Nurse Education in Practice 13 (2013) 553e560

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Ethics education for health professionals: A values based approach

Rosemary Godbold 1, Amanda Lees*
Faculty of Health and Environmental Sciences, AUT University, Private Bag 92006, Auckland 1142, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: It is now widely accepted that ethics is an essential part of educating health professionals. Despite a clear
Accepted 19 February 2013 mandate to educators, there are differing approaches, in particular, how and where ethics is positioned in
training programmes, underpinning philosophies and optimal modes of assessment. This paper explores
Keywords: varying practices and argues for a values based approach to ethics education. It then explores the pos-
Health care ethics sibility of using a web-based technology, the Values Exchange, to facilitate a values based approach. It
Ethics education
uses the findings of a small scale study to signal the potential of the Values Exchange for engaging,
Values based decision making
meaningful and applied ethics education.
Ó 2013 Elsevier Ltd. All rights reserved.

Introduction Background

There is now widespread acceptance that ethics is an essential Ethics education

part of educating health professionals (Bridgeman et al., 1999;
Lofton, 2004). Today’s health care environment is more consumer
focused, patient autonomy is valued over traditional paternalistic
approaches, consumers have more choice, are more knowledge-
able with increased access to information, and technology pro-
liferates (Paterson, 2002; Petrova et al., 2006). In addition, a raft
of events internationally has undermined the confidence of the
public in health professionals.2 In New Zealand, acknowledge-
ment of ethical standards is a legal requirement for all registered
health professionals (Health Practitioners Competence Assurance
Act, 2003; NZ). Despite this clear mandate, the optimal way to
deliver ethics education for health professionals is contentious.
This paper examines varying practices and argues for a values
based, process oriented approach. It then explores the possibil-
ities of using a web-based technology, the Values Exchange, to
facilitate a values based approach, using the findings of a small
scale study to signal its potential for engaging, meaningful and
applied ethics education.
* Corresponding author. Tel.: þ64 4499219999x7647.
E-mail addresses: rgodbold@aut.ac.nz (R. Godbold), amandab.lees@aut.ac.nz
(A. Lees).
1
Tel.: þ64 4499219999x6902.
2
For example, the Cartwright report (1988) was a damning indictment of
research into cervical cancer at National Women’s Hospital in Auckland, New
Zealand and in England the Bristol Inquiry investigated poor paediatric cardiac
surgical practices (Kennedy, 2001).
Although inclusion of ethics in the education of health pro-
fessionals either in the tertiary setting or as part of on the job
training is increasingly prevalent, there is variation in content,
depth and approach taken (Campbell et al., 2007). The delivery may
be one off guest lectures, entire courses and, particularly in medical
schools, provision of ethics education throughout each year of ed-
ucation (Goldie, Schwartz, McConnachie, & Morrison, 2001). There
is a general acceptance that ethics education is difficult both to
teach and assess (Bertolami, 2004; Campbell et al., 2007; Singer
et al., 2001; Wong and Chung, 2003). This is in part due to an
emphasis on providing outcome based courses in what is often seen
as an intangible subject area (Wong and Chung, 2003). Moreover,
ethics education may have little effect, given that behaviours may
be clearly established by the time the student enters tertiary edu-
cation (Campbell et al., 2007; Bertolami, 2004; Cooper et al., 2012).
Variation in teaching ideology exists. Three main examples include
ethics education whereby students are taught from a predomi-
nantly theoretical perspective, education which promotes the
achievement of objectively ‘right’ answers to ethical questions, or
education based on understanding ethical ‘process’.
Ethics education is often based on knowledge and application of
traditional ethical theories such as utilitarianism and deontology.
Several limitations exist with this approach. The theory-practice
gap is problematic and students often find it difficult to apply
knowledge gained in class to real situations in practice (van der
Burg and van de Poel, 2005). A study by Parsons et al. (2001)

1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nepr.2013.02.012
554 R. Godbold, A. Lees / Nurse Education in Practice 13 (2013) 553e560
looked at student’s responses to a knowledge based approach and
while some found the courses favourable, others considered the
content ‘heavy going’ with one claiming that ‘health care ethics is
generally not enjoyed by students’ (p.51). Hattab (2004) found that
ethics teachers are often from philosophy departments who may
not always have first hand experience of the specific health care
setting. The terminology used is also contentious. The use of un-
fortunate esoteric sounding theory names may do little more than
alienate students (Cowley, 2005). As Gillon observed, ‘ethics is
there for everyone, not just people with a PhD in philosophy”
(Gillon, 2003, p.311). While knowledge of ethical concepts and
theories can be objectively measured, application of this knowl-
edge in real life everyday health care practice is more challenging to
assess.
A range of programmes utilise some form of objective test for
assessing ethics education. Crisham’s 1981 study developed a
‘Nursing Dilemma Test’, measuring responses to recurrent nursing
dilemmas in an attempt to verify taught ethical material. McAlpine,
Kristjanson and Poroch (1997) developed the Ethical Reasoning
Tool to identify learning/reasoning deficiency that can be addressed
by educational interventions while Green et al. (1995) established
the ‘Gold standard’ as marking medical student’s appraisals of
ethical vignettes. In a more recent study by Goldie et al. (2002),
medical student’s responses to ethical vignettes were judged on
their consensus with responses given by “specialists in medical
ethics” (p.497).
Solving ethical issues requires critical thinking skills rather than
just learning to match correct responses. Not only do these
methods of teaching and learning suppose that ethics is something
that can be objectively taught, but they may constrict the in-
dividual’s own capacity to reason. Not only does this limited style of
education rule out helping students to better understand them-
selves and their own decision making processes it could reinforce
professional values devoid of any sort of scrutiny and remove the
potential for students to adopt the important “habit of constructive
analysis” (Campbell et al., 2007, p.432).
Rather than ethics being about the transference of knowledge, a
process orientated view recognises that the decisions we make are
subjective and in many instances there will not be a ‘right’ answer.
A more effective way to deliver ethics education is through a self-
reflective curriculum whereby students come to better under-
stand themselves and learn how to make decisions in line with
their own beliefs (Bertolami, 2004). Such programmes often utilise
case study discussion, critical analysis and self-reflective journals
(see Malpas, 2011 for example). There are advantages for this
approach. For example, quiet students or those from different
cultures or who are speaking a second language could feel intimi-
dated by a theoretical format (Hattab, 2004). Many courses in ethics
now include an amalgamation of theory based knowledge as well
as a more interactive reflective approach.
Values based decision making
The authors have been teaching cross disciplinary ethics edu-
cation to a variety of health professionals for over 8 years. In
accordance with other values driven education philosophies (see
for example, McLean, 2012; who advocates for a values based cur-
riculum model in nurse education) values are central to the phi-
losophy which underpins our ethics education. The emphasis of
decision making in health care is often evidence based, with a
generally accepted assumption that this provides beneficial out-
comes for patients (Dickenson and Vineis, 2002). Within a pre-
dominantly evidence based environment, the place of values in
health care decision making is not always acknowledged or
understood.
The main assumption underpinning values based decision
making is that all decisions are a mix of evidence and values. Ful-
ford has developed what he calls the counterpart to evidence-based
medicine (2004). Values-based medicine (VBM) is a fact þ values
model of reasoning, which proposes that values and evidence are
“the two feet on which all decisions in health (and any other
context) stand” (p. 209). This approach is counter to the belief that
individual values can, and should be separated from decision
making in the health care context (See for example Savulescu
(2006), who argues that value-driven medicine has the potential
to create “bigoted, discriminatory medicine” (p.297)). Seedhouse is
another proponent of a more realistic approach that accounts for
the integral role of values. “All decisions are a balance of evidence
and values. Obviously we should regard values as at least equally
important as evidence. And yet we don’t” (Seedhouse, 2005, p.23).
His theory is concerned with exposing the values which drive and
inform decision making, arguing that in health care, while evidence
is visible, values are often not visible, transparent, or recognisable
(Seedhouse, 2009).
Both practitioners and students need to be more aware of the
role of values and recognise the influences of their own, as well as
the values of those they are working to help (Fulford, 2004). As well
as illuminating the role that values play in decision making, ethics
education should equip students with reasoning skills to enable
them to be more aware of situations within their practice, to
consider a range of possible courses of action and to confidently
justify the particular action taken. So how can educators effectively
achieve these goals in an engaging, applied and meaningful way?
The Values Exchange
The Values Exchange is web-based technology which provides
users with a framework for thinking and justifying decisions
(Fig. 1).
It has been used as a teaching and assessment tool for a variety
of health science students at AUT University (Auckland, New Zea-
land) since 2004. It is used internationally by universities, schools
and an increasing number of health care institutions (AUT
University Values Exchange, 2011). It is an example of a process
orientated approach to ethics education, reflecting the view that a
good decision is one that is robustly justified, rather than achieving
a pre-prescribed right or wrong answer (Seedhouse, 2009). Using
everyday language the software incorporates traditional theoretical
approaches, but does not impose intellectual authority. It is
underpinned by Seedhouse’s values based theory of decision
making with the primary goal of values transparency.
The software has a series of interactive screens which facilitate
ethical analysis. The user is first required to consider a case pro-
posal (Fig. 2) and take a position on whether they agree or disagree
(Fig. 3).
In our teaching, students are given cases relevant to their clinical
practice, such as whether to resuscitate terminally ill patients
where no clear orders exist or mandatory influenza vaccinations for
health care workers (See for example Lees and Godbold, 2012;
which reports on the use of the software by student physiothera-
pists asked whether to break the confidentiality of a patient with
suicidal intent against their expressed wishes). They must then
select who matters most in the case and what they see as the most
important factor for consideration. Once these initial responses
have been made the software is used to expand and explain
thinking using the interactive rings screen (Fig. 4) and the ethical
grid (Fig. 5). People familiar with Seedhouse’s earlier work will
recognise the rings of uncertainty and ethical grid on which screens
3 and 4 are based and which have evolved to provide a visual
window into users’ thinking.
 R. Godbold, A. Lees / Nurse Education in Practice 13 (2013) 553e560
Fig. 1. The AUT Values Exchange home page.
The final screen asks users to review and submit their case. The
system instantly generates individual reports which can be viewed,
along with the reports of others who have deliberated the same
case (Fig. 6).
Computer based ethics programmes
Insufficient research has been done into learning and teaching
methods (Goldie et al., 2001), but it is clear that more innovative
methods are required in ethics education (Campbell et al., 2007).
Computer based ethics programmes have been developed within
engineering (Goldin et al., 2001) and business (Mathieson, 2007)
and health care (Fleetwood et al., 2000). Research focused on the
educational potential of web based programmes for ethical deci-
sion making in health contexts is limited. Fleetwood et al. (2000)
attempted to bridge the gap between theory and practice with
their MedEthEx computer based learning programme. They found
that students valued responding in their own time, that software
programmes helped to avoid peer pressure to respond in a certain
moral way and provided personalised, instant feedback. However,
using multi choice tests, the results of students using the software
were not significantly different from the students assigned to small
group discussions.
Ellenchild Pinch and Graves (2000) examined a web based
discussion forum where a class of 29 nursing students engaged in
555
dialogue around topical ethical case studies. The authors shared a
similar ethos; “bioethics education is not a process of memorisation
or the development of the ability to respond ‘correctly’; values,
beliefs, and traditions need to be recognized, shared, and possibly
defended” (p.705). Their goal was to facilitate discussion through
student interaction. They found students were able to expand upon
the discussions outside of the classroom and quiet students were
encouraged to participate. The web-based learning environment
had the potential for flexible access and participation, with scope
for interdisciplinary discussions (Ellenchild Pinch and Graves,
2000). While this study focussed solely on nursing students, its
authors discussed the importance of interdisciplinary learning in
ethics education and the potential for educational technologies to
facilitate such learning.
Values exchange pilot study
While the use of the Values Exchange is now widespread,
research into its effectiveness as an educational tool for health
professionals is limited. A recent pilot study explored the potential
of the software as an educational tool in ethics education for
health professionals. A descriptive case study methodology guided
by the values based ideology of the software investigated the
experiences of five health professionals with experience in med-
icine, public health, nursing, dietetics, occupational therapy,
556 R. Godbold, A. Lees / Nurse Education in Practice 13 (2013) 553e560

Fig. 2. Case information and proposal.

mental health, health geography and health research who used
the Values Exchange to work through an ethically complex,
representative case from health care practice. Would they break
the confidentiality of a client who had disclosed an intention to
commit suicide and requested that the practitioner keep this
disclosure confidential?
In keeping with case study design, although the number of
participants was small, three data collection methods (question-
naires, face to face interviews and Values Exchange case reports)
resulted in rich and diverse data (Simons, 2009; Bassey, 1999;
Flyvbjerg, 2006; Morse, 2000). AUT University’s Ethics Committee
approved the study. Permission to name AUT University and to
publish website screenshots was received from the Faculty
Research Dean and Values Exchange developer, Dr David Seed-
house, respectively.
Findings and discussion
A thematic analysis of the three data sources using Braun and
Clarke’s six step process (2006) identified three main themes:
recognising the inherent tensions in decision making, new ways of
seeing and foundations for thinking. While the findings are not
generalisable, they do signal the potential of the Values Exchange to
facilitate engaging, reflective, practice based ethics education.

Fig. 3. Proposal position and initial focus questions.

R. Godbold, A. Lees / Nurse Education in Practice 13 (2013) 553e560 557

Fig. 4. The Rings screen.

Fig. 5. The Grid screen.

558 R. Godbold, A. Lees / Nurse Education in Practice 13 (2013) 553e560

Fig. 6. Example of individual user report.

Recognising inherent tensions
In contrast with bioethics which adopts a quasi-legal form to
find correct outcomes to regulate and guide technological ad-
vancements in health care, a values based approach focuses on the
process used to decide on a course of action. Focusing on process
enables students to understand the complex and integral role of
values and to learn to justify the decisions they make. Raised
awareness of the complexity of decision making was a marked
feature of participants’ experiences, both of the ethical issues
within the case and possible and actual responses to it. For
example, tensions between personal and professional roles,
competing duties to the patient, the family and themselves, and the
desire to act beneficently versus promoting patient autonomy. “I
did not realize how diverse and complex these problems are and how
many different opinions exist”. This was beneficial in helping par-
ticipants understand others’ perspectives as well as finding com-
mon ground.
Some aspects of the Values Exchange experience can be dis-
comforting. The overtly subjective nature of the process resulted in
participants feeling vulnerable, particularly being judged on per-
sonal perspectives and anxious about peer and employer criticism.
However, the process also led users to think candidly about
themselves and their values. “It forced me to be honest with myself
 R. Godbold, A. Lees / Nurse Education in Practice 13 (2013) 553e560
about unconscious aspects of my thinking and my beliefs. That was
incredibly helpful even if uncomfortable.” An important aspect of the
Vx is that it offers transparency and users can elect whether or not
their reports will identify them by name. Generally, anonymity was
seen as a way to feel more comfortable about using the system.
However, people were more willing to be named if a trusting,
supportive environment for decision making was present. As one
participant said “People need to learn that it’s ok for others to have
alternative perspectives and opinions and to be willing to discuss
differing opinions to come to a greater understanding”.
Many health science programmes are dominated by positivist
science based paradigms and influential thinkers have promoted the
possibility that emotions can be eliminated from ethical reasoning
(see for example, Rachels and Rachels, 2006, p.43). It is therefore not
surprising that participants were uncomfortable about the role their
emotions played in their response to the case. Some felt they were
somehow betraying the client by disclosing his intention to commit
suicide and others highlighted a tension between their perceived
professional duty and an emotional response to the situation. For
example, one participant viewed sympathising too strongly with
the client would prevent them helping him in an appropriate way
and carrying out their perceived duty to the client, his family and
themselves; to break the confidence. Another participant felt that
sympathizing with the patient might even put effective decision
making at risk. One participant used her emotions to remain patient
centred and gauge the appropriateness of her decision. Others
talked about managing or controlling their emotional response.
New ways of seeing
Seedhouse claims that the Values Exchange “enhances our un-
derstanding of different points of view and fosters deeper commu-
nication between people who might never otherwise encounter
each other” (Seedhouse, 2005, p xii). This he considers a necessity,
especially “where people in positions of authority claim to be
making decisions in the interests of people subject to that author-
ity.and where technical evidence and expertise is not decisive”
(p.124). Viewing others’ responses to the same case had a powerful
and positive impact on most participants. It helped them to
understand the thinking processes of others and provided an
appreciation of broader perspectives. For some this was a chance to
re-evaluate the way they had approached the scenario and also
offered an incentive to strengthen their argument. For example, one
participant had not considered the legality of the case and through
reading others’ reports saw the importance of this aspect of the case.
These insights were seen as a learning experience and even caused
some participants to reconsider their position.
An effective way to deliver ethics education is through a self-
reflective curriculum where students come to better understand
themselves and learn how to make decisions in line with their own
beliefs (Bertolami, 2004). Following their use of the Values Ex-
change, participants reported new understandings about them-
selves. For example, one participant was surprised by the cut and
dried way she approached the case and another by the need she felt
to protect health professionals and the health organization. One
participant realised her inability to make decisions and for another
it helped to make sense of her values and how she responds to
ethical issues in practice. ‘I’ve learned that I see the patient as inex-
tricably part of a family and wider group and so I would never put the
rights of an individual above the rights of the group. I didn’t realise this
before. It’s no wonder that medical decision making has sometimes
been very challenging for me, given the Hippocratic Oath.” For most,
the experience helped them realise that they could be confident
decision makers and that with clear justification, their views were
valid, whatever their perspective.
559
There is often an assumption that the patient is central and
beneficence underpins health care decision making (Hope et al.,
2003). By using the Values Exchange to work through this scenario,
the participants’ need to protect themselves as well as the client
surfaced. This was a new and important realisation for some partic-
ipants: ‘I saw that I took a legal/self preservation angle rather than
patient centred e this surprised me.I only realised when I compared
my answers to others.’ All participants also expressed concerns which
went beyond the client; about the future, the intrinsic value of life and
the impact of suicide on the client’s family and friends. These expe-
riences demonstrate the need for greater understanding of the
complex and integral role of values in health care decision making
and signal the potential of the Values Exchange to achieve this.
Foundations for thinking
Web-based technology has the potential to create environments
which enhance student engagement with course content (Mason,
2009) and can reduce the influence of peer pressure in ethics ed-
ucation (Fleetwood et al., 2000). Using technology to deliberate
ethical issues was a new experience for the participants who re-
flected on the space for thinking created by the software. Some
found this restricting, others that it enhanced thinking. For
example, some found that the written word created an almost
unhelpful barrier between the issue and its resolution and
preferred a live debate. One participant observed that her thinking
was more flexible and “able to take into account more situational
variables than a software programme limited by words”. Conversely,
others felt a positive impact on their ability to think through the
issues compared to a verbal dialogue and on the unclutteredness of
being able to consider the case alone. The potential for an internet
based system to break down barriers which may exist in face to face
to discussions was also seen as important.
The software provided structure for thinking and this was
experienced in two ways. Firstly the actual software mechanisms
provided a framework to guide the thinking process. Secondly the
values exchange framework seemed to operate as a trigger for
additional thinking about new and different aspects of the case
they had not first been considered. Most participants felt they had
benefitted from this structure. They found the software generally
easy to use, that it helped clarify ethical issues and offered a range
of cases relevant to both professional and daily life. As one partic-
ipant explained, it was “an inspiring way to both express and clarify
individual ethical opinions whilst at the same time gauging overall
opinions”.
All participants saw the educational potential of the Values
Exchange, both for clinicians and students. This included the pos-
sibility of reducing the theory practice gap which is a significant
challenge for ethics educators, particularly with students who have
little or no hands on experience.
If you’re using this as a teaching device for people who are in say,
their first year of studying and not been exposed to those really difficult
challenging things, then yeah it’s a really good window to start them
off, to ease them into it.
I think it’s a great teaching tool for those coming to learn about how
ethical decision making occurs.I’m just thinking about some of the
young nursing grads e people like that who haven’t been exposed to a
clinical environment.it has the potential as part of an e-learning
frame for clinical practitioners.
It has the capacity to be useful for experienced practitioners and
even for supervisions to present as a medium for clinicians to work
through dilemmas they may be facing in their practice. Equally so for
teams who are facing demanding complex situation where it is difficult
for the clinical team to reach consensus on the way forward, where one
ultimately needs to be reached.
560 R. Godbold, A. Lees / Nurse Education in Practice 13 (2013) 553e560
This was further evidenced by links that participants made to
how they managed ethical issues in the past and how this experi-
ence would influence their responses in future practice. For
example, one participant talked about the importance of being
open and not solely relying on their own perspective to resolve
issues and achieve best patient outcomes. Another considered how
being aware of others’ views and the new thinking which resulted
prompted her to think of other ways to deal with ethical issues.
Conclusion
There is an onus on ethics educators to equip current and future
health professionals to deal with ethically challenging modern
health care delivery environments. A values based approach offers a
realistic, pragmatic, process oriented approach which recognizes
and promotes the role of individual values in health care decision
making. While more research is required, this small scale study
suggests that the Values Exchange may assist students understand
the complexity of ethical decisions and their responses to them. It
provides students with a framework to contemplate real practise
based scenarios in a structured, engaging and accessible way.
Interested readers are welcome to view the most recent version of
the AUT University Values Exchange website here: http://aut.
vxcommunity.com. By making values transparent, the Values Ex-
change has potential for reflective learning about our own, and
others perspectives, and for achieving a more balanced framework
for thinking.
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