Nurse Education in Practice 32 (2018) 108–114

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/locate/nepr

Original research

Discovering mental models and frames in learning of nursing ethics through T

simulations
J.L. Díaz Agea, M.R. Martín Robles, D. Jiménez Rodríguez, I. Morales Moreno, I. Viedma Viedma,
C. Leal Costa∗
Faculty of Nursing, Catholic University of Murcia, Spain

A R T I C LE I N FO A B S T R A C T

Keywords: The acquisition of ethical competence is necessary in nursing. The aims of the study were to analyse students'
Clinical simulation perceptions of the process of learning ethics through simulations and to describe the underlying frames that
Ethical competence inform the decision making process of nursing students. A qualitative study based on the analysis of simulated
Mental frame experiences and debriefings of six simulated scenarios with ethical content in three different groups of fourth-
Reflexive learning
year nursing students (n = 30), was performed. The simulated situations were designed to contain ethical di-
Ethics in nursing
Debriefing
lemmas. The students' perspective regarding their learning and acquisition of ethical competence through si-
mulations was positive. A total of 15 mental models were identified that underlie the ethical decision making of
the students. The student's opinions reinforce the use of simulations as a tool for learning ethics. Thus, the
putting into practice the knowledge regarding the frames that guide ethical actions is a suitable pedagogical
strategy.

1. Introduction 2. Background

In the healthcare professions, the responsibility of acquiring ethical
competence has a clear moral undercurrent, both in the training of
students and in the clinical practice of professionals. Debates exist re-
garding the best ways to teach ethics to nurses (Cannaerts et al., 2014),
and active student participation in acquiring ethical competence ap-
pears to respond well to this issue. Also, reflection and debate are es-
sential in the process of learning about ethical issues (ethical reflection)
(Gallagher, 2006).
Simulations have been presented over the course of several decades
as a tested method for training health professionals (Thomas et al.,
2015). They are beneficial (Shin et al., 2015) because they have the
advantage of being a form of experiential learning that is reflexive with
no risks to patients (Naik and Brien, 2013). Also, they help to settle the
ethical dilemmas that arise during the training of professionals who
have traditionally been trained with real patients (Berndt, 2014).
Through simulations, students can acquire many types of compe-
tencies (i.e., clinical and non-clinical skills, knowledge, behaviour, etc.)
by experiencing situations and later reflecting on them (debriefing)
with the guidance of a facilitator, thereby improving the nursing stu-
dents' knowledge (Cant and Cooper, 2017).
Nurses must possess ethical competence (Kulju et al., 2016) to
perform their daily tasks, and it should be taught as part of the study
programmes at universities. After an exhaustive analysis, Kulju et al.
(2016) defined ethical competence in health care as: “a personal capa-
city including ethical awareness, courage, willingness and skills in decision-
making and ethical action.” (p.10).
A systematic review (Poikkeus et al., 2014) emphasized the need to
develop evidence-based support to increase the ethical competence of
nurses, concluding that more attention should be paid to the conceptual
perspectives, theory, and especially the practice of ethical competence.
Experiences with clinical simulations (simulation-based learning)
have verified their relevance for learning about the ethical and legal
issues in nursing (Smith et al., 2013), as they contain elements of ex-
periential (Kolb, 2015) and reflexive (Ryan and Ryan, 2012) learning
that can be ideal for acquiring ethical competencies, particularly re-
garding reflections on actions, known as debriefing, in a simulation
(Palaganas et al., 2016).
During debriefing, students conduct a self-critical review that fa-
cilitates guided reflection (Waznonis, 2014), generating knowledge by
the active thinking about their experience and developing clinical
judgement and critical thinking skills. This analysis favours the learning

∗
Corresponding author.
E-mail addresses: jluis@ucam.edu (J.L. Díaz Agea), cmartinrobles@hotmail.com (M.R. Martín Robles), djimenez@ucam.edu (D. Jiménez Rodríguez),
imorales@ucam.edu (I. Morales Moreno), iviedma@ucam.edu (I. Viedma Viedma), cleal@ucam.edu (C. Leal Costa).

https://doi.org/10.1016/j.nepr.2018.05.001
Received 11 October 2017; Received in revised form 26 March 2018; Accepted 7 May 2018
1471-5953/ © 2018 Elsevier Ltd. All rights reserved.
J.L. Díaz Agea et al. Nurse Education in Practice 32 (2018) 108–114

process (Wotton et al., 2010), and this knowledge is likely to be
transferred to real clinical practice, thereby contributing to the pre-
serving of patient safety during the process of learning clinical and non-
clinical skills (Aebersold et al., 2012; Grady et al., 2008; Shearer, 2013;
Singer et al., 2011).
This article proposes a new perspective on the training of nurses
based on reflexive work regarding the frames (mental representations,
interpretations, and simplifications of reality) that precede ethical ac-
tions. In this work, we have used the terms mental frame and mental
model (Johnson-Laird, 2010) referring to psychological representations
of real, hypothetical, or imaginary situations. In simulation learning the
term “frame” is used to refer to the perspectives through which parti-
cipants interpret their experiences for decision making. Frames are
knowledge, attitudes, feelings, goals, rules and/or perceptions that are
based on previous experiences of individuals. When debriefing is con-
ducted with the good judgment method, the facilitator can infer the
participants' frames, and while actions and verbalizations are ob-
servable, frames are invisible but inferable during debriefing in simu-
lation based learning (Rudolph et al., 2007).
3. Method
3.1. Research design
For this study, a qualitative study approach was adopted and spe-
cific objectives identified: To analyse the perceptions of fourth-year
nursing students regarding the process of learning about bioethical is-
sues through a high-fidelity nursing simulation using a mannequin or
an actor and to describe and analyse the underlying frames that inform
the decision making and actions of students (the meanings of actions
and their consequences).
Ethical content and competencies were intentionally included in the
design of the simulated scenarios. The study utilized qualitative
methods (discussion groups for debriefing on the simulated scenarios).
The following simulated scenarios were developed (Table 1), and
ethical elements were added to the discussion of the actions during
debriefing.
3.2. Participants and research context
The study was conducted between March and May 2016 at the
Catholic University of Murcia in Spain. Non-probability convenience
sampling was used. Each simulation group was comprised by an
average of 10 students, and the sample consisted of three independent
groups of students (n = 30), with each group comprised by the students
and a facilitator.
All of the students were trained on the learning methods that use
clinical simulations in the Catholic University of Murcia (Simulation
based learning and Self-Learning Methodology in Simulated
Environments MAES©) (Diaz et al., 2016). Each scenario consisted of
approximately 1 h of group work (10 min of video-recorded simulation
and witnessed live by the entire group and 50 min of discussion-de-
briefing).
In these simulation experiences, the recommendations for best
practice in simulation by the International Nursing Association of
Clinical Simulation and Learning (INACSL©) were followed, especially
those related to facilitation and development of debriefing (INACSL
Standards Committee, 2016a,b).
The high fidelity simulations were performed in two 4-h sessions for
each group, separated by one week. In each session, 3 simulated sce-
narios were worked on. The sessions were structured into: briefing,
simulated experience and debriefing phases (a reactions phase, an un-
derstanding phase and a summary phase) (Eppich and Cheng, 2015;
Palaganas et al., 2016).
Between each case a rest period of about 20 min was set. A high-
fidelity mannequin (Simman Essential® & SimBaby® from Laerdal Co.)
was sometimes used, as in the case of women with postpartum he-
morrhage, resuscitation of a pregnant woman, child abuse due to ne-
glect or the foreign patient with hypoglycaemia. In all other scenarios, a
previously-trained actor played the role of a simulated patient. An actor
was used as non-clinical skills are best worked on when the simulation
is performed with a real person as a patient as opposed to using a
dummy (although it is ideal for performing techniques or care involving
physical risk such as injecting medication, etc.). All three groups
completed all 6 scenarios and the students’ groups remained cohesive.

Table 1
Simulation scenes and related ethical competences.
Simulated Scenarios. Ethical Competencies to be acquired through simulation
(experience/reflection/discussion)

Scenario 1. Puerperal hemorrhage. Related to the principle of autonomy.

Woman with uterine atony who needs management of postpartum hemorrhage. She is a Jehovah's When and when not?
Witness and refuses treatment with transfusion. Specific cases of Jehovah's Witnesses.
Scenario 2. Child abuse due to neglect. A child, son of a drug addict mother who is brought to the Ethical reaction to suspected abuse.
pediatric emergency room due to unconsciousness. Possible accidental heroin poisoning. First of all, she When to report suspected abuse?
does not confess that her son may have taken a sheet of heroin from the bedside table drawer that could Have you witnessed situations considered as mistreatment in your
have been put inside his mouth and ingested, due to the fear of having her son taken away. She says work?
that she is a good mother all the time. Would you report to a co-worker if you think there is a situation in
which patients are being injured?
Scenario 3. Suicide attempt. Suicide from the ethical point of view.
A woman, who after a sentimental failure, swallows an indeterminate amount of poison. The Protection of life vs. Principle of autonomy. Informed consent.
emergency team attends her at home.
Scenario 4. Cardiorespiratory arrest in a pregnancy with eclampsia. Ethical subjects related to CPR:
When can we stop doing it?
What are the criteria about mother/Fetus?
Contraindications to CRP
Scenario 5. 56-year-old woman diagnosed with stage four pulmonary neoplasm. Therapeutic relentlessness. What is it?
A 56 year-old woman diagnosed with stage-four lung neoplasm, spreading to bones and liver. The Euthanasia vs palliative care.
family claims the assistance of the Emergency Service of Primary Health Care at home because the Is sedation a kind of euthanasia?
patient has removed the nasogastric catheter during a change in body position. In addition, the family The use of morphine pumps in terminal patients; What is it and
notices that the patient is in pain and they do not know if the on-demand morphine drip is working or how is it used? Is it ethical?
not. Other ethical questions about the end of life and its management
(spiritual support, etc.)
Scenario 6. 27-year-old hyperglycemic Moroccan immigrant. Related to the principle of autonomy.
A 27 year-old Moroccan woman who is admitted to the emergency room due to her diabetes. First of all, Situations in which a patient cannot sign the voluntary leaving
she refuses to receive some of the prescribed treatments. There is an important cultural and idiomatic from hospital form.
barrier Attention to people from other cultures.

109
J.L. Díaz Agea et al.
Both the simulated experiences of each scenario and the debriefings
were video-recorded, and the information was transcribed verbatim for
later analysis. During the discussion, the behaviour of the participating
students was analysed, as well as the clinical content (which was not
studied in this article) and the ethical content of each situation. Errors
were identified, although the objective was to elicit trainee's frames
using the advocacy-inquiry method (Rudolph et al., 2007). This method
consists of a guided reflection in which a facilitator states what was
executed in a clinical simulation activity or shares critical insights
about it unambiguously (advocacy) and then asks the students for an
explanation of their thoughts and actions (inquiry). Inquiry seeks to
learn what others think, know, want, or feel; whereas advocacy in-
cludes statements that communicate what an individual thinks, knows,
wants or feels (Lopreiato et al., 2016).
The goal was to discover frames that led to concrete actions and to
develop it through group discussion (Stewart and Shamdasani, 2014)
using the good judgment approach proposed by Rudolph et al. (2007).
A total of 16 h of debates were analysed, which corresponded to the
simulation/debriefing of six different scenarios with three independent
groups of students.
3.3. Content analysis
To achieve Objective 1, categories or general topics that were of
interest for identifying issues related to learning (learning, perceptions/
emotions and satisfaction) we defined. Starting with these basic cate-
gories, the perceptions of the students were analysed through the
content transcribed from their verbalizations. During the learning
through simulation, it is typical that these general topics be habitually
discussed during the debriefing session after each simulation scenario,
especially in the summary phase, where a period of time is set to discuss
the perceptions on the learning –what has been learned and how
(Phrampus & O'Donnell, 2013).
Thus, a directed content analysis was conducted (Hsieh and
Shannon, 2005). This type of analysis starts with a previous plan (based
on previous experience, theories or research results that are relevant for
the researchers) as a guide for the initial categorization. This is why the
dimensions that were to be explored were previously defined.
The codification/categorization process consisted of identifying
passages of text in a document that represented an idea or concept
(Saldaña, 2015), adding codes and segments of texts, and identifying
and differentiating units of meaning. Specific software for qualitative
analysis was utilized for this process (MAXQDA® V.10).
To organize the information, a list of codes was utilized (Table 2)
that allowed for the use of different levels of codification or grouping of
sub-codes (hierarchical) for some categories, while for other categories,
a list of codes was used without sub-codes (non-hierarchical). Once the
information was organized, it was analysed.
Table 2
Categories or general topics that were of interest for identifying issues related to learning.
Category or dimension Subcategory Code
Learning of Bioethics After the simulation • Learning stimulus
topics in Nursing experience • Expanding knowledge
• Clinical simulation becomes better by
including Bioethics
Perception/emotions During the simulation
experience
• Perception about the experience of
ethical problems
During the debriefing • Clarification
• Perception about the importance of
Bioethics improvement
• Wellness
• Easy comprehension
Satisfaction • Satisfaction/will repeat
• Recommends the experience
• Improving realism and achievement
110
Nurse Education in Practice 32 (2018) 108–114
The main dimensions/categories are described in the following
table (Table 2).
To achieve the second objective, another analysis approach was
utilized. The frames or mental models were identified starting from the
analysis of scenarios and the responses of the students in the analytical
phase of the debriefing, which was when the strengths and weaknesses
were identified and analysed. For this, a type of analysis named “ad-
vocacy-inquiry method” (Rudolph et al., 2007) was conducted, which
has been described for the analysis of the student's actions after a si-
mulation, when a debriefing session has taken place (in the analytical
phase), It was chosen for the inferences the facilitator makes on the
student's responses to the questions: why did you act in that way? Or
what were you thinking about when you made that decision? Thus, the
frames of meaning of the students begin to emerge, when they are
verbalized by the students themselves. This method is explained in
detail by Rudolph et al. (2006) and Rudolph et al. (2007).
The reliability of the data was ensured through the viewing of the
video recordings, and the transcription and interpretation of the results
were independently corroborated by the research group.
3.4. Ethical considerations
This study was conducted in accordance with all ethical principles
and followed the characteristic recommendations of qualitative re-
search (Miller et al., 2012). Informed consent was acquired from all
participants that ensured the confidentiality of the data and other
ethical variables, such as the researcher-participant relationship and
risk-benefit ratio (Emanuel et al., 2010; Houghton et al., 2010). To
ensure their anonymity, the participants were assigned alphanumeric
codes with S for “student” plus a corresponding number based on the
order in which their testimony appeared (S1, S2, etc.).
This study was approved by the ethical committee of the Catholic
University of Murcia and was evaluated with a favourable opinion
(reference number: 5939 02/02/2016).
4. Results
The sample was predominantly female (75%), with an average age
of 25.2 years (DT = 6.462), a minimum age of 21 and a maximum age
of 50.
4.1. Students’ perceptions of the learning process
4.1.1. The learning dimension
The students acknowledged the importance of learning about
ethical issues through simulations (Fig. 1).
“I think the debriefings after a simulated scenario are the best
context in which we can talk, debate and learn about ethical issues,
Description
Knowledge assessment after experiencing the simulated situation with ethical
contents
Related to questions such as subjective perception of the experience,
sensations that appear in the moment of the intervention in clinical simulation
scene, emotions and case reflection.
This category is related to the wellness statement, feeling or agreement with
the experience
J.L. Díaz Agea et al.
Fig. 1. Learning perceptions of bioethics contents in the students with clinical
simulation support. Map of concepts.
and the fact of it being a small group of students encourages active
participation by everyone in the debate”. (S23)
Key points mentioned by the students included the applicability to
real life, the practical and amenable nature of the learning process, the
holistic perspective on care and the illuminating quality of the teaching.
In many cases, students recognized that their performance in the si-
mulation was spontaneous behaviour that could contradict their pre-
vious ethical knowledge. Thus, the dissociation between ethical
knowledge (knowing the right thing) and clinical practice (doing the
right thing) became evident in some occasions, especially with regards
to the ethical principle of patient autonomy.
4.1.2. The perception and emotions dimension
In general, the students reported having a positive feeling of well-
being when participating in scenarios with bioethical content (Fig. 2).
The students also emphasized on the need to address these issues in a
practical way during their nursing studies because there was a per-
ceived deficiency in training on ethical issues, which had led to feelings
of confusion.
Feelings of safety and comfort were also generated because of an
increased competence on bioethical issues. On one occasion, the impact
of experiencing an ethical dilemma related to end-of-life care caused
unexpected emotions to arise.
“On some occasions, I felt a little affected given my situation, since I
recently lost my mother and I'm very sensitive. But in general, I've
Fig. 2. Perception and emotions. Map of concepts. Most of the students were
located on the right side of the map.
111
Nurse Education in Practice 32 (2018) 108–114
gotten along well”. (S21)
4.1.3. The satisfaction dimension
The desire to repeat the experience was strong, and there was also a
strong recommendation for practicing practice scenarios with ethical
content. The perceived benefit from the experience was high, and the
results confirmed that the experience was very satisfactory.
“I liked that they introduced these aspects in the simulation because
since we had theory in the second year, we hadn't addressed that issue
again, and I also liked facing those dilemmas, with the actions of fellow
students and explanations for each case”. (S18).
4.2. Frames that underlie the ethical decisions for each simulated scenario
Information on the sequential structure of each scenario is presented
below:
a) Analysis of student conduct. Response to the ethical situations. What
did the students do?
b) Analysis of students' frames using the “advocacy-inquiry” approach.
The underlying frames worked of each scenario are presented in
Table 3.
4.2.1. Scenario 1. puerperal hemorrhage
a) The first group of students was not sure but finally decided not to
transfuse the patient and infused a saline solution, but just to be
sure, they first called the doctor to confirm the decision. Before
calling the doctor, they attempted to convince the mother (patient)
with arguments such as “If you die, who will take care of your
child?” The doctor instructed them to prepare for immediate sur-
gery. They complied with the instructions. The students relied on
the doctor when they lacked a clear decision regarding an in-
travenous transfusion. The second team insisted more strongly that
the patient comply, and used arguments that entailed moral judge-
ment concerning the mother. Another team was more uncertain but
more respectful of the mother's decision.
b) The dilemma took the students by surprise. They commonly as-
sumed that written medical orders were followed by patients, and
reluctance was unexpected. The lack of preparation for this situation
was evident in the responses analysed, and the doubts that arose
regarding the principle of respect for patient autonomy were also
evident. During the debriefing, there was a discussion on the ap-
propriateness of disregarding the principle of autonomy and in-
stances in which it was legal to do so. Lastly, the students reached
the conclusion that the respect patient's freedom as a right took
precedence over prescriptions or treatments (with the exception of
legal imperatives).
4.2.2. Scenario 2. child abuse due to neglect
a) The students (the three teams in general) suspected the mother
because of her strange and disturbed behaviour, but they initially
focused on reviving the child and calling the paediatrician. The
woman (an actress) admitted that the baby put a packet of heroin
into his mouth and was already unconscious when she found him.
The mother insisted that she didn't want her child taken by social
services and that the event was an accident. One student commented in
front of the mother that “Now social services are going to come,” and
this disturbed the mother much more. The case ended with the mother
worried about the possibility of losing custody of her child.
b) There was a degree of unanimity around the idea that this scenario
was an instance of child abuse through carelessness or negligence by
J.L. Díaz Agea et al. Nurse Education in Practice 32 (2018) 108–114

Table 3
Frames detected. Reinforcement or modification of the frames in the learning of ethics through a simulation.
Frame detected during the simulated experience and subsequent debriefing Frame modified for being Reinforced frame
wrong

The hegemony of medical orders over the will of the patient. x

The prudent need to consult with other people when one cannot choose or does not know the correct approach x
Fear of job loss or of damaging social relationships at work, which impedes the reporting of situations or behaviors that cause x
harm to others (i.e., abuse, negligence, harm to patients)
The rights of disabled or vulnerable (minors) people that take precedence over confidentiality when there is a situation of harm x
or a risk or suspicion of abuse.
Patients who have attempted suicide lose all rights to freedom and autonomy x
Treatment and care can be forced on to patients who have attempted suicide (persuasion, empathy and active listening are x
secondary procedures).
Confidentiality may be breached when the practitioner considers that there is a risk to the patient's life and under ethical x
conditions.
Confusion concerning what to do in a situation of cardiorespiratory arrest during pregnancy regarding lifesaving measures for x
the mother and the fetus.
In a situation of cardiorespiratory arrest in a previously healthy patient, when CPR is unsuccessful, massage should be x
prolonged even if asystole continues for longer than 20 min (for donation of their organs).
The priority in palliative care is the patient, while the family has secondary importance. x
The spiritual arena is secondary to providing care to patients in general and terminal patients in particular. Attention to x
spirituality is taboo because it could cause the patient to realize that she may be dying.
The use of opiates in general is a taboo issue because opiates can induce death through respiratory arrest (although pain is x
present and persistent).
In a terminal situation, the wishes and needs of patients should be respected, and therapeutic obstinacy should be avoided. x
Cultural issues are not given sufficient attention and care; social and cultural circumstances are secondary. x
The autonomy of a patient should be respected except in limited circumstances that are clear. x

the mother. The problem was made more advanced when a student
wondered whether the accident could have occurred with detergent
instead of heroin and asked “would that be abuse?” This question
stimulated debate, and the professor stated that “We have to eluci-
date whether we are the ones who decide whether it is abuse or
whether we are the ones who have to report that possibility. We can
report the possibility or the suspicion, but we cannot dictate whe-
ther it is abuse. Who dictates it?” Issues were then raised regarding
legalities (the role of a judge) and established procedures (existing
protocol).
Again, the professor attempted to promote critical thinking with the
following reasoning: “If she seems like a good mother that is concerned
about her child but is addicted to drugs, should we keep her secret?”
There were doubts about this. Comments were made about disclosing
confidential information, cooperating in wrongdoing in other cases of
the abuse by third parties, and the different types of abuse that exist.
4.2.3. Scenario 3. suicide attempt
a) Upon arriving at the scene, the students found a woman lying on the
kitchen floor, quiet, with a jar of poison in her hand. In response to
questions by the medical team, the woman cried inconsolably. The
woman experienced an anxiety attack, which the team unsuccess-
fully attempted to control (they left her alone with the poison still in
her hand). At no point did the students decide to ask the woman to
sit down in a nearby chair, and they continued to tend to her on the
floor.
that judged the patient's behaviour, and they offered advice with set
phrases.
b) The discussion centred on the possibility that a patient who has
attempted suicide may not wish to receive treatment or even go to a
facility. Most of the students believed that in this case, one must
circumvent consent, but this opinion was based on common sense;
therefore, they were not clear on how to proceed. Another question
related to confidentiality was when a patient had attempted suicide
and asks that their close family members not be notified, although
there is a risk of a future suicide attempt. There was also discussion
concerning the ethical issue of reviving persons who have attempted
suicide.
4.2.4. Scenario 4. cardiorespiratory arrest in a pregnancy with eclampsia
a) The students encountered a hypertensive crisis in a pregnancy.
Finally, the woman enters cardiorespiratory arrest. The students
(the three teams) did not call the doctor immediately and were
nervous and indecisive, as they were overwhelmed by the situation.
The students performed CPR on the mother.
b) Issues raised in debriefing regarding the ethical aspects of CPR,
particularly during pregnancy, maternal-foetal care and the possi-
bility of extracting the fetus (if it was viable) within the first 5 min
after cardiac arrest. Issues regarding organ donation during asystole
were also raised.
4.2.5. Scenario 5. 56-year-old woman diagnosed with stage four pulmonary
neoplasm

She began to express the reasons that led her to attempt to take her
a) Students entered the patient's room and found that she was fatigued
life, but the students focused on the physical issues (techniques, pre-
and in pain. They decided to give her more oxygen and advised her
paring charcoal, etc.) and showed little empathy with her. The woman
doctor regarding the pain, as the amount of analgesics appeared to
was experiencing an anxiety attack without any empathetic reaction
be insufficient. The students also mentioned to the doctor that her
from the students.
catheter was removed during a change in position. The doctor pre-
Faced with the same scenario, another group of students responded
scribed the administering of a vial of morphine and the reinsertion
with greater empathy. Upon entering the home and seeing the woman
of the catheter. The students discussed with the doctor the possibi-
on the floor (and evaluating the situation), they instructed her to get up
lity that this amount of morphine might depress the respiratory state
and sit on the chair. At all times, they listened to the patient, and they
of the patient and induce death, but the doctor responded that the
took time to help her relax; the anxiety attack ended much sooner than
patient's tolerance to morphine was high. The students attempted to
in the previous case. However, the students made certain comments

112
J.L. Díaz Agea et al.
convince the patient to replace the nasogastric tube, but this in-
volved discomfort; thus, the patient denied further procedures. The
students spoke to her relative and supported the patient's decisions
without forcing her when she reiterated her decision to deny any
type of tube. For all the student teams, care for the family member
had secondary importance.
b) A debate occurred regarding the decision of whether to abstain from
the tube placement, whether it was necessary, and the issue of
therapeutic obstinacy. Other issues discussed were the use of mor-
phine, sedation, care for the family and the poor preparation of
professionals regarding spiritual care. Doubts were also raised re-
garding resuscitation when cardiac arrest occurs in a terminally ill
patient. The students described cases based on their experiences in
practice.
4.2.6. Scenario 6. 27-year-old hyperglycaemic Moroccan immigrant
The patient was a 27-year-old Moroccan immigrant with no relevant
history who came to the emergency room with hyperglycaemia. She
had lost 6 kg in the last month. Her sole concern was returning home
because she had left a three-year-old child unattended.
a) The students continually prioritized the pathophysiological condi-
tion of the patient, who refused all proposed measures. At one point,
the students attempted to persuade her with arguments regarding
the complications that she might suffer. The students became
stalled, and it did not occur to them to offer other opinions to
convince the patient, such as calling her husband, seeking an in-
terpreter or attempting to contact a family member to take care of
her child (which was her main concern). However, the situation was
resolved with the patient's acceptance of treatment, and she be-
lieved that she would return home, which was clinically impossible.
b) In the debriefing, issues raised regarding the influence of culture on
health, patient autonomy and particularly the cases in which a vo-
luntary discharge could not be signed. Another question was the
influence of the culture of origin and language barriers in medical
care.
5. Discussion
Regarding learning, students offered a satisfactory evaluation of the
clinical simulation as a valid tool for learning about ethical issues. We
provided a safe learning environment in which students could openly
reflect on the values that are in play in clinical practice, which we
believe contributed to the students’ positive evaluation of the learning
process.
Cannaerts et al. (2014) have demonstrated that the learning of
bioethical competence in nursing increases the perceptions of the im-
portance of ethics education of students and the development of skills
that involve reflection and analysis. However, bioethical education's
contributions to the development of ethical conduct are scarcely men-
tioned. This study (according our learning program design and results)
revealed two essential characteristics that nursing ethics education
should possess, namely, the active participation of students in the dis-
cussions of case studies and the use of ethical frameworks.
Regarding the dimension of learning, we found that students highly
valued the non-clinical aspects and ethical content, given the im-
portance of a holistic approach to caring for patients.
In their clinical practice, nurses must often make decisions that
because of limited time and resources, can delay or omit some inter-
ventions and give priority to others. This situation, which has been
demonstrated in other studies (Burston and Tuckett, 2013; Fry and
Johnstone, 2008; Vryonides et al., 2015), increases the risk of adverse
results for the patient and threatens the safety, quality and dignity of
care. However, it was not clear whether there was an ethical element in
the streamlining of nursing care or whether research had been con-
ducted on how nurses experienced the phenomenon in terms of their
113
Nurse Education in Practice 32 (2018) 108–114
ethical perspective.
The students had a positive perception of these simulated scenarios
and assigned importance to the ethical dimension of clinical decisions.
In our view, this perception favours the proper and advantageous use of
the competencies addressed through simulations.
An important aspect to discuss is the students' satisfaction related to
the de-personalization of the patient. Incorporating ethical elements
into the simulated clinical scenarios has led to the emergence of the
more human aspects of patient care, their will and perspective. It has
transformed the vision of a purely biological perspective that has been
predominant in the practical learning of health professionals.
Facing an ethical dilemma implies taking ethical theory and prac-
ticing it in the real world (although it was simulated). The dissociation
between theoretical knowledge on ethics and decision-making in
practice has been made clear in our research. The students recognized
that they had ethical knowledge that was not materialized in the si-
mulated practices that we performed. The classic disassociation be-
tween theory and practice is the product of an educational system that
is based on behavioural budgets, oriented towards occupational prag-
matism and distanced from constructivist tendencies (Jonassen and
Land, 2012) (which promote learning oriented towards justifying ex-
perience as the basis of ethical knowledge).
The knowledge acquired by the groups of students who participated
in the experiences was based on reflexive learning (Bulman and Schutz,
2013) and experiential learning (Kolb, 2015) and reinforced the idea
that this type of methodology is essential for the training of ethically-
competent professionals. We believe that this study contributes to a
better understanding of how students learn to develop ethical skills and
the factors that influence this learning. As demonstrated in one article
(Cannaerts et al., 2014), this understanding can help professors develop
plans of study that involve the correct learning of ethics in nursing.
Working on the knowledge of the frames that guide ethical action
has been one of the pillars of this study. The basis and structure of this
type of learning (Kolbe et al., 2015) justifies a new approach of re-
flecting on the ethical dilemmas that nurses may face.
As for the frames detected, it was notable that from the 15 identi-
fied, 9 were identified as erroneous, and had to be worked on to try to
change, and 6 were models of behaviour suitable to the ethical para-
digm of nursing (Kangasniemi et al., 2015) or the responsive nurse–-
patient relationships based on essential ethical elements (respect, trust,
and mutuality) (Tarlier, 2004).
When examining the nature of the erroneous frames discovered in
our study in depth, it was observed that most came from a rationalist,
positivist and pragmatic worldview, which emphasizes the care focused
on physio-pathological aspects of people, disregarding other spheres
(such as psychological, spiritual, cultural and social) that are con-
sidered less important. A clear example was the secondary role of the
family for the students in the case of palliative care, or the little at-
tention to spiritual aspects with a dying patient (scenario 5).
The multi-dimensional nature of the human being is the basis of
ethical behaviour in nursing, and in this study, the need for a deeper
addressing of the assumptions that guide the actions and the making of
decisions. These assumptions, from the students in our study, were
sometimes based on irrational beliefs, such as the taboo use of opiates
or the little attention to cultural aspects of the patients (scenario 6).
The moral reasoning of the students, before making a decision, was
not to explore the area of learning in depth, and we believe that this
study could contribute to increasing knowledge in this respect.
It has been demonstrated that a simulation and subsequent reflec-
tion can be suitable tools to provoke behaviour changes in the students
who participated in this research. In agreement with Hsu (2011), we
believe that combining traditional teaching and learning models with
active methodologies can lead to satisfactory results in terms of
learning about ethics in nursing. Other articles have noted that active
methodologies are effective in providing nursing ethics education (Lin
et al., 2010; Smith et al., 2012).
J.L. Díaz Agea et al.
A limitation of this study was the fact that the results obtained relate
to the sample that was studied and cannot be generalized. The asso-
ciations among variables were not examined in this study, which em-
phasized perceptions following a training experience in a descriptive
spirit (without establishing causal relationships). To generalize the re-
sults, it would be necessary to broaden both the number of scenarios
and the number of simulation groups to validate a tool for the quanti-
tative analysis of the dimensions studied. Therefore, this study is a pilot
study for other prospective research in the future.
6. Conclusion
Clinical simulations made it possible to experience situations in-
volving ethical dilemmas and allowed these situations to be reflected
upon.
Students believed that a simulation of ethical dilemmas promoted
holistic care for patients and that this type of learning was enjoyable,
illuminating, practical, and applicable to real life.
Student satisfaction was high. Positive emotions were generated
during the experience (well-being, comfort, empathy and greater con-
fidence in facing ethical issues). However, negative feelings also arose
(confusion or ignorance regarding some of the content presented and
sadness related to sensitive issues such as end-of-life care).
After analysing the student responses to the simulated situations
with ethical implications, contradictions were identified between the
actions demonstrated during the simulations and prior ideas and
knowledge regarding the issues were addressed.
Lastly, 15 different frames that informed the ethical decision
making among the students were identified.
Declaration of interest
The authors report no conflict of interest. This study was supported
by a research grant awarded by the Catholic University of Murcia
(PMAFI-ID- 07/15). The project was endowed with a grant of 600
Euros.
References
Aebersold, M., Tschannen, D., Batís, M., 2012. Innovate simulation strategies in education.
Nursing Research & Practice 2012, 1–7. https://doi.org/10.1155/2012/765212.
Berndt, J., 2014. Patient safety and simulation in prelicensure nursing education: an integrative
review. Teach. Learn. Nurs. 9 (1), 16–22. http://doi.org/10.1016/j.teln.2013.09.001.
Bulman, C., Schutz, S., 2013. Reflective Practice in Nursing, fifth ed. Wiley-Blackwell,
Pondicherry. India.
Burston, A.S., Tuckett, A.G., 2013. Moral distress in nursing Contributing factors, outcomes and
interventions. Nurs. Ethics 20 (3), 312–324. https://doi.org/10.1177/0969733012462049.
Cannaerts, N., Gastmans, C., Casterlé, B.D., 2014. Contribution of ethics education to the ethical
competence of nursing students: educators' and students' perceptions. Nurs. Ethics 21 (8),
861–878. https://doi.org/10.1177/0969733014523166.
Cant, R.P., Cooper, S.J., 2017. The value of simulation-based learning in pre-licensure nurse
education: a state-of-the-art review and meta-analysis. Nurse Educ. Pract. 27, 45–62.
https://doi.org/10.1016/j.nepr.2017.08.012.
Diaz, J.L., Leal, C., Garcia, J.A., Hernandez, E., Adanez, M.G., Saez, A., 2016. Self-learning
methodology in simulated environments (MAES©). Elements and characteristics. Clinical
Simulation in Nursing 12 (7), 268–274. https://doi.org/10.1016/j.ecns.2016.02.011.
Emanuel, E.J., Wendler, D., Grady, C., 2010. What makes clinical research ethical? J. Am. Med.
Assoc. 283 (20), 2701–2711. https://doi.org/10.1001/jama.283.20.2701.
Eppich, W., Cheng, A., 2015. Promoting excellence and reflective learning in simulation
(PEARLS): development and rationale for a blended approach to health care simulation
debriefing. Simulat. Healthc. J. Soc. Med. Simulat. 10 (2), 106–115. https://doi.org/10.
1097/SIH.0000000000000072.
Fry, S., Johnstone, M.J., 2008. Ethics in Nursing Practice: a Guide to Ethical Decision Making,
3th ed. Wiley-Blackwell, Pondicherry, India.
Gallagher, A., 2006. The teaching of nursing ethics: content and method. In: Davis, A., Tschudi,
V., De Raeve, L. (Eds.), Essentials of Teaching and Learning in Nursing Ethics: Perspectives
and Methods. Churchill Livingstone, London, UK, pp. 223–239.
Grady, J., Kehrer, R., Trusty, C., Entin, E.B., Entin, E.E., Brunye, T.T., 2008. Learning nursing
procedures: the influence of simulator fidelity and student gender on teaching effective-
ness. J. Nurs. Educ. 47 (9), 403–408. https://doi.org/10.3928/01484834-20080901-09.
Houghton, C.E., Casey, D., Shaw, D., Murphy, K., 2010. Ethical challenges in qualitative re-
search: examples from practice. Nurse Res. 18 (1), 15–25. https://doi.org/10.7748/
114
Nurse Education in Practice 32 (2018) 108–114
nr2010.10.18.1.15.c8044.
Hsieh, H.F., Shannon, S.E., 2005. Three approaches to qualitative content analysis. Qual. Health
Res. 15 (9), 1277–1288. https://doi.org/10.1177/1049732305276687.
Hsu, L.L., 2011. Blended learning in ethics education: a survey of nursing students. Nurs. Ethics
18 (3), 418–430. https://doi.org/10.1177/0969733011398097.
INACSL Standards Committee, 2016a. INACSL standards of best practice: SimulationSM
Facilitation. Clinical Simulation in Nursing 12 (S), S16–S20. December. https://doi.org/
10.1016/j.ecns.2016.09.007.
INACSL Standards Committee, 2016b. INACSL standards of best practice: SimulationSM
Debriefing. Clinical Simulation in Nursing 12 (S), S21–S25. December. https://doi.org/10.
1016/j.ecns.2016.09.008.
Johnson-Laird, P.N., 2010. Mental models and human reasoning. Proc. Natl. Acad. Sci. Unit.
States Am. 107 (43), 18243–18250. https://doi.org/10.1073/pnas.1012933107.
Jonassen, D., Land, S., 2012. Theoretical Foundations of Learning Environments, 2th ed.
Routledge, New York.
Kangasniemi, M., Pakkanen, P., Korhonen, A., 2015. Professional ethics in nursing: an in-
tegrative review. J. Adv. Nurs. 71 (8), 1744–1757. https://doi.org/10.1111/jan.12619.
Kolb, D.A., 2015. Experiential Learning: Experience as the Source of Learning and
Development, 2th ed. Pearson Education, New Jersey.
Kolbe, M., Grande, B., Spahn, D.R., 2015. Briefing and debriefing during simulation-based
training and beyond: content, structure, attitude and setting. Best Pract. Res. Clin.
Anaesthesiol. 29 (1), 87–96. https://doi.org/10.1016/j.bpa.2015.01.002.
Kulju, K., Stolt, M., Suhonen, R., Leino-Kilpi, H., 2016. Ethical competence: a concept analysis.
Nurs. Ethics 23 (4), 401–412. https://doi.org/10.1177/0969733014567025.
Lin, C.F., Lu, M.S., Chung, C.C., Yang, C.M., 2010. A comparison of problem-based learning and
conventional teaching in nursing ethics education. Nurs. Ethics 17 (3), 373–382. https://
doi.org/10.1177/0969733009355380.
The Terminology & Concepts Working Group, 2016. In: Lopreiato, J.O., Downing, D., Gammon,
W., Lioce, L., Sittner, B., Slot, V., Spain, A.E. (Eds.), Healthcare Simulation Dictionary.
Agency for Healthcare Research and Quality, Rockville, MD Retrieved from. https://www.
ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-
resources/research/simulation_dictionary/sim-dictionary.pdf.
Miller, T., Birch, M., Mauthner, M., 2012. Ethics in Qualitative Research. Sage Publications,
London.
Naik, V.N., Brien, S.E., 2013. Review article: simulation: a means to address and improve pa-
tient safety. Can. J. Anaesth. 60 (2), 192–200. https://doi.org/10.1007/s12630-012-
9860-z.
Palaganas, J.C., Fey, M., Simon, R., 2016. Structured debriefing in simulation-based education.
Advanced Critical Care 27 (1), 78–85. https://doi.org/10.4037/aacnacc2016328.
Poikkeus, T., Numminen, O., Suhonen, R., Leino-Kilpi, H., 2014. A mixed-method systematic
review: support for ethical competence of nurses. J. Adv. Nurs. 70 (2), 256–271. https://
doi.org/10.1111/jan.12213.
Phrampus, P.E., O'Donnell, J.M., 2013. Debriefing using a structured and supported approach.
In: Levine, A.I., DeMaria, S., Schwartz, A.D., Sim, A.J. (Eds.), The Comprehensive Textbook
of Healthcare Simulation. Springer, New York, NY.
Rudolph, J.W., Simon, R., Dufresne, R.L., Raemer, D.B., 2006. There's no such thing as “non-
judgmental” debriefing: a theory and method for debriefing with good judgment. Simulat.
Healthc. J. Soc. Med. Simulat. 1 (1), 49–55.
Rudolph, J.W., Simon, R., Rivard, P., Dufresne, R.L., Raemer, D.B., 2007. Debriefing with good
judgment: combining rigorous feedback with genuine inquiry. Anesthesiol. Clin. 25 (2),
361–376. https://doi.org/10.1016/j.anclin.2007.03.007.
Ryan, M., Ryan, M., 2012. Theorising a model for teaching and assessing reflective learning in
higher education. High Educ. Res. Dev. 32 (2), 244–257.
Saldaña, J., 2015. The Coding Manual for Qualitative Researchers. Sage Publications, London.
Shearer, J., 2013. High-fidelity simulation and safety: an integrative review. J. Nurs. Educ. 52
(1), 39–45. https://doi.org/10.3928/01484834-20121121-01.
Shin, S., Park, J.H., Kim, J.H., 2015. Effectiveness of patient simulation in nursing education:
meta-analysis. Nurse Educ. Today 35 (1), 176–182. https://doi.org/10.1016/j.nedt.2014.
09.009.
Singer, S.J., Hayes, J., Cooper, J.B., Vogt, J.W., Sales, M., Aristidou, A., et al., 2011. A case for
safety leadership team training for hospital managers. Health Care Manag. Rev. 36 (2),
1–13. https://doi.org/10.1097/HMR.0b013e318208cd1d.
Smith, K.V., Klaassen, J., Zimmerman, C., Cheng, A.L., 2013. The evolution of a high–fidelity
patient simulation learning experience to teach legal and ethical issues. J. Prof. Nurs. 29
(3), 168–173. https://doi.org/10.1016/j.profnurs.2012.04.020.
Smith, K.V., Witt, J., Klaassen, J., Zimmerman, C., Cheng, A.-L., 2012. High-fidelity simulation
and legal/ethical concepts: a transformational learning experience. Nurs. Ethics 19 (3),
390–398. https://doi.org/10.1177/0969733011423559.
Stewart, D.W., Shamdasani, P.N., 2014. Focus Groups: Theory and Practice, 2th ed. Sage
Publications, London.
Tarlier, D.S., 2004. Beyond caring: the moral and ethical bases of responsive nurse–patient
relationships. Nurs. Philos. 5 (3), 230–241. https://doi.org/10.1111/j.1466-769X.2004.
00182.x.
Thomas, I., Nicol, L., Regan, L., Cleland, J., Maliepaard, D., Clark, L., et al., 2015. Driven to
distraction: a prospective controlled study of a simulated ward round experience to im-
prove patient safety teaching for medical students. Quality & Safety 24, 154–161. https://
doi.org/10.1136/bmjqs-2014-003272.
Vryonides, S., Papastavrou, E., Charalambous, A., Andreou, P., Merkouris, A., 2015. The ethical
dimension of nursing care rationing: a thematic synthesis of qualitative studies. Nurs.
Ethics 22, 881–900. https://doi.org/10.1177/0969733014551377.
Waznonis, A.R., 2014. Methods and evaluations for simulation debriefing in nursing education.
J. Nurs. Educ. 53 (8), 459–465. https://doi.org/10.3928/01484834-20140722-13.
Wotton, K., Davis, J., Button, D., Kelton, M., 2010. Third-year undergraduate nursing students'
perceptions of high-fidelity simulation. J. Nurs. Educ. 49 (11), 632–639. https://doi.org/
10.3928/01484834-20100831-01.