation of students in teaching ethics as an important contributor to promoting the process of effective learning (18). Their findings also supported contemporary thinking that adult learners do better with less direction and more participation. This includes nursing baccalaureate students in ethics class as well.

The findings indicated contrasting experiences for the students in traditional groups and those in the new teaching method group. The former described their experience of ethics classes as boring, unattractive and useful only for passing the course. They also stated that they got nothing practical from the course that would help them perform their role in the real world. The study by Noland and Smith, on ethical awareness among first year medical, dental and nursing students, showed that the majority of students want a course on ethics which is practically based and will help them to cope with situations that they are likely to encounter in their professional practice (19).

As the findings showed, the students in the new teaching method group expressed great satisfaction with the process of learning. In addition, their attendance in class, scores in the final exam, perception questionnaire, and ethical behaviour checklist scores were significantly higher than were those in the traditional class. Clarkburn suggests that an ideal ethics intervention would last four to 12 weeks and be based on student-centred teaching methods involving students’ participation in ethical dilemmas (8). This way of confronting ethical issues in nursing is recommended by some ethicists who believe that nursing ethics, like all ethics courses, must deal with problems and not only theory, and is therefore best taught when the teacher builds in time for dialogue. For this reason the most effective format is that in which students engage with each other and the teacher to address the issue (3).

It is important for nurse educators to understand that ethics education should provide students with ways of conceptualising situations and arriving at practical ethical solutions (3).

Conclusion

There have been a number of changes in the field of ethics the world over and also in Iran in recent years. The findings of this study provide evidence of the value of using practical content as well as interactive, realistic approaches to teach ethics in nursing.