Background
In nursing, there is an inherent accountability for nurses to ensure that all aspects of patient care align with responsible decision making, professional use of authority and ethical principles [1] as guided by various codes of ethics in various regions of the world. However, nurses have limited knowledge, and hence are unprepared to deal ethical issues in practice [2]. Nurses cannot act ethically or analyse ethical problems and provide rationale for the decisions and actions [3] and some feel powerless and frustrated when encountering and having to deal with ethical dilemmas in clinical practice [4].
Ethics are essential for all healthcare workers, and for nurses, they are equally paramount as nurses deal with ethical issues [1]. Ethical practice is essential for nurses when delivering daily nursing care to their patients [5]. It was once considered that physician loyalty, high moral character, and obedience by nurses is ethical practice, or nursing ethics [1]. We now know that when an individual can recognise their feelings when they encounter what is morally right or wrong and reflect on those feelings to direct their decisions and act in ways which bring the highest level of benefaction for the others’ best interest, that individual is known to be ethically competent [6]. Ethics are moral principles that govern how an individual or a group will behave or conduct themselves, with a specific focus on the right and wrong of actions, including decision-making process of determining the ultimate consequences of those actions [1]. Other definitions of ethics and ethical competence hover around interconnected concepts including ethical knowledge, ethical sensitivity, reflection, ethical decision-making, ethical action, and ethical behaviour [7‐9].
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In healthcare, ethics are essential because healthcare providers ought to recognise ethical dilemmas, make good judgments and decisions based on their values while keeping within the laws that govern them. In nursing, ethical practice means that “the patient is the central focus of a nurse’s work and that they are to protect the moral environment in which patients receive care” [10]. The International Council of Nurses (ICN) developed the Code of Ethics for Nurses to “provide ethical guidance in relation to nurses’ roles, duties, responsibilities, behaviours, professional judgement and relationships with patients, other people who are receiving nursing care or services, co-workers and allied professionals” [11]. Similarly, the American Nurses Association (ANA) developed the Code of Ethics for Nurses as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession [12]. In other regions such as the United Kingdom, the Nursing and Midwifery Council [13] developed The Code and in Australia, Nursing and Midwifery Board of Australia [14] developed Code of Ethics for Nurses in Australia. These documents contain ethical standards that nurses and midwives in their various functions as practitioners, researchers, leaders and educators are required to uphold whenever they are providing direct care to individuals, groups or communities [13, 14].
In South Africa, the South African Nursing Council (SANC) [15] developed Code of Ethics for Nursing Practitioners to serve as the “foundation of ethical decision-making aimed at informing Nursing Practitioners and the public of the ethical and moral principles applicable to Nurse Practitioners in the performance of their duties”. The document includes ethical principles such as social justice, non-maleficence, beneficence, veracity, fidelity, autonomy, and caring which must be always upheld by all Nursing Practitioners in whatever role they fulfil [15]. However, the health sector in South Africa continues to face significant adverse electronic and print media reports on nursing professionals’ ethical misconduct and dilemmas [16‐18]. SANC [19] regular statistical report relating to professional misconduct indicates increasing professional and ethical misconduct cases among various categories of nurses.
Some of these shortfalls might be related to the neglect and side-lining of ethics in the education system in South Africa [20]. In nursing education, current strategies and practices in place for ethics education are inefficient [21]. The current teaching strategies for ethics education in nursing include formal lectures, group discussions, buzz sessions, individual assignments, self-study and role-play, with assessment methods such as class tests, predicate tests, and exams [2]. However, there is reported lack of criteria for passing ethics modules, and lack of coherence between the curriculum, course outcomes, teaching processes, and course evaluation [2].
Teaching strategies for ethics education for healthcare profession students has been a challenge in Australia as well where underutilisation of opportunities for teaching ethics was reported [22]. There are debates among educators on the best ways to teach ethics to nursing students, enabling them to contribute positively to the ethical issues arising in clinical practice [23]. However, strategies such as reflection, case studies, debates, flipped classroom, audience response system, and simulation with role plays to facilitate ethical competence among healthcare profession students before, during and after their clinical placement have been previously recommended [22].
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The use of simulation-based learning in nursing education has been reported [23]. With the use of simulation to facilitate ethical competence, students indicated increased confidence, interest and skills in implementing ethical principles [24]. Simulation-based learning is an educational strategy that provides students with a realistic clinical situation [25]. There are advantages of simulation-based learning in nursing education and other health professionals’ education. Firstly, simulation-based learning allows student to practice nursing procedures until they are competent and confident enough to perform the procedure on live patients [26]. Thus, ensuring that an ethical principle of “no harm” among others, is upheld [27]. Secondly, simulation-based learning allows students to practice ethical skills by using simulation technology where mannequins are treated as patients [28].
Due to the Covid-19 pandemic, most higher education institutions worldwide suspended in-person learning as part of disease prevention and control [29]. Hospitals had to suspend clinical student nurses’ placement to curb the rapid spread of Covid-19 [30]. However, higher education institutions had to device means to ensure that undergraduate students’ clinical hours required for practical skills, clinical outcomes and competencies are met. As such, higher education institutions were left with complex and unique challenges for clinical learning. Higher education institution had to ensure continued clinical education while ensuring safety of the students. Higher education institutions had to become creative in accommodating students with the resources they already had [31]. Therefore, the higher education institution under study relied solely on limited resources for simulation-based learning to accommodate a significant number of student nurses and ensure continued clinical education.
Methods
Aim
Higher education institutions faced challenges of insufficient ethics education for nursing students due to Covid-19 restrictions. In addition to inefficient ethics education strategies, limited resources for the simulation-based learning due to Covid-19 restrictions made it challenging for higher education institutions to facilitate clinical and ethical competence for nursing students. Therefore, this study’s aim was to explore and describe how simulation-based learning could be used to facilitate nursing students’ ethical competence at a selected higher education institution.
Design
Qualitative, descriptive, exploratory, and contextual research design was adopted for this study. This design allowed the researchers to explore and describe the barriers and ways to facilitate student nurses’ ethical competence through simulation-based learning.
Setting
Setting for this study included a nursing department within the Faculty of Health Sciences at a selected higher education institution in the City of Johannesburg Metropolitan Municipality in Gauteng Province, South Africa. This department uses simulation laboratory for demonstrating various clinical procedures for nursing students. These simulation sessions are compulsory and are done during designated periods, typically led by nurse educators and clinical preceptors. Nursing students are given opportunities to practice such skills and procedures under supervision of the nurse educators and clinical preceptors. Prior to the Covid-19 pandemic, nurse educators and clinical preceptors would normally have simulation sessions with up to 50 students in simulation rooms that are designed to accommodate between 15 and 30 students. For Work Integrated Learning (WIL), nursing students of this higher education institutions are placed in some of the busiest public hospitals and clinics in the area catering for communities of various nationalities, socioeconomic backgrounds, races, cultures and ethnicities.
Research population and sample
Population for this study included nurse educators and clinical nurse preceptors at a higher education institution under study. The sample consisted of 5 clinical preceptors and 4 nurse educators. The nurse educators were involved in teaching ethics to undergraduate nursing students while clinical preceptors used simulation-based teaching to facilitate various clinical skills among nursing students. Both nurse educators and clinical preceptors had qualifications in Nursing Education, thus, they were trained on various teaching strategies including simulation. Purposive sampling method was used to identify and recruit participants who fit the inclusion criteria and could provide rich, in-depth information regarding the topic. Criteria for inclusion in this study were nurse educators teaching ethics, and nurse educators and clinical nurse preceptors using the simulation-based learning approach, with at least two years’ experience in teaching. Sample size of 9 participants was determined by data saturation, which occurred when new themes could not be identified from additional participants [32].
Data collection
Data collection occurred between February and May in 2021 after gatekeeper permissions and ethical clearance were obtained. Semi-structured interviews were done online via Microsoft Teams and Zoom, during the days and times chosen by the participants. The researcher provided participants with a password-protected interview link to ensure their privacy and minimise interruptions. The researcher conducted all online interviews. One central question, which was formulated specifically for this study, based on the objective of the study was asked, followed by probing questions and use of communication skills such as active listening, probing, reflecting clarification, paraphrasing, silence, and summarising. Each of the 9 interviews lasted no more than an hour. The question was: “How can simulation-based teaching be used to facilitate student nurses’ ethical competence?”
Data analysis
Verbatim transcription was done by the researcher after each interview to prepare for data analysis process. Giorgi’s thematic analysis method, as outlined by Clarke and Braun [33]. An independent coder, who had an extensive experience in qualitative data analysis was involved to verify the accuracy of the analysis and reach consensus on the themes that emanated.
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Results
Participants in this study comprised 5 clinical preceptors and 4 nurse educators with simulation teaching experience ranging between one and ten years. Based on the interviews and concurrent analyses, two themes and related five subthemes were extracted from data. Table 1 displays the two themes of barriers that hinder the facilitation of ethical skills among for nursing students and transformative approaches to fostering ethical competency through simulation– based learning with five related subthemes included for discission in this article.
Table 1
Themes and subthemes
Theme | Subthemes |
|---|---|
1. Barriers that hinder the facilitation of ethical skills for nursing students | 1.1 Covid-19 restrictions led to space constraints in simulation laboratory. |
1.2 Facilitators focus on skills and procedures only instead of facilitating ethical competence due to time constraints. | |
2. Transformative approaches to fostering ethical competency through simulation– based learning | 1.3 Empowering critical thinking through role play |
1.4 Provide constructive feedback to the students | |
1.5 Using high-fidelity simulations to integrate theory and practice |
Theme 1: Barriers that hinder the facilitation of ethical skills for nursing students
This theme indicates how Covid-19 restrictions and time constraints posed as a barrier for facilitators using simulation laboratory to facilitate ethical competence among nursing students. Participants reflected on Covid-19 restrictions which led to space constraints in simulation laboratory and limited time which led to facilitators focusing on other clinical skills and procedures while neglecting ethical skills.
Subtheme 1: Covid-19 restrictions led to space constraints in simulation laboratory
According to the participants, the simulation laboratory typically accommodates lesser number of students than a normal lecture room, making it difficult to manage students due to overcrowding. Participants further indicated that Covid-19 restrictions imposed by the university meant that educators had to comply with a specific educator students-ratio which means that more time was spent covering limited clinical component as students must be divided into smaller groups:
“It is difficult for me as a clinical preceptor to manage group of students, let’s say 40 students; I end up not knowing which student is ethically competent, as they are so many. With this Covid-19, the 40 students are divided into small groups of 10 as determined by the size of the available venue. The faculty must review or extend the current simulation space used at it is not big enough” (P1).
“Currently, due to Covid simulation lab rooms accommodates a maximum of 15 students, so can you imagine how long it will take to divide a group of 50 students? Will we have rooms to accommodate all this? No. It is a good strategy but needs time, big, different venues and training. We need different venues with technology to stream what is taught in one venue to different 3 to 4 other venues.” [Sounded worried] (P4).
Another participant indicated the challenges of missing at-risk students and having to repeat the same content multiple times when attempting to facilitate ethical skills using online teaching:
“Many students also make it difficult to facilitate ethical competence, especially if you are alone. It is difficult to identify who is lagging and who is competent. It is worse now with Covid-19, which caused this emergency remote teaching; one will take the whole three weeks covering one concept. As a preceptor, you must keep reminding students to keep social distance, wear a mask, sanitize.” (P6).
Subtheme 2: Facilitators focus on skills and procedures only instead of facilitating ethical competence due to time constraints
Participants reflected that simulation-based learning is typically used to demonstrate clinical skills and procedures. Some barriers expressed by participants when attempting to facilitate soft skills such as ethics, included time constraints and lack of knowledge on strategies to be used in simulation-based learning.
The following participants mentioned that added responsibilities and creating scenarios to incorporate ethical skills in simulation-based learning is time consuming, and that simulation-based learning is used for clinical skills and procedures:
“When using simulation-based learning, we focus on skills, like suturing not on ethics or ethical principles. Creating scenarios is time consuming.” (P1).
“The mistake I am picking up from myself as an educator is I use this strategy mostly for skills and procedures, and in these procedures, I hardly reemphasize on ethics. Creating scenario is time consuming, preparing a list of equipment needed for scenario, I still have to give theory lecture, set tests, accompany students in hospitals, oh and publish.” [Sad] (P8).
Other participant expressed the challenges of not knowing which strategies to use to incorporate ethical skills in simulation-based learning:
“How simulation is used is difficult to assess or facilitate ethical competence, mainly because we use mannequins; we concentrate on skills and procedures. We are not using live patients to portray ethical dilemma” (P2).
“Yes, many of us mostly use the simulation learning method to perform clinical procedures or step-by-step demonstration of a clinical skill. When it comes to ethics, the content is covered in theory modules because we are still struggling to use this method” (P3).
Theme 2: Transformative approaches to fostering ethical competency through simulation– based learning
This theme indicates various strategies that participants used could be used in simulation-based learning to facilitate student nurses’ ethical competence. The subthemes under this theme included the use of role-play to facilitate critical thinking, providing constructive feedback to the students, and the use of high-fidelity simulations to integrate theory and practice and facilitate ethical competence among nursing students.
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Subtheme 1: Empowering critical thinking through role play
Participants reflected on the effective use of role play, whereby student act out roles of scenarios in simulation-based learning to give targeted practice for the purpose of facilitating ethical skills. According to the participants, role playing using real life scenarios to stimulate critical thinking in simulation-based learning to facilitate ethical skills:
“During role-play, students gain different experiences, such as the experience of being the patient, the nurse, the patient’s family and the assessor. They are divided into groups or teams; the other team will critique and correct what others are doing in line with the objectives. Students are encouraged to critically think about the scenario, think out of the box. Role-play also helps with behaviour modification or awareness, and the scenario can include unethical behaviour occurring in clinical practice. Students are given real-life scenarios to role-play, which stimulates their critical thinking and allows them to explore difficult ethical situations and find solutions for complex situations.” [Sounds confident] (P5).
In addition to critical thinking, another participant reflected on the effectiveness of role play in improving students decision-making skills and clinical reasoning during the facilitation of ethical competence:
“In the role play, I encourage them to solve ethical dilemmas occurring, creating real-life scenarios, and enabling the nurse educator to see if student nurses can implement the ethical principles learned in class. It improves decision-making skills and promotes critical thinking and clinical reasoning, and in assessing the ethical competence, and on which ethical principles and approaches are a student still struggling with or are mastering it” (P7).
Another participant reflected on how role play allows students to link theory to practice, share experiences and solutions related to ethical dilemmas:
“Role-play enables students to share their experiences, brainstorm on how to resolve ethical dilemmas encountered in hospitals and reflect on the ethical dilemmas and principles learned in theory classes and come up with solutions. I encourage our students to have small pocket notepads to note down different ethical principles and dilemmas experienced in hospitals, do research, and share with other classmates what they saw, how it was handled, and that opens class discussions and reflective thinking. They can connect the dots of what was learned in class, the practice in simulations and what is encountered in hospitals. Let them ask questions, question the principles, not just accept not knowing the logic behind those principles. Ask questions and research” (P8).
Subtheme 2: Providing constructive feedback to the students
According to the participants, providing constructive feedback as a teaching strategy in simulation-based learning enables them to facilitate ethical competence among nursing students. One participant reported that students could gauge their performance during constructive feedback concerning the scenario and ethical skill being presented or engaged in:
“As soon as the simulation ends, students are given a chance to retrace their steps to determine if they were “right” or “wrong” on how they applied ethical principles. They evaluate themselves to see if they feel they are ethically competent. It is helpful to allow them to verbally affirm their feelings before asking their classmates how they role-played the scenario. We lay down rules such as respecting others, non-judgemental attitude, professional critique, whether positive or negative and giving others a chance to ask questions” (P5).
Subtheme 3: Using high-fidelity simulations to integrate theory and practice
Participants reported on the use of high-fidelity simulation, which mimics patients’ clinical conditions as closely as possible in simulation-based learning which allows students to gain hands-on experience while applying ethical skills and promotes their competence. Some participants reflected on the use of mannequin to mimic real life situations to improve students’ ethical competency:
These high-fidelity rooms and high-fidelity mannequins offer the best opportunity for students to apply ethical knowledge to real-life situations and gain collaborative and ethical competency” (P8).
“High fidelity makes use of advanced mannequins and computers, with different software to make everything look real. Students are technology-driven generation, they thrive well with equipment, so this high fidelity will benefit them in critical thinking, clinical skills and makes them creative when faced with ethical dilemmas (P6).
Discussion
This study intended to explore and describe the role of simulation-based learning in the facilitation of nursing students’ ethical competence. A couple of themes which relates to the barriers and opportunities were reported. The first barrier related to the Covid-19 pandemic adjustments that were aimed at containing the spread of the virus but ended up in disruptions of the normal teaching and learning activities. Given the high infectivity and subsequent rapid community spread, the South African government rapidly developed and implemented measures to contain and mitigate the risk of imported cases and community transmission [34]. These measures presented higher education institutions with complex and unique challenges for clinical learning as the undergraduate nursing clinical practicum had to be suspended, impacting on clinical hours required for practical skills consolidation and clinical competencies. These disruptions to teaching and learning activities due to the pandemic were a global phenomenon, where schools and universities found themselves having to reorganise their activities to avoid negative educational outcomes for students [35]. Some adjustments, whereby, physical social distance between student had to be maintained meant that a simulation venue that usually accommodated a full class had to accommodate even lesser number of students determined by the room size and ventilations system [36]. These adjustments meant that facilitators had to repeat one clinical skill multiple times to accommodate the entire group.
Changes in schedules and simulation space and layout caused extra workload and stress among nurse educators and simulation staff [37] leaving them with little time to focus on facilitating ethical skills among nursing students. Hence facilitators only focused clinical skills and procedures instead of facilitating ethical competence due to time constraints. Focusing only on skills and procedures instead of facilitating ethical competence in nursing education due to time constraints would lead to ethically incompetent nurses. Ethically incompetent nurse practitioners create threats to ethical values in healthcare, which if not managed appropriately, has a potential to jeopardise patients’ health [38]. The threats to ethical values in healthcare and ethical problems in everyday healthcare work necessitates the much-needed ethics education among healthcare professionals including nursing students [39]. Therefore, “making ethical competence learning possible, having awareness of one’s own thoughts and perceptions, and doing right by the patient’s best interests are important aspects when seeking to increase the understanding and management of ethical problems in everyday healthcare work” [38].
Despite the barriers imposed by the Covid-19 pandemic and the resulting restrictions, some relevant transformative strategies that could be adopted to facilitate ethical competency among nursing students using simulation-based learning were raised. Role-play, which is “an experiential learning technique whereby student nurses act out roles of scenarios to give targeted practice, feedback and train skills” [40] was seen as one of the most effective strategies to facilitate ethical competence in simulation-based learning. Participants reflected that role-play stimulates nursing students to become proactive in identifying unethical practices that might be present in the clinical settings and stimulates critical thinking. Critical thinking, which is the ability to apply higher-order cognitive skills and make appropriate decisions [41], requires students to be open-minded and inquisitive to gain insight into applying ethical principles to ensure ethical competency. Therefore, role-play in simulation-based learning is recommended to enable the students to better understand and conceptualise ethical concepts, for student to students to discuss and learn how to resolve ethical dilemmas in clinical practice. Role-playing in simulation-based learning prompts nursing students to work together to familiarise themselves with different ethical principles and learn how to resolve ethical dilemmas pertinent in the clinical practice [40]. Role-playing further allows student nurses to practice communication skills, improve critical thinking skills, and develop clinical judgement, which is essential when an ethical dilemma arises in clinical practice [40]. Through this strategy, student nurses analyse the scenario, evaluate the scenario content and claims, use logical reasoning and appropriate references, and apply ethical principles to indicate appropriate ethical competency skills.
However, role-play as a strategy for facilitating ethical competence in simulation-based learning may present a few barriers. To begin with, scenarios created for role-play need to be realistic and engaging enough to effectively develop ethical decision-making skills among the nursing students. Therefore, facilitators would need to design scenarios that accurately reflect the complex ethical dilemmas that students may face in real healthcare settings. Secondly, balancing the educational goals with the emotional impact of these scenarios on the student nurses may be a challenge to manage.
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Participants also reflected on providing constructive feedback as a transformative strategy for facilitating ethical competence among nursing students. Feedback is the one-way conveyance of information to a student on the gap between their performance and a standard, with suggestions on how the gap might be bridged [42]. Feedback as a strategy, allows students to assess their ethical actions, decisions, and ability to deal with the ethical dilemmas in clinical practice [38].
Furthermore, constructive feedback is an unbiased critique of performance to correct errors and increase student nurses’ understanding [43]. Whether positive or negative, it must provide logical connections and always have a fair reflection of events. Feedback, whether positive or negative, should always be unbiased, and delivery style plays a crucial role in whether a student accepts, modifies, or rejects feedback [44]. However, one key limitation of feedback as a strategy for facilitating ethical competence is that feedback can be subjective, influences by the facilitator’s personal perspectives and biases. Secondly, the timing of feedback is critical; delayed feedback may not have the same impact on students’ ethical competence. Therefore, debriefing is a better transformative teaching strategy for facilitating ethical competence [45].
Debriefing is a bi-directional, interactive, and reflective discussion [42]. During debriefing sessions, students can comprehensively consider past ethical events, encounters, and experiences to learn from them, are aware of their ethical competence knowledge gaps, and can work towards bridging those gaps [45]. Debriefing improves clinical reasoning and reflective thinking by giving the student nurses new and positive experiences to draw from in clinical practice and when faced with an ethical dilemma [46].
Debriefing for Meaningful Learning is one strategy that has been reported to help students become reflective practitioners and enhance the progress of clinical reasoning skills [47]. It a is a debriefing method used to foster meaningful learning, cultivate reflective thinking through challenging assumptions, and reveal relations between thinking and actions taken [48]. Through Socratic questioning approach, the facilitator, asks a series of ethical competence questions, so student nurses get deeper ethical awareness of their knowledge. Students can evaluate their ethical competence in an objective, non-judgemental atmosphere through guided discussions and are encouraged to engage in self-reflection. To ensure that Debriefing for Meaningful Learning is effective in facilitating ethical competence among students, the facilitator should ensure that enough time for engagement, dialogue and reflection in the has been allocated [48].
Lastly, the participants also reflected on use of the high-fidelity simulation to integrate theory and practice. Integrating high-fidelity simulation into nursing education is an effective method to bridge the gap between theory and practice, especially for developing ethical competence among nursing students [49, 50]. By creating realistic and engaging scenarios, students can apply theoretical knowledge to practical situations, enhancing their decision-making skills in ethical dilemmas. These simulations provide a safe environment to make mistakes, reflect on their actions, ultimately preparing them for challenges of real ethical dilemmas in clinical practice.
Limitations
This was an exploratory and descriptive study, and data were collected from 9 nurse educators and clinical nurse preceptors from one higher education institution using an online platform. Therefore, the results of this study may not be generalised to other higher education institutions. Another limitation relates to occasional poor network connection which would sometimes disrupt flow of information and quality of the videos, making it hard for the researcher to interpret non-verbal cues, thus, affecting the depth of the information shared during the interviews.
Conclusion
This research revealed some barriers that were exposed by the Covid-19 pandemic. Barriers related to insufficient human resources and infrastructure made it almost impossible to facilitate ethics education for nursing students. This research further revealed some transformative solutions that could be adopted by higher education institutions to ensure that ethical competence is effectively facilitated. These solutions would ensure that ethics education would continue without putting the lives of patients, students, and facilitators at risk despite future pandemics.
Recommendations
In addition to the transformative solutions raised in this study, virtual simulation approach could also be adopted to help address the learning gap by providing ongoing clinical practice for student nurses in situations where face-to-face is not possible [51]. Virtual simulation will provide nursing students with learning opportunities in their own time and space while preparing and exposing them to different diverse ethical dilemmas and producing professional nurses who can comprehensively manage challenging situations.
Acknowledgements
The authors would like to acknowledge participants for their willingness to share their experiences.
Declarations
Ethics approval and consent to participate
Ethical clearance was obtained from the Faculty of Health Sciences Research Ethics Committee of the University of Johannesburg (REC-754-2020) to conduct this research. Online informed consent was voluntarily obtained from each participant to confirm their willingness to participate in this study after being informed of all aspects of the research relevant to their participation. Participants’ privacy and confidentiality were maintained by ensuring that only the researcher, research supervisors, the independent coder had access to the transcripts and recorded audios. This was achieved by storing the interview recording on a password-protected folder on the researcher’s personal computer. Furthermore, this research adhered to additional ethical principles including the principles of autonomy, beneficence and non-maleficence, and justice.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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