RN-BSN Students Desire More Healthcare Ethics Education

Ethics, also called moral philosophy, is a discipline concentrated on what is morally good and bad, right and wrong [9]. While both morality and ethics are loosely used to distinguish the difference between ‘good and bad’ or ‘right and wrong,’ morality generally is used as something that is personal or normative, whereas ethics is the standards of ‘good and bad’ distinguished by a certain community or social setting [10].


Introduction
Nursing is a form of healing arts with nurses providing care to patients and family with utmost privacy and respect [1]. According to the 2017 Gallup Poll, nurses are the most trusted and ethical professionals, and have been for the last 16 consecutive years [2]. They are the frontline healthcare workers in many healthcare settings. Nurses are expected to provide high quality physical patient care, ranging from relieving pain to helping patients with their recovery process, to obtaining goals in health promotion and providing coping support to patients and families [1]. However, it is commonly known that nurses face many unique ethical challenges that arise during their patient care routines causing moral conflicts or conscience struggles.

Background
Research has shown nurses encounter morally distressing situations routinely in their professional practice [3]. Nursing burnout is attributed to emotional exhaustion with high stress levels [4]. How to handle moral conflicts has been a core issue at both beginning and advanced levels of practice [5]. Because of the lack of ethics training, new nursing graduates initially handle moral conflicts with their individual moral codes and eventually change their views to conform to expectations of others with some level of environmental pressure [6]. Unfortunately, few nursing curricula offer any course that is dedicated specifically to ethical decision making [7]. Associate degree nursing programs offer curriculum primarily focusing on preparatory nursing skills to function at an entry level of nursing. As a result, associate degree nurses often develop their critical thinking skills when evaluating clinical situations, including ethical situations, from their own clinical experiences. These nurses may only have the knowledge they have gained from their experiences in clinical settings to guide them in ethical dilemmas, without a clear structured Moreover, the stressful work environment with work overload, lack of power and role conflict can affect patient care. In a systematic review article on nurses' moral sensitivity and hospital ethical climate, researchers found unresolved moral distress and poor ethical climate at the work place had significant effects on nursing turnover [13]. The turnover rate for registered nurses (RNs) has been trending upward. In 2015, the turnover rate for bedside RNs was 17.2%, compared to 11.2% in 2011 [10]. The average cost of a bedside RN turnover ranges from $37,000 to $58,000, resulting in an average hospital cost of $5.2 to $8.1 million in losses. Each percentage in RN turnover averages $373,200 in cost per facility [14]. In addition to the economic cost, increased vacancies of RN positions in hospitals negatively affect the quality of patient care. Further, stress related to ethical decisionmaking can have serious consequences on nurses' health. Research has shown high work stress and low social support were the main predictors of overweight and obesity in hospital nurses [15].
However, Cerit and Dinc have found that ethical decision making has a positive correlation with professional behaviors [16]. Nurses who reported being psychologically engaged with their jobs reported a lower intention to leave their current job [17]. Numminen, Leino-Kilpi, Isoaho, & Meretoja found nurses who were at a higher ethics competence level perceived the ethnical climate significantly more positively and had higher job satisfaction and a lower turnover rate [18].
Ethics training concentrates in defining ethical concepts and providing methodologies to assist learners in making moral decisions [19]. Healthcare ethics principally deals with ethical situations that healthcare professionals face while providing patient care. Experts have identified the importance of ethics education in nursing [20]. A lack of ethical preparation in undergraduate students hinders nurses' ability to work collaboratively with other healthcare members and share their concerns when ethical issues confront clinicians and their patients and families [20]. Despite the importance of ethics education in fostering competence and job satisfactions in nursing professionals, there is a widening gap in ethics education and pedagogy in nursing curricula [7]. Very little education focuses on ethics intervention and ethics research in healthcare providers and healthcare students [21]. The associate degree prepared nurses may have even more challenges, because ADN programs often focus on preparatory nursing skills necessary to function at an entry level of nursing. They undergo intensive basic nursing training, enough to provide fundamental nursing care [7]. These nurses are often left to develop the skills of critical thinking, decision making, and conflict resolution and the ability to support the patients, families and healthcare members on their own, after graduation. They are frequently faced with complex situations requiring ethical decisions that demand knowledge on moral reasoning without having adequate education in a welldeveloped ethical model for nursing professionals [3]. Developing an effective ethics course in nursing curriculum is crucial to the successful retention of nurses.

Purpose
This study is aimed to assess the knowledge and perceptions of the associate degree nurses pursuing a bachelor's degree in nursing. The hypothesis addressed in this descriptive, exploratory, quantitative methodological study is that associate degree nurses desire more training and education in healthcare ethics because they frequently encounter ethical dilemma in their clinical practice.

Methods
After obtaining approval from the Institutional Review Board at California State University, Bakersfield, a researcher developed questionnaire in paper format was piloted with three associate degree nurses, who were not students of California State University, Bakersfield, testing for validity. The same questionnaire was input into SurveyMonkey®. The researchers then sent the SurveyMonkey® web link to potential participants through the students' emails in the university registration system. The participants would access SurveyMonkey®, starting with a screen providing them information on this study and an opportunity to give consent. A short demographic survey and the survey questionnaire followed. The participants could complete the survey at any time and place at their convenience. The survey was available for 2 weeks at the beginning of the semester prior to their healthcare ethics course. No known risk was identified in this study. Perceived benefit of this study was to assist faculty in better preparing for the healthcare ethics course. This study was completely anonymous and voluntary. No identification can be linked to the survey. No tracing capability on who completed the survey was tracked. Participants could stop the survey at any time without any repercussion by closing their web browser.

Sample
Participants were associate degree prepared RNs who attended California State University, Bakersfield in pursue of a bachelor's degree in nursing (BSN). These students were taking online classes either through the Extended University Program or State Program. They were classified as RN to BSN (RN-BSN) students.

Instrument
A 20-item questionnaire was developed by the researchers to assess the RN-BSN students' knowledge and perceptions on healthcare ethics. Demographic data was asked on the RN's experience, age, and clinical practice. Other questions assessed their perceptions on previous healthcare ethics training as well as their knowledge on the basic concepts in healthcare ethics. Specifically, there were questions based on hypothetical case scenarios providing the participants an opportunity to make ethical decisions based on morally challenging situations. These case scenarios were constructed by the researchers to evaluate the study participants' knowledge on ethical terminology, such as autonomy, beneficence, non maleficence, fidelity, justice and values. They also provided an opportunity to identify knowledge deficiencies and educational needs. The participants' responses to the case scenarios were assessed based on their selection of burden versus gain and benefits versus potential harm. In addition, there were questions on their reading of the American Nurses Association Code of Ethics and California Practice Act. Finally, there was a question on whether they had ever been subpoenaed to testify on patient care.

Results
Sixty-six potential participants were emailed the SurveyMonkey® web link for this study. Thirty subjects responded with a response rate of 45%. Over 70% ranged in age from 26 to 45 years old ( Figure  1A). Eighty three percent were female and 80% of the subjects had practiced nursing five years or less ( Figure 1B), mainly in acute care hospital settings ( Figure 1C).
More than half of the subjects noted they had received some form of healthcare ethics training in their associate degree nursing program. However, 40% were somewhat satisfied with the previous healthcare ethics training and 26.6% were not satisfied with their previous training (Figure 2A). An overwhelmingly majority of the students (96.6%) expressed interest in receiving more healthcare ethics training ( Figure 2B).
More than 90% of the nurses reported encountering ethically challenging situations in their nursing practice ( Figure 3A); 90% believed they had come across morally distressing situations ( Figure  3B). Over 60% reported no previous training in healthcare ethics specifically to deal with morally distress situations ( Figure 3C).
On case scenarios depicting healthcare ethical concepts in this survey, the majority of the subjects understood the concept of autonomy in giving consent. More than half of the participants correctly distinguished the concept of ethics. The participants had a difficult time with a question concerning the difference between ethics and values. Twenty four percent of the participants incorrectly identified the concept of beneficence and 50% wrongly identified the concept of non maleficence. Participants also had difficulty with the concept of fidelity (43% were incorrect) and the concept of justice (13% were incorrect). Almost half of the participants had never read the American Nurses Association Code of Ethics ( Figure 4A). Thirty percent had never read the California Nursing Practice Act ( Figure 4B). Only two nurses had ever been subpoenaed to testify regarding patient care. Ninety percent of the participants felt comfortable to join in discussions on issues relating to ethics and laws.

Discussion
A large study by Grady et al. investigated the relationship between ethics education and confidence in moral decisions in 1215 nurses and social workers [22]. They found that approximately 22.7% of nurses reported no ethics education and only 51.2% had ethics course work in their basic and/or advanced professional program [22]. In their study, Grady et al. had concluded that ethics education had a significant positive influence on moral confidence, moral action, and use of ethics resources by nurses and social workers [22]. In contrast, our study is simply a descriptive study and did not examine the relationship between the ethics education and confidence in ethical decision making. However, similar to Grady et al., we found more than half of the participants had some type of education in healthcare ethics. Only 26.6% were not satisfied with the previous healthcare ethics training. What was noteworthy was that a clear majority (96%)  of the nurses in our study strongly desired more training on the topic of healthcare ethics, regardless of previous training, or if they were satisfied with previous training.
Nursing practice is interwoven with moral complexity. Newly graduated nurses entering the clinical setting must be ready to deliver quality patient care while maneuvering through relationships with patients, family, healthcare workers and adapting to organizations and policies [20]. Eighty percent of our study's participants had five or less years of experience and mainly practiced in hospital settings. More than 90% of study participants have encountered ethically or morally challenging situations in their work and had come across potential distressing situations.
The results highlighted that ADN prepared nurses were well aware of the importance of healthcare ethics competence. ADN nurses with less clinical experience can be particularly vulnerable when encountering challenging situations because of the lack of healthcare ethics training in their ADN education. These findings underscore the importance of supporting new nurses, because high stress levels experienced by hospital nursing staff has been found contribute to staff burnout and turnover [12]. Hence, ethics education is a very important component in equipping new and professionally inexperienced nurses with the knowledge and skills necessary to cope with challenging ethical situation successfully.

Limitation
While the findings of the study were interesting, the study was limited by the small size of the sample, convenience sampling method, and the one-school sampling. This study included a small, convenient sample of ADN students coming to California State University, Bakersfield (CSUB) to pursue higher degree in nursing through an online program. The majority of the participants resided in the communities within Kern County, which is located in the central valley of California with a population close to a million. This study may not represent, be generalized or compared with other geographical locations. Further, due to the small sample size and the large predominance of nurses with 5 or less years clinical experience, it was not possible to differentiate responses between nurses with greater clinical experience and those with less.

Conclusion
Nurses often experience moral distress when they encounter ethically challenging situations. They may find difficulties in translating their moral decisions into moral action due to lack of healthcare ethical training and education. To address these issues, ethical training is necessary to educate student nurses and new nurses on ethical concepts and methodologies on recognition and moral decision making when encountering ethically challenging situations. The costs of unrelieved moral distress are high. It may affect the quality of patient care, cause burnout and distress, accrue financial cost to hospitals, and result in increased health care cost. More ethical  training and education should be developed for nursing students, particularly the associate degree nurses, because ADN program curricula often intensely focuses on fundamental nursing training, without adequately addressing the development of ethical framework for professional action and decision making.

Implication
The results of this study have assisted nursing faculty in planning a successful educational curriculum in healthcare ethics. At CSUB Department of Nursing, we have incorporated healthcare ethical concepts into the RN-BSN curriculum. This has included simulated case scenarios to present the students with ethical challenges in a contextual environment. Further, educational sessions on identifying possible solutions to solve ethical and moral conflicts were conducted with students to empower their knowledge on healthcare ethics.
This study contributes to the body of knowledge on the topic of healthcare ethics in health care education. It highlighted that nurses, particularly ADN prepared nurses, desired more health care ethics education. This study could be useful in guiding educators and faculty to develop strategies to incorporate healthcare ethics in the nursing education. Moreover, it could spark further research on the topic of improving healthcare ethnics education in healthcare professionals. Future research could focus on the effectiveness of the simulated case scenarios and other pedagogies in improving ethical decision making. Improving healthcare ethics training in nursing education could contribute to the increase of nursing workforce retention, the improvement of nursing job satisfactory, and the positive organizational and patient outcomes.