Developing ethical competence is a required component of nursing education as described by the American Association of Colleges of Nursing (2008) and specifically defined in Essential VIII-Professionalism and Professional Values. The rationale for the essential stipulates that baccalaureate graduates should be prepared to respond to numerous dilemmas and to make decisions within an ethical framework. Clearly, students are expected to be capable of managing clinical situations when ethical implications exist.

BACKGROUND

Entering the workforce as a new nurse can be overwhelming. New graduates expressed that they felt overwhelmed when faced with making decisions quickly, and nurses with less than five years of experience reported higher levels of stress when managing ethical issues than nurses who had more than five years of experience (Ulrich et al., 2010). Nurse educators may not be aware of how new graduates perceive their entry into practice, nor hear how unprepared students are to meet the needs of employers. Although new nurses and nursing students frequently expressed a sense of not being prepared because of a perceived lack of technical skills, the focus on procedures and the ability to perform technical skills may obscure achievements in relational areas, thus influencing the professional identity of the new nurse (Beckett, Gilbertson, & Greenwood, 2007).

Instruction in ethical theory, along with exposure to ethical dilemmas in a clinical environment, is necessary to prepare practitioners who are able to manage clinical situations with ethical considerations. Identifying learning experiences that result in the achievement of desired outcomes related to ethics is a major concern among nursing programs because nursing curricula vary in how ethics are taught (Park, Kjervik, Crandell, & Oerman, 2012; Vynckier, Gastman, Cannaerts, & de Casterle, 2015). Thus, the purpose of this research was to examine the relationship between knowledge about ethics in practice and choices of action in a clinical situation in order to assess the educational preparation of BSN nursing students.

METHOD

This study was exploratory and utilized two instruments. The institutional review board of the educational organization overseeing the research process approved this study, and all policies and procedures applicable to working with human subjects were followed.

Instruments

One instrument was a questionnaire to collect data on demographic and individual characteristics of study participants. The researcher utilized it to determine if specific experiences and characteristics of the student would influence the student's connection between knowledge and action when managing situations that have ethical implications. The characteristics explored were amount of education credit in college courses on ethics, previous experience in making decisions about the health care of others, and any previous experience in health care prior to enrolling in a nursing program. The amount of coursework should increase the knowledge base of students, whereas experience would help with the integration of knowledge into clinical practice. According to Benner, Sutphen, Leonard-Kahn, and Day (2008), it is important for nurses to have evidence-based knowledge to guide their actions, and that experience, which Benner et al. refer to as skilled know-how, is necessary for competent clinical practice.

The primary instrument was the 2007 version of Ketefian's Judgments About Nursing Decisions, an instrument consisting of eight patient care vignettes with ethical implications present in each scenario. A list of nursing actions follows each vignette. Each action is recommended, not recommended, or ambiguous according to the 2001 American Nurses Association Code of Ethics. Aligned with each action are two columns. In Column A, using a Likert-type scale, the participant is asked to rate the action regarding whether or not it would be a recommended response (knowledge). In Column B, the participant, again using a Likert-type scale, responds regarding how likely the nurse is to implement the behavior identified (action). Because clinical settings are complex, it is possible that an action would be rated as recommended, but not rated as an action likely to be implemented.

The Likert-type scale used for this study was a 5-point scale (5 = strongly agree, 3 = neutral, 1 = strongly disagree). Scores were added together, and the numerical average of all responses for each column became the score. The researcher then determined the mean for each response for every action in Column A and Column B. Comparison of the mean for identifying each action to the likelihood of implementation illustrates the strength of the relationship between knowledge and action.

Using the mean score for each column, the relationship between the action and the likelihood that the action would be implemented was determined separately for each subgroup using Pearson's r. Correlation coefficients were then compared using a z score; a z score for a 95 percent confidence interval of 1.96 was necessary to conclude that the results were significant.

Sample

The population was a convenience sample of senior nursing students from several BSN programs in the Midwest who were scheduled to graduate in December 2013. All 183 participants were recruited from a class required of every graduating senior. As several surveys were incomplete, only 172 were used in the data analysis. This researcher visited each class to obtain informed consent and administer the questionnaires.

Students varied in gender, age, previous life experiences, and coursework not related to their nursing curriculum. Most students were women (n = 153, 87.4 percent). Most were Caucasian (n = 147, 84.5 percent); 4.6 percent were African American (n = 8); 7 percent were Asian (n = 4); 4.6 percent identified as mixed ethnicity (n = 8); four students did not answer. The majority of students were between 20 and 24 years (n = 91, 52.3 percent); 27.6 percent were between 25 and 29 years (n = 48); 9.2 percent were between 30 and 34 (n = 16); 5.7 percent were between 35 and 39 years (n = 10); 3.4 percent were between 40 and 45 years (n = 6); three students (1.7 percent) were 46 to 50 years.

RESULTS

Using Pearson's r, the relationship between knowledge and action in senior BSN students was determined to be positive and significant, r(172) = .45, p < .01. In order to determine if individual characteristics influenced the strength of this relationship, participants were divided into subgroups according to three individual characteristics: amount of college credit in ethics courses, previous experience in health care, and previous experience in making decisions about the health care of others.

With regard to college credits, Group 1 participants (n = 155) had earned six hours or less; Group 2 (n = 19) had earned seven or more hours of college credit. For participants in Group 1, r(155) = .449, p < .01; for participants in Group 2, r(19) = .458, p < .05. Both groups indicated a positive and moderate correlation between knowledge and action. The z score for the two subgroups was 0.04 and not significant, indicating that increased coursework in ethics did not influence the relationship of knowledge to action.

The second characteristic was previous experience in making decisions about the health care of others. Group 1 (n = 24) had experience making decisions, whereas Group 2 (n = 150) did not. For the participants in Group 1, r(24) = .575, p < .01; for participants in Group 2, r(150) = .431, p < .01. Although the correlation coefficient for both groups was positive and moderate, the correlation coefficient in the group that had experience making decisions was larger, indicating a stronger relationship. The z score was 0.83, and though larger than the other variables studied, it was still not significant, indicating that the strength of the correlation did not change with experience in making health care decisions for others.

The last characteristic explored was any type of experience in health care prior to starting in nursing school; this experience was general and included work such as nursing assistant and pharmacy technician. Group 1 (n = 80) had experience in health care; Group 2 (n = 92) did not have previous experience. For participants in Group 1, r(80) =.463, p < .01; for participants in Group 2, r(92) =.421, p < .01. Both indicate a positive and moderate correlation between knowledge and action. The z score was 0.34 and not significant, indicating that strength of the correlation did not change with previous health care experience.

DISCUSSION/IMPLICATIONS FOR NURSING EDUCATION

It is important to note that, although many nursing programs require a course in the ethics of health care, others only require a generic course on ethics that is not specific to nursing. Additional options include embedding the content throughout all courses in the curriculum or including instruction on ethical principles only when situations arise during a clinical practicum (Benner et al., 2008). Although nursing curricula vary considerably in how ethics is taught, identifying learning experiences that result in the achievement of desired outcomes related to ethics has become a major concern of nursing programs, and efforts to promote ethics education in nursing have intensified in recent years (Cannaerts, Gastmans, & Dierckx de Casterle, 2014; Park et al., 2012; Vynckier et al., 2015).

As complexity of health care environments can lead to conflicts in values, nurses often state that they have difficulty implementing the ethical dimension of their practice. Educators in nursing are responsible for and challenged to prepare students to practice in the complex health care environment. This includes preparation that enables nurses to assist patients to make tough decisions that are reflective of the patient's values.

Ethical competence is more than recognizing situations with ethical implications; it also requires the ability to take action (Goethals, Gastman, & de Casterle, 2010; Ulrich et al., 2010). Yet the data in this study showed that increasing the amount of coursework in ethics did not influence the ability of the student to relate knowledge to action.

One recommendation identified from the data is to conduct research to evaluate the teaching methodologies nursing education programs use and to direct nurse educators to assess and evaluate how nursing students learn to manage the ethical component of practice. Additional research expanding the geographical area should provide access to a more diverse sample and more equal representation between subgroups. Stronger representation in each subgroup should help determine which characteristics of nursing students, if any, would strengthen the relationship between ethical knowledge and action. Simulations where students work through the process of making ethical decisions in a controlled environment may be especially beneficial because the group of participants who had experience in making health care decisions for others demonstrated the strongest relationship between knowledge and action.

The sample was one of convenience with limited diversity located within a central region of one state in the Midwest. There were large differences within the subgroups of two of the three characteristics studied, which may have influenced the effect of the variable on the relationship between knowledge to action. Participation was voluntary, but data collection occurred as part of class time, making it possible that students felt pressured to complete the survey.

CONCLUSION

In the today's complex health care environment, nurses must be able to provide ethical care to patients. Providing this level of care is time-consuming and can be challenging. The patient may require assistance in making choices between treatments that influence outcomes. Development of ethical reasoning abilities and experience with making ethical decisions throughout the BSN educational experience should enable new nurses to experience increased confidence and accuracy in managing clinical situations where ethical implications are present.

Educational programs in nursing are designed to prepare generalists who should be able to manage these clinical situations, but it is unclear which methods are the most effective. It is also not clear if specific individual characteristics of each nursing student can be identified and developed in order to increase confidence and enhance the relationship between knowledge of ethics and choice of action, ultimately increasing the ability to manage ethical situations in practice.

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