Evaluation of the Effect of Team-Based Learning on Students’ Opinions and Learning in Distance Ethics Education in Nursing

Fethiye Yelkin Alp PhD, RN, Lecturer^1; Ezgi Karadağ PhD, RN, Professor¹

1. Dokuz Eylul University, The Institute of Health Sciences, Faculty of Nursing, Inciraltı Health Campus, Izmir 35330, Turkey

OPEN ACCESS

PUBLISHED: 31 January 2025

CITATION: Alp, FY., and Karadağ, E., 2025. Evaluation of the Effect of Team-Based Learning on Students’ Opinions and Learning in Distance Ethics Education in Nursing. Medical Research Archives, [online] 13(1). https://doi.org/10.18103/mra.v13i1.6244

COPYRIGHT © 2025 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v13i1.6244

ISSN 2375-1924

Abstract

The aim of the study was to evaluate the effect of the teamwork-based learning method on ethics education in nursing. The population of the descriptive cross-sectional type of research consisted of the students of a Nursing Faculty who were taking an Ethics in Nursing class in the Spring semester of the academic year 2020-2021, and the sample consisted of the students taking this class who were willing to participate in the research. A Student Descriptive Characteristics Form and a Teamwork-Based Learning Method View Form were used to collect data, together with an Ethical problem Identification Form, which the students submitted after the teamwork. In this research, ethics cases suitable for the students were prepared according to the number of teams, the students were divided into teams and instructions given, and they worked on the cases. The reports submitted by the interactive teams, which were considered as purposive sampling, a qualitative examination method, were collected as data. The final test was applied with the teamwork view form. Numerical and percentage distributions, means and t-test analyses were used in the evaluation of quantitative data. The mean age of the participants was 19.60±1.12 years, and 58% were female. Students were enabled to report based on evidence and the literature ethical problems which they had taken as a team on the online education platform of the Ethics in Nursing class as a result of investigations. The ethical problems and solutions in the reports submitted by the teams were categorized under themes of ethics principles. According to the results of the teamwork view form at the end of the research, the items most agreed on by the students were “Working together with team members helps to develop the skill of problem solving”, 85.2%, and “Working as a team has enabled me to feel greater respect for the ideas of others”, 87.5%. With the team-based learning technique, students’ ethical problem-solving skills regarding the cases analyzed by the teams under the supervision of a guide were developed, and the analyses contributed to the literature by examining themes of ethical principles and ethical values.

Keywords:

Teamwork-based learning, ethics education, student nurse.

1. Introduction

The Covid-19 pandemic affected the education and higher education systems of all countries which experienced it. In education it opened the way to the use of government-supported distance learning in place of face to face education with the aim of preventing the disease from spreading. In 2020, in the Covid-19 pandemic, there was an increase in the whole world in the need for emergency distance learning in crisis conditions and its importance in education. This unexpected situation brought with it a number of problems. It is stated in the literature that it is important to ensure student interest and participation through interactive methods in conceptual courses such as Ethics, which require abstract thinking. It was aimed with the teamwork-based learning method to provide the active participation of students in the class and the learning process.

Although it took time to compile the article due to adaptation to the new normality after the pandemic, this study includes methods for students to interest and participate in ethical problem solving at all times. It is important teaching ethical sustainability to nurses, updating the curriculum with the latest evidence on environmental determinants of health, will contribute significantly to protecting the preparedness to sentinel events for future generations. This study highlights ethically empowering healthcare professionals in sustainable healthcare practices has many social, economic, occupational and environmental benefits.

Ethics education for nurses, especially at the first degree and postgraduate levels, is extremely important in practical professional life. Otherwise, it would mean following an intuitive path and moving away from professionalism in the ethical decision-making process. It is shown in the literature that nurses do not feel ready to solve ethical problems in nursing practice. Providing competence in ethics education in nursing is important for bringing to life modern nursing roles, providing good quality patient care, and for being able to fulfil the professional roles of nursing. Professional ethics education aims to enable nurses to behave ethically and responsibly in their professional lives, and bring them to a state of being able to make ethical decisions.

It has been emphasized that active learning approaches in education make learning skills easier. One of the active learning strategies whose use has recently been increasing in the field of health sciences is the team based learning method. Teamwork-based learning has been developed as an effective active learning strategy in the education of health professionals. Teamwork-based learning can be defined as a teaching strategy which takes place as activities inside and out of class to achieve individual and team learning in groups of student under the management of a single instructor who is an expert in the subject.

There are a few studies examining team-based learning in nursing students. The use of the team-based learning technique in theory classes makes a positive contribution to students’ development of working with their peers, to increasing their problem solving skills and to working respectfully with team members. Students report that they are undecided on whether the information which they learn in the team is more than the information which they learn in class. For this reason, a need is felt for more work on the contribution of this technique to students’ academic success. At the same time, it is thought that the study is important because it is one of the few to be conducted in Turkey on this topic. The results of this study may guide educators in the development of theoretical education with active education methods. Students encountering and examining ethical problems during their education encourages them in critical thinking on what they would do when they meet ethical dilemmas as they begin to work in their professional field. There have been few studies in Turkey on the awareness of student nurses to ethical problems and to their evaluation of these problems in an ethical framework. Therefore, considering the importance of the subject, it was felt necessary to conduct this study.

In the practice of professional nursing, it is of benefit not only to the profession but also to patients that nurses should attach importance to ethical education. It has been reported that nurses who receive ethics education behave better and more responsibly towards patients, and when they see positive results, their professional satisfaction increases. For this reason, there is a need to examine the views of trainee nurses on ethics classes in nursing education, and to determine whether it has an effect on students’ learning to solve problems with the ethics case examples which provide the application of ethical problem solving steps.

It has been shown in the literature that nurses do not feel ready to solve ethical problems at works. Ethical decision-making necessitates knowledge of ethics theories and ethical principles and practices and also management skills. For this reason, ethics education for nurses, particularly at a degree and postgraduate level, are of the greatest importance in practical professional life. This raises the question of whether ethics education in nursing is adequately effective with regard to method and content in developing nursing students’ ethics knowledge and skills. This is because effective measurement of learning results and behavioral changes in students, evaluation and provision of feedback are important factors in the learning process. Multi-directional assessment of the effectiveness of ethics education in nursing is of great importance in determining the quality of education and in restructuring education. In this way, developing a clear ethics awareness and sensitivity in student nurses receiving quality education can enable them to take responsibility in making ethical decisions.

There are studies in the literature assessing team-based education in international studies and positive outcomes in the education process. There are no studies examining the effect of team-based learning conducted with student nurses taking an ethics class. Our research is important in comparing with data in the literature and in contributing data created to future research. In the pandemic climate, it is important to determine the effect on students of various teaching techniques in order to increase the effectiveness of the class, as students’ perception of the world and the profession in the current situation is transformed by distance education.

2. Material and Method

2.1. RESEARCH DESIGN, PARTICIPANTS

The study was conducted in the nursing department of a university situated in the west of Turkey. Its aim was to evaluate the effect on student views and learning of the teamwork-based learning method in ethics education in nursing. The population of the descriptive cross-sectional type of research consisted of the 280 students of a Nursing Faculty who were taking an Ethics in Nursing class in the Spring semester of the academic year 2020-2021, and the sample consisted of the students taking this class who were willing to participate in the research.

The Ethics in Nursing class was held in accordance with the curriculum in the Spring semester of the academic year 2021 for two hours a week. For the first half of the semester, classical education was given under such headings as ethics, the concepts of moral deontology, ethical principles, nursing values, ethical codes, obtaining informed consent and ethical decision making. In the second half of the semester, sample cases were discussed in order to increase retention by giving concrete examples of ethical decision making on human and patient rights in health services. In the case discussions, ethical problems met in nursing practice and topics constituting dilemmas were portrayed realistically, and the students were enabled to discuss the decision making process in a suitable way. The nursing faculty students were also given the opportunity to access the lesson through a distance learning portal in addition to the classes. The content of the education portal was updated weekly by the course coordinator. The students could quickly access the system’s contents on a desktop or mobile device through the University Distance Education Center.

2.2. DATA COLLECTION METHOD AND DATA COLLECTION TOOLS

Data collection was performed by means of a Student Descriptive Characteristics form and a Teamwork Views form, and an Ethical problem Identification Form submitted by the students after the teamwork. In the Ethics in Nursing class conducted on the online teaching platform, the students were given information on team-based education, and the teams formed took part in a three-stage process with the team-based learning method. The first stage consisted of trainer preparation, the second stage consisted of students’ individual preparation, group preparation and application, while the third stage consisted of classroom discussion. In the first stage of this research, an ethical case suitable for first-year students was prepared according to the number of teams, and the students were divided into teams and worked on the described case. After the teams finished their work, an interactive environment was created for the team spokesperson to present the cases to the other classmates. In the final stage, interaction was enabled when the teams presented their cases. The teamwork view form and data on the solution of the ethical problem as a team were collected from the students, and a final test was given for their views on teamwork. The reports submitted by the interactive teams, which were considered as purposive sampling, a qualitative examination method, were collected as data.

2.3. DATA ANALYSIS

Analysis of data obtained in the research was performed using the program SPSS (Statistical Package for Social Sciences) for Windows 25.0. In the evaluation of data, descriptive statistical methods were used: numerical, percentage and min-max values, means and standard deviations. The responses given to each of the questions on the Ethical problem Identification Form were categorized and collected under headings. In the evaluation of quantitative data, numerical and percentage distributions, means and t-test analyses were used. A teamwork view form and a final test were applied.

2.4. ETHICS OF RESEARCH

Ethical considerations Before commencing the research, institutional permission was obtained from the nursing faculty where the study was conducted. After obtaining permission to conduct the research from the Non-Interventional Ethics Committee of University (IRB approval number: 2021/16-09), written approval was obtained from the students participating in the study.

3.Results

The mean age of the participants was 19.60±1.12 years, and 58% were female. As a result of investigations conducted, students were enabled to report on the online teaching platform of the Ethics in Nursing class ethical problems which they had addressed as a team based on evidence and the literature. The ethical problems and their solutions put forward by the teams were categorized under themes of ethics principles. According to the results of the Teamwork View form at the end of the research, the items which the students most agreed with were “Working with team members has helped to develop problem solving skills”, 85.2%, and “Working as a team has enabled greater respect to be felt for the ideas of others”, 87.5%.

Satisfaction with team experience	I agree	I am undecided	I disagree
I have found working as part of a team a valuable experience.	%80.2	%17.6	%2.20
All team members have worked compatibly.	%70.4	%26.8	%2.80
All team members have worked with mutual respect.	%87.0	%10.8	%2.20
I have found team work useful regarding the time spent in class.	%70.3	%23.0	%6.70
Working with team members is more educational than working individually in class.	%75.6	%19.2	%5.20
I have learned more in the team than I do in class.	%35.5	%46.0	%18.50
Working with team members has contributed to developing my existing knowledge.	%84.4	%14.2	%1.40
Working with team members has helped to develop my problem solving skills.	%85.2	%13.6	%1.20
Making decisions as a team has allowed me to see things with a more critical eye.	%80.4	%16.2	%3.40
Discussing a topic in the team has developed my capacity to think about a problem.	%86.5	%11.3	%2.20
Working with a team has helped my skills in working with others.	%82.8	%16.0	%1.20
Working as a team has enabled me to feel more respect for the ideas of others.	%87.5	%10.1	%2.40
Working as a member of a team has allowed me to realize myself.	%76.8	%19.0	%4.20

PARTICIPANTS’ STATEMENTS ON SOLUTIONS FOR ETHICAL PROBLEMS BY THE TEAMWORK METHOD

The situation taken as an ethical problem by Team 1: It was “Not telling a patient diagnosed with cancer of their diagnosis, and hiding it.” The participants stated that the unwanted situation in the case was not giving the patient information on their illness, and hiding it. They said that the desired situation was communication of the diagnosis to the patient, and respect to be shown for the patient’s autonomy.

“Keeping information from the patient and hiding it is a source of an ethical problem. Patients have the right to respect for their autonomy, and the principles of honesty and benefit are in conflict. When health personnel think of the patient’s benefit, they violate the principle of honesty.” (Team 1, Participant 1)

“When people’s rights are examined from the view point of duties and authority, patients have a right to autonomy. The duty of health personnel is to respect the patient’s autonomy and to pass on the truth as it is. Health personnel have no authority to hide the truth from a patient.” (Team 1, P 2)

“Looking at the benefits and risks of solving an ethical problem, when patients learn the truth, they may want to plan the next procedure and they may be able to make decisions freely themselves, but there’s the possibility that the patient can’t relieve the pain or their psychological condition may deteriorate.” (Team 1, P 3)

“When the procedure is evaluated in terms of its conformity to self-esteem and emotions, everyone has different personality characteristics, and health personnel may display different attitudes when they make decisions. However, all health personnel who have adopted professional nursing behaviors must be able to make decisions in accordance with professional values, and must be careful not to mix work and emotions.” (Team 1, P4)

“Examining an ethical problem with regard to a solution, even though the problem seems to be solved as a result of the solution applied, it may cause other problems. The solution to one ethical problem may open up another ethical problem. Such things are possible, and health personnel must act correctly in this situation. After patients learn the truth, they may feel bad psychologically. It is of great importance to provide psychological support from the moment they learn to truth.” (Team 1, P 5)

The ethical problem considered by Team 2: It was of an elderly patient not being admitted to the clinic because of a lack of beds in the clinic. The participants stated that the unwanted situation in the case was not admitting the patient to the clinic by making a discrimination because of age and by saying that there were no empty beds. They said that the desired situation was for the patent to be admitted, but if that could not be done under the existing conditions, for the patient to be enabled to be referred to another hospital without delay.

“The reason why this was an ethical problem was that there was age discrimination. Health workers must provide service without taking account of age or gender, and be conscious of the fact that everyone has equal rights. We should work with the awareness that human life is the highest value that must be protected, and that these values cannot be given up under any circumstances, so that patients should not be left to die.” (Team 2 P1)

“Examining the benefits and risks in the solution of the ethical problem, there must be an awareness that elderly patients should not be persons who are to be ignored at the first opportunity. The principle of equality must be observed and an approach must be adopted which is in accordance with patients’ rights and which does not discriminate between people by age. Considering the risks in solving the ethical problem, if the approach is negative, trust in the hospital and the health personnel may be reduced. A long waiting time may carry a life-threatening risk for a patient, or irreversible symptoms may appear.” (Team 2 P 2)

“When an evaluation is made in accordance with self-esteem and feelings during a procedure, behavior must conform to the values of equality and impartiality if the patient cannot be admitted and there is no other hospital nearby.” (Team 2 P 3)

“When the ethical problem is examined with regard to a solution, the roles and responsibilities of health personnel when providing care to elderly individuals must be specified with written care protocols. Information on old age and the aging process should be integrated into education programs. Health personnel should be encouraged to specialize in the health of the elderly.” (Team 2 P 4)

The situation considered by Team 3 as an ethical problem: It was sharing the diagnosis of a patient with Hepatitis-B with people in the clinic who shouldn’t know about it. The participants stated the unwanted situation in the case as the careless sharing of a patient’s diagnosis with people outside the health team. They stated the desired situation as the personnel in the health team showing the necessary care for the principle of patient privacy.

“The existence of patient rights reflecting human rights in the field of health and ignoring these rights in this case causes this to be a problem of ethics.” (Team 3 P1)

“…Violating a patient’s right to privacy is an ethical question. If this information is received negatively by the patient’s social circle, it may lead to concern about social isolation.” (Team 3 P2)

<p“Hepatitis-B is a disease which must be reported. The hospital management are responsible for taking the necessary measures. It is not ethical for other patients to know, or for it to be shared outside the health team.” (Team 3 P3)

“Examining people’s rights, duties and authority, patients have the right to expect the doctor to show the necessary respect for medical and personal information concerning themselves (1981 Lisbon Declaration); Right to Confidentiality, Bali Declaration (Lisbon II Declaration); the right to request information not to be given (Patients’ Rights Regulations Section 8); showing respect for privacy and the right to demand this (Patients’ Rights Regulations Section 9); the right to keep information confidential (Patients’ Rights Regulations Section 11); the right to identify, select and change personnel (Patients’ Rights Regulations Section 4. In the different declarations or within the same declaration, stress is laid on an individual’s right to confidentiality.” (Team 3 P2)

“Healthcare professionals take protective measures for the individual in cases where notification is mandatory. They provide preliminary information on the limits of confidentiality. The ethical problem here is health personnel not being cautioned for carelessly sharing patient information. The confidentiality of patient information and patient privacy must be protected in accordance with professional ethics.” (Team 3 P4)

“Examining the benefits and risks in the solution of ethical problems, patients’ privacy is protected. A negative picture is created in the image of health personnel who do not show correct behavior in social perception. However, if we compare it with the principle of benefit and harm in order to protect the image of the profession, cautioning a person who behaves negatively will be a more appropriate decision than damaging the image of the entire professional group. If a patient changes personnel or institution, there may be setbacks in connection with the transfer to the new institution. Changing the institution and personnel may make a patient feel secure and at ease.” (Team 3; P1, P2, P4, P4)

“When the procedure order is evaluated in terms of its suitability to self-values and emotions, it is important to respect the individual and pay due attention to the confidentiality of the patient’s or healthy individual’s information. A person who has determined their own values and judgments will directly realize whether or not the value in question suits them.” (Team 3 P3)

If the hospital management knows the patient’s illness and takes the necessary measures, sharing this between the health team and those outside it is against my values. In this situation, the patient’s privacy is the first priority.” (Team 3 P4)

“Examining the ethical problem with regard to its solution, other problems may emerge as a result of the solution applied. The solution of one ethical problem may bring out another different ethical problem. Having the patient go to another institution and having their treatment and care continued by another health team may solve the ethical dilemma.” (Team 3 P3)

A patient’s right to know, choose and change the personnel or the institution from which they are receiving care is something which is accepted in law. This provides a more effective and free environment based on ethical rules. In this way, securing two-way communication and having free will may solve the problem.” (Team3 P5)

The situation considered as an ethical problem by Team 4: It was a clinical researcher taking blood from a patient in your clinic for research purposes, but not informing the patient that the blood was taken for research. The unwanted situation was taking blood for research purposes without taking the informed consent of the patient, and the desired situation was that the patient was informed and their consent obtained.

“It is the responsibility of the patient’s nurses to take action if they see that the patient has not understood any part of the treatment and care procedure, that the patient has been given incomplete information or that the patient’s informed consent has not been obtained. Although the nurse’s mechanisms in this process generally require the nurse to obtain the patient’s signature on the consent form due to the patient’s rights advocacy role, the nurse’s primary priority is to ensure that all criteria necessary for the autonomous decision-making process are met.” (Team 4 P1)

“Communicating with the patient without the knowledge of their primary physician and nurse contradicts the value of truth, and if the patient is incapable of autonomy, the guardian or healthcare team must ensure that the informed consent process is carried out properly and that it is recorded.” (Team 4 P2)

“In our teamwork, we accessed the relevant laws and regulations in the literature. It is clearly stated in the regulations that the medical and social benefits expected from medical research cannot take precedence over the lives of volunteers who have agreed to the research being conducted on them or the preservation of their bodily integrity. The attention and attitude of health professionals in the field are very important for monitoring the application of laws and regulations.” (Team 4 P3)

“Examining the benefits and risks of the solution of an ethical problem, and evaluating a procedure with regard to its conformity to self-values and feelings, the participants stated that they had evaluated the situation according to the principles of autonomy, correctness and justice.” (Team 4; P1, 2, 3, 4, 5)

The situation considered as an ethical problem by Team 5: It was the use of inappropriate words by the assistance staff when they had difficulty repositioning an overweight, conscious, bedridden patient because of their weight. The participants stated the unwanted situation as disregarding the patient’s right to receive health care and treatment while maintaining their dignity. They expressed the desired situation as every individual being able to receive health care in accordance with patient and human rights with the awareness of their uniqueness and individuality.

“In these ethical problems, the principles of providing benefit, not harming and reliability had been violated. The principle of providing benefit is that of the health worker helping the patient to recover by behavior which is beneficial to them. During procedures which do not harm, the patient should not be harmed and should be treated in a kind and friendly way, and their trust in the health provider should not be upset.” (Team 5 P1)

“Health care procedures are based on the principle of preserving human dignity and not causing harm. In this case, benefit, not causing harm and autonomy were disregarded and came into conflict. This behavior to which an individual was exposed causes a deficiency of self-confidence and leads to withdrawal. Human, moral, conscientious and professional values, as well as the prestige of the hospital, the profession and the healthcare team, and of the patient, are negatively affected.” (Team 5 P2)

“Studies have shown that nurses are prejudiced in their approach to obesity in patients. Of course this may cause health workers to avoid providing care by affecting their perceptions, judgments and interpersonal behavior, and obese patients may be exposed to these kinds of problem.” (Team 5 P3)

“Some nurses argued that this attitude was due to the difficulty they experienced while providing care and the lack of equipment and personnel. It was found that the education received by the personnel included in the research reduced their prejudice. A lack of specialized equipment for these patients in healthcare institutions is also a reason for this. Difficulty in moving an overweight patient during care, the high risk of injury to workers, the difficulties of care and the time taken cause workers to be unwilling and unhappy in performing their duties.” (Team 5 P4)

“Among personal rights, duties and powers, the patient has the right to autonomy. The duty of health personnel is to respect the patient’s right to autonomy and to pass on realities as they are. Health personnel have no authority to hide the truth from the patient.” (Team 5 P2)

“Examining the benefits and risks in the solution to the ethical problem, if health personnel are knowledgeable on the subject of ethical codes, ethical theories, ethical principles and the ethical decision-making process, they can cope with ethical problems in a more productive way and with more focus on the solution. In addition to this, the personnel must examine health and illness as individual professional values, and they must be courteous and respectful to the patient. The ability to use intellectual and moral characteristics in balance necessitates cooperation with other health workers, as there are ethical theories which can be made use of to solve problems.” (Team 5 P3)

“In evaluating the order of a procedure in terms of its conformity to self-value and emotions, each person has different personality characteristics, and when making decisions, health personnel may display different behaviors from one another. However, every health worker who has adopted professional nursing behavior must be able to make decisions in accordance with professional values, and must take care not to involve their emotions.” ( Team 5 P4)

The situation considered as an ethical problem by Team 6: It was that during the Covid-19 pandemic, the use of a mask, a personal protective measure, was very frequent, but not showing the necessary care when disposing of the masks made the hospital cleaning staff angry.

“Examining the benefits and risks in the solution of the ethical problem, individual sensitivity was important during Covid-19 in disposing of used masks in the right way so that the virus did not spread further. Cleaning staff have the right not to have their health damaged when performing their duties and to be able to work in better conditions, and so it is necessary to act responsibly as individuals and to dispose of used masks in such a way as not to put anyone’s health at risk.” ( Team 6 P1)

The situation considered as an ethical problem by Team 7: It was as follows; during your clinical observation, you see that the doctor concerned with a patient cannot perform a particular procedure as he should because he is at the beginning of his profession and has little experience, and an experienced nurse in the clinic steps in and performs the doctor’s duty. The unwanted situation is a doctor not knowing a procedure which is his responsibility, and the procedure being performed by a nurse who does not have that responsibility, and the desired situation is for the doctor to perform correctly a procedure which is appropriate for the patient.

“Examining the benefits and risks in the solution of the ethical problem, the patient’s health may be at risk because a procedure is being performed by a member of the health personnel who does not have the authority. The doctor’s and the nurse’s professional lives may be at risk.” (Team 7 P1)

“Examining why this is an ethical problem, it is seen that the doctor lacks the necessary self-confidence and cannot perform his or her duty correctly, and is inexperienced, and it is seen that the nurse is performing a procedure outside his or her duties, confusing the definition of their duties.” ( Team 7 P2)

“Examining from the aspect of law, rights, duties authority and professionalism which must be considered, the patient has the right to receive correct care and treatment. Nurses and doctors have duties which are different from one another. A nurse has the authority to be able to perform a procedure correctly.” ( Team 7 P3)

Discussion

Ethical dilemmas arising under pandemic conditions are thought-provoking, increasing the importance of students gaining critical thinking skills and being able to carry them over into practice. The principles of benefit, justice, not harming, autonomy and confidentiality in biomedical ethics form the basis of pandemic ethics discussions. In the Covid-19 pandemic, the basic aim in the distribution of health services was to provide the greatest possible good or benefit to the greatest number of people. In the Covid-19 pandemic, the ethical principles of justice and benefit were in conflict.

Examining the statements of the nursing students regarding ethical problems, the students demonstrated ethical sensitivity regarding vulnerable patient groups and identified ethical problems in the case examples presented. It is believed that education has an important effect on ethical behavior and professional values. This assumed relation between the education process and ethical behavior depends on evidence that nursing education has a critical duty in providing for nurses to be ethnically competent. Although the ethics course given to students in the classroom is introductory and short-lived, ethics education has a great role in the development of professional identity and competent ethical behavior in nursing students. When students encounter an ethical problem, they act in the ethical decision-making process in a way resulting from both the students’ personal values cultivated by their own culture and family and the professional knowledge and values they have acquired during their education and practice.

It is impossible not to encounter ethical problems in clinical environments where patients are cared for and treated. From the moment that nursing students begin clinical education, they start to enter the real world and see problems, and are witness to events. It was emphasized in one study that nursing students encountered real ethical problems, but that when they needed to speak, they felt a lack of self-confidence and so remained silent as students.

Examining the students’ statements in the present study, it was seen that they were able to identify the ethical problems and present evidence-based suggestions for solutions. It was seen that they defined the ethical violations they were aware of in accordance with the laws and regulations regarding patient and human rights. It is seen in studies conducted not only in Turkey but in other countries also that ethical violations are committed by nurses. Consistent with our study findings, it was found in a study by Lemonidou et al. (Lemonidou et al., 2004), that students experienced ethical problems with health professionals regarding their failure to comply with ethical codes and violating patients’ rights.

Of the ethical problems identified by the students, the ethical value most violated was identified as human dignity, and the most violated ethical principle was that of not harming and benefit. It has been found in similar studies also that among the ethical problems encountered by students, the value which was violated was often human dignity. Therefore, the basis of health care practices must focus on preserving human dignity and on the principle of not causing harm.

The nursing students in our study identified ethical problems, determined violations of ethical principle, and were able to show the sources of ethical problems, and their approaches to ethical problems were in the framework of ethical principles and values. However, for various reasons, the students were unable to take an active role in the ethical decision making process. The students may have felt under pressure both from their teachers and from health team members in the process of ethical decision making. At the same time, nursing students may not have been able to internalize developing an ethical attitude in the face of an ethical problem. This is because their attitude resulting from internalizing their feelings and thoughts turns into behavior. For this reason, students must be allowed to see ethical problems not only in theory but also in practice in the ethical context of the clinic, and to analyze cases.

Conclusion

It was seen in this study that, consistent with the literature, nursing students were aware of ethical problems experienced in the field of health, and showed ethical sensitivity. Students should be encouraged not to ignore ethical violations under any circumstances, and to play a part in effectively regulating the ethical decision making process. For this, theoretical ethics classes should be included in students’ professional education. It is recommended in feedback from students that interactive methods should be added to classes, lesson content should be enriched with particular examples of cases of ethical problems, and students’ interest in the lesson should be actively maintained with the use of videos. Moreover, in nursing education, scenarios on ethical problems should be prepared and integrated into daily routine, an opportunity should be given to students to discuss their feelings on their experiences, and opportunities should be given to students to think about clinical scenarios to understand their values better and to learn the steps in ethical problem solution. The acquisition of professional ethical behavior during the education of nursing students, who will be the health care professionals of the future, will be effective in their showing a humane approach in their professional lives and in their provision of individual care.

Author Contributions:

FYA contributed to the design of the study, data collection and analysis. FYA and EK conceptualize, prepared and supervised the study. All authors approved the final version for submission.

Conflict of Interest

The authors declared no conflict of interest.

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