Ethics Education for Baccalaureate Nursing Students Multi-Course Sequential Learning

Purpose

This project designed and implemented ethics education for undergraduate nursing students. The educational experience, designed as a single course, consists of a number of modules that can be integrated into several courses, both classroom and clinical , throughout the undergraduate curriculum. In the process of creating these modules, the university's nursing faculty enhanced their ability to help students to apply ethical principles in practice. The initial grant and a subsequent dissemination grant served a third audience of nursing educators in the U.S. and Canada by making course materials and teaching strategies widely available.

Innovative Features

The embedding of modules and activities, structured to constitute a single, integrated course, into several separate courses represents a new way of providing ethics education for nurses. This strategy solves the problem of how to give the teaching of ethics identifiable curricular space, but it also allows students to consider ethical issues at all stages of their program and in both classroom and clinical settings. Ethical considerations are thus kept constantly before the students, who are able to address them with increasing sophistication as they mature in their educational experience. Students receive a grade for a single course at the end of the program.

The units are included in thirteen required courses, eight didactic and five clinical. Workshops at the beginning of each of the first two years of the project helped faculty to become more proficient in dealing with ethics issues and the strategies and mechanics for integrating the ethics units into their courses. The ethics faculty designed learning objectives and teaching strategies for each unit, and evaluated most of the student work. The only material not graded by the ethics faculty was the ethics section that most of the clinical teams added to the care plans or journals required of students in clinical courses.

Student learning was evaluated in multiple ways, including questions on take-home exams, multiple-choice questions in course exams, a term paper, a written small group exercise and a graded group presentation. During the period of project funding stude nts received an integrated report of their performance in all the course modules.

Evaluation

Students also completed the Defining Issues Test (DIT) developed by James Rest, whose work formed the conceptual base for the program. The instrument was administered both before students began the program and after its completion. As an effort to establish a control group, the last class admitted before the new program was initiated was also tested, although they went through their undergraduate experience in an atmosphere strongly influenced by the strategy of spreading the ethics instruction over s everal courses.

The attitudes of faculty toward the new materials and instructional strategies and the reception of the dissemination audiences were evaluated through questionnaires.

Project Impact

On work evaluated by the ethics faculty and involving multiple readings of discursive responses, most students received grades in the A or B range, with a minority of C's and a very few lower grades. Thus, in the eyes of those who established course goals, student performance was quite good.

All student groups, except for one whose circumstances of admission and rate of persistence were anomalous, showed significant improvements in their scores on the Defining Issues Test. However, the patterns of difference in performance on the DIT among the three treatment groups and between those groups and the control group show no consistencies that suggest that the gains are attributable to the revised strategy of ethics instruction. It is impossible to know the degree to which those gains are attributable to the ethics course, as opposed to the curriculum in general or to greater maturity. It seems reasonable to conclude, however, on the basis of other research, that an environment in which ethical and moral issues are continuously raised fosters moral development.

Evaluative research on the project does show a strong positive influence of moral reasoning ability on clinical performance. Stepwise regression analysis showed that scores on the Defining Issues Test accounted for as much as 34 percent of the variance in scores on a faculty-developed Clinical Evaluation Tool, which provided a standardized rating of student performance in clinical situations.

Questionnaires indicated that the faculty were satisfied with the workshops. By the end of the funding period, 87 percent agreed that their teaching had been influenced by the project and 86 percent felt that it had affected their own nursing practice. Their collective estimate of impact on students, on a seven point scale, was 5.8 for ethical sensitivity, with lower but still positive estimates of effect on reasoning, commitment and action.

Lessons Learned

Faculty resistance to taking classroom time to deal with ethical issues was perhaps less than might have been expected. Only four of the 16 faculty surveyed found the time commitment to these matters excessive.

Students, however, persisted in seeing the ethical models as add-ons to their courses, despite the fact that other course content had been reduced to accommodate the ethical issues. The p ersistence of this view may have arisen from a faculty attitude that the ethics units belonged to the ethics faculty rather than to the whole faculty. Some students also expressed concern about the episodic nature of the ethics units, preferring a complete course devoted to those issues.

Project directors had to work hard to retain those parts of courses which it had originally been agreed would be devoted to ethical issues. This problem was partly a matter of instructor turnover and the need to work with teachers who had not been party to the original agreements.

Project Continuation and Recognition

The multi-course sequential strategy has become an established part of the University of Minnesota School of Nursing curriculum. The model has proven adaptable to the program reorganization that resulted from students being admitted to the program at t he jun ior rather than the sophomore level. Research on project effects and program dissemination activities continues.

The project has reached several external audiences. A national conference on the topic "The Care-Justice Puzzle: Education for Ethic al Nursing Practice" drew 145 participants. The attendees, plus others who requested it, received the 200-page handbook of instructional modules and teaching strategies developed during the project. Three workshops involving ten institutions, six of the m in Alberta, Canada, were enthusiastically evaluated.

Available Information

Various aspects of the program have been described in six published articles, four of them in the Journal of Nursing Education. Copies of the project handbook and information about the curriculum are available from:

Muriel B. Ryden
Laura Duckett
University of Minnesota
School of Nursing
6101 Unit F
308 Harvard St. SE
Minneapolis, MN 55455
612-624-6939 (Ryden)
612-624-9160 (Duckett)

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