Content area
Aims
The aim of this study was to explore the characteristics of public health ethics education programs designed for nursing students to inform the development of curricula that produce nurses with a strong ethical compass.
BackgroundThe COVID-19 pandemic has highlighted the urgent need for public health ethics education in nursing. While the importance of balancing individual rights and the health of the community is well-recognized, there is a dearth of effective educational programs and materials to equip nursing students with the necessary skills to navigate these complex ethical issues.
DesignThis study is a scoping review of the literature
Data sources:
The PubMed, CINAHL and Web of Science databases were searched to identify studies that met the inclusion criteria.
MethodsA total of 16 studies were obtained within a search period of 2012–2023.
ResultsOur analysis showed that some of the studies included other faculty members and practitioners. Effective teaching methods included narrative media and gaming methods, while Internet technology posed teaching challenges. Evaluation methods ranged from analyzing student discussions and reports to using specific measurement scales.
ConclusionsThese findings suggest the need to develop a broader range of evaluation methods and collaborative efforts among educators to ensure the sharing of educational resources.
The concept of public and general health has been considered together over the years. Currently, it is a framework for measures such as health promotion, disease prevention and health crisis management, contributing to the extension of human lifespan ( Tulchinsky and Varavikova, 2014). Public health has focused on the social determinants of health, with a goal of reducing health disparities to reduce health inequities. A framework for monitoring the current situation is being developed ( Affun-Adegbulu and Ardalan, 2021). To achieve this goal, public health professionals must cultivate their own ethical standards in considering issues such as fairness and social justice. During epidemics, the rights and needs of individuals and needs of the community may be unbalanced. The threat posed by the coronavirus disease 2019 (COVID-19) pandemic has highlighted the potential of public health activities aimed at preventing mass infections to restrict and control individual behaviors ( Tao et al., 2023), sometimes increasing human rights infringement risk ( Bhanot et al., 2020). To address such situations, studying ethics, or more specifically, philosophy is needed ( Holland, 2023).
Philosophy plays a crucial role in nursing by providing a framework for understanding patients and guiding actions to address health challenges in a complex society where definitive answers are often unclear ( Lipscomb, 2023). Additionally, Holland (2023) highlighted the significance of philosophy in assessing the appropriateness of public health interventions, suggesting that it offers a foundation for determining the justification of such measures. Ethics, also known as moral philosophy ( Metz and Miller, 2016), is a fundamental academic discipline for nursing professionals responsible for public health. As a professional group, nursing professionals are tasked with the realization of a society where individual human rights are protected and respected, as outlined in their ethical principles ( International Council of Nurses, 2021). Consequently, a high level of ethical awareness is imperative for the nursing profession. In nursing education, ethics training is essential. However, emphasis is primarily placed on ethics related to the direct provision of medical care to patients ( Bueno et al., 2023; Lee et al., 2020; Rahmani et al., 2023; Zolkefli, 2021).
The COVID-19 pandemic has highlighted the need for policies to restrict individual behavior, consequently preventing the spread of infection and highlighted the current situation where the strength of such restrictions is affected by factors such as mortality rates ( Agyapon-Ntra and McSharry, 2023). This shows that to protect the health of populations and communities, restricting individual rights may be necessary. The dilemma of right restrictions reflects the possibility of ethical conflicts in public health, wherein the ethics of protecting personal rights may contradict the ethical imperative of safeguarding public health.
The importance of public health ethics education is undisputed. With the context described above, ethical education, which considers the interests of the larger community and emphasizes the ethics of professionals who fulfill their responsibilities to the society, rather than medical ethics, which has traditionally focused on protecting the rights of individual clients, is needed ( Nakazawa, 2023; Swain et al., 2008). Nurses, who are equipped to protect human rights, should develop ethical sensitivity to grasp situations in case of dilemmas, where the rights of the interest groups and individuals are conflicting and develop a strong ability for moral reasoning to guide how they act. However, the curriculum for such education is still in the developmental stage, with individual schools and educators in the “trial and error” stage.
A 2018 survey of nursing universities in Japan revealed that over 90 % of the surveyed institutions considered public health ethics education necessary. However, more than 40 % indicated a lack of capable faculty to deliver such education ( Kobayashi et al., 2018). Furthermore, the reported challenges in implementation have been attributed to the absence of specific curricula and teaching material ( Kobayashi et al., 2018). Despite an extensive review of subsequently published literature, we did not identify definitive models for public health ethics education in nursing education or reports on the latest related survey results. The literature regarding the impact of the COVID-19 restrictions on nursing education has mainly focused on the lack of clinical experience due to the inability to conduct clinical training ( Spector and Silvestre, 2024), provide simulation education using virtual reality technology ( Zaragoza-García et al., 2021) and assess the usefulness of e-learning ( Bourgault et al., 2022). Furthermore, educational content has focused on public health education as a disaster-prevention measure ( Leaver et al., 2022).
Therefore, we conducted a comprehensive review of domestic and international databases to examine previous and current methods used in ethical education practices and thus gain insights into the most beneficial forms of ethics education for nursing students studying public health.
This scoping review aimed to explore approaches to public health ethics education with the goal of enhancing foundational competencies in nursing students to address ethical challenges in public health. Specifically, we examined educational objectives, content, teaching materials and evaluation methods in public health ethics education. Through this review, we sought to clarify how public health ethics education can effectively contribute to the development of essential skills for nursing students engaged in ethical issues in public health. Furthermore, integrating these findings to propose a unified model could be a valuable resource for designing effective curricula. The findings of this review can contribute substantively to the ongoing discourse on the optimal approach for educating nursing students on public health ethics.
2 MethodsThis scoping review was conducted in accordance with the ethical guidelines for literature reviews. A scoping review is a research methodology that maps and synthesizes the available evidence in a subject area ( Affun-Adegbulu and Ardalan, 2018). It can be used to measure the extent, scope and nature of research activity, determine the value of conducting a more formal systematic review; identify evidence gaps; and identify research questions. Like systematic reviews, the reporting items of scoping reviews have been formalized and established ( Tricco et al., 2018).
In this review, we used publicly available data from existing literature and did not collect primary data from human participants; therefore, formal ethical approval was not required. The literature search was conducted using PubMed, CINAHL and Web of Science, selected for their relevance to public health, nursing and education. PubMed covers biomedical and public health literature, CINAHL focuses on nursing and allied health and Web of Science provides a multidisciplinary scope. These databases were chosen in consultation with a librarian to ensure a comprehensive and focused search. To focus on events that have had a major impact on ethics in Japan, such as nuclear power safety issues that caused the Great East Japan Earthquake and the start of global democratization, the search period was limited to the last 10 years (2012–2023) and we included only English-language papers. The search formula was developed in consultation with a librarian and included thesaurus terms with the keywords “public health,” “ethics,” education,” “nursing,” and “students.”
The inclusion criteria were as follows: 1) nursing students who were enrolled in a course to obtain a national license, regardless of whether they were from a graduate school, university, junior college, or vocational school; 2) articles published in the search databases as original articles or case reports/practice reports (excluding review articles, protocol articles and conference proceedings); and 3) all study designs, including randomized comparative studies, non-randomized controlled trials, pre-posttests and interrupted time series tests, used in studies on public health education as the intervention method and in studies that assessed the effects of the intervention methods. Additionally, observational descriptive studies, activity reports, descriptive cross-sectional and longitudinal studies and case-control study designs were included. The target literature was selected through a primary screening of the literature titles by six assessors, followed by a secondary screening of the texts, each thoroughly read independently by the assessors. The six assessors, with two assigned to each database, were teachers and had experience working as public health nurses. The screening results were then discussed by two other researchers to reach a consensus.
Data were extracted from the articles included in this scoping review by two independent reviewers using a data extraction table developed by the reviewers. The extracted data included specific details of the participants, concepts, contexts, study methods and key findings relevant to the review question.
The initial data extraction tool was modified and revised as necessary throughout the data extraction process. All modifications were thoroughly documented in this scoping review. Any disagreements between reviewers were resolved through discussion or, if necessary, in consultation with an additional reviewer (EY). Where appropriate, the authors of the articles were contacted to obtain any missing or additional data.
The data analysis outcomes are comprehensively reported and illustrated in a Preferred Reporting Items for Scoping Reviews flow diagram ( Page et al., 2021; Fig. 1). The geographical location, context, study settings and key contents or issues related to implementation strategies in public health ethics education are presented and synthesized in tables. A narrative summary is provided alongside tabulated and/or charted results, describing our findings along with other pertinent findings.
3 Results3.1 Overview of the literature ( Table 1)
Table 1. The analysis included 16 articles reporting the content of courses related to ethical issues in public health for nursing students ( Gangwani et al., 2022; Hsu, 2011; Lee et al., 2017, 2020; Levett-Jones et al., 2015; Lewis et al., 2019; Lin et al., 2013; Maddineshat et al., 2019; Monteverde, 2014; Nold and Deem, 2020; Park, 2013; Vermeesch et al., 2018; Wald and Monteverde, 2021; Willsher, 2013; Xue et al., 2023; Yeom et al., 2017). Considering that era and social background influence ethical issues in education, this review focused on studies published from 2011 until 2023 when debates, which began in 2010 (the year referred to as the Arab Spring), were held about the safety of nuclear power generation and wave of democratization movements in the Middle East and North Africa.
Only one article was a commentary and not a research paper. Of the remaining 15 articles, seven were intervention studies and eight were observational studies. Regardless of the design, we examined and reported effective educational strategies and methods. The findings of six articles were summarized from students’ discussions, post-class reports, opinions and impressions, whereas the remaining studies used a scale to measure the abilities intended to be acquired through education. The specific scales are described in detail later in this study. All but two of the intervention studies used a pretest–posttest design without a control group. Of the studies that used a control group, one used a cluster randomized design ( Xue et al., 2023) where students were randomly assigned to one intervention group and the other was a comparison between student groups that had taken the course at different times. Additionally, the evaluators were not specified; therefore, the researchers, who were educators, were assumed as the evaluators.
The educational targets were primarily undergraduate students, with only one study involving graduate students ( Vermeesch et al., 2018). While four studies specified that the participants were final-year students, the remaining studies only indicated that the students took the relevant course without specifying the year levels. Some studies involved medical students ( Lin et al., 2013) or mixed groups from other faculties such as engineering, whereas others included practicing nurses ( Vermeesch et al., 2018) and retirees from various professions ( Willsher, 2013). The number of nursing students ranged from 6 to 251 and the class size ranged from 10 to 251.
Factors that facilitated education included the use of media with narratives, such as films and real-life case studies, to provide students with more realistic imagery and the use of game-based methods to engage students' interest. However, concerns were raised about the use of gaming for ethical education and the passive nature of students when using Internet-based technologies, such as virtual reality, due to the lack of interactive elements.
3.2 Educational themes, teaching materials and models usedThe most common educational themes or ethical issues in ethics education for nursing students were 1) dilemmas in bioethics, 2) professionalism, 3) ethical issues in infectious disease control, 4) protection of the human rights of participants in clinical research and 5) ethical dilemmas in clinical practice (nursing care) ( Table 2). Bioethics was reported in multiple studies and as specific examples of dilemmas that arise between respecting the autonomy of patients and respecting life, four studies addressed the refusal of organ transplants, including blood transfusions and discontinuation of life-sustaining treatment. Three studies assessed birth control and medical malpractice. Two ethical dilemmas in clinical practice (nursing care) were examined: dealing with the difficulty of considering the pace of individuals in a nursing home community and the desire of individuals who are in care facilities owing to the family burden to remain at home.
Regarding public health issues, a commentary highlighted the risk of infection among medical staff in the discharge of duties during the COVID-19 restrictions, as well as concerns regarding identifying those at high risk of infection as a fear response and regarding feeling secured through isolation. Ethical issues were also raised regarding dealing with individuals who refused vaccination for parental or religious reasons. Other topics that were addressed included ethical considerations of the risks and benefits of testing, the extent to which medical staff should prepare for unprecedented disasters and other topics related to social justice, such as the fair distribution of medical resources.
Table 3 lists the teaching materials and models used. Examples of teaching materials include movies and games as audiovisual materials, as well as actual practice cases, but only one specific publicly available teaching material, published on the United Nations Educational, Scientific and Cultural Organization (UNESCO) website, could be referenced. The book was titled "Moral Games for Teaching Bioethics" ( Macer, 2008); the full text is currently available on the web. Learning of the material involved simulating the experience of ethical dilemmas in practical training through a game ( Maddineshat et al., 2019). A case study reported an actual case of a girl with spina bifida. The case report was posted on a hospital’s website and could be referenced; although a reference link was provided in the paper, it could no longer be accessed during our write-up ( Willsher, 2013). In addition, the literature that used films suggests the effectiveness of using studies published in students’ countries, considering the influence of cultural background on their understanding ( Gangwani et al., 2022). One study also devised an approach to create a more realistic experience of dilemmas encountered during care provision by developing an online virtual community and strengthening the perspective of recognizing people being supported as living beings ( Levett-Jones et al., 2015). In addition, a study aimed to innovatively address ethical problems through interprofessional education among engineering and nursing students by using Makerspace technology, which is gaining attention as a tool for providing a hands-on learning environment and for cultivating critical thinking skills ( Lewis et al., 2019).
The models used in the studies included the Visual, Auditory and Kinesthetic (VAK) model, which recommends using visual teaching materials to realistically understand ethical issues and narrative medicine, which helps students visualize the problem as a story. Other models included problem-based learning and the Analysis, Design, Development, Implementation and Evaluation (ADDIE) model for designing educational methods. The four-topic method, a form of ethical decision-making in clinical medicine, was also used to promote a problem-solving mentality.
3.3 Learning achievement and ability assessment toolsRegarding methods for assessing the achievement levels of students’ learning goals or acquired abilities, nine studies used qualitative assessments through reports and comments during class, open-ended questionnaires and group interviews after class. Nine tools used in seven studies assessed changes in learning achievement or student abilities using a reference scale ( Table 4) and three of the tools were developed by the authors, making reference to existing scales ( Hsu, 2011; Lin et al., 2013). One of the tools, the Moral Sensitivity Questionnaire (MSQ), which measures moral sensitivity, was the most frequently used tool and was used after translation and modification into the languages of respective countries.
4 DiscussionTo provide an overview of public health ethics education for nursing students, we targeted papers that reported or stated opinions on educational content, and we reported target students, educational themes covered, academic models and teaching materials and evaluation methods for the classes. The results showed that the targeted students were in various years of education and included some students from fields and experiences other than nursing and that the educational period was also diverse. More than half of the studies were reports regarding practice and the remaining intervention studies that verified effectiveness were mainly one-group before-and-after comparative studies, making it difficult to compare the more effective educational approach. There was a high possibility that the evaluators were educators, indicating that bias existed with the verification of effectiveness.
Although the keyword “public health” was included in the literature search, the educational themes were mostly bioethics and clinical ethical dilemmas centered on individual care in medical institutions and other facilities. Public health issues included the risks and responsibilities of medical workers during an infectious disease pandemic, the dilemma between individual rights and public interest that arise during vaccinations, optimization of the risks and benefits of health checkups and fair distribution of medical resources. Furthermore, the literature on “professionalism” suggests that the basis of professional behavior is problem recognition and decision-making through ethical sensitivity and ethical reasoning, respectively and that the consequent high sense of ethics and ethical behavior are essential requirements for professionals ( Xue et al., 2023).
Regarding educational models, problem-solving education methods such as problem-based learning were reported in some studies and others used the “four-topic method” used by clinicians to make clinical decisions ( Jonsen et al., 2021) and used tools for thinking methods that are useful in postgraduate clinical practice. The ADDIE ( Boling et al., 2011) and VAK models, which are widely used as instructional design models in the development of educational curricula, are also considered to have similar intent. Game-based teaching methods are a gamification technique designed to allow students to enjoy and actively commit to problem-solving processes ( Christopoulos and Mystakidis, 2023) and are also used in ethics education. However, there are concerns regarding its validity and further consideration is required.
The teaching materials used in education were mainly the author’s ingenuity, using cutting-edge science and technology, such as Makerspace and creating virtual communities. However, the only way such material could be used effectively was through the UNESCO website version, which is still publicly available. This suggests that public institutions can store such materials as intellectual property and share them worldwide. Teaching materials are only meaningful if they are used and can be further improved. Currently, the Massachusetts Institute of Technology (2001) and Rice University (2012) offer free courses or subscription-based textbooks and public institutions related to education can create and promote such opportunities. Alternatively, support could be provided for the development of educational materials by providing subsidies and other resources to enable the storage of educational materials that individual educators have passionately developed, which can be shared as intellectual property and made public.
Seven studies that incorporated scales into their educational evaluation methods used nine tools, three of which were developed by the authors of the respective studies. The most used tool was the MSQ, developed by Lützén et al. (1994) and translated into multiple languages. Moral sensitivity, which involves recognizing and understanding the moral aspects of situations ( Rest and Narváez, 1994), is considered essential for addressing moral and ethical issues. However, the challenge that ethical sensitivity reflects the culture and values of a country remains; therefore, an evaluation that considers this challenge is required. This suggests that a single approach is not appropriate. The above discussion shows that the target of ethical education, which is to foster and enhance the abilities and sensitivities of students, is diverse, the assessment methods are varied and ethical education is still developing. Furthermore, evaluating the educational methods using a single standard suggests that simply comparing methods to determine the appropriate type of education can be challenging.
This paragraph considers how nursing ethics education should be evaluated. The evaluation of educational effectiveness means evaluating the degree of achievement according to educational goals, such as testing the state of knowledge acquisition; however, measuring this is difficult and it is often subject to evaluator bias ( Daskalopoulou, 2024). To evaluate the effectiveness of ethics education, it is necessary to focus on its purpose. Ethics education aims at helping students acquire the ability to resolve ethical dilemmas. This implies that rather than an appropriate understanding of the educational content or student satisfaction, the acquisition of the ability to independently choose ethical and moral behaviors in a clinical setting with no correct answers, evaluate the impact of that behavior and improve on it is vital. The concept of authentic assessment may be important for evaluating educational methods aimed at developing such abilities. Authentic assessment involves evaluating knowledge and skills that can be applied in real-world contexts ( Hart, 1994) and emphasizes learners’ ability to deal with their challenges.
From this perspective, it is necessary to evaluate how one discovers and resolves ethical problems, and this evaluation must be conducted within nursing practice. Our findings show that evaluating the effectiveness of nursing ethics education requires time and that it should be evaluated in practice. However, evaluation is essential for improving education and considering the setting of short-term evaluation goals in the future is needed.
4.1 LimitationsThis study is limited by its exclusion of articles that were not reported in English, which might have resulted in an incomplete overview of educational practices. Another limitation is the potential bias from reports authored by individuals who were also involved in providing the education, making it challenging to ensure the validity of the evaluations. Owing to the varied educational methods and diverse evaluation methods used in the included studies, effective educational methods could not be established in this review.
4.2 Practical implicationsThis study showed that the goal of most public health ethics education is to develop ethical sensitivity to recognize and resolve ethical dilemmas and that useful scales, such as the MSQ ( Lützén et al., 1994), can be used as indicators to evaluate the effectiveness of such education. In addition, regarding educational methods, a common educational framework that involved teaching basic ethical concepts, highlighting issues using audiovisual materials that allow students to understand and address dilemmas and encouraging discussions among students was presented in this study. These models may be useful for instructors who are developing curricula in the future.
Future research should incorporate more objective evaluation methods, such as involving separate evaluators and educators, to improve the reliability of the findings.
5 ConclusionsThis study analyzed existing papers on public health ethics education for nursing students and reported educational content, target students, teaching methods and evaluation methods. The results showed that the education programs used in the included studies were varied and that the evaluations were diverse, making it difficult to determine the most effective educational method. To ensure a more effective ethics education, it is important to develop a variety of evaluation methods and share educational materials through collaboration between educators.
Ethics statementThis work did not need ethical consideration as it is a literature review.
FundingThis work was supported by the Japanese University of the Air Educational Foundation. The funding body played no role in the design of this study, the review’s data collection, analysis, and interpretation or in writing this review protocol.
CRediT authorship contribution statementHaga Chiyori: Writing – original draft, Visualization, Validation, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Takei Yusuke: Writing – review & editing, Resources, Methodology, Formal analysis, Data curation. Yoshikawa Etsuko: Writing – review & editing, Validation, Resources, Methodology, Data curation. Okamoto Nahoko: Writing – review & editing, Validation, Formal analysis, Data curation. Oda Mikiko: Writing – review & editing, Supervision, Data curation.
Declaration of Competing InterestThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
AcknowledgmentsA librarian at the Japanese Red Cross College of Nursing provided guidance for developing the search strategy.
Author contributionsConceptualization: CH; Data curation, CH, YT, NO, MO, EY; Formal analysis, CH, YT, NO; Funding acquisition, CH; Investigation, CH, YT; Methodology, CH, EY; Project administration, CH; Resources, CH, YT, EY; Software, CH; Supervision, NO, MO, EY; Validation, NO, MO, EY; Visualization, CH, YT; Writing – original draft, CH; Writing – review & editing, YT, NO, MO, EY.
| No. | Author(s), year of publication, study location | Aims of the study, educational methodology, study design, duration of the education, student type. | Theme/ issues | Description of specific type of educational program | Promoting factors and barriers |
| 1 | Xue et al. (2023), China | To analyze the effects of narrative medical theory learning and narrative writing on nursing students' professionalism, empathy and humanistic care ability,
Cluster randomized controlled trial; class for 12 months; 85 nursing students who are fourth-year nursing undergraduates entering clinical practice | Professionalism, empathy and humanistic care ability | The seminar participants learn about narrative medicine and write stories about their experiences in clinical training. These stories are evaluated and discussed in class, allowing students to reflect on their own emotions and learn from each other's experiences. The seminar is 3.5 hours long and is held once every two weeks. | The promoting factor is to focus on the patient and their story and subsequently nursing interns. This can lead to a stronger doctor-patient relationship and help interns to reflect on their own behavior and thoughts. |
| 2 | Gangwani et al. (2022), India | To determine whether Trigger Films can be used to teach professionalism and ethics as an innovative and interesting tool and to identify whether this results in any changes in knowledge.
A cross-sectional observational study (A mixed-method research design); for a 2-hour session within the curriculum; 75 undergraduate nursing and 170 medical students | Bioethical Dilemmas | The educational intervention was a 2-hour class held online due to the restrictions. It consisted of screening four short clips from Bollywood movies and discussing ethical issues in each clip. Participants were given a pre-post questionnaire to gather feedback on the session. | Movie clips were more effective in this situation because they had a greater emotional impact, were short and could quickly portray the situation. |
| 3 | Wald and Monteverde (2021), USA and Switzerland | To propose expanding the notion of resilience to the field of ethics education under the conditions of remote learning.
Not a study but a commentary | Severe moral distress from COVID−19 | The creation of prima facie “unpurposed spaces” within the curriculum enables students to reflect on their experiences as citizens or health professionals during the restrictions. | The facilitation factors for addressing the moral determinants of health include collaboration among educators, students and practitioners and advocating for health policies that address social determinants. |
| 4 | Nold and Deem (2020), USA | To prepare nursing students for challenging discussions with vaccine-refusing families and participating in decision-making with colleagues regarding whether to dismiss or continue to provide care for these families.
Uncontrolled before-and-after study designs, the period for the course; Undergraduate students in nursing; the data were obtained from more than 200 students completed the course. | Addressing parental vaccine refusal | The course consisted of two parts, the simulation experience and the debriefing session. The simulation involves a scenario where nurses encounter a parent who refuses to vaccinate their child during a routine pediatric wellness visit. The simulation is designed to lead to various possible outcomes, such as conflict resolution, continued discussion, or consultation with colleagues. The simulation includes a role-playing exercise where students act as nurses. | The high-fidelity ethics simulation helps nursing students develop communication skills for handling ethical issues with patients, families and healthcare professionals. |
| 5 | Lee et al. (2020), Korea | To describe nursing students' perspectives on and experiences of a case-centered approach to nursing ethics using the four-topics method, Qualitative Research, for 15 days, fourth-year students of Bachelor of Science in nursing | Bioethical Dilemmas | The course covered ethical principles, decision-making, nursing ethics issues and case analysis (four-topic method). Students worked in teams to analyze cases on induced abortion and withdrawal of life support. | Promoting factors is to provide opportunities to learn professional ethics and professionalism through discussion. On the other hand, barriers are the lack of opportunities to think for oneself and exchange opinions with other students. |
| 6 | Maddineshat et al. (2019), Iran | To determine the impact of teaching ethics using games on Iranian nursing students' moral sensitivity.
A quasi-experimental study; for one semester; 30 sophomore nursing students in a professional ethics class, | Professionalism | The course used games and competition to teach students about ethical scenarios in healthcare. The lessons were based on the book "Moral Games for Teaching Bioethics." The games were translated into Persian and adjusted for the Iranian culture. | Simulating ethical dilemmas in the game made it possible for students to increase their awareness of moral difficulties. On the other hand, it is suitable to use gaming in professional education. |
| 7 | Lewis et al. (2019), USA | To assess student ethical reasoning pre/post course where students concurrently produce innovative products.
A pre- and posttest comparison design; duration is unclear; 6 nursing students and 18 other majors (ex. Engineering and Chemical Engineering) | Ethical reasoning | Students from traditionally design oriented (engineering) and non-design oriented (nursing and pre-professional health) disciplines worked together in the course to create innovative and tangible solutions to community health problems. The course was instructed in a Makerspace; an open learning environment with tools for both quick and well-developed prototyping | A positive attitude towards collaboration with other fields is a facilitating factor. On the other hand, if the level of preparation is already high before the class starts, there is no room for improvement. |
| 8 | Vermeesch et al. (2018), USA | To identify educational methods to improve students' ability to identify and resolve ethical dilemmas.
A pre-and posttest comparison design; the duration is unclear; 57 DNP with PhD and DNP student | Ethical dilemmas | An ethical framework and four case studies based on original case studies of clinical encounters by students. The class refers to the model curriculum "the American Public Health Association Model Curriculum in Ethics and Public Health" ( https://courses.washington.edu/bethics/violations/ASPHEthicsCurriculum.pdf) | Multifaceted collaboration and realistic case studies are useful to determine their solutions. |
| 9 | Yeom et al. (2017), Korea | To examine the effects of nursing ethics education on the moral sensitivity and critical thinking disposition of nursing students.
A one-group pre- and post-test quasi-experimental design; for 7 weeks, 70 senior undergraduate nursing students | Ethical dilemmas | The course consisted of seven 90-minute lectures and exercises. It used a variety of teaching methods, including lectures, group discussions, question and answer sessions and films. The course adopted the methodology advocated by UNESCO, which includes case studies and film viewing. | Conducting a critical examination with questions is one of the promoting factors. Emphasis on individual approaches and conceptualizations of ethical competence is one of barriers. |
| 10 | Lee et al. (2017), Taiwan | To explore the effect of nursing ethics educational interventions based on multiple teaching strategies on student nurses' moral sensitivity.
A quasi-experimental study; for 18 weeks; 250 third-year nursing students in a 5-year junior college | Moral sensitivity | The VAK model was used to teach nursing ethics. Three teaching strategies were integrated: 1) the value of nursing care; reading Nightingale's Diary, 2) emphasizing "patients' healthcare and life expectations" by analyzing the personal experiences shared by patients after kidney transplant and 3) ethical decision-making by practicing clinical ethical decision-making according to the four-topic approach. | Learning was facilitated by incorporating three learning styles and providing hands-on decision-making practice over eight weeks from weeks 11–18.
Barriers included the fact that the intervention period took up only 1.6 % of the total educational time and the lack of experience in clinical training. |
| 11 | Levett-Jones et al. (2015), Austlaria | To illustrate an innovative educational approach "Wiimali" that uses virtual tours, digital stories and other interactive features to teach concepts such as social justice, person-centered care and patient safety.
Case report; duration is unclear; 1st to 3rd grade students | Social justice, person-centered care and patient safety | Wiimali is a digital storytelling platform that uses personal narratives to enhance student learning of social and health issues. It supports independent exploration and group discussions. | Improving nursing students' understanding of threshold concepts is the facilitation strategy. |
| 12 | Monteverde (2014), Switzerland | To evaluate the feasibility and acceptance of the novel framework for teaching ethical theories by student evaluations.
Case report; for 6 weeks; 93 students in nursing science | Ethical theories teaching | The "Systemic Nursing Care and Ethics" module contains three cycles of problem-based learning (PBL), which cover the domains of nursing ethics, ethical theories and legal aspects of patient autonomy. | The online module used educative playgrounds to help students distinguish the frame and name of the ethical issues they encounter. |
| 13 | Park (2013), Korea | To evaluate a case-based computer program to train ethical decision-making competency for nursing students.
A cross-sectional observational study, for one semester, 251 nursing students (including a 4-year program for junior and senior students and a 3-year program for senior students) | Ethical decision-making | The program simulates a realistic clinical environment where learners play the role of a registered nurse and make decisions in ethical scenarios. The program consists of an introduction, a homepage, an orientation and seven cases. Storyboards were developed based on the ethical vignettes and the decision-making process. The program requires a personal computer with a Pentium or higher-level processor and a sound card. | The program promotes learning through realistic nursing scenarios, structured learning paths, convenient access, repeatability and a summary lecture. However, there were technical issues with installing and starting the program and more detailed information can be added to the program contents. |
| 14 | Lin et al. (2013), Taiwan | To evaluate the interprofessional PBL curricular impact on interprofessional students’ attitudes and confidence in collaborative teamwork.
A cross-sectional observational study; for 4 weeks; 18 4th-year nursing students and 18 5th-year medical students | Clinical ethics | The PBL tutorial used a rich narrative format with multiple perspectives to explore different characters' viewpoints. This included a main story and side stories from various perspectives. Students used a multiple perspective problem identification tool to analyze problems from different professions, documenting their agreements for each section. | PBL tutorial sessions and multi-perspective stories are promoting factors.
Frustration when professional ethical obligations and values clash are barriers. |
| 15 | Willsher (2013), Australia | To investigate and elaborate on concepts, beliefs, judgments and feelings which are shaped by experience.
Case report; the duration is unclear; undergraduate nursing students | Bioethics and palliative care | Joanna's scenario was presented in an ethics module of the course. The module discussed utilitarian and deontological theories and how they relate to ethical decision-making. The tutorial included brainstorming and group work to encourage critical thinking. Students presented their findings to the class. | Experience of encountering actual patients or having some disabilities will be promoted.
Assessing the daily lives of people with disabilities using the medical model may be one of the barriers. |
| 16 | Hsu (2011), Taiwan | To clarify the educational effects of blended learning, which combines multiple delivery media.
A cross-sectional survey design; for one semester; 99 senior undergraduate nursing students | Ethical issues involved in health care | The course features online course outlines, interactive discussions, no-score tests, ongoing feedback and scenario-based learning to encourage critical thinking. | The facilitator is to allow students to access the course whenever and wherever they want. The course should include learning support features such as a poll system, scenario discussion and simulated ethical films. |
| Topics | Literature number | ||||||||||||||||
| 1 | Bioethics | 2 | 5 | 8 | 9 | 10 | 11 | 13 | 15 | 16 | |||||||
| 1–1 | Economic quality of patient care (emergency care for the uninsured) | (2) | (8) | (11) | |||||||||||||
| 1–2 | Organ (including blood) transplants | (2) | (10) | (13) | (16) | ||||||||||||
| 1–3 | Withdrawal of life-sustaining treatment: DNR or Surrogate Decision-Making | (5) | (9) | (13) | (16) | ||||||||||||
| 1–4 | Fertility Control: Hope for the perfect baby through abortion and artificial insemination | (5) | (9) | (16) | |||||||||||||
| 1–5 | Informed consent for patients with cancer | (13) | (16) | ||||||||||||||
| 1–6 | Medical malpractice | (2) | |||||||||||||||
| 1–7 | Support for the independence of people with mental disorders | (2) | |||||||||||||||
| 1–8 | Palliative care for infants born with spina bifida | (15) | |||||||||||||||
| 1–9 | New therapy trials/alternative therapies without scientific evidence | (16) | |||||||||||||||
| 2 | Professionalism | 1 | 6 | 9 | 10 | 14 | |||||||||||
| 3 | Ethical issues in responding to and taking measures against infectious diseases | 3 | 4 | 8 | 16 | ||||||||||||
| 3–1 | Individual and collective interests: Privacy of infected persons | (3) | (16) | ||||||||||||||
| 3–2 | Emergencies in pandemic and working conditions of healthcare workers | (3) | (16) | ||||||||||||||
| 3–3 | Rationalization by identifying people vulnerable to infectious diseases | (3) | |||||||||||||||
| 3–4 | Vaccination: Family refusing to vaccinate, exemptions for religious reasons | (4) | (8) | ||||||||||||||
| 4 | Advocacy for human rights in clinical research | 7 | 8 | ||||||||||||||
| 5 | Ethical Dilemmas in Nursing Care | 10 | 11 | ||||||||||||||
| 5–1 | Supporting elderly people who take their time to eat in nursing home | (10) | |||||||||||||||
| 5–2 | The burden on caregivers and the patient's desire to return home | (11) | |||||||||||||||
| 6 | Preventive activities for health promotion | 8 | 11 | ||||||||||||||
| 6–1 | Recommendations for breast cancer screening using mammography | (8) | |||||||||||||||
| 6–2 | Targeted tobacco advertisement | (8) | |||||||||||||||
| 6–3 | Disaster management and multiple accident prevention | (11) | |||||||||||||||
| 7 | Social justice | 12 | 13 | ||||||||||||||
| 7–1 | Truth telling, such as informing people with dementia of their illness | (12) | |||||||||||||||
| 7–2 | Respect for patient decision-making and paternalism | (12) | |||||||||||||||
| 7–3 | Fair distribution of medical resources | (13) | |||||||||||||||
| 8 | Empathy/human care skills | 1 | |||||||||||||||
| Literature No. | |||||||||
| Teaching model/ curriculum | |||||||||
| Narrative medicine | 1 | ||||||||
| The four-topic method | 5 | ||||||||
| Bioethics core curriculum by UNESCO; Section 1 | 9 | ||||||||
| VAK (Visual, Auditory and Kinesthetic) model | 10 | ||||||||
| Problem-Based Learning (PBL) | 12 | 14 | |||||||
| The ADDIE Model
(analysis, design, development, implementation and evaluation) | 13 | ||||||||
| Teaching materials | |||||||||
| Trigger Films | 2 | ||||||||
| Moral Games for Teaching Bioethics by UNESCO | 6 | ||||||||
| MakerSpace | 7 | ||||||||
| Virtual community | 11 | ||||||||
| | | | | |
| 1 | Professionalism | Chinese version Hall’s Professionalism Inventory | Professor Richard Hall in 1968 | Chen X, Yu Q, Yu F, Huang Y, Zhang L. Psychometric evaluation of the Chinese version of the Snizek-revised Hall's Professionalism Inventory Scale. J Int Med Res 2019 (Mar);47(3):1154–1168. doi: 10.1177/0300060518817401. Epub 2019 Jan 7. PMID: 30614338; PMCID: PMC6421374. |
| 1 | Empathy | The Jefferson scale of empathy for nursing students | Dr. Mohammadreza Hojat in 2009 | https://www.jefferson.edu/academics/colleges-schools-institutes/skmc/research/research-medical-education/jefferson-scale-of-empathy.html |
| 6 | Moral sensitivity | The Moral Sensitivity Questionnaire (MSQ) | Lutzen in Sweden in 1994 and
amended in 1997 and 2003 | Lützén K, Nordström G, Evertzon M. Moral sensitivity in nursing practice. Scand J Caring Sci 1995;9(3):131–8. doi: 10.1111/j.1471–6712.1995.tb00403.x. PMID: 7569517. |
| 7 | Ethical Reasoning (SER) | 8 Key Questions as an Instructional Method for Ethical Reasoning (8KQ) | James Madison University's Center for Assessment and Research Studies and Madison Collaborative in 2017 | https://www.jmu.edu/ethicalreasoning/slos/mc−17–18-annual-assessment-report_final.pdf |
| 9 | Moral sensitivity | Korean MSQ | Sung-Suk Han, in Korea in 2010 | Han SS, Kim J, Kim YS, Ahn S. Validation of a Korean version of the Moral Sensitivity Questionnaire. Nurs Ethics. 2010 (Jan);17(1):99–105. doi: 10.1177/0969733009349993. PMID: 20089629. |
| 10 | Moral sensitivity | The Modified Moral Sensitivity Questionnaire for Student Nurses (MMSQ-SN) | Rhonda Comrie modified MSQ by Lutzen for student nurses, in 2011 | http://nej.sagepub.com/content/19/1/116 |
| 14 | Interprofessional communication and
collaboration in clinical ethics | Interprofessional communication and collaboration questionnaire
(ICCQ) | Author's original, Yu-Chih Lin in Taiwan in 2013 | In this article |
| 16 | The attitudes of students in doing ethical case analysis | The Chinese Version of Case Analysis Attitude Scale (CAAS) | Author's original, Li-Ling Hsu in Taiwan in 2011 | In this article |
| 16 | Students' satisfaction on blended learning | Blended Learning Satisfaction Scale (BLSS) | Author's original, Li-Ling Hsu in Taiwan in 2011 | In this article |
©2025. The Authors