Lecture-based versus problem-based learning in ethics education among nursing students

Abstract

Background:

Moral reasoning is a vital skill in the nursing profession. Teaching moral reasoning to students is necessary toward promoting nursing ethics.

Objectives:

The aim of this study was to compare the effectiveness of problem-based learning and lecture-based methods in ethics education in improving (1) moral decision-making, (2) moral reasoning, (3) moral development, and (4) practical reasoning among nursing students.

Research design:

This is a repeated measurement quasi-experimental study.

Participants and research context:

The participants were nursing students in a University of Medical Sciences in west of Iran who were randomly assigned to the lecture-based (n = 33) or the problem-based learning (n = 33) groups. The subjects were provided nursing ethics education in four 2-h sessions. The educational content was similar, but the training methods were different. The subjects completed the Nursing Dilemma Test before, immediately after, and 1 month after the training. The data were analyzed and compared using the SPSS-16 software.

Ethical considerations:

The program was explained to the students, all of whom signed an informed consent form at the baseline.

Findings:

The two groups were similar in personal characteristics (p > 0.05). A significant improvement was observed in the mean scores on moral development in the problem-based learning compared with the lecture-based group (p < 0.05). Although the mean scores on moral reasoning improved in both the problem-based learning and the lecture-based groups immediately after the training and 1 month later, the change was significant only in the problem-based learning group (p < 0.05). The mean scores on moral decision-making, practical considerations, and familiarity with dilemmas were relatively similar for the two groups.

Conclusion:

The use of the problem-based learning method in ethics education enhances moral development among nursing students. However, further studies are needed to determine whether such method improves moral decision-making, moral reasoning, practical considerations, and familiarity with the ethical issues among nursing students.

Keywords

Ethics education lecture-based learning moral development moral reasoning problem-based learning

Introduction

Moral decision-making is an integral part of the nursing responsibility and is one of the major goals of nursing education. During their internship in clinical settings, nursing students face moral dilemmas, and they may feel unable to solve the ethical problems in these conditions.¹ Moral decision-making is achievable through moral reasoning.² Moral reasoning refers to one’s ability to make reasonable decisions when faced with ethical dilemmas.³ It is a cognitive phenomenon that emanates from the individual’s knowledge and experiences⁴ and is influenced by cultural factors, personal characteristics, and religious background.⁵

Teaching ethics can provide the opportunity to develop nursing students’ critical thinking and moral reasoning skills.⁶ McLeod-Sordjan⁷ emphasized the key role of ethics education in enhancing moral reasoning and judgment skills in nursing students. Similarly, Woods⁸ highlighted the importance of choosing appropriate teaching methods for improving ethical performance in nurses. Case studies, lecture-based (LB) methods, and group discussions are recommended as appropriate methods for teaching ethics.⁹

An effective method of teaching ethics should be able to prepare nursing students for their future career. Nurses should have the ability to respond to their patients’ demands and to apply their knowledge in solving problems. Nursing curricula should therefore incorporate problem-solving strategies.¹⁰ Problem-based learning (PBL) is an effective educational method that reinforces students’ critical thinking skills.¹¹ Besides providing more in-depth learning, compared with conventional training programs, PBL enables students to learn important skills and qualities, such as personal relationships skills, critical thinking, decision-making, reasoning, the use of different information sources, team work, cooperation, respect for group members, curiosity, and patience.¹² Some scholars believe ethical knowledge and ethics education should be based on actual situations and real problems.¹³

In a Taiwanese study, the students reported satisfaction with the scenario-based learning method in nursing ethics education.¹⁴ Lin et al. showed that the students’ critical thinking, problem-solving skills, and social interactions were enhanced. The PBL group of Taipei nursing students also achieved higher scores in identifying ethical issues and in self-motivation.¹³ It has also been emphasized that compared with conventional education, PBL can improve Iranian nursing students’ problem-solving performance and competence in clinics.¹⁰

Nursing ethics education can possibly help to develop and improve the ability to identify and solve ethical problems among nursing students. In Iran, the dominant method of nursing ethics education is LB, which seems better replaced by PBL. This study was therefore carried out to compare the effectiveness of PBL and LB in ethics education on moral reasoning, moral development and clinical reasoning among nursing students.

Methods

Study design and setting

A repeated measurement quasi-experimental study was carried out among nursing students at the School of Nursing and Midwifery in a University of Medical Sciences in west of Iran. The PBL method was used to teach a nursing ethics course to the experimental group, whereas the LB method was applied in the control group. The outcome measures were the improvements in moral decision-making, moral development, moral reasoning, and practical considerations among the nursing students.

Eligibility criteria

Inclusion criteria

The nursing students registered in the field internship courses were considered eligible because they generally have adequate knowledge and skills in clinical settings and have been confronted with clinical ethical issues (n = 71).

Exclusion criteria

Students who missed more than one session of the nursing ethics course and those who did not complete the questionnaires in the evaluation stages were excluded from the study (n = 5).

The interventions: the PBL and LB groups

The research team designed and approved the content of the nursing ethics course, which included definitions of ethics, principles and codes of nursing ethics, patient rights, decision-making methods in solving ethical problems, and six scenarios of moral dilemmas.¹⁵ The research group confirmed the content validity of each scenario and carried out the interventions in four 2-h sessions for each group (LB and PBL).

The LB group

In the first of the four sessions in the LB group, the course objectives, students’ responsibility, and content were presented using lecture and Microsoft PowerPoint presentations. Furthermore, the students were familiarized with ethical decision-making methods and were given an ethics training package that included a booklet and a CD containing the materials taught. In the second to the fourth sessions, the instructor analyzed two of the six scenarios of moral dilemmas by herself. The students answered the questions and made suggestions.

The PBL group

In the PBL group, the content was presented in four sessions using a seven-step PBL method. The first session was similar to that in the LB group. At this stage, the ethical scenarios were distributed only among the students. The seven-step PBL method has the following stages: (1) clarifying concepts, (2) defining the problem, (3) discussing/analyzing the problem, (4) identifying possible solutions, (5) setting objectives and prioritizing the problem, (6) problem solutions, and (7) problem-solving based on the measures (physical feasibility, health team acceptability, time allotment, cost-effectiveness, and patient satisfaction). These stages were repeated for two of the six scenarios in each session.

Outcome measures

The data were collected using two instruments: a demographic questionnaire and the Nursing Dilemma Test (NDT).

Demographic questionnaire

The demographic questionnaire consisted of the student’s age, gender, marital status, grade point average (GPA), clinical experience, and duration of work experience. A question on the student’s frequency of experience of moral issues during the clinical internship was added.

NDT

The NDT developed by Crisham (1981) and later used by Ham¹⁵ was used to measure moral reasoning. The NDT assesses moral dilemmas based on Lawrence Kohlberg’s theory of moral development. This instrument consists of six scenarios: (1) newborn with anomalies, (2) forcing medication, (3) adult’s request to die (euthanasia), (4) new nurse orientation, (5) medication error, and (6) uninformed terminally ill adult. There are three sections of questions (A, B, and C) for each scenario.

In the section on moral decision-making (section A), the respondent is asked what the nurse should do in each dilemma, given three options. Choosing the correct option indicates that the respondent is making an absolutely moral decision. The option chosen in this section does not affect the student’s moral reasoning score.

Section B consists of six questions that nurses consider when faced with each ethical clinical dilemma. The respondent ranks the questions from the most important to the least important. The most important question is assigned six points, and the second to the sixth in importance are given five points to one point, respectively. The points for each stage are calculated by the totality ranked scores of the six scenarios.

The moral development level is determined based on the student’s option for each scenario because this implies the main reason for the choice made in the first section. Given that each scenario indicates one level of moral development, the final moral development level can be determined by adding the selected options. Thus, the nursing students’ moral development is ultimately categorized into three levels: (1) pre-conventional, the sum total of the first and second stages; (2) conventional, the sum total of the third and fourth levels; and (3) post-conventional, the sum total of the fifth and sixth stages. The range of moral development scores is between 6 and 36.

The moral reasoning is determined by a combination of stages 5 and 6. Thus, the best score for moral reasoning is 11 in each scenario and 66 in the six scenarios. The lowest score for moral reasoning is 3 in each scenario and 18 in the six scenarios.

The sixth question in each scenario pertains to practical considerations that could influence ethical reasoning. The student’s score is determined based on the priority she or he has given to this option in each scenario. The total score ranges from 6 to 36.¹⁶

In section C, the respondents are asked to indicate on a 5-point Likert-type scale if they have been involved in a similar ethical problem in the past. The familiarity score is calculated by adding the points across the six scenarios to indicate the respondent’s previous involvement in ethical problems. A score of 6–17 indicates familiarity, and a score of 18–30 indicates unfamiliarity, with ethical problems.

To determine the reliability of the study questionnaires, a test–retest method was used. A Pearson correlation coefficient of 0.73 and Cronbach’s alpha of 0.82 confirmed the reliability of the questionnaire (p < 0.05).

The students completed the questionnaires before the intervention, immediately after the intervention, and 30 days later.

Sample size

The sample size was calculated as 33 students in each group (66 participants in total) for 80% power with a two-sided significance level of α = 0.05 and an effect size of 0.70.

There were 10 groups in the seventh and eighth semesters of the field internship courses. Each group was included 7–9 students according to the routine schedule of the Clinical Education Department. The researchers obtained a list of the students in the seventh and eighth semesters in winter 2015–2016. Of the total 74 senior nursing students in winter 2015–2016, 71 met the eligibility criteria and were therefore invited to participate in the study (Figure 1).

Figure 1.

CONSORT flow chart of the study.

Randomization and allocation

Randomization was carried out by writing “seventh semester” and “eighth semester” on separate pieces of paper of the same size, which were then folded and dropped into a box. Each student randomly drew a piece of paper from the box. The students in the seventh semester were assigned to the PBL groups (36 students in five groups) and those in the eighth semester were assigned to the LB groups (35 students in five groups).

Statistical methods

The data were analyzed using the statistical software SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL, USA) at a 95% confidence interval. The differences in demographic variables and baseline scores between the PBL and LB groups were compared by applying a chi-square test. Repeated measures analysis of variance (ANOVA) was done to examine the changes in the outcome variable scores for each group.

Ethical considerations

This study was carried out according to the Declaration of Helsinki and was approved by the Ethics Committee of the Vice Chancellor of the Research and Technology Council in a University of Medical Sciences (no: /16/35/9/706) in west of Iran, after being registered on the Iranian Registry of Clinical Trials (IRCT; IRCT2014052417821N1). The study objectives and program were explained to the all participants, and all the students reviewed and signed the voluntary participation and informed consent form before the start of the study.

Results

Participants’ socio-demographics

The mean ages of the students were 22.33 ± 0.88 years in the LB group and 22.72 ± 0.94 years in the PBL group; the independent two-sample t test showed no statistically significant difference in age between the two groups (p = 0.086). No significant differences in GPA were observed between the LB group (GPA = 16.23 ± 0.94) and the PBL group (GPA = 15.91 ± 1.26) (p = 0.250). Moreover, the groups were not significantly different in gender, clinical work experience, and duration of clinical work experience (p > 0.05) (Table 1).

Table 1.

Demographic groups of students LB and PBL (n = 66).

Socio-demographic characteristics		LB group (n = 33)	PBL group (n = 33)	Chi-square statistic test results (p value)
Gender	Man	18 (54.6%)	13 (39.4%)	χ² = 1.52, p = 0.230
Gender	Female	15 (45.4%)	20 (60.6%)	χ² = 1.52, p = 0.230
Marital status	Single	22 (66.7%)	23 (69.7%)	χ² = 0.07, p = 0.791
Marital status	Married	11 (33.3%)	10 (30.3%)	χ² = 0.07, p = 0.791
Housing	Dorm	22 (66.7%)	21 (63.7%)	χ² = 0.07, p = 0.822
Housing	Non-dorm	11 (33.3%)	12 (36.3%)	χ² = 0.07, p = 0.822
Having clinical work experience	Yes	27 (81.9%)	24 (72.8%)	χ² = 0.77, p = 0.382
Having clinical work experience	No	6 (18.1%)	9 (27.2%)	χ² = 0.77, p = 0.382
Duration of clinical work experience (years)	≤1	17 (63.0%)	16 (66.7%)	χ² = 0.08, p = 0.783
Duration of clinical work experience (years)	>1	10 (37.0%)	8 (33.3%)	χ² = 0.08, p = 0.783

LB: lecture-based; PBL: problem-based learning.

Outcomes

Section A of the NDT: moral decision-making in ethical scenarios.

The results showed that before the intervention, there were no significant differences between the LB and the PBL groups of students according to their scores in moral decision-making for six scenarios (p > 0.05). Based on the data analysis, there was a significant difference between the views of the LB and the PBL groups on student’s moral decision for scenario four (new nurse orientation) (p < 0.05). No significant differences were observed for the other scenarios (p > 0.05) (Table 2).

Table 2.

Comparison of scenarios in dealing with moral dilemmas in the decision-making student training groups LB and PBL.

		Before education(N = 33)			Immediately after education(N = 33)			A month after education(N = 33)			Generalized estimating equations test results
		Absolutely ethical decisionN (%)	No decisionN (%)	Unethical decisionN (%)	Absolutely ethical decisionN (%)	No decisionN (%)	Unethical decisionN (%)	Absolutely ethical decisionN (%)	No decisionN (%)	Unethical decisionN (%)	Generalized estimating equations test results
Scenario 1	LB	19 (57.6)	10 (30.3)	4 (12.1)	28 (84.8)	4 (12.1)	1 (3.0)	21 (63.6)	10 (30.3)	1 (3.0)	χ² = 0.915 p = 0.339
Scenario 1	PBL	26 (78.8)	6 (18.2)	1 (3.0)	27 (81.8)	5 (15.2)	1 (3.0)	27 (81.8)	2 (6.1)	4 (12.1)	χ² = 0.915 p = 0.339
Scenario 2	LB	25 (75.8)	7 (21.2)	1 (3.0)	13 (39.4)	20 (60.6)	1 (3.0)	21 (63.6)	10 (30.3)	1 (3.0)	χ² = 3.326 p = 0.068
Scenario 2	PBL	26 (78.8)	7 (21.2)	0 (0.0)	17 (51.5)	15 (45.5)	1 (3.0)	24 (72.7)	8 (24.2)	1 (3.0)	χ² = 3.326 p = 0.068
Scenario 3	LB	29 (87.9)	4 (12.1)	0 (0.0)	29 (87.9)	3 (9.1)	1 (3.0)	27 (81.8)	4 (12.1)	1 (3.0)	χ² = 2.794 p = 0.095
Scenario 3	PBL	31 (93.9)	2 (6.1)	0 (0.0)	29 (87.9)	3 (9.1)	1 (3.0)	27 (81.8)	2 (6.1)	4 (12.1)	χ² = 2.794 p = 0.095
Scenario 4	LB	15 (45.5)	16 (48.5)	2 (6.1)	7 (21.2)	25 (75.8)	1 (3.0)	6 (18.2)	25 (75.8)	1 (3.0)	χ² = 4.154 p = 0.042
Scenario 4	PBL	15 (45.5)	14 (42.4)	4 (12.1)	14 (42.4)	19 (57.6)	0 (0.0)	14 (42.4)	16 (48.5)	3 (9.1)	χ² = 4.154 p = 0.042
Scenario 5	LB	29 (87.9)	2 (6.1)	2 (6.1)	26 (78.8)	7 (21.2)	0 (0.0)	17 (51.5)	15 (45.5)	1 (3.0)	χ² = 3.276 p = 0.911
Scenario 5	PBL	22 (66.7)	5 (15.2)	5 (15.2)	28 (84.9)	5 (15.2)	0 (0.0)	20 (60.6)	8 (24.2)	5 (15.2)	χ² = 3.276 p = 0.911
Scenario 6	LB	12 (36.4)	16 (48.5)	5 (15.2)	24 (72.7)	7 (21.2)	1 (3.0)	15 (45.5)	17 (51.5)	1 (3.0)	χ² = 0.013 p = 0.911
Scenario 6	PBL	8 (24.2)	16 (48.5)	9 (27.3)	12 (36.4)	18 (54.5)	3 (9.1)	16 (48.5)	14 (42.4)	3 (9.1)	χ² = 0.013 p = 0.911

LB: lecture-based; PBL: problem-based learning.

Section B of the NDT

Students’ moral development

The independent two-sample t test showed that the two groups were homogeneous in their scores on moral development before the intervention (p > 0.05). In the LB group, there was no statistically significant difference in the mean score on moral development in the three stages of the study (p > 0.05), whereas a statistically significant difference was observed in the PBL group (p < 0.05). The two-way repeated measures ANOVA showed a significant difference in the mean scores on students’ moral development between the two groups (p < 0.05) (Table 3).

Table 3.

Compare LB and PBL students’ moral development, moral reasoning, and practical considerations in the two groups before, immediately, and 1 month after interventions.

	Before education(Mean ± SD)	Immediately after intervention(Mean ± SD)	After 1 month of intervention(Mean ± SD)	RM-ANOVA	Two-way of RM-ANOVA
Moral development (scores 6–36)
LB	24.7 ± 3.77	25.85 ± 4.53	24.46 ± 4.37	F = 1.41, p = 0.25	F = 1.23 p = 0.04
PBL	24.25 ± 4.32	29.58 ± 9.93	26.64 ± 4.32	F = 7.41, p = 0.001	F = 1.23 p = 0.04
Moral reasoning (scores 18–66)
LB	46.97 ± 8.12	47.61 ± 8.48	49.91 ± 16.42	F = 0.621, p = 0.541	F = 1.23 p = 0.587
PBL	47.07 ± 8.14	51.22 ± 7.39	50.91 ± 7.8	F = 4.45, p = 0.015	F = 1.23 p = 0.587
Practical consideration (scores 6–36)
LB	20.82 ± 3.56	19.32 ± 3.98	20.16 ± 4.48	F = 1.351, p = 0.509	F = 0.26 p = 0.771
PBL	19.82 ± 4.85	19.82 ± 4.85	19.32 ± 3.98	F = 0.836, p = 0.658	F = 0.26 p = 0.771
Familiarity with similar dilemmas (scores 6–30)
LB	16.77 ± 2.35	17.09 ± 2.27	17.35 ± 2.50	F = 0.95, p = 0.393	F = 1.74 p = 0.192
PBL	16.23 ± 2.61	16.65 ± 2.34	16.78 ± 2.98	F = 0.92, p = 0.404	F = 1.74 p = 0.192

LB: lecture-based; PBL: problem-based learning; RM-ANOVA: repeated measures analysis of variance; SD: standard deviation.

Students’ moral reasoning

The independent two-sample t test showed no statistically significant differences in the mean score on moral reasoning between the two groups before the intervention (p > 0.05). In the LB group students, there was not found increasing in the mean scores of moral reasoning immediately and 1 month after the intervention (p > 0.05). The PBL students had a significant improvement in their mean scores of moral reasoning immediately and 1 month after intervention (p < 0.05). Considering the baseline mean scores of moral reasoning, the two-way repeated measures ANOVA showed no differences in the mean scores on moral reasoning between the two groups (p > 0.05) (Table 3).

Students’ practical considerations

The independent two-sample t test indicated that the two groups were homogeneous in their pre-intervention scores on practical considerations (p > 0.05). The two-way repeated measures ANOVA showed no significant difference in the mean scores on students’ practical considerations between the two groups (p < 0.05) (Table 3).

Section C of the NDT: familiarity with similar dilemmas

The familiarity scores of the LB group (16.77 ± 2.35) were similar to those of the PBL group (16.23 ± 2.61) at the entrance (p > 0.05). The two-way repeated measures ANOVA showed no significant difference in the mean scores on students’ familiarity with similar dilemmas between the two groups (p > 0.05) (Table 3).

Discussion

This study was carried out to compare the effectiveness of nursing ethics education through LB versus PBL in improving moral decision-making, moral development, moral reasoning, and practical considerations among nursing students.

Moral decision in dealing with ethical scenarios

The students in both the LB and the PBL groups made ethical decisions in the scenarios of resuscitation of a newborn with anomalies, forcing medication, adult’s request to die, medication error, and uninformed terminally ill adult (p > 0.05). In other words, the two methods did not significantly increase the rate of correct decision-making. The results are in agreement with a previous study that found no differences between LB and PBL in increasing students’ learning.¹⁷ Wijnia et al.¹⁸ reported that PBL does not always lead to higher motivation. Nevertheless, some PBL students have stated that they experienced more stress due to schoolwork compared with LB students.¹⁹ This similarity may be due to the short length of the course provided and the inadequate preparation of the PBL students.

The present results showed that the PBL students made better decisions than the LB students only in the scenario of new nurse orientation (p < 0.05). Previous studies have reported that the PBL method could significantly improve nursing students’ problem-solving skills,^10,20,21 critical thinking,^13,20,22,23 metacognitive awareness,²² and learning progress.²⁴

Moral development, moral reasoning, and practical consideration

Moral development

The data analysis showed an improvement in the mean score on moral development in the two groups. These results are consistent with a longitudinal study in the United States, in which the levels of moral development among nursing students were found to be improved.²⁵ Zirak et al.² also emphasized that ethics training can improve moral development in nursing students. Ethics education is able to reinforce ethical judgment among nursing students regardless of the educational method used.¹³ Similarly, a study in the United States showed a significant relationship between the training received and moral development.²⁶ Ethics education has also been reported to improve both ethical knowledge and moral development among nurses.¹⁵ Despite the improved levels of moral development in the LB group in all stages of the measurement, no significant differences between the scores were observed (p > 0.05). However, in the PBL group, the increase in the mean score on moral development in all stages was found to be significant (p < 0.01). A significant difference in moral development in the three stages was found between the LB and the PBL groups (p < 0.05). It can be argued that the PBL is more effective in improving moral development. These results are consistent with those obtained in South Korea, in which the PBL approach had more positive effects on moral development among the students.¹³

In China¹¹ and the United States,²⁷ it was found that the PBL method could contribute more positively to critical thinking. The PBL method is an effective method for developing professional competence among nursing students.¹⁰ It has also been emphasized that moral development is further improved by PBL than by LB education.¹³

Moral reasoning

The results showed an increase in the moral reasoning scores obtained in both the LB and the PBL groups in all stages of measurement. Thus, ethics education can improve moral reasoning. These findings are similar to those obtained by Park et al.²⁸ It has also been argued that ethics training intervention can positively affect moral reasoning.²⁹ Teaching ethics and incorporating discussions into curricula can help nursing students become more sensitive to ethical issues, increase their moral reasoning abilities, and enable them to perform better.¹³

In this study, the difference in the scores on moral reasoning was significant only in the PBL group (p < 0.05). Lin et al.¹³ compared the LB and PBL methods and showed a significant advantage in the ethics learning of the PBL group. In the work by Uys et al.,³⁰ the students showed a higher problem-solving ability in the PBL than in the LB group. A quasi-experimental study in nursing oncology internship showed a significant difference in students’ ability to solve clinical problems between conventional learning and the PBL method.¹⁰

An important finding of the present work was that the differences in moral reasoning between the PBL and the LB students at the end of the study were not significant (p > 0.05). Similarly, the nurses trained in the PBL and the non-PBL methods were found to have equal clinical competence.³¹ In a comparison of the effectiveness of PBL and conventional learning among nursing students in the Netherlands, no significant differences in general and clinical competence and professional development were found.³² The lack of difference in outcomes between the two groups in the current work could be due to the short duration of the training interventions. In fact, moral reasoning is a cognitive ability that is reinforced through frequent and prolonged dealing with ethical issues. Weekly training sessions over a period of 3–12 weeks are recommended to increase students’ moral reasoning.²⁸ Casterlé et al.³³ pointed out that improving moral reasoning among nurses requires extensive training in clinical settings. It has also been reported that increasing the duration of ethics classes could further contribute to the promotion of moral reasoning.¹³ A previous study showed that a problem-based approach and longer ethics classes are the two key factors in the development of moral reasoning among undergraduate nursing students.²⁹

Practical considerations

The results showed no significant increase in the mean scores on practical consideration in the both the PBL and the LB groups (p > 0.05). Nursing students may have a number of considerations in making a practical and ethical decision. A previous study found that Malawian student nurses faced many ethical dilemmas and conflicts in practice. Thus, there is a need for programs that teach critical thinking in clinical practice.³⁴ Casterlé et al.³³ stated that critical and creative thinking in ethical practice should be constantly encouraged among nurses. In this study, the interventions did not improve the clinical consideration scores in both groups. However, PBL has been acknowledged by other researchers as a method for improving critical^20,35
–37 and creative thinking^20,35
–37 and creative thinking³⁵ among nursing students.

Familiarity with similar dilemmas

In ethics education, the application of student-centered strategies to the lived experience of clinical practice is advised,³⁸ However, our results showed no significant increase in the mean scores on familiarity with similar dilemmas in both the LB and the PBL groups (p > 0.05). This disagreement may be due to the inadequate nursing practice of the students. In a previous correlational study, most of the nurses were found to be familiar with ethical dilemmas in clinical practice.³⁹

Conclusion

This study compared the effectiveness of LB and PBL in ethics education in improving moral reasoning and development among nursing students. The results showed a marked increase in the score on moral reasoning and the level of moral development in both the LB and the PBL groups. The PBL group, however, showed a significantly higher improvement in the scores on moral reasoning and moral development, which indicates the better short-term effects of this method in ethics education. Therefore, the researchers recommend the PBL method for ethics education in undergraduate nursing students and encourage the use of the PBL method as a more efficient tool in other courses as well. Furthermore, in our country, ethics education is not considered as a continuing education for clinical nurses. Thus, the provision of nursing ethics education through a combination of PBL and LB methods is suggested as part of continuing education programs for nurses.

Footnotes

Conflict of interest

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Vice Chancellor for Research and Technology of a University of Medical Sciences in west of Iran.

References

Ahn

Yeom

. Moral sensitivity and critical thinking disposition of nursing students in Korea. Int J Nurs Pract 2014; 20(5): 482–489.

Zirak

Moghadasian

Abdollahzadeh

, et al. The study of level of ethical development in nurses working in training-treatment hospitals affiliated in Tabriz University of Medical Sciences, Tabriz, Iran. Qom Univ Med Sci J 2012; 6: 32–39.

Burnard

Chapman

. Professional and ethical issues in nursing: the code of professional conduct. 2nd ed. London: Scutari Press, 1993.

Zirak

Hasankhani

Parizad

. The ethical reasoning ability of nurses and nursing students: a literature review. Iran J Med Eth Hist Med 2015; 7(6): 15–28.

Riesch

von Sadovszky

Norton

, et al. Moral reasoning among graduate students in nursing. Nurs Outlook 2000; 48(2): 73–80.

Callister

Luthy

Thompson

, et al. Ethical reasoning in baccalaureate nursing students. Nurs Ethics 2009; 16(4): 499–510.

McLeod-Sordjan

. Evaluating moral reasoning in nursing education. Nurs Ethics 2014; 21: 473–483.

Woods

. Nursing ethics education: are we really delivering the good(s)? Nurs Ethics 2005; 12(1): 5–18.

Vynckier

Gastmans

Cannaerts

, et al. Effectiveness of ethics education as perceived by nursing students: development and testing of a novel assessment instrument. Nurs Ethics 2015; 22: 287–306.

10.

Khatiban

Sangestani

. The effects of using problem-based learning in the clinical nursing education on the students’ outcomes in Iran: a quasi-experimental study. Nurse Educ Pract 2014; 14(6): 698–703.

11.

Yuan

Kunaviktikul

Klunklin

, et al. Promoting critical thinking skills through problem-based learning. J Soc Sci Humanit 2008; 2(2): 85–100.

12.

Distler

. Critical thinking and clinical competence: results of the implementation of student-centered teaching strategies in an advanced practice nurse curriculum. Nurse Educ Pract 2007; 7(1): 53–59.

13.

Lin

Chung

, et al. A comparison of problem-based learning and conventional teaching in nursing ethics education. Nurs Ethics 2010; 17(3): 373–382.

14.

Hsu

. Blended learning in ethics education: a survey of nursing students. Nurs Ethics 2011; 18(3): 418–430.

15.

Ham

. A comparison of ethical reasoning abilities of senior baccalaureate nursing students and experienced nurses. Unpublished Doctoral Dissertation, The University of Memphis, Memphis, TN, 2002.

16.

Crisham

. Measuring moral judgment in nursing dilemmas. Nurs Res 1981; 30(2): 104–110.

17.

Khoshnevisasl

Sadeghzadeh

Mazloomzadeh

, et al. Comparison of problem-based learning with lecture-based learning. Iran Red Crescent Med J 2014; 16(5): e5186.

18.

Wijnia

Loyens

Derous

. Investigating effects of problem-based versus lecture-based learning environments on student motivation. Contemp Educ Psychol 2011; 36(2): 101–113.

19.

Wardley

Applegate

Almaleki

, et al. A comparison of students’ perceptions of stress in parallel problem-based and lecture-based curricula. J Physician Assist Educ 2016; 27(1): 7–16.

20.

Choi

Lindquist

Song

. Effects of problem-based learning vs. traditional lecture on Korean nursing students’ critical thinking, problem-solving, and self-directed learning. Nurse Educ Today 2014; 34(1): 52–56.

21.

Gabr

Mohamed

. Effect of problem-based learning on undergraduate nursing students enrolled in nursing administration course. Int J Acad Res 2011; 3(1): 154–169.

22.

Gholami

Moghadam

Mohammadipoor

, et al. Comparing the effects of problem-based learning and the traditional lecture method on critical thinking skills and metacognitive awareness in nursing students in a critical care nursing course. Nurse Educ Today 2016; 45: 16–21.

23.

Zhang

, et al. Improvement in critical thinking dispositions of undergraduate nursing students through problem-based learning: a crossover-experimental study. J Nurs Educ 2013; 52(10): 574–581.

24.

Sangestani

Khatiban

. Comparison of problem-based learning and lecture-based learning in midwifery. Nurse Educ Today 2013; 33(8): 791–795.

25.

Duckett

Rowan

Ryden

, et al. Progress in the moral reasoning of baccalaureate nursing students between program entry and exit. Nurs Res 1997; 46(4): 222–229.

26.

Baxter

Boblin

. The moral development of baccalaureate nursing students: understanding unethical behavior in classroom and clinical settings. J Nurs Educ 2007; 46(1): 20–27.

27.

Rounds

Rappaport

. The successful use of problem-based learning in an online nurse practitioner course. Nurs Educ Perspect 2008; 29(1): 12–16.

28.

Park

Kjervik

Crandell

, et al. The relationship of ethics education to moral sensitivity and moral reasoning skills of nursing students. Nurs Ethics 2012; 19(4): 568–580.

29.

Gaul

. The effect of a course in nursing ethics on the relationship between ethical choice and ethical action in baccalaureate nursing students. J Nurs Educ 1987; 26(3): 113–117.

30.

Uys

Van Rhyn

Gwele

, et al. Problem-solving competency of nursing graduates. J Adv Nurs 2004; 48(5): 500–509.

31.

Applin

Williams

Day

, et al. A comparison of competencies between problem-based learning and non-problem-based graduate nurses. Nurse Educ Today 2011; 31(2): 129–134.

32.

Cohen-Schotanus

Muijtjens

Schönrock-Adema

, et al. Effects of conventional and problem-based learning on clinical and general competencies and career development. Med Educ 2008; 42(3): 256–265.

33.

Casterlé

Dierckx

Izumi

, et al. Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis. J Adv Nurs 2008; 63(6): 540–549.

34.

Solum

Maluwa

Severinsson

. Ethical problems in practice as experienced by Malawian student nurses. Nurs Ethics 2012; 19(1): 128–138.

35.

Chan

. Exploring creativity and critical thinking in traditional and innovative problem-based learning groups. J Clin Nurs 2013; 22(15–16): 2298–2307.

36.

Kong

Qin

Zhou

, et al. The effectiveness of problem-based learning on development of nursing students’ critical thinking: a systematic review and meta-analysis. Int J Nurs Stud 2014; 51(3): 458–469.

37.

Oja

. Using problem-based learning in the clinical setting to improve nursing students’ critical thinking: an evidence review. J Nurs Educ 2011; 50(3): 145–151.

38.

Hickman

Wocial

. Team-based learning and ethics education in nursing. J Nurs Educ 2013; 52(12): 696–700.

39.

Cerit

Dinç

. Ethical decision-making and professional behaviour among nurses: a correlational study. Nurs Ethics 2012; 20: 200–212.