Table 2 Characteristics of the included articles
References and country | Design | Aim | Participants | Data collection | Analysis | Key findings | Quality scores |
|---|---|---|---|---|---|---|---|
Baykara et al. [15], Turkey | Quantitative | To determining the effect of ethics training on fourth-year students of the nursing department on recognition of ethical violations experienced in the hospital and the development of ethical sensitivity | 50 nursing students | Questionnaires Observation form | Analytical and descriptive statistics | Moral Sensitivity Questionnaire: The total pre-test scores in the experiment group were determined to be 93.88 + 13.57, and 91.48 + 17.59 in the control group. The total post-test scores in the experiment group were determined to be 89.24 + 15.90, and 97.72 + 19.91 for the control group. No significant differences were found between the pre- and post-tests. Observations: The experiment group performed more observations of ethical violations compared to students in the control group | Good |
Blomberg et al. [45], Sweden | Qualitative | To explore and describe nursing students’ ethical reasoning and their supervisors’ experiences related to participation in clinical group supervision | 17 nursing students | Interviews | Interpretative description | The form and content of clinical group supervision stimulated reflection and discussion of how to effectively handle situations with ethical aspects. Unethical situations were identified, and the process uncovered underlying caring actions | Good |
Bowsher et al. [71], United Kingdom | Qualitative | To investigate the impact of a structured programme delivered online to support learning about ethical issues | 19 medical students | Online transcripts | Thematic analysis | Five themes constitute the findings: (1) adopting a position on ethical issues without overt analysis, (2) presenting issues in terms of their effects on students’ ability to complete tasks, (3) describing local contexts and colleagues as ‘other’, (4) experiencing difficulties navigating between individual and structural issues, and (5) overestimating the impact of individual actions on structures and processes. While the students reflected on ethical issues, limited evidence of questioning or modification of their views was found | Good |
Buxton et al. [54], USA | Qualitative | To describe an innovative use of interactive simulations to help midwifery students apply ethical principles in practice | 20 midwifery students | Observations and online evaluation | Unknown | Ethical simulation can help improve the ability to reflect and deal with ethical issues. The simulation can be used as a formative experience | Poor |
Chou et al. [52], Taiwan | Mixed methods | To explore how interprofessional education works in learning clinical ethics via problem-based learning and how different professions’ perspectives influence each other | 45 medical students, 44 nursing students | Questionnaires | Analytical and descriptive statistics | Nursing students performed favourably on course engagement, caring, and communication, while medical students performed positively on issue identification and the life science aspect. Interprofessional group participation strengthened both professions’ performance better through the learning process | Fair |
Gallagher et al. [55], United Kingdom | Qualitative | To describe experiences from an immersive 24-h simulation | 18 nursing students | Focus groups interviews | Thematic analysis | Simulation is a way to promote ethics and to change participants’ perspective on caregiving and care-recipients | Fair |
Gillam et al. [40], Australia | Qualitative | To introduce ethics educators to a narrative ethics approach in teaching | Part I: 12 educators Part II: 44 educators | Part I: Interviews Part II: Notes from small-group discussion, comments, and written feedback | Part I: Thematic analysis Part II: Unknown | Part I: Ethics educators should teach students about rational thinking. Part II: Ethics educators should teach students about how to manage emotions and handle unexpected and unwanted potential emotions | Poor |
Grace et al. [39], USA | Case study | To describe a bioethics educational module | Medical residents, number of unknown participants | Unknown | Unknown | The five-box technique for bioethical decision-making included beneficence, nonmaleficence, autonomy, justice, and clinical integrity. Challenges have often been time based and related to the difficulty of predicting how long it will take to work through a case | Very poor |
Harasym et al. [48], Taiwan | Theoretical paper | To discuss problem-based learning as an instructional strategy for teaching ethics | Not applicable | Not applicable | Not applicable | Problem-based learning is an effective instructional method for developing student ethical behaviours | Very poor |
Hem et al. [43], Norway | Qualitative | To evaluate the significance of participating in systematic ethics reflection groups that focus on ethical challenges related to coercion | 127 healthcare professionals | Focus group interviews | The analysis was inspired by the concept of ‘bricolage’ | Most participants report positive experiences with participating in ethics reflection groups. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes, the method for ethical reflection was utilised in a rigid way | Good |
Honkavuo [41], Finland | Qualitative | To deepen the understanding of ethics simulation in nursing education | 6 nursing students | Interviews | Hermeneutic analysis | The nursing students’ narratives resulted in the meaning units: ethical being and ethos, nursing students’ formation process, bridge-building between theory and clinical practice, and teacher and ethics simulation | Good |
Hsu [64], Taiwan | Quantitative | To assess nursing students’ satisfaction and attitudes as participants in a scenario-based learning (SBL) exercise and investigate the pedagogical application of SBL in a blended learning environment | 99 nursing students | Questionnaires | Analytical and descriptive statistics | Students are relative positive with blended learning. Most of them (mean 4.10, SD 0.63) considered themselves good at using various learning strategies; a few (mean 2.55, SD 0.98) said they spent more time learning online than learning in class. Students reported that they ‘sometimes’ got involved in ethics discussions and determined appropriate action in ethically challenging situations. They ‘rarely’ helped patients make decisions on ethical issues | Fair |
Kong et al. [62], United Kingdom | Qualitative | To evaluate a near-peer case-based undergraduate ethics teaching programme | 32 medical students, 35 Foundation Doctors (FD) | Students: Anonymous feedback form FD: Face-to-face and email correspondence | Unknown | This programme provided students with an open and protected space in which they could reflect on their ethical behaviour. This programme was beneficial to FDs who were able to develop their own teaching and ethical reasoning skills and to reflect on the influence of the hidden curriculum on their own behaviour | Very poor |
Kuhn et al. [69], Germany | Quantitative | To improve moral judgment, ethical reflection and strengthen individual resilience in value conflicts | 13 medical students and young physicians | Web-based evaluation sheet | Descriptive statistics | Didactic concept with case conferences, discussion about ethics issues and lectures were considered helpful for dealing with ethical questions at the clinic. The format was also relevant for their later profession | Fair |
Langlois et al. [61], Canada | Qualitative | To explore the experiences and learning of student health professionals engaged in an ethics module | 91 health mentor programme students | Interviews | Thematic analysis | Five major themes emerged: (1) patient autonomy and expertise in care, (2) ethical complexity and its inevitable reality in the clinical practice setting, (3) patient advocacy as an essential component of day‑to‑day practice, (4) qualities of remarkable clinicians that informed personal ideals for future practice, and (5) patients’ perspectives on clinician error and how they enabled suggestions for improving future practice | Good |
Lee et al. [63], Korea | Qualitative | To describe nursing students’ perspectives on and experiences of a case-centred approach to nursing ethics education using the four topics method | 10 nursing students | Focus group discussion | Content analysis | Four themes emerged: 1) the importance of ethics education as perceived by nursing students,2) problems in current nursing ethics education, 3) the experience of case-centred nursing ethics education using the four topics approach, and 4) suggestions for improving nursing ethics education | Good |
Lee et al. [73], Korea | Quantitative | To identify the effects of a nursing ethics seminar on the moral sensitivity and ethical behaviour of nurses working in a hospital setting | 35 nurses | Questionnaires | Analytical and descriptive statistics | Moral sensitivity and unethical behaviour showed a negative correlation (r = 0.400, p < 0.05). After the ethics seminar, the experimental group’s moral sensitivity was not significantly increased (t = 1.039, p = 0.314). The experimental group’s mean scores of unethical behaviours at pre- and post-test were 12.59 and 9.47, respectively, indicating a statistically significant difference (t = 3.363, p = 0.004). There was no statistically significant difference in the mean score in both moral sensitivity and unethical behaviour at pre- and post-test in the control group | Good |
Lillemoen et al. [44], Norway | Qualitative | To explore how ethics reflection in colleague groups was experienced and evaluated by the employees, facilitators, and service managers | Unknown | Focus group interviews Observations Written reports | Content analysis | Ethics reflection is a valuable measure to strengthen clinical practice. Ethics reflections have an impact on the climate of cooperation, not simply among the staff, but also with patients and their families. Ethics reflection is a process of change and both professional and personal development. Ethics reflection as a fragile established practice. This department has been characterised by high turnover and management changes | Good |
Lin et al. [51], Taiwan | Quantitative | To pilot an interprofessional problem-based learning curriculum of clinical ethics and evaluate the curricular impact on interprofessional students’ attitudes and confidence in collaborative teamwork | 36 medical students and nursing students | Questionnaires | Analytical and descriptive statistics | There was significant difference among different groups in terms of the students’ abilities and attitudes about ‘interprofessional communication and collaboration’ (p = 0.0184). The scores in the mixed group (37.58–3.26) were higher than those in the medical group (32.10–4.98). In terms of the students’ course satisfaction, the general satisfaction rating was around 79.41%. Most students (82.35%) considered the course effective in improving their understanding of clinical ethics | Good |
Maddineshat et al. [65], Iran | Quantitative | To determine the impact of teaching ethics using games on moral sensitivity | 30 nursing students | Questionnaires | Analytical statistics | The total score for moral sensitivity before and after the intervention showed significant changes (p = 0.02). Satisfaction with the ethics games for each session was higher than 4.4 out of 5. There was no significant trend between the means of the sessions (p = 0.66) | Fair |
Martins et al. [67], Portugal | Quantitative | To determine whether bioethics education in nursing influences the level of moral competence and opinion of nursing students about three ethical dilemmas | 122 nursing students | Questionnaires | Analytical and descriptive statistics | Nursing students showed a moral competence stagnation (1.2-point difference between the two assessments), although this did not reach statistical significance (p = 0.268). Regarding performance for each of the dilemmas, students showed an increase in performance for the worker's and judge's dilemmas and a sharp decrease in performance for the doctor's dilemma | Good |
Martins et al. [68], Portugal | Quantitative | To investigate if the teaching of ethics can influence the moral competence of both medical and nursing students | 263 nursing students and 70 medical students | Questionnaires | Analytical and descriptive statistics | For both nursing and medical students, C-score was lower after the attendance of the ethics curricular units, with a statistically significant decrease in the total score (from 21 to 19.5 on average; p = 0.046) for nursing students and a decrease not statistically significant for medical students (from 23.2 to 22 on average; p = 0.358). A multivariate analysis did not find any association between this decrease and gender, course, or age. The phenomenon of moral segmentation was observed, with better performance in the worker and judge dilemma, than in the doctor dilemma | Good |
McCormick et al. [53], USA | Qualitative | Unknown | Medical social workers, number of unknown participants | Unknown | Unknown | Case studies could be used to illustrate ethical concepts and stimulate discussion, as well as to present new material to the participants | Poor |
Mohammadi et al. [49], Iran | Quantitative | To examine the effect of bioethical principles teaching on moral attitude of paramedic emergency personnel in Kerman city of Iran | 60 prehospital paramedic personnel | Questionnaires | Analytical and descriptive statistics | Ethical attitude means for both groups of control and intervention demonstrated that ethical attitude has meaningfully increased after the workshop | Good |
Monteverde [50], Switzerland | Quantitative | To evaluate the feasibility and acceptance of the novel framework | 58 nursing students | Questionnaires | Unknown | The framework was founded on problem-based learning. Students considered ethical theories—as taught within the proposed framework—as practically applicable, useful, and transferable to practice | Fair |
Pandya et al. [58], India | Qualitative | To describe the experiences of using of narratives written by students in teaching | Unknown | Unknown | Unknown | The student writes a narrative from a patient’s perspective, based on real experiences. The sharing of narratives in the classroom, followed by discussion, can help to add different perspectives, and encourage both the narrator and the class to learn more about a scenario | Very poor |
Parker et al. [38], Australia | Qualitative | To pilot an ethics teaching programme, with a focus on ethical issues that students are likely to encounter in their clinical education | 47 medical students | Questionnaires | Analytical and descriptive statistics | Students feel a lack of experience and confidence in clinical ethics. Students liked the ‘real-life’ curriculum and the learning that comes from discussion of cases and personal experiences | Fair |
Paton et al. [42], United Kingdom | Qualitative | To examine how storytelling and practical wisdom play integral roles in the medical ethics education of junior doctors | 46 junior doctors | Interviews | Thematic analysis | Three major themes: (1) Learning medical ethics through storytelling, (2) Developing phronesis through storytelling and ‘story-listening’ and (3) Passing on/teaching phronesis through ‘phronesis narrative’ | Fair |
Sánchez-Izquierdo et al. [75], Spain | Quantitative | To develop a behavioural intervention to decrease paternalistic behaviours in formal caregivers and to increase care behaviours | 118 health care professionals | Questionnaires | Analytical and descriptive statistics | Compared with the control group, caregivers in the behavioural intervention group displayed significantly lower paternalistic appraisals at the post-test and follow-up. Regarding the intervention group, caregivers at the post-test and follow-up showed a significantly greater occurrence of autonomist behaviours being promoted and lower paternalistic appraisal | Good |
Savitha et al. [72], India | Mixed methods | To introduce an interactive and integrated ethics programme into the physiology course for first year medical students and to evaluate their perceptions | 60 medical students | Questionnaires Focus group discussions Observer feedback | Descriptive statistics Content analysis | Students were exposed to a variety of ethical issues to reflect upon and stimulate their thoughts. All students felt that the programme was relevant to them | Fair |
Schonfeld et al. [37], USA | Qualitative | To compare two teaching methods for ethics education | Medical students, number of unknown participants | Focus group interviews | Grounded theory | One theme: Student development and student engagement. Two categories: (1) understanding and (2) perspective | Fair |
Shamim et al. [46], Saudi Arabia | Mixed methods | To develop and refine a contextually relevant approach to ethics education in the region of Saudi Arabia | 46 medical students, 4 faculty members and 11 experts in the field | Focus group discussions Interviews Expert critique | Content analysis | Four main themes: 1) design features, 2) content, 3) teaching methods and 4) assessment. The results improved the design of the educational strategy | Good |
Sherer et al. [36], China | Mixed methods | To examine ethics education programmes at three medical schools to understand their curricular content, teaching and learning methods, forms of assessment, and changes | 407 medical students, 11 educators | Questionnaires Realistic cases for discussion | Analytical and descriptive statistics | Teaching methods: Lecture, small‑group discussion, and role play. Case-based learning: Appropriate when it involves a real‑world medical ethics issue. Inappropriate if it involves subject matter that students have not yet been exposed to | Poor |
Silén et al. [60], Sweden | Quantitative | To investigate whether ethics rounds could improve the ethical climate | 51 professionals from different professional groups | Questionnaires | Analytical and descriptive statistics | Ethics rounds did not result in significant changes in ethical climate | Good |
Smith et al. [56], USA | Mixed methods | To evaluate high-fidelity patient simulation in teaching legal and ethical issues | 221 nursing students | Questionnaires Scenario observation and debriefing | Analytical and descriptive statistics Content analysis | Simulation could support interaction, learning about real-life situations, and applying legal and ethical content in the scenario. Students need more preparation and information about the scenario and what they can do with the simulator. There were no significant differences between the students who played the nurse and those who played family members. However, students who played nurses were better at fulfilling their roles than students who played family members (p = .042) | Fair |
Torabizadeh et al. [74], Iran | Qualitative | To evaluate the impacts of Socratic questioning on the moral reasoning of nursing students | 103 nursing students | Questionnaires | Analytical and descriptive statistics | Both the teaching approaches improved the subjects’ moral reasoning; however, Socratic questioning proved to be more effective than lecturing | Good |
Tsai et al. [70], Taiwan | Qualitative | To describe an ethical reasoning model and indicate how it can be used to foster moral and ethical behaviours | 16 physicians | Interviews | Immersion and crystallisation approach | Ethical reasoning always began with information gathering, with or without verbalising the corresponding ethical problems. This was followed by decision making and, finally, by the production of an action plan. Ethical problems were described only when asked for; medical concerns were always raised first | Fair |
Tsuruwaka et al. [57], Japan | Qualitative | To explore the effectiveness of learning the ethics of nursing practice using narrative writing | 86 nursing students | Narrative scenes Comment sheets | Content analysis | Two core categories: (1) awareness of habits and trends in one’s own thoughts, and (2) awareness of organisational and administrative issues | Fair |
Watts et al. [59], Australia | Quantitative | To evaluate Rural Ethics Ward Rounds | 47 medical students | Questionnaires | Unknown | Students indicated that after participation, they were more aware of rural ethical issues (p < 0.01). Students found the openness of the sessions beneficial (91.7%) and were positive about the use of videoconferencing (86.6%) | Very poor |
Yeom et al. [47], Korea | Quantitative | To examine the effects of nursing ethics education on moral sensitivity and critical thinking | 70 medical students | Questionnaires | Analytical and descriptive statistics | There were no significant changes after the intervention in terms of moral sensitivity (p = 0.07) and critical thinking disposition (p = 0.44). There was a significant positive correlation between moral sensitivity and critical thinking before (p = .007) and after the intervention (p = .001) | Fair |