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Interventions to improve ethical decision-making skills in nursing students:

A systematic review

Article in Nursing Ethics · April 2024

DOI: 10.1177/09697330241239917

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Review

Nursing Ethics
2024, Vol. 0(0) 1–12
Interventions to improve ethical © The Author(s) 2024
Article reuse guidelines:
decision-making skills in nursing sagepub.com/journals-permissions
DOI: 10.1177/09697330241239917
journals.sagepub.com/home/nej
students: A systematic review

Mağfiret Kaşıkçı
Ataturk University

Zeynep Yıldırım 
Ardahan University

Abstract
Background: Interventions to improve ethical decision-making are available in nursing education. Evidence
of its effectiveness is essential.
Objective: This review examined the effectiveness of interventions to improve nursing students’ ethical
decision-making skills.
Methods: A structured search was performed in Google Scholar, Web of Science, Science Direct, Pubmed,
Scopus, Cochrane Library, Elsevier, CINAHL EBSCO, and ULAKBIM. The Joanna Briggs Institute Meta-
Analysis of Statistics Assessment and Review Instruments (JBI-MAStARI) was used to assess the quality of
studies.
Ethical considerations: Ethical approval was not required for this systematic review.
Findings: The final review was composed of six studies of published between January 2013 and 2023. Nine
different teaching methods applied to students. Although the importance of ethical decision-making skills in
solving ethical problems that nurses may encounter at any time is known, it is thought that there is a lack of
data in the literature in the last 10 years. The last 10 years were chosen as this aims to provide a review based
on the most current, relevant and quality information. The review indicated that all of the teaching methods
improved ethical decision-making.
Conclusion: Different teaching methods can be used in the nursing education curriculum to meet the
learning needs of nursing students in ethical decision-making.

Keywords
Nursing students, nursing ethics, decision-making, intervention study

Corresponding author:
Zeynep Yıldırım, Faculty of Health Sciences, Ardahan University Campus, 75002 Kartalpınar/Ardahan, Turkey.
Email: zeynepyildirim@atauni.edu.tr
2 Nursing Ethics 0(0)

Introduction
Nursing is a caring career that has a significant effect on people’s lives, health, and well-being. Advances in
science and technology have made patient care increasingly complex.1 On the other hand, the low number of
nurses, different approaches to illness between nurses and patients, role confusion, moral conflicts, and value
conflicts often lead nurses to an ethical dilemma.2 For these reasons, nursing faces more ethical problems than
other professions.3 Nurses’ ability to manage these problems in patient care requires an accurate under-
standing of ethical principles and decision-making skills.4
Ethical decision-making is a logical process involving making the most appropriate ethical decisions
through systematic reasoning in conflicting situations.5 Ethical decision-making is one of the core skills in the
nursing profession. Studies conducted with nursing students reveal that ethical decision-making is positively
related to professional behavior, moral sensitivity, professional values, and professional behavior.6–8 In
addition, it has been reported that nurses with high ethical decision-making can establish better nurse-patient
relationships and provide quality care.9 Bang (2020)10 argues for strengthening the ethics education of
nursing students to develop positive nursing professionals who are confident in ethical decision-making.
A study shows that 97% of nursing students face at least one ethical and clinical challenge, and 48% have
unresolved ethical issues.11 Nursing students who encounter ethical problems need help solving them in the
clinical setting.7 Therefore, Lee et al. (2020)12 stated that nursing students’ knowledge and skills related to
ethical decision-making should be developed. Hoskins et al. (2018)9 reviewed many studies and found that there
is a gap in ethics education between nursing curricula and clinical practice. The traditional teaching method can
lead to lower levels of student satisfaction, learning outcomes, knowledge discovery and assimilation,13 which
often indicates that it is inadequate to develop students’ ethical decision-making skills.14 Therefore, inter-
ventions should be designed to enable future nurses to solve problems related to ethical decision-making.6
Different interventions can meet the need to teach students how to deal with an ethical situation and how to make
ethical decisions during an ethical dilemma as part of their preparation for working in the real field.15
A systemic review of interventions that improve ethical decision-making skills for nursing students helps
identify effective strategies in education, improve the quality of education, evaluate student performance,
ensure compliance with professional standards, and promote patient safety. This enables nursing students to
deal with ethical issues and develops a more ethical and effective approach to patient care. The specific
limitations and deficiencies in the existing literature have led to the need for a systematic review, particularly
in relation to the enhancement of ethical decision-making skills in nursing students. In evidence-based
medicine, systematic reviews are at the top of the evidence pyramid.16 While randomized controlled trials
(RCTs) generally represent studies conducted under ideal conditions, quasi-experimental studies may better
reflect real-world applications. Therefore, using both types together provides more comprehensive guidance
on how to behave in both ideal and real-world situations.17 There are interventions in the literature to improve
ethical decision-making in nursing students.18–23 This systematic review, which is a combination of RCT and
quasi-experimental study, will provide reliable evidence for future studies on the subject. Therefore, this
review examines the interventions to improve nursing students’ ethical decision-making in this context.
Research questions are as follows?

· What are the practices for improving ethical decision-making skills in nursing students?
· Are practices aimed at improving ethical decision-making skills in nursing students effective?

Methods
In this study, a systematic review process was carried out in accordance with the guidelines in the PRISMA
guideline.24
Kaşıkçı and Yıldırım 3

Eligibility criteria
The research question and research topic were determined within the framework of PICOS criteria:

· Population: Nursing undergraduate students

· Intervention: Educational intervention
· Comparison: Teaching methods that affect ethical decision-making skills
· Outcomes: Effect levels educational making on ethical decision-making
· Study design: Quasi-experimental studies and RCTs.

Non-randomized (quasi-experimental) studies and randomized clinical trials (RCTs) published in

peer-reviewed journals were eligible for the systematic review. In this systematic review, studies
evaluating the effect of “interventions” applied to “nursing students" on “ethical decision-making” were
examined. On average, there may be a delay of 2–3 years in scientific publications. Therefore, the last
10 years generally include the most recently published and reviewed studies. In addition, education and
training methods are changing day by day with developing technology. Data from older studies may
sometimes be less reliable or appropriate than data obtained with current methods and technologies. For
this reason, the research was planned based on the last ten years, as it was thought that it would be more
accurate to conduct teaching methods in the last ten years. Studies published and accessible in the last
10 years between January 1, 2013, and January 1, 2023, written in English and Turkish and whose full
text can be accessed, were included in the study. Descriptive, qualitative, and methodological studies,
meta-analyses, systematic reviews, reviews, theses, book chapters, congress papers, and studies without
application were excluded.

Information resources and search strategy

Data from January 1, 2013, to January 1, 2023, were scanned. Google Scholar, Web of Science, Science
Direct, Pubmed, Scopus, Cochrane Library, Elsevier, CINAHL EBSCO, and ULAKBİM databases were
used for searching. These databases were searched with the keywords “ethical decision-making,”
“intervention” “nursing,” “student,” “experimental,” and were combined with Boolean conjunctions
(AND or OR). In addition, the content of MeSH (Medical Subjects Headings) for English keywords and
Türkiye Bilim Terimleri (TBT) (https://www.bilimterimleri.com/) was used to create the Turkish
equivalent of English keywords. In addition, bibliographies of the scanned articles were searched again
for additional suitable articles.

Selection and data collection process

Microsoft Excel was used to design a specific spreadsheet for data extraction. Full texts of eligible
studies were extensively evaluated for inclusion. An increase in the post-test score of the scales
measuring ethical decision-making skills was accepted as a significant change. The extracted data is as
follows:

· Study data: name of first author, year of publication, study design

· Interventions: Description of each intervention
· Number of data: Number of nursing students included in interventions
· Results: The effect of teaching methods on ethical decision-making.
4 Nursing Ethics 0(0)

Bias risk
Using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instruments (JBI-
MAStARI), quasi-experimental studies and RCTs that met the inclusion criteria were evaluated for quality.
“Checklist For Quasi-Experimental Studies (Non-Randomized Experimental Studies)” was used for quasi-
experimental studies, and “Checklist For Randomized Controlled Trials” was used for RCTs. Two researchers
independently reviewed the assessments (M.K. and Z.Y.).

The role of researchers

According to eligibility criteria, two researchers (M.K. and Z.Y.) independently read and eliminated irrelevant
studies from the title and abstract. In addition, both researchers recorded and critically reviewed full-text
articles independently (M.K. and Z.Y.). Any case of inconsistency in data extraction or study selection was
discussed by two researchers (M.K. and Z.Y.). As a result of the examinations of two researchers (M.K. and
Z.Y.), appropriate titles were decided to present the data in tabular form: name of the article, year of
publication, and authors, sample, intervention, method, result.

Ethical aspect of research

The studies that were open to access in the databases were included in the sample, and the research was carried
out without the need for any ethics committee permission.

Data collection
Experimental studies in Turkish and English with nursing students, examining ethical decision-making skills,
and a control group were inclusion criteria. A total of 2244 results were obtained by typing the words “ethical
decision-making,” “intervention,” “nursing,” “student,” and “experimental” in search engines. When the
titles and abstracts of these articles were examined, 2196 studies were eliminated because they were du-
plications, were not related to nursing students or ethical decision-making, were not full text, and were not in
English or Turkish. Six articles were reviewed in this review, as 22 out of 28 articles were excluded for
different reasons (Figure 1).

Results
This review examined 4 quasi-experimental and 2 RCT studies published between 2013 and 2022, which
were conducted to improve nursing students’ ethical decision-making skills. The samples of the research
examined consisted entirely of nursing students. Therefore, the sample number of the studies examined in the
review consisted of 550 nursing students. Teaching methods applied to students in research; Standardized
Patient Use (n = 2), Case Analysis (n = 2), Ethical Reasoning Program (n = 1), Online Synchronous
Classroom (n = 1), Online Asynchronous Classroom (n = 1), Narrative-Based Teaching (n = 2), Problem-
Based Instruction (n = 1) and Inquiry-Based Instruction (n = 1) (Table 1). It was concluded that there was a
significant increase in the average score of the students after the 8 teaching methods applied in the studies
were applied and that it was an effective method in improving ethical decision-making (Table 1).
In the research examined, in order to determine the ethical decision-making level of the students, It was
determined that the “Special Questionnaires Developed by the Researchers” “Nursing Dilemma Test (NDT),”
and “Ethical Decision-Making Scale-Revised (EDMS-R),” measurement tools were used.
Kaşıkçı and Yıldırım 5

Figure 1. Flow chart showing the literature search (PRISMA).24

Since the same measurement tool is not used in every study, the superiority of teaching methods over each
other cannot be mentioned. Suliman et al. (2022)22 used a 5-set scale developed by the researchers in their
study. The fifth set (7 questions) that included agree and disagree questions were used to measure students’
ability to solve an ethical dilemma. Kucukkelepce et al. (2020),21 Basak and Cerit (2019),18 and Khabitan
et al. (2019)19 used NDT, developed by Patricia Crisham in 1981. NDT was used to reveal the moral problems
in patient care, and six ethical dilemmas specific to the nursing practice were included within the scope of the
test.25 The NDT contains six scripted ethical dilemmas. The six vignettes deal with following problems:
 6

Table 1. Included studies and characteristics.

Author/Publication year/ Measurement

Article name Sample Intervention Method tools Result JBI

Suliman et al., 2022 127 nursing Use of online RCT Special It has been determined that the 10/13
The impact of online students synchronous and questionnaire ethical decision-making skills
synchronous versus online developed by of the students who attend
asynchronous classes on asynchronous the researchers the synchronous and
nursing students’ classes asynchronous online classes
knowledge and ability to have improved
make legal and ethical
decisions
Kucukkelepce et al., 2020 89 nursing Standardized patient Quasi-experimental NDT It has been determined that 7/9
Effects of using standardized students use and case standardized patient use and
patients on nursing analysis use case analysis methods
students’ moral skills improve the decision-making
method of ethical students
Pai et al., 2019 101 nursing Use of ethical RCT EDMS-R After the intervention, it was 11/13
Effects of an ethical decision- students reasoning determined that the ethical
making reasoning scheme in program decision-making
nursing students: A competences of the students
randomized, open-label, improved more in the
controlled trial intervention group
compared with the control
group
Basak and Cerit, 2019 70 nursing Simulation and case Quasi-experimental NDT Compared with the case 8/9
Comparing two teaching students analysis use analysis method, it was
methods on nursing determined that the use of
students’ ethical decision- standardized patients was
making level more effective in developing
students’ ethical decision-
making skills

(continued)
Nursing Ethics 0(0)
 Kaşıkçı and Yıldırım

Table 1. (continued)

Author/Publication year/ Measurement

Article name Sample Intervention Method tools Result JBI

Khabitan et al., 2019 66 nursing Use of lecture-
Lecture-based versus students based and
problem-based learning in problem-based
ethics education among teaching methods
nursing students
Zhang et al., 2019 97 nursing Use of inquiry-
A comparison of inquiry- students oriented and
oriented teaching and lecture-based
lecture-based approach in teaching methods
nursing ethics education
Quasi-experimental NDT It has been determined that 7/9
lecture-based and problem-
based methods improve
students’ ethical decision-
making skills
Quasi-experimental Special It has been determined that 8/9
questionnaire inquiry-oriented teaching
developed by and lecture-based teaching
the researchers methods improve students’
ethical decision-making skills
7
8 Nursing Ethics 0(0)

Newborn with Anomalies, Forcing Medication, Adult’s Request to Die, New Nurse Orientation, Medication
Error, and Uninformed Terminally III Adult. Each ethical dilemma comprises three parts. This study used the
second part of the test for evaluation. In the second part, Nursing Principled Thinking (NP) and Practical
Considerations (PC) scores related to ethical decision-making were calculated. The second part of the test
presents six items for the scenarios that incorporate moral dilemmas. These items are used to assess the
scenario and the approach to solve the problem. The students’ order of importance rankings were used to
calculate the NP and PC scores. NP is used to assess the emphasis placed on taking moral principles into
consideration while making moral decisions in nursing. PC measures the emphasis placed on environmental
factors by nurses such as the number of patients, number of resources, organizational policies, and physician’s
control in making decisions about ethical issues. The NP and PC scores were obtained separately for each
dilemma and then combined to determine total NP and PC scores. The range of NP and PC scores that can be
obtained from the tests is 18 to 66 and 6 to 36, respectively.
Pai et al. (2019)20 used EDMS-R developed by Dufrene and Glosoff.26 EDMS-R includes six dilemmas
and 12 questions corresponding to six patient types. Students’ ethical decision-making was examined using
the EDMS-R, which comprises six dilemmas that correspond to six client types: (a) a suicidal client who is
terminally ill, (b) a husband and wife, (c) a client who has AIDS, (d) a counselor who has had sexual
relationships with his clients; (e) a client who is requesting services in a rural area, and (f) a child client who is
suspected of having been abused.26 Because this dilemma has four ranks that equal 10 points to distribute.26
There are nine possible points (i.e., 9 = 4 + 3 + 2), the possible scores ranged from 1 to 90, with higher scores
as indicating participants who thought principled considerations were vital to or more complex forms of
ethical decision-making.
Zhang et al. (2019)23 used the scale developed by researchers, which aims to measure students’
knowledge, attitudes and abilities regarding nursing ethics. The content validity of the scale used was verified
by 8 experts. The scale consists of 36 items and 6 sub-dimensions. The sub-dimensions are the necessity of
learning nursing ethics, theoretical foundation of nursing ethics, the professional relationship, ethics related to
nursing practice, ethics related to nursing research, and ethical decision-making. Students’ ethical decision-
making levels were measured with the scale containing the ethical decision-making dimension. The 5-point
Likert scale ranges from 1 = completely disagree to 5 = completely agree.
Using JBI-MAStARI, quasi-experimental studies and RCTs that met the inclusion criteria were evaluated
for quality. “Checklist For Quasi-Experimental Studies (Non-Randomized Experimental Studies)” was used
for quasi-experimental studies and the studies were evaluated over 9 points, and “Checklist For Randomized
Controlled Trials” was used for RCTs and the studies were evaluated over 13 points.

Discussion
Since ethical decision-making is a skill that can be developed, different education and training methods are
used to improve ethical decision-making skills.18–23 Some of the training methods used in research are online
synchronous and asynchronous classes. In this review, Suliman et al. (2022)22 examined the effect of online
synchronous versus asynchronous classes use on the level of ethical decision-making in nursing students.22
Students in synchronous classes were presented with various examples illustrating ethical and legal situations.
Then, students were presented with real-life case scenarios depicting ethical and legal challenges in the
context of their future clinical practice. These educational sessions were conducted twice a week over a span
of two weeks. Concurrently, students in asynchronous classes received identical instructional materials and
were encouraged to review these materials independently during the designated lecture times. It was
concluded that the use of online synchronous and asynchronous classes increased the level of ethical decision-
making, according to the findings of the study.22 However, there were no significant differences in the
development of students’ ethical decision-making skills in synchronous and asynchronous classes.22 Bijani
Kaşıkçı and Yıldırım 9

et al. (2019) 27 similarly concluded that classrooms should be provided where nursing students are given real
case scenarios and encouraged to analyze and discuss ethical dilemmas. The use of teaching methods such as
dialogues on ethical dilemmas and group discussion in online synchronous and asynchronous classroom
groups contribute to ethical decision-making by creating awareness.
Harder (2018)28 stated that standardized patients could help students learn complex and abstract concepts
and suggested using them in ethics education. In this review, Kucukkelepce et al. (2020)21 examined the
effects of standardized patients and case analysis on students’ ethical decision-making levels. Kucukkelepce
et al. (2020)21 gave brochures with scenarios to students in standardized patient groups. Students were
prepared according to the specified scenario and a 15-minute face-to-face interview was held with a standard
patient. Afterward, all students attended information sessions and seeing standard patients under different
scenarios shared their experiences and discussed their roles. In the case analysis group, students were divided
into small groups of five to six people and each group was given a case. After being briefed by the guidance
counselor, each group had 15 minutes to discuss the case analysis and 5 minutes to make a presentation. In the
study, it was concluded that the ethical decision-making skills of students in standardized patient education
and case analysis training increased in the post-test.21 It was found that there was no statistically significant
difference in NDT scores between the standardized patient and case analysis groups.21
In this review, Başak and Cerit (2019)18 examined the effects of simulation practice using standardized and
case analysis on students’ ethical decision-making levels. Researcher trained the simulation and case analysis
groups with four different ethical scenarios. In the simulation group, all 35 students participated in at least one
simulation and at least four performances were performed for each scenario. Each simulation lasted ap-
proximately 15 minutes and lasted approximately 30 minutes. Students in the simulation group attended the
information session to share their ideas about their simulation experiences and contributions. In the case
analysis group, after the theoretical training, students were given training in the case analysis method.
Students were divided into four subgroups and each group was given the same cases used by the simulation
group. The groups discussed these case studies in class using interactive educational methods and techniques
and answered questions directed by the researchers. At the end of the discussion, each group shared their
opinions with the other groups. In the study, it was found that case analysis was not effective in developing
students’ ethical decision-making skills, but simulation was effective.18
Ethical issues require ethical judgment in decision-making.29 In the study conducted with the Ethical
Reasoning Program (ERP), developed by the researchers examined in this review, it was concluded that
there was an increase in the ethical decision-making levels of the students at the end of the program.20
Evidence-based practice steps were used for students to learn ethical care issues gradually. In ERP, many
teaching methods have been used, such as training on ethical reasoning and ethical decision-making,
watching movies on ethics, brainstorming, dialogues, and group discussion. Similarly, in Martinsin et al.
(2020)30 study, it was concluded that at the end of the training, the decision-making skills of nursing
students increased when faced with dilemmas. Since ERP teaches students to use different sources of
information, cooperation, teamwork, and interpersonal relations, it is thought to improve students’ ethical
decision-making skills.
Khabitan et al. (2019)19 examined the effect of lecture-based (LB) and problem-based learning (PBL) of
nursing students on their ethical decision-making skills. Students in the LB group were informed about ethical
decision-making methods and were given an ethical training package consisting of a booklet and a CD
containing the taught materials. The instructor then analyzed two of the six moral dilemma scenarios alone.
Students answered questions and made suggestions. The content was presented to the students in the PBL
group in four sessions using the seven-stage PBL method. Students in the LB group were also informed about
ethical decision-making methods and were given an ethical training package consisting of a booklet and a CD
containing the taught materials. At this stage, ethical scenarios were distributed only to students. The stages of
the seven-step PBL method are included. These stages were repeated for two of the six scenarios in each
10 Nursing Ethics 0(0)

session. A significant increase in the moral reasoning score was found in both the LB and PBL groups.
However, the PBL group showed a significantly higher improvement in moral reasoning scores.19
In the current nursing ethics education, various teaching methods are needed to improve nursing students’
knowledge acquisition and comprehensive ability. Zhang et al. (2019)23 examined the effect of inquiry-
oriented teaching and lecture-based learning of nursing students on their ethical decision-making skills.
Students in the lecture-based group were educated using the traditional education method. During the inquiry-
oriented teaching, the students were required to consider themselves as nurses who were involved in an-
alyzing and resolving a diversity of ethical issues. They were also required to identify nursing ethical issues by
studying literature, interviewing nurses, and visiting patients in hospitals. A discussion board was created to
facilitate the communication between the students and instructors outside of classes. In the study, inquiry-
oriented teaching and lecture-based learning improved the ethical decision-making level of students. Also it
was found that after the inquiry-oriented group on average scored higher than the lecture-based group in
ethical decision-making.23 Since inquiry-oriented learning causes students to focus on the problem, reason,
and think critically to solve the problem, expression-based teaching is thought to improve students’ ethical
decision-making skills. It provides theoretical education that helps them identify, understand and know the
approaches to solving ethical problems.

Conclusions
Interventions to improve ethical decision-making skills are effective methods. Ethical decision-making is a
skill that can be changed and improved. Six studies and nine teaching methods used in the studies were
examined in this systematic review. As a result, it seems that the most striking method in improving ethical
decision-making skills focuses on simulation practice, problem-based learning, and inquiry-based learning. In
order to meet the learning needs of nursing students on nursing ethics, it is necessary to include interventions
in the nursing education curriculum that improve patient-nurse communication, help identify ethical
problems, increase their awareness of choosing the most appropriate ethical approach, and improve their
ethical decision-making skills. In addition, it will be beneficial to organize in-service pieces of training for
nurses with planned training methods to improve their ethical decision-making skills. The scans show that
interventions for ethical decision-making skills have been made in recent years and are limited in number. In
addition to existing education methods, innovative approaches should be adopted, and teaching methods
should be designed to improve ethical decision-making skills.

Acknowledgments
The authors would like to express our sincere gratitude to Dr Serpil ÖZCAN.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD
Zeynep Yildirim  https://orcid.org/0000-0002-8926-5464
Kaşıkçı and Yıldırım 11

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