The Reflection of Ethics Education on Clinical Practices in Undergraduate Nursing Education: A Qualitative Study

Aim: This research aims to reveal the reflections of ethics education given to nursing students in undergraduate education on clinical practices. Method: A focus group interview from qualitative methods was held to obtain and interpret information regarding the reflections of ethics courses. Fifteenvolunteernursing students studyingatthe faculty of health sciences ofa public university in Turkey were included in the research. For the data analysis, the method used to code and categorizefocus group data were adapted from approaches to qualitative data analysis. Results: Six main themes emerged from the data: (1) opinions about ethics courses; (2) ethical issues; (3) the factors that cause ethical issues; (4) the effects of ethics courses on the approach towards ethical problems; (5)contradictory situations between the ethics course and clinical practices; (6) recommendationsabout the ethics course and educators. Conclusion: According to the data obtained in this study, the researcher concluded that the lecturers and teaching methods used are important in ethics education in nursing.


Introduction
Nursing ethics is the thinking activity of nurses abouttheir actions during nursing practices; it can also be defined as the examination of the moral responsibilities felt by nurses, as well asthe analytical thinking in nursing practices 1,2 . In this context, nurses are responsible for fulfilling ethical and moral obligations towards patients/healthy individuals. Nursescan be deemed to have acted in a "good" and"right" manneronly if theyact in a way that protects the dignity of individuals with whomthey have an ethical relationship 3 . In light of this information, nursesrequire to take an extensive and high-quality ethics education during the undergraduate periodin order to get integrated into the professional ethical decision-making process and to gain ethical sensitivity bylearning professional ethical principles 4 .
Ethics education is indispensablefor nursing students to make ethical decisions andto actualize care practices by acting according to ethical principles and codes in their professional lives 5 . Thus, ethics education should be deliveredwith contentsand methods that will ensurethe development of clinical decision-making, critical thinking, and problemsolving skills of nursing students 2 . When the relevant literature is reviewed, different techniques are seen to be used in ethics courses such as the traditional narratingmethod, case analysis method, small group discussions, problem-based learning, and reflection [6][7][8]4 . The study of Milton 1 (2004), which includes the views of ethics experts, reports that ethics education should be different ateachlevel of nursing education and distributed to the entire curriculum instead of being delivered as a separate course. Even though there is a consensus about the importance of ethics education in nursing, in Turkeycertain differences are observed regarding howethics education is delivered 9,2 .
Although there are not any standards in ethics education in Turkey, ethics-related issuesare handled within the scope of The History of Nursing and Deontology Coursein many colleges. In order for ethics education to achieve its goal, students must gain ethical thinking and analysis skills, as well as ethical sensitivity. In this regard, the content anddelivery method of ethics education gains importance. However, Nolan and Markert 10 (2002) state that there is still a problem inplanning and implementing ethics courses, and there is a small number of publications about theissue. Although ethics course has been a part of the nursing curriculum for a long time, a lot of nurses today do not considerthemselves qualified in terms of ethics knowledge and skills 10,11 . In a research conductedin Turkey by Aydın Er 12 (2012) on nursing students, ethics education in nursingwas determined to be not able to develop certain attitudes regarding patient rights on a sufficient level. In another study conducted on nurses by Aksu and Akyol 13 (2011) in Turkey, 61.1% of the nurses who participated in the study was determined to get no education onethics, whereas 65.0% of the participants receiving such education was found to receive it at college and have a moderate level of ethical sensitivity. This situation reveals the need to raise nursing students in a qualified manner regarding their approaches to ethical issues. Necessary foundations are laid during undergraduate education to render the nurses, who provide care to healthy and sick individuals, trustworthy, honest, and adhering to ethical principles. Today, in Turkey,in 124 nursing undergraduate education programs, ethics education is deliveredwithincompulsory courses.Yet, it is delivered rather theoretically, and its reflections on clinical practices have not been evaluated to a sufficient degree. This research aims to revealthe reflections of ethics education deliveredto nursing students in undergraduate education on clinical practices.

Research Design and Sample
Afocus group interview from qualitative methodswasheld to obtain and interpret informationregarding the reflections of ethics coursesreceived in undergraduate education on clinical practices.Fifteen voluntary nursing students studying atthe faculty of health sciences ofa public university in Turkey wereincludedin the research. There areplenty of different opinions in the literature about the ideal number of participants for a focus group interview, but the common opinion is to perform it with a small number of participants, and this number is approximately between 4-10 people 14 .
In the study, two focus group interviewswere held, and groups were made up 7-8 people.

Data Collection
A moderatorand reporter,who wereinformed about the topic of the research, collected the data using a semi-structured interview formin April and May 2017. The semi-structured questionnaire prepared for the focus group interviewincludes open-ended questions that are created byscreeningthe literature with regard tothe topic of the research [2][3][4][5]9 . These questions are as follows: • How do you evaluate the courses you have receivedonethics during your undergraduate education?
• What do you think the content of an ethics course should be?
• What kind of problems do you face while providingcare to your patients in clinical practices?
• Which of these problems that you have faced do you think are ethical issues?
• What kind of an impact do you think the courses that you received about professional ethics have on evaluating suchethical issues?
In the pre-interview held before the focus group interview, students were informed about "what a focus group is" and "the research in general". They were also notified that "the interviews would be recorded with an audio recorder."The data were collected in an interview room where all participants were seated in a way that they could see each other. Eachinterview lasted for approximately 45-60 minutes, and they were recorded with an audio recorder. Participants were provided with tags numbered between 1-8 that they would pin to their collars. The seating arrangement was made according to these numbers.
Moderator ensured the group members revealtheir opinions about the topic of the research by asking the questions in the questionnaire. As for the reporter, s/ he observed the emotional reactions (angry, cheerful, tense, etc.) of the group members bytaking short notes during the interview.

Data Analysis
Interview recordings obtainedthrough focus group interviews were reported to be analyzed by researchers. Later on, a content analysis was performed by the researchers on the data obtained from the focus group interviews to attainexplanatory concepts and relations.
For the content analysis; 1. Statements of the participants wereread once more after transcribingthe recordings in a computer environment.
2. The statements in the interview text were "coded" by assigning names.
3. The data were organized by associating the codes that show similarities.
4. After all the data were coded in this way, a code list was formed.

5.
Named codes were categorized according to their similaritiesand differences.
6. Themes and subthemes were formed by linking the meanings of categories to each other.
The process of the content analysis is given in Figure 1.

Results
A total of 15 (13 female, 2 male) studentshave participated in the study. The main themes and subthemes were determined after the data analysiswas made. The data relatingto these themes are given below:

Theme 1: Opinions about ethics courses
All nursing students participating in the research weredetermined to have received a course about professional ethics and have knowledge regarding the issue. Most of the students emphasized the fact that the ethics course they have taken during undergraduate education is delivered through the theoretical narrationmethod. Students stated that within the scope of this course they were informed about subjects such as professional roles and responsibilities of nurses, professional values, professional ethical principles (providing benefits, respect to autonomy, keeping secrets, and honesty), as well asunethical behaviors. Also, some of the students stated that some partsof thelectureswere

Theme 4: The effects of ethics courses on approach towards ethical problems
Most of the nursing students that participated in the study emphasized the importance of the ethics education they took in undergraduate education. However, students also indicated that it was difficult for them to applywhat they have learned to clinical practice.
"I believe that ethics courses helpedus make the right decision while evaluating ethical problems." (Group 1, Student 1) "First of all, I think, in order to evaluate such [ethical] problems, courses that we have taken on professional ethics need to be understood well. In that way, I think, we can solve ethical problems that we encounter at the clinic." (Group 1, Student 2).

Theme 5: Contradictory situations between the ethics course and clinical practices
Nursing students that participated in the research think that the theoretical knowledge they have learned from the ethics course isnot applied correctlyto theclinical practice. Students indicated the fields in which they have experienced most conflict between what they have learned to be the right behavior in the ethics course and the actual situation within the clinic as follows: malpractice, relationships within the team, end-of-life practices, and respect to individuals. Below are the expressions of the students about this topic: "What I have learned as the right behavior is to intervene when the heart of the patient stopped. However, I saw that it was not like that in the intensive care unit. The patient died, and they did not even felt the need to give him/her a heart massage.

Theme 6: Suggestions about the ethics course and educators
The nursing students gave suggestions regarding the content,teaching style and methods, and lecturers of the ethicscourse that they take during undergraduate education. When the literature about the topic is reviewed, even though a consensus is observedregarding the necessity and importance of ethics education in nursing, disagreements are seen regarding the teaching methods to be used in ethics education 2,9,11 . There are different teaching techniques used in ethics education. Researches show that there are techniques like the traditional teaching method, case analysis method, small group discussions, and problem-based learning and reflection 3,4,6-8 . Especially the use of the case analysis method was found to contributetothe development of ethical behaviors and ethical decision-making of students in nursing practices 4,6 .
Hence, Gastmans 15 (2002) emphasized that the ethics course must develop the ethical sensitivity of nurses, and more comprehensive content and methods should be usedrather than beingrestrictedby certain concepts and rules (ethical principles, ethical decision-making, etc.). When all these results are evaluated together, enriching the ethics course with active learning methods (analyzing real-life cases, concept maps, group discussions, role-play exercises) is thought to contributeto the acquisition of ethical thinking skills and ethical sensibility by students.
In our study, nursing students were determined to face ethical issues inthe clinical practice, and these issues are about certain nursing ethicalcodes such as justice and equality, self-determination/ respect to individuals, privacy, and keeping secrets. Furthermore, students indicated that several factors that cause ethical issues, which are the insufficient amount of nurses, excessive workload, and communication problems. In their study with senior nursing students,Kalaitzidis and Schmitz 16 (2012) have reported many examples regarding ethical issues mentioned by studentssuch as the honesty principle, patient's right to refuse, and getting the permission of patients. In another study,nursing students have indicated that there is psychological maltreatment towards patients in clinical practices, and most of the violated ethical principles are related to self-determination of individuals (30.0%), respect to privacy (22.0%), and no harming (16.0%). This studyhas also determined that the ethical issues arose fromthe lack of the use of adequatecommunication techniques when communicating with patients/ patient relatives/hospital directors 17 . These findings are similar to the results of our study.
The aim of the ethics course given in nursing education is to render students capable of acting ethically and making ethical decisions in their professional life 18 . In this study, students stated that the knowledge they gainedin ethics lectures was hard to apply toclinical practice, which is the crucial dimension of ethics education. Findings from different researches support that ethics education has an important effect on the moral acts of nurses, and it develops the ethical awareness and ethical decision-making skills of students by ensuring them to gain the attitude and behaviors indispensable for a nurse 2,19,20 . When all of these are taken into consideration, it is essential to rearrange the ethics education programso that it containsclinicalethicsissuesand practice.
Students who participated in the study stated that there were many situations in which they experienced a conflict between the actual situation in the clinical practice and what they had learned as the right behavior according to the ethical principles. Most of the students stated that these situations wereabout malpractice, relationshipswithin the team, end-of-life practices, and respect forindividuals. In the previous researches, ethical dilemmasthat nursing students often come across were determined to be about giving patients false information, givingup treatment, end-of-life care practices, not caring about patient's privacy enough, and erroneousapplicationsregarding patient safety 10,17. Students participating in our study suggested that the content of ethics lectures should be specific to the nursing profession. When the literature on the topic was examined, no standard approach was foundregarding professional ethics courses in nursing, and in some nursing schools, ethics was found to betaughtwithin medical ethics lectures 21 . In their study with nursing students who had not taken any ethics course, Can et al. 21 (2014) reported that the participants wanted the topics covered in the course to be related toconditions that might be encountered in nursing practices.Nolan and Markert 10 (2002) stated that ethics lecturesshould be related to nursing practices and situations that students expect to come across throughout their careers.As tothe teaching style, students indicated that ethics lectures should be delivered to small groups and bygiving reallife case examples. Cannaerts et al. 19 (2014) drew attention to the need for providing ethics education in a safe learning environment, where there is adequate support and student-centered teaching techniques are actively used. The abovementioned study results are in parallel with our findings.
Another suggestion reportedby the students concerns the lecturers. Nursing students emphasized that the lecturers that deliver the ethics lectures should be an expert in thefield, well-equippedonthe professional ethics of nursing, and should use active teaching methods.Students also stated that it will be appropriate if the professional ethics course is given by a clinically experienced lecturer in nursing.In the literature, there are different viewsabout lecturers who teach ethics. Akbaş et al. 2 (2014) stated that, along with other qualities, the lecturers, who teach ethics/deontology, should have clinical experience. Baykara et al. 3 (2014) emphasized that in order to achieve the purpose of the ethics course, studentcentered education techniques and methods should be implemented. Jahromi et al 22 . (2018) stated that educators should develop and implement effective training programs in order to increase awareness and commitment to nursing professional values.In line with this information, although suggestions of the students should not be deemed to be theone and main determinant in ethics courses, it willbe soundto think that lecturesmay become more effective if the student feedbacks are considered.

Limitations of the Study
The study was conducted in a nursing school in the northwestern region of Turkey. Findings obtained from the study apply tothe nursing school where the research wasconducted. Therefore, the findings cannot be generalized to students of all nursing schools in Turkey. Another limitation of this study is that it depends on the judgments of the nursing students participating in the research. Therefore, the results are limited to answers given by the nursing students in the research.

Conclusion and Recommendations
According to the data obtained in this study, the researcher concludes that lecturers and teaching methods used in the lectures are important in ethics education in nursing. Students emphasized especially that the course will bemore instructive case examples are given. However, students are observed to experience difficulties and contradictions in applying their knowledge to solve ethical issues that they come across in clinical practice. The use of active teaching methods is among the most important factors that should be consideredto increase the ethical awareness and sensitivityof nursing students. In this regard, the ethics lectures shouldbe developed to enable students to participate actively in the lectures and rearrangedto contain the clinical experiences of students. Besides, the arrangement of the ethics education in a way to reduce the moral stress of nursing students and to enable them to gain insight into their experiences, emotions and perspectives regarding ethical problems in clinical practice is thought to increase the effectiveness of the lectures.Along with teaching nursing ethics as a separate course within the curriculum, mentioning ethical dimensions of the topics handled in practical courses, evaluating the cases from an ethical perspective, discussing and analyzing interesting cases are also important. Another important pointin education of nursing ethics according to the results of the presentstudy is the quality of lecturers. Therefore, in order to increase the quality of lecturers, the researcher recommendssupporting their participation in activities about ethics, ensuring them to follow closely current publications in the ethics education field, andregularly organizing professional development programs about ethics education for all lecturers who take part in nursing education.