critical thinking skills of nursing students in lecture based teaching and case based learning

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Critical Thinking Skills of Nursing Students in Lecture-Based Teaching and Case-Based Learning

Mahmoud Kaddoura , University of San Francisco Follow

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In today's technologically advanced healthcare world, nursing students should be active learners and think critically to provide safe patient care. A strategy that promotes students' active learning is case-based learning (CBL). The purpose of this study was to examine critical thinking (CT) abilities of nursing students from two different curricular approaches, CBL and didactic teaching. The design used in this research was a comparative descriptive survey. The sample included 103 participants; 65 students from the CBL nursing program and 38 students from the didactic nursing program offered by the MOH Schools of Nursing in the United Arab Emirates (UAE). Data were collected using the California Critical Thinking Skills Test (CCTST) Form B to measure the CT abilities of the participants. The data were analyzed using the SPSS. The independent t-test results revealed that the CBL participants performed better in the total CT score and all CT subscales than the didactic program participants.

10.20429/ijsotl.2011.050220

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Kaddoura, Mahmoud A. Ph.D. (2011) "Critical Thinking Skills of Nursing Students in Lecture-Based Teaching and Case-Based Learning," International Journal for the Scholarship of Teaching and Learning: Vol. 5: No. 2, Article 20. https://dx.doi.org/10.20429/ijsotl.2011.050220

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Effectiveness of Problem-Based Learning on Development of Nursing Students’ Critical Thinking Skills

A systematic review and meta-analysis.

Wei, Baojian MD; Wang, Haoyu BS; Li, Feng MSc; Long, Yan MSc; Zhang, Qi MSc; Liu, Hang MSc; Tang, Xiujun MSc; Rao, Mingjun MD

Author Affiliations: Adjunct Professor (Dr Wei), School of Nursing, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, Shandong, China; and Instructor (Messrs Wang, Li, Zhang, Liu, and Tang and Ms Long), Professor (Mr Tang), and Adjunct Professor (Dr Rao), Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

Correspondence: Dr Rao ( [email protected] ) and Mr Tang ( [email protected] ) , Department of Plastic Surgery, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.

This work was supported by the Research Program of Taishan Medical College Education and Teaching Research Project (No. XY2018051).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website ( www.nurseeducatoronline.com ).

Accepted for publication: September 17, 2023

Early Access: November 16, 2023

Cite this article as: Wei B, Wang H, Li F, Long Y, Zhang Q, Liu H, Tang X, Rao M. Effectiveness of problem-based learning on development of nursing students’ critical thinking skills: a systematic review and meta-analysis. Nurse Educ . 2024;49(3):E115-E119. doi:10.1097/NNE.0000000000001548

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background:

Problem-based learning (PBL) is a student-centered approach to teaching that has been applied in medical and nursing education. The effectiveness of PBL in promoting critical thinking in nursing students has been studied extensively with mixed results.

Purpose:

The meta-analysis aimed to investigate the impact of PBL interventions on critical thinking skills of nursing students.

Methods:

PubMed, Embase, Cochrane, and CINAHL databases were electronically searched. Methodological quality was examined using the Newcastle-Ottawa Scale and version 2 of the Cochrane risk-of-bias tool. Data were analyzed with 95% confidence intervals based on random-effect models.

Results:

Nineteen studies involving 1996 nursing students were included in the analysis. The results of the analysis demonstrated greater improvement in critical thinking skills compared with the control group (overall critical thinking scores: standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .01).

Conclusions:

The meta-analysis indicates that PBL can help nursing students to improve their critical thinking.

Nursing occupies a critical role in health care. The profession entails a myriad of responsibilities, including recognizing patients’ symptoms, taking measures to administer medications, providing other measures to help relieve symptoms, and collaborating with other health care workers to optimize patients’ comfort and families’ understanding and adaptation. 1 To effectively fulfill these responsibilities, nurses require professional knowledge across various aspects of health care. 2 , 3 Critical thinking, an essential cognitive capacity, plays a pivotal role in enabling nurses to make informed decisions and fulfill their diverse roles. 4 It involves a combination of cognitive skills and affective dispositions, as defined by the American Philosophical Association, and positively influences clinical practice, patient health, student education, and the growth of nursing science. 5 , 6

Problem-based learning (PBL) is an innovative teaching method that has gained widespread application among institutions worldwide, particularly in the fields of medical and nursing education. 6 , 7 As described by Zakaria et al, 8 PBL is a student-centered, outcome-based approach that has been proven to enhance the quality of learning across various disciplines and academic levels. PBL is described as a process-focused teaching strategy that employs small groups centered on solving well-integrated clinical problems. Unlike traditional instruction, which relies heavily on lectures and limited self-directed learning, PBL encourages active problem-solving and collaboration among students. 9 PBL has been hailed as the “most significant innovation in education for professions in many years,” a testament to its transformative impact on the field of education. 10-12 Indeed, PBL has emerged as a game-changer in medical education, and its effects on nursing education have also been studied extensively. 13

Numerous studies have shown that PBL significantly enhances critical thinking skills (CT skills) among medical students. 14 As Hajrezayi et al note, critical thinking involves purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, skills that are invaluable in the clinical setting. 15 PBL, as a teaching strategy, focuses on engaging students in group discussions to address complex and ambiguous clinical problems. This process involves analyzing problems, setting objectives, gathering information, summarizing ideas, and reflecting on problem-solving experiences. 16 Research has demonstrated that this teaching strategy effectively develops critical thinking abilities in medical students. 17

However, the efficacy of PBL as a teaching method for enhancing critical thinking in nursing students remains a topic of debate among researchers. Previous systematic reviews evaluating critical thinking in PBL have produced mixed results, with some studies supporting a positive relationship between PBL and critical thinking and others disputing it. 18-20

To address these inconsistencies and provide a more comprehensive understanding of the effectiveness of PBL in promoting critical thinking in nursing students, we synthesized the data of previous studies published and conducted a more comprehensive meta-analysis.

Methodology for Meta-analysis

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a systematic and transparent process. The PRISMA statement comprises a 27-item checklist and a 4-phase flow diagram, which guide the analysis. 21 We carefully applied each item on the checklist to guarantee transparent reporting of our systematic review, while the flow diagram helped us visualize and track the different stages of our analysis. The review protocol was registered on PROSPERO (PROSPERO ID: CRD42023406592).

Search Strategy

We conducted a comprehensive search of the literature using electronic databases (PubMed via National Library of Medicine, Embase via Elsevier, Cochrane via Cochrane library, and CINAHL via EBSCO) from inception to September 9, 2023, supplemented by a manual search of reference lists of relevant articles. There was no limit to search date, language, and publication period. We used a combination of keywords and MeSH terms related to the topic to optimize the search results, detailed in the supplementary material (see Supplemental Digital Content 1, available at: https://links.lww.com/NE/B450 ).

Study Selection

Two reviewers (R.M. and W.B.) independently screened the titles and abstracts for eligibility. Articles that did not meet the inclusion criteria were excluded. The same 2 reviewers then independently reviewed full texts of remaining articles for inclusion in the meta-analysis. Discrepancies were resolved through discussion and consensus with a third reviewer (T.X.).

Included studies satisfied the following criteria: (1) participants were nursing students including graduate and undergraduate nursing students, (2) the intervention group used PBL, (3) the control group used traditional lectures, (4) trials evaluated critical thinking, (5) reported sample size, mean difference, and standard deviation of critical thinking scores. Excluded studies included nonnursing subjects, interventions other than PBL, no critical thinking evaluation, and incomplete/duplicate articles. Both randomized and nonrandomized controlled trials were included.

Data Extraction

Two reviewers independently extracted data from the included studies using a standardized data extraction form. The data extracted included study characteristics (author, year of publication, and country), participant characteristics (sample size and grade), description of PBL, teaching methods combined with PBL, research of design, and critical thinking tools (the mean difference from baseline to post-test, as well as standard deviation). Any discrepancies were resolved through discussion and consensus with a third reviewer.

Quality Assessment

Two reviewers independently assessed the quality of the included studies using a Newcastle-Ottawa Scale (NOS) for cohort studies, and version 2 of the Cochrane risk-of-bias tool for randomized trials. A study was considered as high quality if the NOS score was 7 or more, moderate quality if the NOS score between 4 and 7, and low quality if the NOS score less than 4. As for version 2 of the Cochrane risk-of-bias tool, when there are “some concerns” (or high risk of bias ratings) in some domains, the overall risk of bias is rated as “some concerns” (or high), respectively. Any discrepancies were resolved through discussion and consensus with a third expert.

Data Analysis

We used a random-effects model to pool the effect sizes across studies. To determine the significance of our findings, we set a threshold of a 2-sided P value less than .05 for all analyses. We assessed heterogeneity using the I 2 statistic and P value of Cochran's Q statistic, P value < .10 and I 2 > 50% were considered as heterogeneity. The I 2 statistic, which indicates the percentage of variation attributed to heterogeneity, was an easily interpretable way to assess the degree of heterogeneity. We considered an I 2 statistic of 25% to 50% to indicate low heterogeneity, 50% to 75% to indicate moderate heterogeneity, and more than 75% to indicate high heterogeneity. If there is heterogeneity, we explored potential sources of heterogeneity using subgroup analyses based on the duration of PBL intervention (hours or weeks), the grade of nursing students, and the assessment tools of CT skills. We conducted sensitivity analyses to examine the robustness of the findings and assessed publication bias using funnel plots and Egger's test. All analyses are conducted using R software.

Ethics Approval

As this study is a meta-analysis of previously published studies, no ethical approval was required.

We conducted a thorough review of available literature on PBL interventions for nursing students and ultimately obtained 19 studies (see Supplemental Digital Content 2, available at: https://links.lww.com/NE/B451 ).

Study Characteristics

All included studies were published between 2004 and 2021 and involved 1996 nursing students from Iran (n = 3), South Korea (n = 8), China (n = 6), the United States (n = 1), and Turkey (n = 1). The participants included first-year, second-year, third-year, fourth-year, and graduates with a work experience ranging from 1 to 21 years; 1876 participants were undergraduate nursing students while 120 participants were graduate nursing students with a work experience ranging from 1 to 21 years. The length of the PBL intervention period varied, with 7 articles lasting less than 12 weeks and 9 articles lasting 12 weeks or more. PBL interventions were integrated with various teaching methods, including simulation, case-based learning, teamwork, concept mapping, clinical practice, internet, and tutors as guides (tutors help clarify concepts and answer questions).

To assess the critical thinking, 18 included studies adopted different assessment tools including the California Critical Thinking Skills Test (CCTST, n = 6), California Critical Thinking Dispositions Inventory (CCTDI, n = 5), Assessment Technologies Institute Critical Thinking Test (n = 1), Watson-Glaser Critical Thinking Scale (n = 1), and critical thinking tools developed by Yoon (n = 2), Kwon (n = 2), Park (n = 1), McMaster University (n = 1). Among these assessment tools, the CCTST and CCTDI stand out as the primary tools utilized in the studies. The detailed characteristics were presented in Supplemental Digital Content 3, available at: https://links.lww.com/NE/B452 .

Risk of Bias

Nine of the 12 cohort studies had a low risk of bias (see Supplemental Digital Content 4, available at https://links.lww.com/NE/B453 ). However, all 7 randomized controlled studies had a high risk of bias (see Supplemental Digital Content 5, available at: https://links.lww.com/NE/B454 ). None of the randomized controlled studies specified whether the allocation sequence was concealed until participants were enrolled and assigned to interventions, nor were they able to conceal their allocation from the participants, the teachers, and the outcome assessors during the trial.

Meta-analysis Results

Nineteen studies involving 1996 participants (PBL group = 941, lecture group = 1055) reported overall critical thinking scores. The pooled effect size showed significant difference (standardized mean difference [SMD] = 0.47, 95% CI = 0.33-0.61, P < .001) in favor of PBL, compared with traditional lectures (see Supplemental Digital Content 6, available at: https://links.lww.com/NE/B455 ). There was moderate heterogeneity ( I 2 = 52%, P < .01).

Subgroup Analysis and Publication Bias

We conducted further subgroup analyses to explore the underlying sources of heterogeneity. Regarding nursing students of different grades, compared with second-year students, the critical thinking scores of the first- and third-year improved more, but there was no clear pattern of higher or lower critical thinking scores among higher grades (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, we conducted subgroup analysis based on the different assessment tools used in the studies and discovered that nursing students who took the CCTST had higher scores compared with the CCTDI. Furthermore, the subgroup analysis based on intervention time showed that an intervention duration with fewer weeks and more hours had a greater improvement in critical thinking scores (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). This may suggest that nursing students who receive more intensive PBL course arrangements exhibited a higher improvement in critical thinking scores.

Furthermore, during the PBL process, nursing students who visualize the ideas, concepts, and terms using concept mapping show better improvement in critical thinking abilities (see Supplemental Digital Content 7, available at: https://links.lww.com/NE/B456 ). Additionally, students who receive help from teachers to clarify concepts and solve problems also demonstrate better improvement in critical thinking abilities. It is worth noting that among the 9 studies where teachers played a significant role in guiding students (clarifying concepts and answering questions rather than simply directing the slow of the PBL), all were published in 2008 or later. In contrast, among the 9 clinical studies where teachers only assisted in implementing PBL, 4 were published before 2008. This suggests that teachers play a more important role during the development of the PBL teaching strategy.

We conducted a funnel plot analysis to determine the degree of symmetry in our results and conducted Egger's regression test to determine publication bias (see Supplemental Digital Content 8, available at: https://links.lww.com/NE/B457 ). The results showed no publication bias, with bias = 0.7445 ( t = 0.6, df = 7, P = .5580).

In this meta-analysis, we found that PBL has a greater impact on CT skills of nursing students compared with traditional lectures. In the past 2 decades, there have been several meta-analyses published on this topic, but the earlier meta-analysis did not support our current conclusion, that the PBL teaching strategy can improve nursing students’ critical thinking ability compared with traditional lectures. 18 After incorporating more studies, our meta-analyses has new findings that differ from previous meta-analysis.

The discrepancy between our conclusions and those of earlier meta-analyses can be attributed to the continuous improvement of the PBL teaching strategy itself. 22 , 23 Our meta-analysis supported that teachers played a more important role in the development of the PBL teaching strategy. Teachers in the earlier studies mainly helped implement the PBL teaching strategy, teachers in the more recent studies encouraged students to think critically and gave timely feedback. Originally introduced as a novel teaching strategy in medical education, teachers primarily act as a procedural guide, our meta-analysis suggests that increased teacher engagement in the PBL teaching process can enhance nursing students’ critical thinking abilities. Although exhaustively providing students with answers to their questions as a directive lecturer is not conducive to fostering students’ critical thinking abilities, students might be dismayed when their teachers rarely directly answer a question, but instead ask questions back and let the student find the answer independently. 24

Throughout the ongoing improvement of the PBL teaching strategy, case-based learning has been integrated. Cases present clinical problems to nursing students in a fragmented manner, fostering their autonomy in constructing a knowledge framework to investigate the problems and address the presented challenges. 25 Furthermore, the assistance of concept mapping and teamwork during the PBL teaching process further improved the PBL teaching strategy. 26 , 27

Despite various advantages demonstrated by the PBL teaching strategy over the past few decades, it is imperative that we carefully evaluate both the benefits and drawbacks of adopting this teaching strategy over traditional lecture-based learning methods. One of the most celebrated aspects of the PBL teaching strategy is its ability to situate information within the context of real-life clinical problem-solving, bridging the gap between textbook knowledge and practical application. 23 On the other hand, PBL necessitates teachers to invest substantial effort in guiding students’ self-directed learning, while medical institutions should acknowledge adequate resources to support the PBL teaching strategy. 28 Nevertheless, it is worth noting that implementing the PBL teaching strategy effectively may pose challenges for teachers who are accustomed to traditional lecture-based strategy, necessitating additional training to ensure competence in the PBL teaching strategy.

Furthermore, we must acknowledge that clinical problem-solving through the PBL teaching strategy is a complex cognitive task that involves hypothesis generation from ambiguous clues. It requires reasoning based partly on fuzzy categorical knowledge, partly on probabilities, and partly on understanding the urgency and risk-benefit relationship of potential treatments. 29 In essence, for clinical problem-solving to become a meaningful experience, nursing students must possess knowledge and experience directly tied to the clinical problems. Traditional lecture-based learning methods afford teachers the opportunity to assist students in constructing knowledge frameworks based on their own expertise experience. 30 However, in the realm of PBL teaching, students, due to their limited foundational knowledge, may pose numerous seemingly inconsequential questions, potentially appearing chaotic, time-consuming, and misguided in the eyes of teachers. 31 To mitigate this challenge, some studies have leveraged concept mapping and the internet to facilitate rapid access to relevant knowledge, aiding nursing students in comprehending clinical problems. 32 , 33 Moreover, experienced PBL teachers play a pivotal role in helping nursing students build a robust knowledge base by promptly answering their questions. 34

Moreover, the current trend in PBL teaching involves employing cases as guides for learning in specific content areas. In this situation, nursing students typically only learn the definition of possible treatments when the clinical problems are presented. This approach often simplifies the complexities and exceptional aspects of clinical cases, which may serve as illustrative examples of important concepts, which may lack practicality in the actual practice of clinical problem-solving. 31 , 35 However, as nursing students engage in independent collection of background information, teachers help guide them in applying and refining their critical thinking skills to attempt to understand the reading materials, not limiting themselves to textbooks or the small world of their peers and teachers. They are quickly guided into a broader world, namely the current cutting-edge medical issues, by the latest medical articles as well as expert teachers. 25

Our meta-analysis indicates that the PBL teaching strategy can enhance critical thinking skills in nursing students.

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critical thinking skill; meta-analysis; nursing students; problem-based learning

Supplemental Digital Content

NE_2023_09_27_RAO_2023453_SDC1.docx; [Word] (18 KB)
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Critical thinking skills in nursing students: a comparison between freshmen and senior students

Affiliations.

1 School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran.
2 Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, IR Iran.
3 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, IR Iran.
PMID: 25830160
PMCID: PMC4377532
DOI: 10.17795/nmsjournal25721

Background: Critical thinking is one of the most important concepts in the field of education. Despite studies published on nursing students' critical thinking skills (CTS), some suggest that there is not enough evidence supporting the relationship between content of nursing education programs and nursing students' CTS.

Objectives: Given the existing discrepancies, this study aimed to compare the critical thinking skills of freshmen and senior nursing students.

Patients and methods: This comparative study was conducted on 150 undergraduate freshmen and senior nursing students in Kashan University of Medical Sciences, during 2012. The students in the first and the last semesters of their study in nursing were entered in the study using the census method. Data were collected using a questionnaire including questions on demographic data and the California Critical Thinking Skills Test, form B. Data analysis was performed using the SPSS v.13 software. Descriptive statistics were calculated. Moreover, independent sample t-test and Spearman and Pearson's correlation coefficients were used in the data analysis.

Results: Both the freshmen and senior nursing students had low CTS. The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for the freshmen and the senior students, respectively (P = 0.511). Moreover, no significant correlation was found between the students' score in CTS and their age, gender, high school grade point average (GPA), rank in university entrance examination (RUEE) and interest in the nursing profession.

Conclusions: The students were low skilled in critical thinking and their CTS did not significantly change during their nursing degree. Thus it may be concluded that the nursing education program did not affect the CTS of its students. Longitudinal studies are suggested for assessing nursing students' critical thinking over time. Moreover, revising the curriculum and preparing nursing educators for implementing innovative and active teaching strategies are suggested.

Keywords: Mental Competency; Nursing; Students; Thinking.

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Open access
Published: 15 August 2024

Nurturing ethical insight: exploring nursing students’ journey to ethical competence

Sylvia Hansen ORCID: orcid.org/0009-0003-8733-6892 1 ,
Elisabeth Hessevaagbakke 1 ,
Katrin Lindeflaten 1 ,
Kaja Elvan 1 &
Daniela Lillekroken 1

BMC Nursing volume 23 , Article number: 568 ( 2024 ) Cite this article

Metrics details

Ethical competence is a key competence in nursing and the development of the competence is a central part in nursing education. During clinical studies, nursing students face ethical problems that require them to apply and develop their ethical knowledge and skills. Little is known about how ethical competence evolves during students’ initial clinical placements. This study explored the development of ethical competence in first-year nursing students during their first clinical placements in nursing homes.

This exploratory-descriptive qualitative study used focus group interviews to collect data and a phenomenological hermeneutical method for analysis. Twenty-eight first-year nursing students participated in six focus groups. The data were collected between March and April 2024 at Oslo Metropolitan University in Norway.

The naïve reading of the data involved an awareness of the students applying their prior knowledge, modifying their prior knowledge and developing skills that allowed them to manoeuvre ethical practices that, in some cases, appeared excellent and, in other cases, grim. The structural analysis identified three themes: (i) ethical competence forges in practice, (ii) ethical competence evolves at the intersection of knowledge and skills and (iii) ethical competence unfolds through meaningful discussions. A comprehensive understanding of the data was formulated as ‘Being on a journey towards ethical competence’. This presents a metaphor illustrating that nursing students embark on a journey towards ethical competence; from their point of departure, their clinical experiences forge the essential waypoints along their path, knowledge and skills fuelling their navigation in rugged terrain towards their destination.

Conclusions

Nursing students’ ethical competence evolved in intricate ways during their initial clinical period. Being informed bystanders or participants in the care of nursing home residents in situations of ethical tension may be a unique position enabling students to evaluate care options differently from those immersed in the ward culture. The findings indicate that organised professional development in nursing homes needs to focus on more reflexively driven ways of supervising students in their first clinical study period. Educational institutions need to continue and further develop reflection-based learning activities and meeting points with students and their peers during their clinical placement periods.

Peer Review reports

Ethical competence is at the core of nurses’ integrity [ 1 ]. The overall aim of nursing is to deliver proficient healthcare services. However, the assessment of how services are delivered requires value-based and ethical inquiry [ 2 ]. Practicing nursing with integrity amid the complex moral choices and pressures that nurses confront on a daily basis is challenging [ 3 ]. Not living up to the ethical standards of nursing puts patients’ well-being at risk and is associated with human costs on patients’ behalf [ 4 ]. Furthermore, violating the ethical standards of nursing is also associated with moral injury [ 5 ]. To ensure high ethical standards in nursing, it is essential to enhance ethical training in the curriculum [ 6 , 7 , 8 ]; this training aims to cultivate moral qualities in students, preparing them for their roles as nurses. Being a ‘good’ nurse requires not only procedural skills and clinical reasoning but also strong moral qualities and ethical reasoning.

Improvements in nursing students’ ethical competence can positively affect appropriate and timely clinical outcomes [ 7 ]. The ways in which nursing and other healthcare professions educational institutions organise and implement learning activities to promote students’ ethical competence vary, and different approaches may yield diverse results [ 9 , 10 , 11 , 12 , 13 , 14 ]. However, the experiences students in the healthcare professions gain through their clinical studies substantial impact their learning outcome [ 15 , 16 ]. According to Mezirow [ 17 ], encountering a real ethical problem initiates an inner process that is essential to the development of ethical competence. The process consists of two steps. First, one identifies the problem at hand. Then, the essence of the problem is mirrored in the self, and ethical reflection and assessment starts as an attempt to identify just solutions.

In Norway, although learning activities vary from institution to institution, a key requirement in the curriculum for a bachelor’s degree in nursing is that graduates are qualified to reflect on and handle ethical problems in their professional roles. Additionally, they must be qualified to plan and implement respectful, collaborative and comprehensive interactions with patients and the patients’ next of kin [ 18 ]. By their nature, these qualifications are related to clinical skills. Therefore, training and guidance to achieve mandatory qualifications cannot be separated from clinical studies, which make up 50% of the total study hours in nursing education in Norway.

In the bachelor’s programme in nursing at Oslo Metropolitan University [ 19 ] in Norway, nursing students’ ethical training during clinical studies emphasises developing ethical competence through a discursive model of ethical reflection. This model, which is known as the Center for Medical Ethics model, or the CME model [ 20 ], is extensively utilised across interdisciplinary settings in Norwegian health service settings. The application of ethical decision-making models is a widely used method for systematic training as a way to enhance ethically justified reasoning and well-grounded decision-making [ 21 ]. The CME model equips students with a practical and applicable tool for developing ethical competence. The model is considered to be well suited because of its relatively simple structure and ability to apply knowledge and assessment directly to subject matter and practical solutions. Furthermore, using the model enhances discourse and diversity in the structured process of addressing ethical and legal problems.

Over the years, researchers have conducted studies to better understand the concept of ethical competence in healthcare professionals. A review conducted by Kulju et al. [ 22 ] aimed to analyse the concept of ethical competence in the context of healthcare. Based on the results, ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professionals, the experience of professionals, human communication, ethical knowledge and supporting surroundings can be seen as prerequisites for healthcare personnel to develop ethical competence.

In an integrative review, Lechasseur et al. [ 23 ] aimed to clarify the concept of ethical competence, identifying six distinct yet interconnected components related to the concept: ethical sensitivity , the ability to recognise ethical tension; ethical knowledge , the integration of philosophical, normative, deontological and practical knowledge; ethical reflection , a continuous process evaluating alternatives to ethical issues; ethical decision-making , choosing responsibly among options; ethical action , contextually adapted action driven by reflection; and ethical behaviour , embodied moderation and respect. These components elucidate how ethical competence evolves among healthcare personnel and students.

Understanding the concept of ethical competence and its development in nursing students in different learning contexts is still challenging. The various studies addressing ethical competence in nursing students often target one of the six components identified by Lechasseur et al. [ 23 ], the relationship between two or more of the components or one of the components related to other phenomena. For example, Hakbilen et al. [ 24 ] found that students had medium ethical sensitivity after courses, highlighting the need to integrate ethical issues into all nursing education content to improve students’ ethical sensitivity. The results from a study conducted by Chen et al. [ 25 ] indicated that both moral sensitivity and professional values had a positive effect on the improvement of ethical decision-making in Chinese nursing students. Park et al. [ 26 ] reported that senior students had greater moral sensitivity in patient care and conflict than freshmen students and that more hours of ethics education were linked to higher principled thinking scores among seniors. The findings from another study [ 27 ] demonstrated that nursing students’ ethical sensitivity includes perception, affectivity, cognitive processing and cooperation. Using these categories, an educational framework for teaching ethical sensitivity was developed, detailing the purpose, content and methods. Albert et al. [ 28 ] conducted a review to understand nursing students’ ethical dilemmas in clinical settings; they found that dilemmas arose when students had to choose between providing ethical care or accepting unethical practices, staying silent about neglect or reporting it, and offering quality care or adapting to the culture because of a lack of autonomous decision-making. Heggestad et al. [ 29 ] explored the link between affective and cognitive empathy and students’ moral sensitivity, finding that affective empathy was a strong driver of students developing moral sensitivity. Students valued emotions for empathy and feared becoming indifferent. Moe [ 30 ] examined the relationship between ethical knowledge and action choices among graduating nursing students; she found a significant correlation between ethical knowledge and students’ actions after accounting for factors such as ethics courses, healthcare decision experience and general healthcare experience. ‘Action’ was measured by students’ likelihood of implementing behaviours in a list of nursing interventions across eight patient care vignettes. Ramos et al. [ 31 ] studied the ethical conflicts perceived by nursing students in their sixth semester and described their decision-making process. The students used a three-stage strategy: realisation, reflection and intervention. Reflection served as a mediator, drawing on individual insights, others’ input, academic knowledge and context, hence helping students choose the best response to ethical issues.

As the research literature has demonstrated, as a comprehensive concept, ethical competence has been underexplored. As a result, the concept has not yet been operationalised across different contexts and various healthcare settings, particularly in the context of first-year nursing students’ clinical practice in nursing homes. First-year nursing students often start their first period of clinical practice with limited formal ethical knowledge and experience; therefore, more knowledge of the evolution of ethical competence in them is necessary.

Aim of the study

The aim of the present study was to explore the development of ethical competence in first-year nursing students during their first clinical placements in nursing homes.

The current study employed an exploratory-descriptive qualitative (EDQ) design [ 32 ] and used content analysis to analyse the empirical data based on focus group interviews with students.

Recruitment

All five researchers contributed to recruiting the participants. They provided information both face to face and via email to students during and after the clinical period. To be included, students had to (i) be enrolled in the academic year 2023–2024, (ii) have completed the clinical period at a nursing home, (iii) voluntarily participate in the study and (iv) agree to be recorded during the interviews. Students who wished to participate in the study contacted the researchers to arrange a date and time for the interviews.

Participants and study setting

For the present study, purposive sampling was deemed appropriate for selecting participants who could provide the necessary information to address the study’s aim. Sandelowski [ 33 , 34 ] suggested that, in qualitative research, it is crucial to ensure that the sample size is sufficient to obtain the quality of the information needed. A total of 113 first-year students were invited to participate in the study, and 28 agreed to participate. Among those who agreed, only three were men. The participants’ ages ranged from 19 to 31 years. At the time of the interviews, their work experience in healthcare services ranged from 0 to 8 years.

During the fall semester of 2023, the students attended a two-hour lecture and a three-hour seminar on ethics in nursing aimed at enhancing their theoretical ethical competence. The study was conducted at the Department of Nursing and Health Promotion, Oslo Metropolitan University, following the students’ completion of a six-week clinical period in a nursing home as part of their first-year curriculum during their bachelor’s degree in nursing.

Data collection methods

The data were collected through focus group interviews using a semistructured interview guide. This data collection method is both time- and resource-efficient, allowing for the exploration of a wide variety of perceptions. Additionally, the participants can build upon each other’s responses, generating new insights and information [ 35 ]. The interview guide was developed for this study by the first author following the five phases recommended by Kallio et al. [ 36 ]: (1) identifying the prerequisites for using semistructured interviews; (2) retrieving and using previous knowledge; (3) formulating the preliminary semistructured interview guide; (4) pilot testing the guide; and (5) presenting the complete semistructured interview guide. After pilot testing, small adjustments to the questions were made to enhance the clarity and relevance of the interview guide. For the interview guide, see supplementary file 1 .

Six focus groups were conducted between March and April 2024. The number of participants varied across the groups: two groups had three participants, two groups had five participants, and two groups had six participants. The interviews were held in a classroom or seminar room and lasted between 30 and 50 min.

Ethical considerations

The present study was approved by the Norwegian Agency for Shared Services in Education and Research (SIKT, project number 334855). Approval to conduct the study was given by the head of studies at the Department of Nursing and Health Promotion at Oslo Metropolitan University. The study was conducted according to the World Medical Association Declaration of Helsinki’s [ 37 ] principles of good and ethical practices in scientific research: informed consent, consequences and confidentiality. All the students who participated provided written informed consent at the beginning of the interviews. The students were informed about the aim of the study and the data collection method and were guaranteed confidentiality and the ability to withdraw from the study at any point in time.

All the researchers moderating the focus groups were nurse educators engaged in students’ clinical studies in nursing homes, and hence some of the participants knew the moderator prior to data collection. Being invited to participate in a focus group conducted by a nurse educator could put students in vulnerable positions given that the nurse educator may be perceived as an authority figure. According to Barbour [ 35 ], researchers should carefully consider the reasons participants may have for taking part in a study. In this study, it would question morality if a student would resort to participate for fear of being disadvantaged or poorly assessed by the nurse educator. Furthermore, if a student would customize his or her statements in the focus group, to convey an image as a ‘good’ student in front of the nurse educator, it would question morality as well as data authenticity. Therefore, the researchers always strived to be as transparent and open as possible with participants regarding potential implications.

In this study, openness related to in-depth information to invited participants concerning the authenticity of willingness as a participating principle, as well as of the genuineness that any statements made in the focus group would not affect the student in any way. Furthermore, the students were detailed informed that the focus group would occur as a conversation with peers, the moderators’ role facilitating discussions, and that any viewpoints would be welcomed. Debriefing before and after the focus group sessions, as recommended by Barbour [ 35 ], disclosed no incidents of students feeling obliged to participate or feeling restrained to express themselves freely.

The interview data were stored as secured computer files that were accessible only to the researchers. The records and transcripts will be permanently deleted after the research project has been completed and the results have been published.

Data analysis

All six focus group interviews were digitally recorded and transcribed verbatim by the researchers immediately after completion. The transcripts resulted in 52 A4 pages taped with 1.5 line spacing and New Roman font size. The duration from transcribing the interviews to completing the analysis ranged from four to six weeks.

To analyse the interviews, a phenomenological hermeneutical method inspired by Lindseth and Norberg [ 38 ] was used, which is ideal for understanding healthcare practices by exploring the narratives of lived experiences. This method involves three steps: naïve understanding, structural analysis and comprehensive understanding.

Initially, each researcher independently read the texts multiple times to gain a naïve understanding and highlighted passages describing nursing students’ perceptions of the preconditions that contributed to enabling their ethical competence. These passages were compared and discussed until a consensus was reached. The researchers then reread the texts to ensure that no relevant material was missed.

During the structural analysis, condensed meaning units were grouped into themes and reflected upon in light of the naïve understanding. The text was reassembled to integrate both naïve understanding and structural analysis. The literature was consulted to refine and deepen the understanding of the preconditions that contribute to enabling students’ ethical competence. A comprehensive understanding was developed, tested against the naïve understanding, discussed and revised multiple times, with further review given by the first author.

The data analysis concluded when that a comprehensive understanding of the meaning units was achieved, indicating saturation [ 39 ]. Coding meaning units involved reviewing each interview and noting every identified issue (or code). Saturation was reached when no new information emerged in any of the coded meanings [ 39 ].

Whittemore et al. [ 40 ] suggested four criteria to improve the rigour of a study with an EDQ design: credibility, authenticity, criticality and integrity.

To enhance study credibility, the researchers selected pertinent excerpts from participant statements to substantiate the findings. Researcher triangulation cross-verified the findings, enhancing credibility. Additionally, credibility was ensured through verbatim transcription of interviews and independent data analysis, which was followed by collaborative coding and theme development to reach a consensus.

Data authenticity was reinforced by encouraging the participants to freely express themselves during the interviews. The researchers supported and accurately represented participant voices in the findings.

The overall integrity of the study was evaluated through rigorous critical appraisal of the research decisions. A detailed description of the research process allows readers to comprehensively assess the study quality at every stage.

Criticality and integrity were further enhanced by addressing researcher bias, employing member checking and engaging in peer review. The researchers reflected on their positions relative to participants and maintained awareness of their preconceptions throughout. Reflexivity was pivotal in enhancing qualitative study rigour. Logistical challenges preclude member checking; however, the students were given ample opportunities during the focus group interviews to provide detailed input and clarify perspectives. Peer review involved all researchers critically evaluating the study for quality, validity and reliability. Although all team members reviewed the empirical data, only the first and last authors conducted structural analysis and developed a comprehensive understanding, with others providing expert assessments.

The interpretation process and findings are derived from the transcripts of six focus group interviews. The findings are presented in three distinct parts: naïve understanding, structural analysis and comprehensive understanding.

Naïve understanding

The nursing students, that is, the participants in the present study, encountered complex ethical situations during their clinical period in nursing homes, particularly when providing care to nursing home residents.

The students often encountered ethical challenges in clinical practice that conflicted with their theoretical knowledge of ethical care from university or from their personal values. They observed healthcare personnel engaging in behaviours they deemed unethical, such as ‘white lies’, causing feelings of powerlessness due to their inability to act. Despite witnessing challenging ethical caring actions, the students also noted positive examples of ethical sensitivity, actions and beneficiary caregiving. They navigated these complex situations by developing their own strategies and reflecting on their roles as future healthcare professionals.

The students recognised that their theoretical knowledge, practical skills and empathy for nursing home residents were crucial in identifying ethical problems. They internalised ethical principles deeply through their experiences, and this was often prompted by residents’ reactions. Although they emphasised the importance of guidance and reflective dialogue to enhance ethical competence, the lack of supervision and specific feedback on ethical problems was perceived as a hindrance to further developing ethical competence. The students valued discussions with peers, nurse educators and interdisciplinary meetings for support and ethical reflection, despite challenges in accessing consistent guidance from nurse preceptors.

Structural analysis

The structural analysis of the data revealed three themes: (i) ethical competence forges in practice, (ii) ethical competence evolves at the intersection of knowledge and skills and (iii) ethical competence unfolds through meaningful discussions. These themes are considered essential preconditions for the development of ethical competence among nursing students. An example of the structural analysis process is illustrated in Table 1 .

Ethical competence forges in practice – being able to identify ethical and unethical care

This theme suggests that ethical competence is developed and strengthened through practical experience, with students having hands-on engagement in ethical situations and being petitioned to act. This implies that students can assess various situations and distinguish between ethical and unethical caregiving and start grounding the course of their own ethical actions through their reflections.

The clinical period was evaluated as a positive experience offering numerous valuable learning opportunities. The students observed healthcare personnel providing ethical and dignified care to nursing home residents. However, they also witnessed some situations in which the care provided was less ethical and undignified. The situations described by the students as unethical caregiving were situations in which the residents resisted care or various procedures, such as changing ostomy bags, or refused personal hygiene tasks, such as grooming or brushing their teeth. Intuitively, most students were aware of the conflict between their own wish to help and the residents’ autonomy and right to say ‘no’. The students observed that, in most situations, healthcare personnel respected the residents’ wish to refuse assistance and, therefore, did not provide any help. One of the students said the following:

In our facility, some residents had not washed themselves for a long time and smelled. However, I appreciated seeing how the principle of autonomy was maintained. I felt that the healthcare personnel managed this very well, ensuring that the residents made their own decisions. Nevertheless, I had concerns about hygiene. If a resident did not want to wash and the healthcare personnel respected their wish, I think that it raised an ethical dilemma … what about the principle of nonmaleficence and beneficence … how are these maintained? (S3, FG1)

Other situations identified as unethical practices and triggering students’ ethical reflection were those situations in which healthcare personnel, because of high workload, time pressure or ingrained habits, ignored residents’ needs and wishes and focused on getting the job done. One of the students said the following:

I think that’s one of the worst things. It truly irritates me when I see nurses doing a job, that they are doing it just because it’s a job. They don’t think about the fact that it’s a person who has had a whole life before they got here [at the nursing home]. I’ve experienced it so many times that for some nurses, it’s just about the job, just about completing tasks and getting it over with. … (S3, FG2).

Ethical competence evolves at the intersection of knowledge and skills – Being able to apply theory in practice

This theme highlights the importance of both theoretical understanding (knowledge) and practical abilities (skills) in the development of students’ ethical competence. This finding suggests that ethical competence emerges as a result of the integration of knowledge and skills.

Several students felt that their ability to assess challenging situations as ethically laden resulted from their reflections on theoretical knowledge, practical skills and empathy for nursing home residents. Witnessing ethically challenging situations prompted them to reflect on ethical principles and find solutions, thereby acquiring and applying knowledge in practice. Students applied their knowledge, including their personal values and beliefs, as well as what they learned at university or during their clinical training, to assess the practical skills required for challenging situations. The skills the students often highlighted included the ability to initiate dialogue with residents to prevent ethical tensions, the capability to mediate and offer alternatives when residents did not comply with health measures, and the ability to articulate persuasive arguments to obtain residents’ consent for specific health measures they initially rejected but were deemed necessary.

Although the students were grateful for prior ethics education at the university and appreciated the knowledge gained from seminars, they believed that clinical practice provided real situations where they could reflect and discuss possible solutions. This is illustrated by one student’s statement:

When you’re in a nursing home, it’s much more real … when you discuss in the classroom, you won’t truly grasp the reality … yes, understanding the situation and what it entails … a case on paper is very black and white, but in reality, it involves emotions, observations and knowledge that help you assess the situation and find solutions. … (S4, FG4).

Nevertheless, the students perceived the nursing home as a valuable learning environment that offered many educational opportunities. Given that many nursing home residents had cognitive impairments or were persons with dementia, ethically challenging situations frequently arose. In addition to reflecting on how to apply their knowledge in practice, several students were interested in preventing the occurrence of ethical problems and/or finding solutions to these ethical situations. Therefore, the students stressed the importance of gaining skills using a model for ethical reflection, which helped them in ethical decision-making. This is illustrated by a student’s statement:

The CME model gave me a lot. I could organise things systematically and consider different courses of action. What can one choose to do and not do. In addition, then, I think in nursing homes, it’s special … you see so much, there are many residents who are diagnosed with dementia, and things where you stand in every day, such as assessing if they are competent to consent or not … Maybe you have to motivate a lot, spend a lot of time on diversion and such things … I think … it’s a place [nursing home] where you learn a lot about ethics. (S1, FG5)

Ethical competence unfolds through meaningful discussions – providing opportunities to exchange knowledge

This theme emphasises the role of dialogue and reflection in the development of ethical competence. This suggests that engaging in meaningful discussions with peers, nurse preceptors or nurse educators facilitates the growth and deepening of ethical competence.

Although most of the students were content with the nursing home as a learning environment and the supervision offered by nurse preceptors, some students revealed feelings of dissatisfaction about observing healthcare personnel conducting unethical practices, including ‘white lies’, breaching of residents’ privacy, respect, removing personal items from the resident, such as cigarettes or a lighter, without residents’ consent or neglecting to display the medication when the resident requested. A situation involving unethical conduct was illustrated by one of the students:

One resident was very sad and anxious about being there [nursing home]. She asked several times, ‘When will I get to go home?’ And then the nurse preceptor said, among other things, that ‘you are going home in three days’. However, that’s not true … The patient was on a two-week stay. The nurse preceptor said she did this to calm down the resident’s anxiety; she gave the resident hope … We discussed a little bit … and I think that it’s a bit of an ethical dilemma because the nurse said this to be kind, but she [the resident] had the right to know about her stay. (S1, FG6)

In such situations, the students felt the urge to discuss their emotions and their own assessments with someone. However, the nurse preceptors were often too busy, restricting their time for reflection and thorough supervision. As a result, the students turned to their peers or nurse educators for discussions. Often students felt safer discussing with peers and educators and found these discussions more helpful. If these discussions were supportive, they could lead the students to find confidence in their assessments and could help them find their voice, advocating for the residents and for ethical behaviour towards the residents.

However, the students also displayed positive experiences. Observations of commendable ethical actions and behaviour from staff and nurse preceptors demonstrating effective techniques for handling value-laden situations helped the students recognise and integrate beneficial ethical actions and behaviours into their own repertoires. At times, both students and healthcare personnel from the same ward were regularly provided with opportunities to reflect on their practices, particularly ethically challenging situations. These group discussions were facilitated by a priest. One student expressed enthusiasm for these discussions:

We had a visit from the priest in the ward to discuss ethical challenges. We stood in a circle, and the healthcare personnel shared the ethical challenges they faced in their daily work. We discussed various ethical dilemmas and explored the best ways to address them so that everyone involved would benefit. I found it quite rewarding to engage in these discussions. Although we did not reach a definitive conclusion, I felt that having such discussions improved my ethical knowledge and understanding. (S3, FG3)

Comprehensive understanding

The naïve understanding and structural analysis illustrate that nursing students embark on a journey towards ethical competence during their first period of clinical studies, with clinical experiences being essential waypoints along the path to their destination, that is, gaining ethical competence. Ethical sensitivity is foundational and the point of departure for the evolution of ethical competence in students. This sensitivity is driven by the compassion and understanding of residents’ needs and best interests, which students observe firsthand. Ethical knowledge evolves at the intersection of theoretical and practical insights within the nursing home setting and fuels and propels students’ ability to assess and reflect upon options in situations where there is ethical tension. Making meaningful discussions with their fellow passengers; peers, nurse preceptors and educators are crucial preconditions fostering students’ ethical reflections and decision-making in navigating the clinically rugged terrain. Ethical action and behaviour are the destinations of students’ journeys and hinge upon their learning of beneficial caring skills and on their opportunities to behave in accordance with their values in their caregiving. Overall, nursing students’ ethical competence evolves when they integrate ethical sensitivity, knowledge, reflection, decision-making, action and behaviour within clinical practice.

First-year nursing students with limited knowledge and skills enter their initial clinical studies and likely do not achieve the final level of ethical competence required in the nursing profession during this period. Nevertheless, our comprehensive understanding is that first-year nursing students begin a crucial journey towards ethical competence during their clinical placement in nursing homes. Their journey progresses through the integration of various components of ethical competence. Most prominently, the characteristics of ethical competence described in the integrative review of Lechasseur et al. [ 23 ] are identifiable in the scenic route the students’ take. Each of the components of ethical competence defined by Lechasseur et al. [ 23 ] evolve in the students, both distinctly and intertwined. Therefore, we find it valuable to discuss the students’ roadmap considering the components of ethical competence outlined by Lechasseur et al. [ 23 ]. We will discuss how ethical sensitivity, ethical knowledge, ethical reflection, ethical action and ethical behaviour play out in our finding, offering interpretations of how ethical competence evolves throughout their journey.

Ethical sensitivity is the point of departure

In all six focus groups, the students provided rich descriptions of the ethical problems that they encountered in their clinical studies and discussed how they individually identified ethical tension in these situations. Drawing on Weaver et al. [ 41 ], Lechasseur et al. [ 23 ] define ethical sensitivity in nursing as both a compassionate-driven and intelligence-driven capacity. The compassionate aspect is related to self-awareness and personal normative knowledge and is particularly described by the students in our study as to ‘imagine themselves in the role of the resident’ as a catalyst for them to identify tension.

The students were strongly affected by the residents’ vulnerability in value-laden situations when they sensed that the residents were not given choices and had to accept receiving care they did not consent to, involuntarily had to relate to strangers, felt that their intimate spheres were being invaded, felt that customised information was not given to them and so forth. For example, one student described her emotional discomfort witnessing a residents’ vulnerability being restricted access to his personal items (cigarettes and lighter). This caused the resident to be restless and his hands to shake.

The students’ emotions appear as a point of departure in their journey towards ethical competence enabling them to identify tension. In this sense, our findings are in line with those of Heggestad et al. [ 29 ], who found that undergraduate nursing students’ moral sensitivity is mostly linked to the affective dimension of empathy.

Studying senior nursing students, Shayestehfard [ 27 ] found that both affective and cognitive dimensions characterise ethical sensitivity in nursing students. In their study, nursing students’ ethical sensitivity is described as being affected emotionally and, hence, becoming aware, awakened, alarmed or shaken. The cognitive side to students’ sensitivity is described as processing signs and symptoms of vulnerability that enable the students to identify caring needs. The students in our study also described the cognitive components of their ethical sensitivity. Many of the descriptions in the focus group discussions represented their interpretations of the consequences of not intervening, professional caring duties in nursing and the beneficence or nonmaleficence of residents in critical situations as strong sources of their identification of ethical tension. Some of the students expressed that they were initially emotionally driven in their identification of ethical problems. However, as time progressed, their understanding and focus could change. One student related this change directly to the forging of ethical competence. As competence forges, the student said, one understands better what is ethically problematic and what is not, and you are not only driven by your feelings, but you are also driven by what you understand to be critical caring needs.

Ethical knowledge – pit stopping to fuel

Sometimes, the students identified ethical tension merely depending on their inherent and personal normative knowledge and values, but often, they also applied other knowledge, especially in the longer term. Lechasseur et al. [ 23 ] define ethical knowledge as multifaceted, including philosophical and theoretical knowledge as well as practical knowledge.

Ethical sensitivity is sometimes solely normative driven, but it is difficult to negate the relevance of factual knowledge in ethical reflection and decision-making [ 31 , 42 ]. Few would deny the importance of factual knowledge concerning the assessment of treatment and healthcare, consequences and obligations for specific patients or their next of kin that lead to decisions [ 42 ]. Thus, philosophical, and theoretical knowledge (‘ knowing that ’) is a necessary condition for assessing options and making decisions. The students described knowledge from medicine, nursing, psychology, and other disciplines as sources of ethical reflection, most frequently concerning the doctrine of informed consent, values and care needs at stake, ethical principles, ethical guidelines or directives and communication strategies and interaction. One student said that theoretical knowledge learned at university prior to clinical studies was ‘worth its weight in gold’. Nevertheless, philosophical, and theoretical knowledge is not merely something one learns and can apply instantly [ 7 , 43 , 44 ]. Decontextualized ethics education does not sufficiently help students transfer learning from the classroom to ethical nursing practice situations [ 45 ]. During the focus group interviews, the students highlighted the importance of the nursing home as a learning arena contributing to their acquisition of ethical knowledge in the form of practical skills. This means that the clinical studies offered them a real-world framework consisting of authentic situations, hence enabling students to acquire practical knowledge (‘ knowing how ’) through a meaningful understanding of the context at hand. Therefore, the students’ journey towards ethical competence hinges on understanding the particularity of each ethical problem, such as what and who it concerns in the specific context in which the problem arises and unfolds. These understandings fuel the forging of ethical competence among students.

Sometimes, the students described situations in which they experienced a noticeable lack of knowledge, which led them to question which skills were applicable and appropriate. According to Andersson et al. [ 9 ], to become ethically competent in clinical studies, three moments should be presented to students: the learning environment should create conditions for learning, nurse preceptors should design strategies for learning, and students should interact with others. The present study has revealed how the students described the nursing home as a learning environment in which encounters are both physical and personal; they learned to recognise and interpret residents’ verbal and nonverbal language and its meanings, and they were required to address ethical problems by applying practical skills and understanding. Concrete situations often triggered their inquiries. In their search for practical knowledge, the students had to interact with others, which fuelled and facilitated their journey towards achieving ethical competence.

Ethical reflection and ethical decision-making – navigating rugged terrain

Clinical studies provided the nursing students with the opportunities to engage in ethical reflection and decision-making processes in their placement wards. The students frequently reflected on the actions to take in various ethically tense situations and often provided sound justifications for their suggestions or raised relevant questions about what to consider. A recurring theme in their discussions was how much to push residents who resisted healthcare, speculating on the least invasive approaches. Ethical reflection represents the thinking process helping decision makers clarify beliefs and thoughts by considering various alternatives to ethical problems [ 23 ]. Ethical decision-making is closely intertwined with the reflective process, but differs in the sense that, when ‘deciding’, one also makes a choice from among the number of alternatives and thereby temporarily pauses the reflective process [ 23 ]. Nevertheless, being a student, especially encountering the clinical field for the first time, is a susceptible position, and it might be challenging for students to reflect on and make decisions. Particularly during the initial period of their placement, students mostly take part in caring actions that are already relatively settled and must learn how to implement prescribed caring chores.

Ranjbar et al. [ 46 ] developed a three-level model illustrating the route for moral development in nursing students. To achieve the final level of ethical competence, the students first pass through phases of development at the lower levels. As students enter their first year and are exposed to clinical practice, they begin acquiring practical and technical skills (first level). Here, their focus is essentially on acquiring and mastering these skills and being able to perform them with ease. It is at the second level that students advance in their ethical judgements. At level two, students can better reconstruct ethical problems and become more effective ethical agents. Until students reach level two, it is difficult for them to make sound ethical assessments without the support of others. In our study, the students’ abilities to take part in ethical reflections and ethical decision-making in practice varied. Some students were not very active in discussions concerning alternative actions and interventions to resolve ethical problems in their ward, but they expressed that they learned from observing and listening. Other students displayed a much more active role in the decision-making processes, discussing and sharing their views and opinions with staff, hence influencing the actions taken. Furthermore, the students often encountered ethical problems that arose unexpectedly or spontaneously and sometimes had to reflect there-and-then and decide what to do, often without supervision and without a prescribed recipe.

However, the process of learning how to understand and make decisions when encountering ethical problems in real-life nursing contexts continues to progress throughout the bachelor’s programme [ 21 ]. Managing ethical problems gave the students and participants confidence, triggering their potential to solve ethical problems now and in the future. However, the students expressed a need to take part in discussions and reflect on how to go forward in situations with ethical tension because they lacked the experience, knowledge and skills to navigate through ‘rugged terrain’. In many cases, the students said that, in their opinion, communication is crucial in solving ethical problems, and they need to reflect on and increase their skills using viable techniques and manners to initiate dialogue, mediation and persuading arguments.

According to Jakobsen et al. [ 21 ], using group discussions and discussing examples of ethical problems can help students engage in a more comprehensive reflection process. Discourse within the clinical setting has been outlined as a prerequisite concerning ethical competence [ 31 , 42 ]. Justifying a certain practice requires more than the competence of one individual; hence, the decision-making process should be based on a multitude of views and opinions, thus contributing to consolidating decisions throughout the healthcare team [ 42 ]. Crucial elements of knowledge and skills are transferred among clinicians through their mutual reflections on appropriate care actions. Hence, being part of ethical reflection is essential to nursing students’ learning [ 31 ]. According to a review of the empirical literature on nursing students’ ethical decision-making, discussions with contemporaries are perceived as the most influential source of developing ethical decision-making abilities [ 47 ]. In their study, Ramos et al. [ 31 ] found that ethical reflection serves as a mediator between the realisation of an ethical problem and the interventions that nursing students carry out. Discussing the problem at hand helps nursing students draw on both individual insights and others’ input, helping the students choose the best response to ethical issues. Sometimes, when lacking the opportunity to reflect, the students turned to peers and educators as sparring pairs, pondering the alternatives to problems. The students found peers to be central in this regard, with peers being in circumstances similar to themselves. Reflecting together with another person was essential to their understanding and ability to develop skills for assessing and knowing how to handle difficult situations. Using the CME model [ 20 ] was considered a fruitful method of sorting information as well as sorting objective facts from subjective emotions, hence resulting in greater clarity.

The students valued ethical reflection partly because they believed that some healthcare personnel’s interventions were based on poor assessments that did not sufficiently advocate for the residents; they also found that nurse preceptors or other employees were sometimes more concerned with getting the job done, avoiding extra work, and coping through the working day when assessing solutions to ethical problems. The students often mentioned ‘reflection’ both as a way of considering alternatives of action when facing ethical problems and as a way of processing their emotions while witnessing poor care and not having the courage to question nurse preceptors’ assessments. The results from a literature review on moral courage in undergraduate nursing students [ 48 ] highlight students’ strong identification with the role of patient advocacy. The same attitude was perceived by the participants in our study; they expressed that residents’ well-being was their primary objective. However, according to Bickhoff et al. [ 48 ], several factors inhibit nursing students from pursuing an advocacy role, sometimes also leading to students taking part in poor practice unintentionally or complying with unethical practices. The characteristics of nursing students’ experiences in their clinical studies, such as feeling or being subordinate on the ward, their identity as ‘just’ or ‘only’ a student, a desire to fit in, fear of reprisals and poor validation, have been reported in numerous studies [ 48 , 49 , 50 , 51 ]. These experiences diminish nursing students’ opportunities to take active roles in ethical reflections and decision-making and, thus, to take part in and influence the ward learning community. On the other hand, students who are given opportunities or who seize opportunities on their own to act as patients’ advocates report gaining the courage to voice their assessments and suggestions in the work environment [ 48 ]. The participants in our study expressed that they sometimes felt subordinate to the ward and were not given a voice, which hindered their ability to make sound assessments for the benefit of the residents. Nevertheless, some students, though not all, found the ability to seize opportunities to advocate for residents’ beneficial care.

Ethical action and ethical behaviour – the destination in sight

Ethical action involves implementing a course of action chosen after considering the possible alternatives, while ethical behaviour is characterised by an attitude of respect, responsiveness and support when carrying out the chosen action [ 23 ]. In a person with high ethical competence, ethical behaviour is embodied [ 23 ]. The students discussed actions they carried out to solve ethical problems, sometimes with nurse preceptors, peers or independently. Similar to the results of a systematic review [ 7 ], our study has revealed that students prioritised maintaining patients’ dignity, privacy and confidentiality, emphasised effective communication to resolve ethical issues and demonstrated a strong commitment to residents’ well-being. Consequently, the students showcased sound ethical behaviour.

Some students described the inability to act in accordance with ethical standards as a bodily experience of distress. One student mentioned that her feelings in tense situations settled in her body. According to Ranjbar et al. [ 46 ], the final level (level three) in the route for moral development in nursing students is where they internalise professional values and the ethos of nursing into their personal identity, making ethical actions and behaviour a reflection of their identity and personality. Few students reach this level during their nursing education [ 46 ]. Although it is difficult and impractical for us to claim that the students in our study had reached level three, their discussions rarely involved knowingly violating ethical values. When they did, they expressed discomfort. For example, one student described lying to a resident to get him indoors when he was not properly dressed because of cold weather, finding the experience distressing. Similar findings have also been presented in previous studies [ 52 , 53 ]. Nevertheless, even though nursing students tend to be idealistic and hold strong values [ 7 ], there is no guarantee that these values will consistently result in virtuous ethical actions and behaviours, either now or in the future.

A literature review investigating nurses’ ethical practices [ 54 ] revealed that contextual circumstances, such as limited time and resources and less authority in the ward hierarchy, can influence nurses’ ability to make decisions. These circumstances result in a conformist approach, adapting to existing practices and sometimes merely executing the decisions made by others. This, in turn, affects nurses’ internalisation of ethical behaviour and leads to less individually adapted care actions. Although this review [ 54 ] focused on professional nurses, there is evidence that nursing students’ ethical behaviour is similarly influenced by these circumstances. For example, Tanaka [ 55 ] reported that nursing students often adjust their ethical values to accommodate certain circumstances. Even when nursing students perceive the actions and behaviours of nurse preceptors as ‘wrong’, they may alter their stance on the issue and reorganise their ethical values to adopt coping behaviours that align with the situation. As a result, nursing students often struggle with prioritising their relationships, with nurses who exhibit inadequate care behaviours or with their commitment to patients. As nursing students progress through their programmes, they may become increasingly disillusioned, cynical and focused on completing their tasks, which ultimately ends with a loss of idealism [ 56 ].

The students participating in our study described instances in which they observed cynicism among certain employees and witnessed violations of residents’ dignity by nurse preceptors and other healthcare personnel. Examples included speaking over residents’ heads, ridiculing them and handling them roughly or even being disrespectful to residents’ family members. In these situations, the students often felt powerless and complicit, feeling ‘dragged along’ because of their subordinate role. Occasionally, they sought explanations from the nurse preceptors, but the responses varied in credibility. The students also observed commendable ethical actions from nurse preceptors, who demonstrated effective techniques for handling value-laden situations. Learning from these positive examples helped the students recognise ethical behaviours. They observed that the manner of coercion mattered and witnessed gentle, informative restraint techniques. Overall, the students were eager to adopt noncoercive approaches, seeking to balance assertiveness with positive persuasion.

Despite witnessing unethical actions and behaviours, these experiences did not necessarily hinder the students’ development of ethical competence. According to Engel et al. [ 57 ], experiencing unethical caregiving can actually strengthen students’ commitment to ethical practices. Most students act as informed bystanders and can navigate the space between observation and action. They may maintain a low profile while also developing the courage to advocate for patients. These adaptive strategies were evident among the students in our study. In distressing situations, the students occasionally assumed caregiving responsibilities to ensure proper care. For instance, when an employee force-fed a resident, a student intervened by gently and patiently helping the resident. We interpret this action as a coping strategy that bridges the gap between observation and action.

The students frequently mentioned that gaining confidence during their clinical studies might empower them to voice their concerns more effectively in the future. However, according to Bickhoff et al. [ 48 ], the lack of authority persists throughout the clinical curriculum, with students often assuming a subordinate role across different periods of clinical study. On a positive note, some students have reported that experiencing a lack of authority motivates them to avoid unethical practices in their future careers [ 48 ]. In our study, the students strongly expressed their desire to maintain their ability to advocate for residents’ best interests in the future. They observed that, for some healthcare personnel, the job had become routine, leading to a loss of perspective on ethical actions. The students were determined not to find themselves in a similar position in their careers.

Implications for nursing education and clinical practice

Findings from the current study suggest that building a solid ethical foundation in nursing involves more than just theoretical and practical knowledge. Several strategies are needed to sustain ethical practice and potentially mitigate moral distress among nursing students and nurses.

One crucial strategy is to integrate ethics education throughout the entire curriculum, rather than treating it as a standalone module. This should include case studies, role-playing, and discussions relevant to real-world scenarios. Additionally, providing strong mentorship and supervision during clinical placements is vital. Experienced nurse educators and preceptors can model ethical behavior, offer guidance, and support students as they navigate complex situations. Encouraging regular reflective practice is also important. Discussions, debriefing sessions, and peer interactions can help students process their experiences and deepen their understanding of their ethical beliefs and responses. Since learning does not occur in a vacuum, creating a supportive learning environment with access to guidance can assist students and nurses in addressing moral distress and seeking guidance. Furthermore, offering diverse and challenging experiential learning opportunities allows students to confront ethical issues in a controlled setting, hence building their confidence and competence in managing ethical problems. Finally, fostering a culture of ethical leadership within educational and clinical environments can set a standard of ethical behavior that positively influences nursing students and nurses.

Strengths and limitations of the study

The present study’s findings are based on participating students’ accounts of their experiences with ethical issues during their first clinical period in nursing homes. One limitation of the study is that the students’ subjective perceptions and narratives may not always accurately reflect their actual ethical actions and behaviour in a real-world caring context.

Out of the 113 invited students, only 28 agreed to participate. It is worth considering whether those students who chose not to participate would have described their experiences differently. Although the sample size was limited to 28 participants across six focus groups, our transcription and analysis of the data indicated that saturation was achieved after the final focus group. Furthermore, our goal has not been to generalise but rather to present a possible interpretation of how ethical competence evolves in nursing students in the context of clinical studies in nursing homes.

Another potential limitation could stem from our interpretations, which might be shaped by our preconceptions, particularly because all the authors are nurse educators engaged in students’ clinical studies in nursing homes and know the curriculum well. To counter potential bias, we rigorously adhered to the data as they emerged from the transcripts.

Another challenge we encountered relates to the varied use of concepts concerning ethical practices by different authors [ 23 , 54 ]. While reviewing the literature on nursing students and their ethical competence, we observed that some studies aimed at exploring or describing ethical decision-making in students but primarily focused on aspects of ethical sensitivity. Therefore, in certain instances, we needed to heavily rely on specific findings from these studies, even if they did not align perfectly with their original aims. Throughout this process, we aimed to maintain accuracy and fairness in referencing other studies.

Some of the studies we have referenced in our discussion were older than five years and were conducted in contexts that may not resemble the environment of Norwegian or Nordic nursing education. Because of the limited research exploring ethical competence in nursing students, we reviewed these studies to provide supporting knowledge for our findings. The geographical differences between the places where the studies were conducted and our study could have led to discrepancies in our discussion of the development of students’ ethical competence during their initial clinical study period in Norwegian nursing homes. However, we did not find studies with aims similar to ours, so our discussion draws on the findings of Lechasseur et al. [ 23 ] and the general literature describing nursing students’ experiences with ethical issues in diverse and varying contexts. However, we believe that ethical competence in nursing students evolves during their theoretical and clinical education, regardless of their country of origin; therefore, our findings could be applicable to similar settings and practices among nursing students.

The aim of the present study was to explore the development of ethical competence in first-year nursing students during their first clinical placements in nursing homes. Our naïve understanding was that the ethical challenges students encounter in their clinical studies often conflict with their theoretical ethical knowledge and personal values. The students navigated complex ethical situations by reflecting on their experiences, expanding and adapting their knowledge base and internalising ethical principles in their actions. Through structural analysis, we identified three key themes that are considered essential preconditions for the development of ethical competence in nursing students. Our comprehensive understanding of the findings reveals that nursing students embark on a journey towards ethical competence, with clinical experiences serving as pivotal milestones.

Our findings illustrate that nursing students’ ethical competence evolves in complex ways when they first time are exposed to clinical settings. The first clinical period in nursing homes offers real-life insights into both ethical and less ethical care practices. Acting as informed observers or active participants in ethical problems involving nursing home residents offers students a unique perspective to critically evaluate care options that are distinct from those immersed in the ward culture. However, students’ ability to resist conventional practices and progress on their ethical journey may vary. Moments of reflection and supportive interactions are crucial for sustaining momentum on this journey. Therefore, peers, nurse preceptors, and nurse educators play vital roles in guiding students by providing robust support and navigation.

Our study suggests that structured professional development in nursing homes should prioritise the reflective supervision of students during their initial clinical placements. Educational institutions should continue to enhance and expand ethical reflection-based learning activities and opportunities for students and their peers during their clinical training.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Student [number] participant in focus group interviews

Focus group [number]

Hemberg J, Hemberg H. Ethical competence in a profession: Healthcare professionals’ views. Nurs Open. 2020;7(4):1249–59.

Article PubMed PubMed Central Google Scholar

Kangasniemi M, Pakkanen P, Korhonen A. Professional ethics in nursing: an integrative review. J Adv Nurs. 2015;71(8):1744–57.

Article PubMed Google Scholar

Ulrich CM, Taylor C, Soeken K, O’Donnell P, Farrar A, Danis M, Grady C. Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs. 2010;66(11):2510–9.

Waterfield D, Barnason S. The integration of care ethics and nursing workload: a qualitative systematic review. J Nurs Manag. 2022;30(7):2194–206.

Čartolovni A, Stolt M, Scott PA, Suhonen R. Moral injury in healthcare professionals: a scoping review and discussion. Nurs Ethics. 2021;28(5):590–602.

Robichaux C. Developing ethical skills: from sensitivity to action. Crit Care Nurse. 2012;32(2):65–72.

Parandeh A, Khaghanizade M, Mohammadi E, Mokhtari Nouri J. Factors influencing development of professional values among nursing students and instructors: a systematic review. Glob J Health Sci. 2014;7(2):284–93.

Standing M. Clinical decision-making skills on the developmental journey from student to registered nurse: a longitudinal inquiry. J Adv Nurs. 2007;60(3):257–69.

Andersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics. 2022;23(1):29.

Cannaerts N, Gastmans C, Dierckx de Casterlé B. Contribution of ethics education to the ethical competence of nursing students: educators’ and students’ perceptions. Nurs Ethics. 2014;21(8):861–78.

Khatiban M, Falahan SN, Amini R, Farahanchi A, Soltanian A. Lecture-based versus problem-based learning in ethics education among nursing students. Nurs Ethics. 2019;26(6):1753–64.

Kaşıkçı M, Yıldırım Z. Interventions to improve ethical decision-making skills in nursing students: a systematic review. Nurs Ethics 2024:9697330241239917.

Ozgonul L, Alimoglu MK. Comparison of lecture and team-based learning in medical ethics education. Nurs Ethics. 2019;26(3):903–13.

Zhang F, Zhao L, Zeng Y, Xu K, Wen X. A comparison of inquiry-oriented teaching and lecture-based approach in nursing ethics education. Nurse Educ Today. 2019;79:86–91.

Pitkänen S, Kääriäinen M, Oikarainen A, Tuomikoski AM, Elo S, Ruotsalainen H, Saarikoski M, Kärsämänoja T, Mikkonen K. Healthcare students’ evaluation of the clinical learning environment and supervision - a cross-sectional study. Nurse Educ Today. 2018;62:143–9.

Vizcaya-Moreno MF, Pérez-Cañaveras RM, Jiménez-Ruiz I, Herrero JJ. Student nurse perceptions of supervision and clinical learning environment: a phenomenological research study. Enferm Glob. 2018;17(3):319–31.

Article Google Scholar

Mezirow J. Transforamtive dimensions of adult learning. San Francisco: Josey-Bass; 1991.

Google Scholar

New Regulation on. a common framework for health-and social studies [In Norwegian]. Retrieved 05.05.2024 from: https://lovdata.no/dokument/SF/forskrift/2017-09-06-1353

Oslo Metropolitan University: Bachelor’s Programme in Nursing. Oslo: Department of Nursing and Health Promotion. 2023. Retrived 07.05.2024 from: https://student.oslomet.no/en/studier/-/studieinfo/programplan/SYKP/2023/H%C3%98ST

Førde R, Pedersen R. Clinical ethics committees in Norway: what do they do, and does it make a difference? Camb Q Healthc Ethics. 2011;20(3):389–95.

Jakobsen LM, Sunde Maehre K. Can a structured model of ethical reflection be used to teach ethics to nursing students? An approach to teaching nursing students a tool for systematic ethical reflection. Nurs Open. 2023;10(2):721–9.

Kulju K, Stolt M, Suhonen R, Leino-Kilpi H. Ethical competence: a concept analysis. Nurs Ethics. 2016;23(4):401–12.

Lechasseur K, Caux C, Dollé S, Legault A. Ethical competence: an integrative review. Nurs Ethics. 2018;25(6):694–706.

Hakbilen HG, Ince S, Ozgonul ML. Ethical sensitivity of nursing students during a 4-Year nursing curriculum in Turkey. J Acad Ethics. 2023;21(1):41–51.

Chen Q, Su X, Liu S, Miao K, Fang H. The relationship between moral sensitivity and professional values and ethical decision-making in nursing students. Nurse Educ Today. 2021;105:105056.

Park M, Kjervik D, Crandell J, Oermann MH. The relationship of ethics education to moral sensitivity and moral reasoning skills of nursing students. Nurs Ethics. 2012;19(4):568–80.

Shayestehfard M, Torabizadeh C, Gholamzadeh S, Ebadi A. Ethical sensitivity in nursing students: developing a context-based Education. Electron J Gen Med. 2020;17(2):e195.

Albert JS, Younas A, Sana S. Nursing students’ ethical dilemmas regarding patient care: an integrative review. Nurse Educ Today. 2020;88:104389.

Heggestad AKT, Nortvedt P, Christiansen B, Konow-Lund AS. Undergraduate nursing students’ ability to empathize: a qualitative study. Nurs Ethics. 2018;25(6):786–95.

Moe CS. Relationship of ethical knowledge to action in senior baccalaureate nursing students. Nurs Educ Perspect. 2018;39(6):363–5.

Ramos FR, Brehmer LC, Vargas MA, Trombetta AP, Silveira LR, Drago L. Ethical conflicts and the process of reflection in undergraduate nursing students in Brazil. Nurs Ethics. 2015;22(4):428–39.

Hunter D, McCallum J, Howes D. Defining exploratory-descriptive qualitative (EDQ) research and considering its application to healthcare. J Nur Healthc. 2019;4(1):1–8.

Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334–40.

Article CAS PubMed Google Scholar

Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77–84.

Barbour R. Doing focus groups. In., 2nd edn. Edited by Flick U. Los Angeles: SAGE Publications; 2018.

Kallio H, Pietilä A-M, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016;72(12):2954–65.

WMA. World Medical Association Declaration of Helsinki: ethical principles for Medical Research Involving human subjects. JAMA. 2013;310(20):2191–4.

Lindseth A, Norberg A. A phenomenological hermeneutical method for researching lived experience. Scand J Caring Sci. 2004;18(2):145–53.

Hennink M, Kaiser BN. Sample sizes for saturation in qualitative research: a systematic review of empirical tests. Soc Sci Med. 2022;292:114523.

Whittemore R, Chase SK, Mandle CL. Validity in qualitative research. Qual Health Res. 2001;11(4):522–37.

Weaver K, Morse J, Mitcham C. Ethical sensitivity in professional practice: concept analysis. J Adv Nurs. 2008;62(5):607–18.

Reiter-Theil S, Mertz M, Schürmann J, Stingelin Giles N, Meyer-Zehnder B. Evidence - competence - discourse: the theoretical framework of the multi-centre clinical ethics support project METAP. Bioethics. 2011;25(7):403–12.

Fantinelli S, Cortini M, Di Fiore T, Iervese S, Galanti T. Bridging the gap between theoretical learning and practical application: a qualitative study in the Italian Educational Context. Educ Sci. 2024;14:198.

Hatlevik I, Smeby J-C. Programme coherence and epistemological beliefs. Nordic Psychol. 2015;67(2):136–53.

Krautscheid L, Brown M. Microethical decision making among baccalaureate nursing students: a qualitative investigation. J Nurs Educ. 2014;53(3):S19–25.

Ranjbar H, Joolaee S, Vedadhir A, Abbasszadeh A, Bernstein C. An Evolutionary Route for the Moral development of nursing students: a Constructivist grounded theory. J Nurs Res. 2018;26(3):158–67.

Numminen OH, Leino-Kilpi H. Nursing students’ ethical decision-making: a review of the literature. Nurse Educ Today. 2007;27(7):796–807.

Bickhoff L, Sinclair PM, Levett-Jones T. Moral courage in undergraduate nursing students: a literature review. Collegian. 2017;24(1):71–83.

Bril I, Boer HJ, Degens N, Fleer J. Nursing students’ experiences with clinical placement as a learning environment for assertiveness: a qualitative interview study. Teach Learn Nurs. 2022;17(4):383–91.

Najafi Kalyani M, Jamshidi N, Molazem Z, Torabizadeh C, Sharif F. How do nursing students experience the clinical learning environment and respond to their experiences? A qualitative study. BMJ Open. 2019;9(7):e028052.

Hosseini SH, Tayebi Z, Poormoosa Poostin Saraee Y. Nursing students’ perception of nurses’ professional misconduct: a descriptive qualitative study. JMED. 2024;17(53):34–44.

Curtis DA, Braziel JM, Redfearn RA, Hall J. Lying to patients: Ethics of deception in nursing. Clin Ethics. 2020;16(4):341–6.

Pritchard J. Using therapeutic lies – an ethical challenge for nurses when caring for people with dementia. Nurs Older People; 2024.

Goethals S, Gastmans C, de Casterlé BD. Nurses’ ethical reasoning and behaviour: a literature review. Int J Nurs Stud. 2010;47(5):635–50.

Tanaka M. Thoughts and feelings that determine how Japanese nursing students deal with ethical issues: a qualitative study. Int J Ethics Educ. 2021;6(2):323–37.

Arries EJ. Professional values and ethical ideology: perceptions of nursing students. Nurs Ethics. 2020;27(3):726–40.

Engel J, Salfi J, Micsinszki S, Bodnar A. Informed strangers: Witnessing and responding to unethical care as Student nurses. Glob Qual Nurs Res. 2017;4:2333393617730208.

PubMed PubMed Central Google Scholar

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Acknowledgements

The authors express their gratitude to the students who participated in this study, thereby contributing to the data collection. Additionally, the authors sincerely thank Oslo Metropolitan University Library for granting approval and for their support in covering the publication fee of this article.

Open access funding provided by OsloMet - Oslo Metropolitan University. This research received no specific grant from any agency in the public, commercial or not-for-profit sectors. Open Access funding was provided by the University Library – Oslo Metropolitan University.

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Sylvia Hansen, Elisabeth Hessevaagbakke, Katrin Lindeflaten, Kaja Elvan & Daniela Lillekroken

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SH was involved in data collection and analysis, reflection, discussions regarding the manuscript’s intellectual content, and drafting the manuscript. DL contributed to the study conception, data collection, and analysis, and was involved in revising the manuscript critically for important intellectual content. EH, KL, KE were involved in data collection, analysis, and discussions regarding the manuscript’s intellectual content. All authors agreed to be accountable for all aspects of work and take public responsibility for appropriate parts of the content.

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The study was approved by the Norwegian Agency for Shared Services in Education and Research (Sikt/Ref. nr. 334855) and by the leader of the Department of Nursing and Health Promotion at Oslo Metropolitan University. This study does not seek to investigate participants’ health status, sexuality, ethnicity, or political affiliation (sensitive information); therefore, it is exempt from ethical approval by the Norwegian Regional Committees for Medical and Health Research Ethics as no health information or patient data are recorded. The study adhered to the principles outlined in the Declaration of Helsinki and followed Oslo Metropolitan University’s guidelines and regulations. Data confidentiality was strictly maintained, and the information was used solely for research purposes. Participant anonymity was safeguarded by not detailing participant characteristics in the paper. Researchers provided both verbal and written information about the study, and written voluntary informed consent was obtained from all participants prior to data collection.

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Hansen, S., Hessevaagbakke, E., Lindeflaten, K. et al. Nurturing ethical insight: exploring nursing students’ journey to ethical competence. BMC Nurs 23 , 568 (2024). https://doi.org/10.1186/s12912-024-02243-x

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critical thinking skills of nursing students in lecture based teaching and case based learning

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Case-based learning in nursing education

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Comparison Between Problem-Based Learning and Lecture-Based Learning: Effect on Nursing Students’ Immediate Knowledge Retention

Yonatan solomon.

1 Department of Nursing, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia

The basic role of teaching at any degree of training is to bring a rudimentary change within the student. To facilitate the method of information transmission, educators ought to apply acceptable teaching strategies that best suit specific objectives and outcomes. Identifying the best method through comparison of problem-based learning (PBL) and the lecture method; so as to improve students’ overall academic performance appear to be important.

The aim of the study was to undertake comparison between problem-based and lecture-based learning methodologies for immediate knowledge retention of nursing students at Dire Dawa University.

Quantitative research method which used a pre-experimental two group pretest and post-test research design was employed to identify effective teaching methods for immediate knowledge retention on 38 nursing students from June 1 to June 15, 2019. The students were grouped randomly into problem-based learning and lecture methods. The pretest-posttest analysis was done after an intervention made: a two-hour lecture and four-hour problem-based learning accordingly. Content validity ratio and content validity index was conducted for authentication of instruments and Cronbach alpha was computed to verify its reliability. A paired t -test was conducted to identify mean score change, and p<0.05 was cut off value to determine if there is a significant mean change in the posttest.

Both methods showed significant knowledge score improvement (t=13.6, p< 0.001) for lecture-based method and (t=11.302, p< 0.001) for problem-based learning. But as compared to the lecture method, problem-based learning has little effect on students’ immediate knowledge retention, and 63.2% of the nursing students prefer the lecture method as the best teaching method.

The lecture method is the best teaching method for immediate knowledge retention for nursing students; it is also the most preferred method of teaching method by the students.

Introduction

Education is a constant strategy that includes achieving alluring changes in students using proper techniques. Advanced education staff endeavors to turn out to be more powerful instructors, so that, students can acquire and learn better, and many investigate techniques to improve their educational practice. 1

With the upheaval in innovation, education throughout the years has transformed hugely tremendously from paper-pen to computer. The conventional teaching techniques are supplanted by new progressed educating techniques. Current students are technologically progressed, which gives them account everything at a flash of speed. Cooperative learning and classroom teaching help more of practical knowledge. 2

The most acknowledged standard for the mensuration of smart teaching is that the quantity of student learning that occurs. There are reliably high relationships between students’ appraisals of the “amount learned” within the course and their general evaluations of the educator and the course. Those who have learned more gave their instructors higher evaluations. 4 This equivalent standard was likewise advanced by Thomas Angelo when he said; “teaching without learning is simply talking.” A teacher’s effectiveness is once more all about the presence of a student’s learning. 5

Teaching methods work successfully primarily on the off chance that they suit students’ desires needs since each student deciphers and reacts to inquiries in a very distinctive way. As such, the arrangement of teaching strategies with students’ desires and the most popular learning influence students’ scholastic achievements. 6

Most universities embrace methods by that students give anonymous feedback at the end of each course they complete. These ratings of teacher effectiveness have been a hotly debated issue since they were initially utilized in the mid-1920, and they produce a vast challenge for nearly every establishment that utilizes them. 7

Throughout the long-term student assessment of educators has changed considerably particularly in the regions of the purpose and methodology. They have changed from being principally used to help students in the choice of courses, to helping teachers’ further advance and improve their instructing abilities and assist managers concerning employees’ decisions. 8

The study conducted by Shahida on effective teaching methods at the university level showed that the majority of the students evaluated the lecture method as the best teaching method. Some of the reasons involved; the teacher gives all the information related to the subject, time-saving, students listen thoughtfully to lectures and take short notes, etc. 9

Lectures are one of the most broadly used teaching methods in medical and nursing education. It has been recommended that teaching methods that improve participation and boost self-facilitated learning can be ground-breaking in passing core knowledge and clarifying vague notions inciting augmentation of learning. 10 But currently, lectures are being continuously changed by team-based learning like the introduction of problem-based learning (PBL) which marks the revolution in some medical and nursing education. 11

PBL is one of the most regularly utilized instructive strategies in clinical schools. In this technique, students use clinical cases to describe their learning targets. The effectiveness of PBL relies upon the quality of the clinical cases. 12

PBL surges thorough training and helps students to accomplish better in assessments. 13 Although allies of PBL express that learning inspiration is one of the benefits of this method, others indicate that it is time-consuming, and does not give a better clinical competence. 14

Numerous investigations were conducted to compare PBL with lecture-based learning. Regarding knowledge acquisition, studies showed various outcomes; In some studies, PBL did not show any tendency over lecture-based learning on the learners’ knowledge. 15–17 On the other hand,; various studies revealed that students got an improved result in the PBL method. 18 , 19

A broad inquiry showed that researches in the field of education are very scarce and the same is true in nursing education. Accordingly, this study was conducted to compare the effect of PBL and the lecture methods on the immediate knowledge retention of nursing students at Dire Dawa University.

The finding of this study will give helpful experiences in understanding the effect of PBL and the lecture method on the immediate knowledge retention of nursing students. Additionally, by uncovering the reasons for perceiving any teaching method as the best one, important recommendations will be provided to higher education teachers for improving the quality of nursing education concerning students’ insight.

Research Questions

Which teaching method [PBL or Lecture] has a great impact on the students’ immediate knowledge retention? And which teaching method [PBL or Lecture] is more preferred by the students? And why?

Methods and Materials

Study setting.

This study was conducted at Dire Dawa University, College of Medicine and Health Sciences (CMHS), Department of Nursing, from June 1 to June 15, 2019. Dire Dawa is situated in the eastern part of the country with a distance of 515 km from Addis Ababa.

DDU is a young higher institution, established and started its teaching and learning activities in 2007 G.C. academic year. The establishment of the university is in line with the Ethiopian Government’s willingness and determination to expand higher education coverage and ensure its equitable distribution across the country to produce competent human resources and research outputs to meet the national development policy and poverty reduction strategy. Now in the 2018 academic year DDU has one Institute of Technology and Five College (College of Natural & Computational Science, College of Business & Economics, College of Social Sciences & Humanities, College of Law, and College of Medicine and Health Science) containing 33 different academic programs. The enrolment has grown to 12,500 regular students in 39 different academic programs. 20

Study Design

Quantitative research approach which uses the pre-experimental two groups: pre-test and post-test research design were employed.

First-year nursing students of the 2019 academic year.

Inclusion Criteria

First-year B.Sc. Nursing students who were admitted to the Dire Dawa University Nursing department, and those students who had completed the first year, first semester examination.

Sample Size

All 38 nursing students were included in the study.

Sampling Methods

Simple random technique was used to divide the students into two groups PBL and lecture method.

Data Collection Tools and Techniques

Questionnaire was one of the data collecting tools. Thus, the questionnaire had three sections: Section I comprises demographic data of the students [age, sex]; section II comprises questions that assess knowledge retention of a specific topic (organophosphate poisoning) for lecturing method and PBL; section III comprises questions that assess student’s preference of teaching methods using Likert scale and an open-ended questionnaire was used to assess student’s reasons for their preferences.

Quantitative content validity assessment was performed based on the content validity ratio (CVR) and content validity index (CVI = 0.81) and a reliability test was also conducted giving a Cronbach alpha result of 0.86.

Regarding the scoring of the questions, if students answer the question, they will get one (1) mark if not, they will get zero (0) mark.

To prevent any form of intervention/teaching bias; both sessions were given by Adult Health Nursing experts and the learning objectives were also similar as it is seen in the nursing curriculum. The author also approved the entire lesson plan for both teaching methods. Additionally, the instructor who delivers the PBL session was trained to run the session.

First, as a baseline demographic data were gathered and administered the pretest for both groups then after the administration of the intervention/lectures and PBL, a posttest was given for both groups.

Data Processing and Analysis

The data were analyzed using SPSS software version 21 for frequency and percentage and presented using table/descriptive statistics and paired t -test was computed to identify mean score change and p<0.05 was cut of value to determine there is a significant mean change in the posttest.

Ethical Consideration

The study strictly followed the principles outlined in the Declaration of Helsinki in addition to obtaining ethical clearance from Dire Dawa University department of Nursing on the date of 12/02/2019 with Ref No: DN/016/19. During the data collection, each respondent was informed about the aim of the study. Participants’ consent was obtained from the study participants before study commencement. The data collectors also discussed the issue of privacy, the confidentiality of the information obtained during the interview, and both verbal and written informed consent was obtained from respondents. Respondents were provided with an information sheet which contains the following main points: purpose/aim of the study, procedure and duration of the interview, risks and benefits of participation, confidentiality and rights of the participants, and contact address of the researcher for any questions and finally declaration of informed voluntary consent.

Socio-Demographic Characteristics

From the total of Nurse Student participants, 22 (57.9%) were males and the mean age were 20.45 year (SD 1.20) (see Table 1 ). When we see students, characteristics based on the two groups; Lecture Method: From a total of 19 participants 31.6% of them were 20 years of age while 68.4% of them were Males; Problem-Based Learning: From those students who participated in PBL 26.3% of them were 20 years of age and 52.6% of them were females.

Distribution of Participant Nurse Students by Their Characteristics of a Study Conducted on Effective Teaching Methods for Immediate Knowledge Retention Among Nursing Students of Dire Dawa University, Eastern Ethiopia 2019 (n=38)

Participant Characteristics		No	%
Sex	Male	22	57.9
Sex	Female	16	42.1
Age	19	10	26.3
	20	11	28.9
	21	9	23.7
	22	6	15.8
	23	2	5.3

Table 2 demonstrates that the knowledge score was increased from the pre-test (M=6.68, SD=2.05) to the posttest (M=14.89, SD=2.62). The difference was significant at (95%) confidence interval with (t=13.6, p<0.001) showing that the lecture method has a statistically significant effect on the immediate knowledge retention of nursing students.

Mean Score of Overall Knowledge Retention of Nursing Students in Lecture Method of a Study Conducted on Effective Teaching Methods for Immediate Knowledge Retention Among Nursing Students of Dire Dawa University, Eastern Ethiopia 2019 (n=38)

	Mean	SD	T		-value
Pretest	6.89	2.052	13.620	18	<0.001
Posttest	14.89	2.622	13.620	18	<0.001

Table 3 also shows that the knowledge score was increased from the pre-test (M=6.89, SD=1.82) to the posttest (M=11.79, SD=2.85). The difference was significant at (95%) confidence interval with (t=11.30, p<0.001) showing that the PBL has a statistically significant effect on the immediate knowledge retention of nursing students. But when we compare the Lecture method with the PBL; PBL has a poor impact on immediate knowledge retention as compared to the Lecture method.

Mean Score of Overall Knowledge Retention of Nursing Students in PBL Method of a Study Conducted on Effective Teaching Methods for Immediate Knowledge Retention Among Nursing Students of Dire Dawa University, Eastern Ethiopia 2019 (n=38)

	Mean	SD	T		-value
Pretest	6.68	1.827	11.302	18	<0.001
Posttest	11.79	2.859	11.302	18	<0.001

Nursing Students’ Preferred Teaching Method

Regarding nursing students’ preferences, 63.2% of them preferred the Lecture method as the most effective teaching method while 36.6% rate PBL as the best teaching method.

Reasons for Nursing Students’ Preferred Teaching Method

The Lecture method was regarded as the best method by 63.2% of nursing students for the subsequent reasons:

Instructors making the lesson simpler.
Instructors are well organized.
Instructors use references which are best and relies on their knowledge.
The use of an LCD projector makes it interesting and easy to follow.
Absence of alteration.
Short notes given by instructors are more important and handily comprehended just as it turns out to be simple during an assessment.
We generally rely upon the short notes of the instructor which we get thoroughly from the instructors.
Use of instructor’s short note is useful during exams.
Usually, lesson plans are well organized.
Overall management of classrooms which is mainly done by instructors form a conducive environment for the teaching-learning process.

Problem-based learning is regarded as the best method by 36.6% of nursing students for the subsequent reasons:

Students are vigorously engaged in the lesson, making it easier for understanding.
Greatly improves leadership abilities.
Enhances decision-making capacity.
Increases the confidence level of students.

The finding of the current study revealed that the lecture method has a better statistically significant effect on immediate knowledge retention as compared to problem-based learning. This means lecture method is more helpful for having an immediate knowledge retention than PBL. This finding is similar to other findings from Korea and Asia 15–17 but it is different from findings from other studies. 18 , 19 This might be because lecturing inclines to encourage “surface” learning, which enables the students to recall what was covered in the sessions.

In contrast, PBL encourages “deep understanding” so that students focus on searching for meaning rather than reproduction. 21 , 22 , Another possible explanation is that Blake also recommended that PBL particularly enhanced students’ capacity on the application of knowledge rather than immediate knowledge retention. 23 Additionally, the variation of different styles of different instructors might affect the outcome of students’ learning.

PBL was prepared for advanced education and for students who already have developed self-directed learning skills, and it is not hard to conclude that those students would do better in a test that only requires simple retrieving of knowledge than in a test that has knowledge application and in-depth analysis (advanced stage).

The other explanation could be that the author believes that; for a long period the Ethiopian education system encourages memorization of knowledge rather than the application; noting the fact that PBL was introduced to the higher education system of Ethiopia too late than the developed world. Pre dominantly starting from lower grade to higher education; the students have been learned through lectures; which could be another factor.

The finding of this study showed that the majority of the students regarded the lecture method as the best method. The reason behind their preference includes; instructors making the lesson simpler, instructors are well organized, absence of alteration, use of instructor’s short note is useful during exams, usually, lesson plans are well organized, etc.

Similarly, a study conducted by Shahida S. revealed that most of the students rated the lecture method as the best teaching method. Reasons included; the teacher gives all the information related to the subject, time-saving, students listen thoughtfully to lectures and take short notes, etc. 9

Limitation of the Study

The author recognizes the small sample size of the study as a major limitation.

The lecture method has a remarkably good effect on immediate knowledge retention as compared to problem-based learning. Even though both lecture and PBL methods have a statistically significant effect on students’ immediate knowledge retention, nursing students rate the lecture method as the best one. Even though the lecture method is the most traditional, it is still preferred by nursing students over problem-based learning.

The author reports no conflicts of interest for this work.

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PDF Critical Thinking Skills of Nursing Students in Lecture-Based Teaching
A strategy that promotes students' active learning is case-based learning (CBL). The purpose of this study was to examine critical thinking (CT) abilities of nursing students from two different curricular approaches, CBL and didactic teaching. The design used in this research was a comparative descriptive survey.
Critical Thinking Skills of Nursing Students in Lecture-Based Teaching
In today's technologically advanced healthcare world, nursing students should be active learners and think critically to provide safe patient care. A strategy that promotes students' active learning is case-based learning (CBL). The purpose of this study was to examine critical thinking (CT) abilities of nursing students from two different curricular approaches, CBL and didactic teaching. The ...
Critical Thinking Skills of Nursing Students in Lecture-Based Teaching
DOI: 10.20429/IJSOTL.2011.050220 Corpus ID: 6615021; Critical Thinking Skills of Nursing Students in Lecture-Based Teaching and Case-Based Learning @article{Kaddoura2011CriticalTS, title={Critical Thinking Skills of Nursing Students in Lecture-Based Teaching and Case-Based Learning}, author={Mahmoud A Kaddoura}, journal={The International Journal for the Scholarship of Teaching and Learning ...
Critical Thinking Skills of Nursing Students in Lecture-Based Teaching
Problem-based learning. In A.J. Lowenstein & M.J. Bradshaw (Eds.), Fuszard's innovative teaching strategies in nursing (3rd ed., pp. 83-106). Gaithersburg, MD: Aspen. Bowles, K. (2000). The relationship of critical thinking skills and the clinical judgment skills of baccalaureate nursing students. Journal of Nursing Education, 38(8), 373-376.
Teaching Strategies for Developing Clinical Reasoning Skills in Nursing
Case-based learning was used to explore and demonstrate the feasibility of implementing unfolding cases in lectures to develop students' critical-thinking abilities . The web-based concept mapping of nursing students was also investigated to determine its impact on critical-thinking skills [ 30 ].
The effectiveness of case-based learning in increasing critical
One method that can be used to improve students' critical thinking skills is the case-based learning method, which has been a new method in nursing education. 8 Case-based learning (CBL) is a method that applies nursing clinic cases that are tailored to the field of science in the case. 9 The application of case studies can improve critical ...
Practice and effectiveness of "nursing case-based learning" course on
Comparison of the effectiveness of two styles of case-based learning implemented in lectures for developing nursing students' critical thinking ability: a randomized controlled trial ... The study suggests that nursing education programs should prioritize teaching critical thinking skills in clinical settings as it is an essential subject in ...
Comparison of the effectiveness of two styles of case-based learning
Purpose: To explore and compare the effectiveness of two styles of case-based learning methods, unfolding nursing case and usual nursing case, implemented in lectures for developing nursing students' critical thinking ability. Methods: 122 undergraduate nursing students in four classes were taught the subject of medical nursing for one year.
Practice and effectiveness of "nursing case-based learning" course on
1. Introduction. University nursing education is to convey theoretical knowledge and cultivate the abilities of students to critically analyze evidence, thus reaching optimal care decisions when faced with complicated clinical issues (Ward and Morris, 2016; Raymond et al., 2018).Scheffer and Rubenfeld (2000) stated that, critical thinking ability in nursing include analyzing, applying ...
Simulation-Based Learning Supported by Technology to Enhance Critical
The research may identify nursing students' reported barriers and enablers for learning critical thinking skills through simulation-based learning supported by technology, and the results may help educators enhance their educational approach through knowledge of students' firsthand experiences and further development of successful teaching ...
Nursing Students' Views and Suggestions About Case-Based Learning
Critical thinking skills of nursing students in lecture-based teaching and case-based learning. International Journal for the Scholarship of Teaching and Learning, 5 (2), 1-18. 10.20429/ijsotl.2011.050220 [Google Scholar] Kanbay Y., Okanlı A. (2017). The effect of critical thinking education on nursing students' problem-solving skills.
The effectiveness of case-based learning in increasing critical
The Case-Based learning approach is a venue for the students to apply the knowledge gained in the classroom and explore the new knowledge by solving the case-based real-life problems.
"Critical Thinking Skills of Nursing Students in Lecture-Based Teaching
In today's technologically advanced healthcare world, nursing students should be active learners and think critically to provide safe patient care. A strategy that promotes students' active learning is case-based learning (CBL). The purpose of this study was to examine critical thinking (CT) abilities of nursing students from two different curricular approaches, CBL and didactic teaching. The ...
Development of Critical Thinking Skills in Nursing Students
as video and audio files within a real-life context. After exposure to the multi-media case studies, students' critical thinking skills were significantly enhanced (Heiney et al., 2019). An emerging strategy to teach critical thinking skills in nursing education is the implementation of the 'Adaptive Learning' (AL) platform.
Practice and effectiveness of "nursing case-based learning ...
Background: Case-based Learning was an effective and highly efficient teaching approach that was extensively applied in education systems across a variety of countries. Critical thinking ability is an important indicator for access the study ability for baccalaureate nursing education. Objectives: The study aimed to explore the effect of "nursing case-based learning" course on the critical ...
The effectiveness of case-based learning in increasing critical
DOI: 10.1016/j.enfcli.2019.07.073 Corpus ID: 214627968; The effectiveness of case-based learning in increasing critical thinking of nursing students: A literature review. @article{Sapeni2020TheEO, title={The effectiveness of case-based learning in increasing critical thinking of nursing students: A literature review.}, author={Muhammad Al-amin R. Sapeni and Syahrul Said}, journal={Enfermeria ...
Effectiveness of Problem-Based Learning on Development of Nursing
Problem-based learning (PBL) is an innovative teaching method that has gained widespread application among institutions worldwide, particularly in the fields of medical and nursing education. 6, 7 As described by Zakaria et al, 8 PBL is a student-centered, outcome-based approach that has been proven to enhance the quality of learning across ...
PDF Teaching and Learning in Nursing
fi. learning strategies. Despite the increased discussion of and evidence for active learning, it is not clear how frequently nurse educators choose to use lectures or active learning in their classes. This study examined the extent to which nursing faculty across schools of nurs-ing use lecture versus active learning.
Critical thinking skills in nursing students: a comparison between
The mean critical thinking scores were 11.79 ± 4.80 and 11.21 ± 3.17 for the freshmen and the senior students, respectively (P = 0.511). Moreover, no significant correlation was found between the students' score in CTS and their age, gender, high school grade point average (GPA), rank in university entrance examination (RUEE) and interest in ...
Nurturing ethical insight: exploring nursing students' journey to
Background Ethical competence is a key competence in nursing and the development of the competence is a central part in nursing education. During clinical studies, nursing students face ethical problems that require them to apply and develop their ethical knowledge and skills. Little is known about how ethical competence evolves during students' initial clinical placements. This study ...
Case-based learning in nursing education
Case-based learning is a recommended method in combination with other pedagogical methods for nursing education that allows the students the opportunity to use their knowledge and critical thinking during problem-solving practice. Aim: The aim of this study was to describe students' experiences with case-based learning as a pedagogical method in nursing education.
Comparative study on the effects of role changes in simulation training
Undergraduate nursing practicum courses should offer an environment that fosters the development of competencies required for integrating the theory and skills necessary for appropriate nursing care in various clinical situations (Korean Accreditation Board of Nursing Education, 2023). However, nowadays, clinical practicum for nursing students tends to primarily focus on observation-centered ...
Comparison Between Problem-Based Learning and Lecture-Based Learning
Even though both lecture and PBL methods have a statistically significant effect on students' immediate knowledge retention, nursing students rate the lecture method as the best one. Even though the lecture method is the most traditional, it is still preferred by nursing students over problem-based learning.