The development of moral sensitivity of nursing students: A scoping review

Abstract

Moral sensitivity is known to be the starting point for moral competence and even is a core concept in the curricula for bachelor’s-level nursing students in the Netherlands. While the development of moral sensitivity in nursing is commonly agreed to be important, there is no clear understanding of how to develop moral sensitivity through nursing education and what components of nursing education contribute to moral sensitivity. Studies on educational interventions could build knowledge about what works in developing moral sensitivity and how to achieve this outcome. Therefore, the aim of this study is to explore if and how educational interventions contribute to the development of moral sensitivity in nursing students. A scoping review was conducted. Four electronic databases were searched: CINAHL, PubMed, MEDLINE and SpringerLink. Articles that were not about formal or initial nursing education and that had no link to moral development or moral sensitivity were excluded. After the final selection on educational interventions, 10 articles out of the initial 964 resources were included in the review. Three different but related dimensions of moral sensitivity emerged from the literature: (1) raising moral awareness, (2) providing the ability to frame and name ethical issues and (3) improving moral reasoning ability. Half of the studies used quantitative measures to evaluate the educational intervention, in particular the Moral Sensitivity Questionnaire; the other half used diverse qualitative evaluation methods. None of the studies presented teaching methods that included all three dimensions of moral sensitivity. Moral awareness of self appears to be more loosely connected to the other two dimensions, which raises the question of whether it can be seen as a prerequisite for them. To encompass all dimensions of moral sensitivity, a mix of quantitative and qualitative measures seems most appropriate to study that topic.

Keywords

Ethics education moral sensitivity nursing education professional ethics scoping review

Introduction

Day to day, nurses are challenged to offer ‘good care’ to people in vulnerable situations. Ethics is a fundamental component in their practice, so the development of ethical competence alongside clinical competence is part of the nursing profession.¹ However, there is limited knowledge about the contribution of ethics education to the ethical competence development of nurses, and there are concerns about the ethical preparedness of nurses in practice.^2,3 In their systematic review of the effects of ethics interventions for healthcare professionals, Stolt et al.³ divided the interventions into four categories: ethics in general, research ethics, identifying ethical problems and ethical empowerment. Their review indicates that various concepts are used, sometimes interchangeably, to evaluate the outcome of ethical interventions. These include ethical knowledge,^4,5 ethical competence,⁴ ethical discrimination ability,⁵ patient advocacy,⁶ moral sensitivity,⁶ moral judgement,⁷ decreasing moral distress,⁸ moral development⁹ and moral reasoning.¹⁰ Despite different ideas about the goals of ethics education in nursing, there seems to be agreement on the idea that moral sensitivity is the starting point of moral behaviour and moral competence.^11

–15 Moral sensitivity is a core concept in all the curricula for bachelor’s-level nursing students in the Netherlands and is part of the CanMEDS role reflective professional.¹⁶

The literature uses the terms ‘moral sensitivity’ and ‘ethical sensitivity’ interchangeably, and there are different descriptions and, sometimes competing, conceptualisations.^14,17,18 Milliken¹⁴ found four major conceptualisations in the literature: as discussed by Weaver et al.,¹⁹ Lützén et al.,²⁰ Rest²¹ and Ersoy and Goz.²² Rest’s²¹ Four-Component Model includes moral sensitivity, moral judgement, moral motivation and moral character. It defines moral sensitivity as ‘the awareness of how our actions affect other people’ which informs people’s judgements and actions. Ersoy and Goz²² described moral sensitivity as the ability to recognise the ethical dimension of a situation. This is in line with Lützén et al.,²⁰ who regard moral sensitivity as the capacity to ‘sense’ the moral significance of a situation, which is developed through experience. They identified three factors that comprise moral sensitivity: sense of moral burden, moral strength and moral responsibility. The concept analysis conducted by Weaver et al.¹⁹ found similar aspects of sensing and identifying ethical questions, and caring for the effects of one’s own actions on others’ comfort and well-being. It is a type of practical wisdom that pursues client comfort and professional satisfaction with care delivery.

According to Milliken,¹⁴ ethical sensitivity is the foundational component of ethical action and can be defined as that which enables nurses to recognise the essentially ethical nature of practice and of every practice action. Diminished or absent ethical sensitivity can result in ethically incongruent care.¹⁴ While the importance of moral sensitivity in nursing is commonly agreed upon, it is not yet clear what components of nursing education contribute to moral sensitivity since the effects of ethics education have not been evaluated in a consistent way.^2,23 In addition, the diversity of conceptualisations of moral sensitivity – and related concepts – makes it hard to design ethics education programmes. Nevertheless, educational interventions have been developed in practice to promote moral sensitivity among nursing students. Studies on these interventions could build knowledge about what works in developing moral sensitivity and how to achieve this outcome. Therefore, the aim of this study is to explore the contribution of educational interventions to the development of nursing students’ moral sensitivity and the methods employed to evaluate the process and outcomes of the interventions.

Method

The intent of the study is to synthesise the current research on the topic of moral sensitivity in nursing education, by mapping and articulating what is known about this topical area. Therefore, a scoping review of the literature was conducted. A scoping review is a ‘form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence and gaps in research related to a defined area or field by systematically searching, selecting and synthesising existing knowledge’.¹⁶ Because the aim of the study is not about addressing the feasibility, appropriateness, meaningfulness or effectiveness of ethics education as relates to the development of moral sensitivity, a systematic review would not be a valid approach for this research.^16,24 A scoping review has less depth compared with a systematic review, but a broader conceptual range. It also provides more flexibility for including a diversity of relevant literature and can serve as a richly informed starting point for further investigations to understand and contribute to research, education, practice and policy.^25,26 Therefore, and because of the limited knowledge on the contribution of ethics in nursing education and the number of different understandings and related concepts of moral sensitivity, a scoping review seems the appropriate method for answering the research question of this study. As methodological framework we used the six steps of Arskey and O’Malley:²⁶ (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data and (5) collating, summarising, and reporting the data.

Search strategy

We searched for articles about moral sensitivity in nursing education in relevant databases (CINAHL, PubMed, MEDLINE and SpringerLink). Because of the different conceptualisations, definitions and related concepts of moral sensitivity in nursing education we used a range of different key terms to not overlook articles that address moral sensitivity without using this term explicitly. The key terms used were ‘nursing education’ AND ‘ethics education’ or ‘moral learning’ or ‘moral development’ or ‘moral perception’ or ‘moral competence’ or ‘moral imagination’ or ‘moral sensitivity’ or ‘ethical sensitivity’ or ‘moral courage’.

Study selection

Of the available literature, 964 resources were initially found to be relevant to the topic of nursing education in relationship to moral learning. Inclusion and exclusion criteria were applied (see Table 1).

Table 1.

Inclusion/exclusion criteria.

Inclusion criteria	Exclusion criteria
Scientific publications	Not about formal or bachelor’s-level nursing education
Published between 2000 and 2019	Articles about codes of ethics
Published in English	No link to moral development/moral sensitivity
	Addressing concepts other than moral development/ moral sensitivity

We used the four major conceptualisations of moral sensitivity in the review of Milliken¹⁴ as sensitising concepts for the identification of relevant studies; therefore, several studies were excluded from this review. First, articles that deal with ‘critical thinking’ were excluded if this was not explicitly linked to moral or ethical development. We also excluded articles on related subjects, such as the incivility of nursing students (e.g. plagiarism), the development of ‘being sensitive’, the role of emotions, inclusive education, diversity, intercultural sensitivity, interprofessional ethics and teaching codes of ethics. These excluded articles did not give insight into the specific topic of our research question: the development of moral sensitivity in nursing education. Those studies that addressed methods (e.g. ‘journaling’, simulation, case descriptions, narrative pedagogy, active learning, problem-based learning) but did not explicitly link them to moral or ethical development were also excluded.

An additional selection was made using specified keywords and synonyms, such as ‘teaching method’, ‘strategy’ and ‘educational intervention’. This resulted in a list of 78 articles about moral development methods in nursing education (see Figure 1).

Figure 1.

Search results.

All resources were put in an online library called Mendeley, which was shared by the researchers. The abstracts then were analysed for their relevance to the research question. If the abstract was not clear about the contents and methods used, the full article was read. For the final study selection, the articles were divided into four clusters: conceptual articles; research articles (e.g. about measurement instruments); descriptive articles that only outline the ‘moral curriculum’ but do not include empirical research; and articles that both describe and evaluate teaching methods and strategies. The latter category was most relevant for our purpose because these articles provide insight into what concrete activities are used into the education of nursing students for the development of moral sensitivity. This focus resulted in the exclusion of 68 articles; a final selection of 10 articles were included in the scoping review (see Table 2).

Table 2.

Overview of papers on moral learning in nursing education 2000–2019 that were included in the review.

Reference	Design, participants	Educational intervention	Definition of moral sensitivity	Goal	Evaluation	Main findings & conclusions
Baykara et al.⁶	Intervention research50 students from the Gazi University Faculty of Health Sciences Department of Nursing (Turkey)	Training on developing skills for recognising ethical violations	A personal capacity for dealing with ethical conflict in particular situations in interpersonal relationships between patients and nurses (Lützén et al., 1995)²⁸	Developing moral sensitivityRecognising ethical violationsEnhancing moral sensitivity in terms of nurses’ professional behaviours and identifying ethical violations	MSQ–Total number of ethical principle protection/violation observations and correct examples from control and experiment groups	No statistically significant difference between pre-test and post-test scores.–Statistically significant difference between the experiment group and the control group.
Hunink et al.²⁷	Descriptive, qualitative and quantitative methods141 documents of nursing students from three nursing schools in the Netherlands	Mentoring sessions in which students and the educator reflect on practical situations that participating students have experienced	The capacity to discern the ethical meaning of a particular situation and to respond accordingly (Gastmans, 2002)²⁹	Identifying moral aspects of everyday nursing care situations	Analysis of the written documents drawn up by the students for their mentoring sessions concerning the submitted situation sketches and their reflections on the discussions	The results indicate that the nursing students rarely identified moral issues, implying that there was little conscious moral reflection and deliberation in their mentoring situation dealing with problematic experiences during their internships.
Kim and Park²³	Pre-test and post-test quasi-experimental study64 undergraduate nursing students at a university in Seoul, Korea	Debate-based ethics education programme	The ability to sensitively perceive ethical situations and make decisions based on ethical principles	Improving moral sensitivity–Improving moral judgement	K-MSQ (Lützén)The Judgments about Nursing Decisions (JAND) tool (Kim, 1999)³⁰	No statistically significant difference was found for moral sensitivity between the debate group and the lecture group.–There was significant improvement in idealistic moral judgement and realistic moral judgement between the two groups.
Lee et al.³¹	Quasi-experimental study234 junior-college student nurses, National Yang-Ming University, Taiwan	Three teaching strategies:Reading Nightingale’s diaryAnalysing personal experiences shared by kidney transplant patientsPractising clinical ethical decision-making according to the Four-Topic Approach (Jonsen & Winslade, 2010)³²	The cornerstone of ethical literacy and the initial step towards developing ethical literacyMorally sensitive people are aware of their roles and corresponding responsibilities in moral or ethical situations (Lützén et al. 2006)³³	Enhancing moral sensitivity based on Lützén	MMSQ-SN, based on the MSQ (Lützén)	Reading Nightingale’s Diary did not significantly correlate with MMSQ-SN scores.Analysing the personal experiences shared by kidney transplant patients significantly correlated with MMSQ-SN post-test scores.‘Practising ethical decision-making’ significantly and positively correlated with MMSQ-SN post-test scores.Scores for the MMSQ-SN categories ‘expressing benevolence’, ‘structuring moral meaning’ and ‘modifying autonomy’ increased significantly, but no significant differences were observed in the remaining categories.The results of this study revealed that the intervention of multiple teaching strategies in nursing ethics education enhances nursing students’ moral sensitivity.
Trobec and Starcic³⁴	Quasi-experiment method, combination of quantitative and qualitative approaches211 first-year nursing students, University of Ljubljana and University of Primorska, Slovenia	Nursing simulation learning method online and in the classroom – comparing the success of the two methods	Ethical sensitivity or moral sensibility:The ability to perceive the ethical dimensionMoral sensibility is the precondition for moral behaviour and moral judgement (Heggestad et al., 2013)³⁵	Developing nursing ethical competences	Students’ ethical sensitivity, analysis and decision-making were assessed. Researchers examined how students perceive and recognise ethical situations, anticipate and interpret potential ethical conflicts and make decisions that lead to potential solutionsExamination of students’ reflective assessment of students’ response capacity of actions and awareness of impacts of those actions on patients. The criteria for assessment of students’ responses were designed based on the Structure for Observed Learning Outcomes (SOLO) taxonomy	No significant difference in the learning outcomes was found between the online setting group and the traditional setting group. Both had a positive impact on learning.Students’ active engagement with the active learning methods in the group enables the development of ethical competences and related communicative competences, interpersonal skills, collaboration and critical thinking.
Tsuruwaka and Asahara³⁶	Qualitative descriptive research86 graduate nursing students who took a nursing ethics class	Narrative writing: Describing a situation where the student experienced uncomfortable feelings in a clinical settingNarrative work: In-class group discussions that used the students’ narrative writing as the subject matter	Ethical sensitivity/ethical awareness not specified	Promoting ethical awareness	Qualitative content analysis to identify students’ awarenessData: students’ narratives that described feelings of discomfort in clinical settings and their comment sheets after narrative group work in nursing ethics classes	The narrative writing was effective in making students aware of (1) habits and trends in their own thoughts and (2) organisational and administrative issues related to ethical issues.Learning ethics of nursing practice by using narrative writing that focused on nurses’ sentiments helped reveal nurses’ thoughts and their attitudes and approaches to patients.
Yeom et al.³⁷	One-group pre- and post-test quasi-experimental design70 undergraduate nursing students, University in Seoul, Korea	Nursing ethics education programme including nursing codes of ethics, ethical decision-making processes, nursing professionalism, and bioethical issuesThe major instructional modules were traditional lectures. Group discussion, question-and-answer sessions, and films with ethical-related themes were also used	The ability to be aware of an ethical conflict, including not only feelings but also self-awareness of one’s own responsibilities in ethically sensitive situations (Lützén, 2006)	Moral sensitivity (Lützén)–Critical thinking (Yoon)	K-MSQ–Critical Thinking Disposition Questionnaire	After the education, the levels for patient-oriented care (a sub-domain of moral sensitivity) and inquisitiveness (a sub-domain of critical thinking disposition) significantly improved.There were no changes in overall scores for moral sensitivity or critical thinking disposition.
McAllister et al.³⁸	Description of three film examples of transformative learning for nursing students	Three films: Good Will Hunting, Wit & My Sister’s Keeper	(no explicit link to moral sensitivity)Ethical comportment: The way in which nurses embody the ability to relate to others respectfully and responsively	Facilitating transformative learning and developing ethical comportment	Evaluations of three educators of nursing students	Educators who use film in their teaching have the opportunity to challenge nursing students to think more deeply and broadly, to question their assumptions and prejudices, and to see their world and the world of healthcare through a new lens.
Monteverde³⁹	Quantitative study58 nursing students, Bern University of Applied Sciences, Switzerland	Novel framework involving: (1) case discussions within tutorials, (2) relating different ethical theories (deontology, consequentialism, ethics of care, principlism) to the cases and (3) strengths and weakness of each theory for nursing practice	(no explicit link to moral sensitivity)	‘Framing’ and ‘naming’ ethical issues students encounter in daily practice, which is seen as an expression of moral resilience	Online survey to explore students’ acceptance of ethical theories teaching, which is considered to be a basic prerequisite for their transferability into practice	Students consider ethical theories – as taught within the proposed framework – to be practically applicable, useful and transferable into practice.
Vanlaere et al.⁴⁰	Description of empathy sessions in a care-ethics lab	Empathy sessions in care-ethics lab ‘sTimul based on experience-oriented learning in ethicsStudents act as care providers	(no explicit link to moral sensitivity)	Achieving ethical reflectionMaking the students’ own vision of good care more explicit	None	In every case, the contrast experiences led to controversy. Controversy can elicit a break from conformist thinking and treatment, a readjustment of one’s own visions, and often also an adjustment of behaviour.

MSQ: Moral Sensitivity Questionnaire; K-MSQ: Korean version of the Moral Sensitivity Questionnaire; MMSQ-SN: Modified Moral Sensitivity Questionnaire for Student Nurses.

Results

The results are presented along two lines. First, the educational interventions used to promote moral sensitivity in nursing education were clustered according to their main focus and the outcomes were discussed. The analysis of these interventions found three different but related dimensions (see Table 3): (1) Raising moral awareness. These educational interventions aim at enhancing the sensitivity of students’ own moral thinking and acting and their awareness of the moral context they are in; (2) Providing the ability to frame and name ethical issues. These interventions take the experienced ethical issues as starting point and contribute to the students’ ability to give words to these experiences; (3) Improving moral reasoning ability. The educational interventions in this cluster focus on ethics as a rational decision-making process by providing deliberation and making the right choices. The studies investigated in this review mostly focused on one dimension; one included two dimensions. None of the studies presented teaching methods that included all three dimensions (see Table 3).

Table 3.

Three dimensions of moral sensitivity and associated articles.

Dimensions of moral sensitivity	Associated articles
Raising moral awareness	Stolt et al.³; Lin et al.⁵; Lerkiatbundit et al.⁷; Frisch⁹
Providing the ability to frame and name ethical issues	Gallagher¹; Cannaerts et al.²; Choe et al.⁴; Monteverde⁸
Improving moral reasoning ability	Stolt et al.³; Baykara et al.⁶; Lechasseur et al.¹¹

Evaluation methods

Two dominant patterns were identified in the evaluation methods used in the studies. Half of the studies used quantitative measures, in particular the Moral Sensitivity Questionnaire (MSQ), and the other half used qualitative methods. Four of the included studies used the Moral Sensitivity Questionnaire (MSQ developed by Lützén et al.⁴¹ or a related version of the MSQ: the Modified Moral Sensitivity Questionnaire for Student Nurses (MMSQ-SN) or the Korean version of the Moral Sensitivity Questionnaire (K-MSQ). The MSQ is a Likert-type measurement instrument used to measure ethical sensitivity. The original MSQ consists of 30 items and includes six subscales: autonomy, beneficence, holistic approach, conflict, practice and orientation. Qualitative evaluation mainly consisted of content analysis of products delivered by the students on the curriculum or case analysis by providing students pre- and/or post-measurement with a hypothetical situation to morally reflect on.

Dimension 1: raising moral awareness

In comparison to the other educational interventions for developing moral sensitivity, the methods used in the studies of Vanlaere et al.,⁴⁰ McAllister et al.,³⁸ Lee et al.³¹ and Tsuruwaka and Asahara³⁶ gave shape to the imagination of the nursing students. These interventions focus on moral awareness, which means students’ awareness of their own moral framework in relation to others, their norms and values and the impact of these on their care for patients. They were challenged to recognise their attitudes and approaches towards patients, question their previous assumptions and prejudices and break from conformist thinking. Diverse methods were used to achieve this: contrast experiences, writing exercises, film, diaries and patients’ experiences.

Contrast experiences

The care-ethics lab ‘sTimul in Flanders⁴⁰ organised empathy sessions by simulation to stimulate ethical reflection. The sessions in the care-ethics lab emphasised experience as a basis for ethical reflection. The empathy sessions comprised two simulation days with one overnight stay, a discussion with an ethics expert and either a return day or a time set aside for ethical reflection. The participants were students and experienced care providers. The experienced care providers played the part of an older resident according to a specific resident profile in a simulation exercise. The nursing students carried out the care process for the simulated residents. The students took responsibility for the entire care process, without the guidance of experienced care providers or supervisors, freeing them from the pressures of supervisor oversight.

Vanlaere et al.⁴⁰ did not systematically evaluate the impact of the empathy sessions in care-ethics lab ‘sTimul on nursing students, but they did find – based on the experiences collected from participants – that the empathy session interrupted the nursing students’ socialisation process because they had to rely on themselves and the values and insights they consider important. Moreover, they were confronted with negative contrast experiences from the simulated care receiver. According to Vanlaere et al.,⁴⁰ these contrast experiences led to controversy, which can elicit a break from conformist thinking and treatment, a readjustment of students’ own visions, and often also an adjustment of behaviour.

Narrative writing

To raise awareness of students’ own moral frameworks, the study from Tsuruwaka and Asahara³⁶ evaluated a narrative writing approach that focuses on nurses’ sentiments instead of their cognition. Here we find a commonality with the ‘sTimul lab, which also focused on students’ empathic feelings. The narrative writing in this study was done individually by the students and consisted of describing situations in which students experienced uncomfortable feelings in a clinical setting. They wrote (1) an objective description of the scene, (2) their own personal narrative of this scene and (3) a description of the presumed perspective of one or two other people who were involved in the scenes. Having the students write a narrative of their own perspective and from another person’s perspective was intended to help them think about trends in their own thoughts and how they perceive others. The study’s authors evaluated the effectiveness using a content analysis of the students’ narratives and their comment sheets after narrative group work in nursing ethics class. The results show that narrative writing was effective in making students aware of two aspects: (1) habits and trends in their own thoughts and (2) organisational and administrative issues related to ethical issues.

Film

In addition to the contrast experiences of the care-ethics lab⁴⁰ and the narrative writing of nursing students in Japan,³⁶ film was also used as an educational intervention for stimulating nursing students’ ‘moral consciousness’. In their article, McAllister et al.³⁸ describe ways to incorporate film as a learning strategy for transformational learning and ethical comportment, using three films: Good Will Hunting, Wit and My Sister’s Keeper. After the nursing students saw the movies, group discussions followed. The article presents three descriptive evaluations of three educators as examples for the use of immersive and transformative learning via film in nursing education. The authors concluded that educators who use film in their teaching have the opportunity to challenge nursing students to think more deeply and broadly, to question their assumptions and prejudices and to see their world and the world of healthcare through a new lens.

Reading Nightingale’s diary

In the study of Lee et al.,³¹ two of the three teaching strategies correlate with developing moral sensitivity by raising moral awareness: (1) reading the book Nightingale’s Diary and (2) analysing the life experiences shared by a kidney transplant patient. The diary of Florence Nightingale focuses readers on the value of nursing care. Students were encouraged to read the diary to gain a strong sense of responsibility and improve their moral consciousness. According to Lee et al.,³¹ the diary states that nurses must be willing to learn and have stable personalities, that interpersonal interaction is based on morality and spirituality, and that nurses reflect on nursing and are ethical. They evaluated the teaching strategy with the MMSQ-SN and concluded that reading Nightingale’s Diary did not significantly correlate with MMSQ-SN scores.

Life experiences of a patient

In the second teaching strategy used by Lee et al.,³¹ a dialysis and kidney transplant patient was invited to share his life experiences and his mission to promote the love of life. This learning strategy included a kinaesthetic learning style by touching a patient’s arteriovenous shunt, as well as analysing the ethical values and consciousness involved in clinical organ transplantation by focussing on patients’ life experiences. Here, the results show that analysing the personal experiences shared by kidney transplant patients did significantly correlate with MMSQ-SN post-test scores. There was an increase in scores for the subscales expressing benevolence, structuring moral meaning and modifying autonomy.

Dimension 2: providing the ability to frame and name ethical issues

This category involves interventions that focus on the ability of nursing students to frame and name ethical issues and problems in daily nursing practice. It includes the teaching methods and strategies investigated in the studies from Trobec and Starcic,³⁴ Monteverde,³⁹ Baykara et al.⁶ and Hunink et al.²⁷ Instead of triggering ‘moral awareness’, these interventions take the confrontation with dilemmas as a starting point for developing moral sensitivity. They pay explicit attention to the relationship between knowledge of ethical theories and the ability to recognise ethical issues.

Relating ethical theories to cases from daily nursing care

In the study by Monteverde,³⁹ the intervention began by providing resources about several ethical theories: deontology, consequentialism, the ethics of care and principlism. Then three cycles of problem-based learning with three frame stories were discussed in the tutorials. The stories involved ordinary, unexceptional cases of daily nursing care, such as maintaining trusting relationships when patients are demanding. Different ethical theories were related to the case, and the tutors were asked to ensure that students explore the strengths and weakness of each theory, mirror it with the situation and calibrate their results with their experience of nursing practice. The assessment included a written examination with a focus on framing and naming ethical aspects of a given situation by means of ethical theories. After the module, the students received an online module evaluation and specific questions referring to the teaching of ethical theories were added. Students considered ethical theories – as taught within the proposed framework – to be practically applicable, useful and transferable into practice.

Nursing simulation online and in the classroom

Within the educational intervention of Trobec and Starcic³⁴ also prewritten scenarios are used. These are based on authentic ethical problems from clinical environment. The authors compared two learning settings, online and in traditional classroom, and their impact on the ethical competence of nursing students by developing understanding and applying ethical principles. Besides theoretical lectures, they use role-play and discussion in small groups as learning method. To investigate whether the students had good achievements, they investigated the comprehension and application of ethical principles of nursing students before the tutorials began and post-test summatively, after the completed tutorials. Students received open-ended questions about ethical principles supported by hypothetical situations. The researchers then examined how students perceive and recognise ethical situations, anticipate and interpret potential ethical conflicts and take decisions towards potential solutions. The criteria for assessing students’ responses were designed based on the Structure for Observed Learning Outcomes (SOLO) taxonomy. A 1 to 5 scale was applied to identify relevant aspects of ethical principles, relations, integration and level of abstraction and generalisation. No significant difference was found between the two learning settings and both had a positive impact on learning. In both groups – online and in a traditional classroom – the average values of the scores were higher after the tutorials were completed.

Students’ own internship experiences

The educational interventions in the studies from Baykara et al.⁶ and Hunink et al.²⁷ used nursing students’ own internship experiences instead of prewritten scenarios. The study from Baykara et al.⁶ was conducted with an experiment group and a control group. Students in the experiment group were given ethics training and consultancy services. Students were taught during their clinical/field applications, using explanation, question–answer, discussion and case study teaching methods. The first training addressed the subjects of ethical principles, patient rights, the nursing code of ethics, characteristics of ethical problems, malpractice and medication administration errors. The second training session involved discussions about the ethical violations experienced by students in the clinical environment, their properties and their source. The students also received guidance about the observations they performed throughout the study and about ethical violations. It was determined that students in the experiment group provided more ethical principle violation observations and correct examples than students in the control group, and the difference was statically significant. Baykara et al.⁶ also evaluated the effect on moral sensitivity with the original MSQ. They conducted a pre-test and a post-test with the MSQ but found no statistically significant difference.

Hunink et al.²⁷ investigated whether nursing students identified moral issues and intended to elucidate the role of mentoring situations in moral development. This is based on the view that systematic discussion of practical experiences in mentoring sessions, such as supervision, constitutes an important educational activity for moral development. The students themselves chose situations from their own internship experiences in which they were confronted with a difficult question or a problem and reflected on it in the group discussion with a focus on what they learned from it. The researchers investigated whether student nurses identified the moral aspects of everyday nursing care situations by analysing documents students wrote for their mentoring sessions about the submitted situation sketches and their reflections on the discussions. A reasonable proportion of the issues submitted by the students were identified as moral by the researchers, although the students themselves rarely typified these issues as moral. The results indicate that the nursing students rarely identified moral issues, implying that there was little conscious moral reflection and deliberation in their mentoring situation dealing with their problematic experiences during their internship.

Dimension 3: improving moral reasoning ability

The third type of educational intervention for the development of moral sensitivity involves improving the ability of nursing students to make moral decisions about the dilemmas they encounter in their professional practice. The studies of Yeom et al.,³⁷ Kim and Park²³ and Lee et al.³¹ investigated educational interventions for improving nursing students’ moral sensitivity by providing opportunities for deliberation and moral decision-making by moral reasoning.

Debate-based

The debate-based ethics education programme developed by Kim and Park²³ included ethical theories, principles and rules (session 2), moral decision-making models and codes of ethics for nurses (session 3) and sessions with dilemma cases (sessions 4–8). Ten dilemma cases were created, and the students were invited to participate in the debate. Participants were instructed to plan how they would present their arguments from the pro and con perspectives, and they were asked to write a thesis analysis and discussion summary before the debate. Students who did not participate in the debate were instructed to write a debate report and a description of whether their positions changed during the debate. Kim and Park evaluated this debate-based ethics education programme in Korea, using a pre-test and post-test K-MSQ and the moral judgement questionnaire. They did not find a statistically significant difference for moral sensitivity. However, the debate group improved significantly more than the lecture group.

Four-topic approach

The study by Lee et al.³¹ also used an ethical deliberation model: the Four-Topic Approach. Over an 8-week education programme, the participants engaged in clinical ethical decision-making learning and practice according to this model. It used (1) visual, (2) auditory and (3) kinaesthetic learning styles by asking students to (1) read descriptions of clinical scenarios that involve ethical dilemmas; (2) brainstorm, exchange values and hold group discussions; and (3) research and synthesise the literature, exchange values and hold group discussions. The class was divided into eight groups, each with the same ethical issue to discuss. Each group was instructed to write their decisions on the blackboard and introduce and explain their results. Then the whole group engaged in discussion. The students were then instructed to identify literary resources, engage in group discussion and employ the Four-Topic Approach to complete their closing report. The teaching strategy was evaluated with the MMSQ-SN; practising ethical decision-making significantly and positively correlated with MMSQ-SN post-test scores. Scores on the MMSQ-SN subcategories expressing benevolence, structuring moral meaning and modifying autonomy increased significantly, but no significant differences were observed in the remaining categories.

Multiple methods

The study from Yeom et al.³⁷ aimed to assess changes in nursing students’ moral sensitivity and critical thinking disposition after a 7-week nursing ethics education programme with 90-min sessions each week. The educational sessions focused specifically on moral problem-solving for ethical dilemmas in a healthcare context. The programme included sample cases about patients involved in various ethical dilemmas, including codes of ethics, ethical decision-making processes, nursing professionalism and bioethical issues (e.g. abortion and withdrawal of treatment). Lectures using audio-visual materials were the major instructional method, but group discussion, question-and-answer sessions, case analysis and films with ethics-related themes were also used. Yeom et al.³⁷ used the K-MSQ to examine the effects of the education programme. They only found significant improvement in the levels for patient-oriented care, a sub-domain of moral sensitivity. There were no changes in the overall scores for moral sensitivity disposition.

Conclusion and discussion

Studies on educational interventions that foster moral sensitivity can be categorised according to what they try to improve. Three dimensions emerged from our analysis: raising moral awareness, providing the ability to name and frame moral issues and improving moral reasoning ability. The three dimensions each shape the development of moral sensitivity from their own particular perspective. The first dimension, moral awareness, refers to the way nursing students embody an ethical attitude, including awareness of their deeply held thoughts, assumptions and feelings about caregiving. This dimension is about awareness of the implications of their caring actions and it fosters the ability to recognise the ethical nature of daily nursing practice in general. The second dimension, name and frame moral issues, puts the focus on the ability to recognise particular ethical issues and describe them in words. In this dimension, ethical issues and dilemmas are the starting point for fostering moral sensitivity. The third dimension, improving moral reasoning ability, stresses the importance of moral deliberation and moral reasoning for strengthening the moral sensitivity of students as a precondition for moral decision-making. Based on these findings, a framework of moral sensitivity is constructed (see Figure 2).

Figure 2.

Framework of Moral Sensitivity.

The results lead to the question of whether the three dimensions follow each other or whether they are separate elements of moral sensitivity that can reinforce each other. More importantly, this review study added a hitherto implicit dimension to moral sensitivity: moral awareness of self. This turned out to be an important dimension in striving for moral sensitivity among students, but it seemed to be more loosely connected to the other two dimensions because it turns the attention less to the ethical situation and more to the ethical person. This attention to the ethical person can be related to another important aspect of ethical awareness outlined by Milliken and Grace.¹² They argued that nurses’ ethical awareness also involves willingness to recognise the ethical nature of nursing practice. The four included studies that focused on moral awareness seemed to define the moral awareness of self as a foundation for ethics education. They did not explicitly refer to the concept of moral sensitivity, but spoke of ‘awareness of feelings and attitudes’,³⁶ ‘empathy’⁴⁰ and ethical comportment defined as ‘relating to others respectfully and responsively’.³⁸

This raises the question whether moral awareness is a dimension of moral sensitivity or whether it can be seen as a prerequisite for it. Since the literature on moral sensitivity stresses the importance of self-awareness of feelings and thoughts¹⁷ and regards ethical sensitivity as a foundational component of ethical action,¹⁴ we would argue that moral sensitivity includes a double movement in the care for others: the critical awareness of self, including feelings, habits and prejudices, and the willingness to be aware; as well as the reflection on the ethics of the situation and ethically responding towards this situation. By this we mean that moral awareness of self in itself is not a sufficient, although necessary, condition of moral sensitivity as an inherent social and contextual phenomenon. Moreover, the development of moral awareness of self is taking place in relation to other human beings and therefore it should not be understood as a purely individual matter. This two-sided movement of moral sensitivity is in line with Gallagher’s definition¹ of ethical competence as the possession of ethical knowledge next to the ability to ‘see’ what a situation presents (ethical perception); to reflect critically about what nurses know, are and do (ethical reflection); to bring out ethical practice (ethical behaviour); and to ‘be’ ethical. This ‘being ethical’ does not refer to knowledge and cognitive-rational processes of perception or decision-making, but to the experience of being touched and the embodied response to this.

Methodologically, the review showed that the three dimensions are evaluated in different ways, thereby also indicating their different natures. Whereas moral awareness was studied using qualitative, including narrative, methods or in a more informal anecdotal way, naming and framing moral issues was captured by observations and reflections by students, and interventions aimed primarily at moral reasoning were most often evaluated by using the validated Moral Sensitivity Questionnaire. One could ask whether the MSQ is a helpful instrument for evaluating the other dimensions of moral sensitivity, since it is difficult for a questionnaire to capture these more hidden and implicit dimensions of professionalism and tacit moral knowing.⁴² A mix of quantitative and qualitative measures seems most appropriate to encompass all dimensions of moral sensitivity.

Implications for practice

The study shows that a notion of moral sensitivity has developed within practice that seems to be founded on three dimensions: moral awareness, naming and framing moral issues and moral reasoning. The educational programmes that were selected mainly address one dimension, sometimes two, but never all three dimensions of moral sensitivity. The combination of moral naming and framing and moral reasoning seems more natural;^23,27,37 the studies show no combination with ‘moral awareness’. Monteverde³⁹ argued that within contemporary healthcare ethics education research, two approaches compete with each other: a cognitive-developmental approach to acquiring moral judgement and moral reasoning that is informed by Kohlberg’s theory; and a motivational or empathic approach – inspired by Dewey’s pragmatist learning theory – that stresses the importance of context, moral habits, feelings and relationships. These two strands meet in our framework of moral sensitivity, with ‘naming and framing moral issues’ and ‘moral reasoning’ representing the cognitive-behavioural approach – which stresses reflection on the ethics of the situation – and ‘moral awareness’ representing the motivational approach that focuses on the critical awareness of self (see Figure 2).

The framework provides more clarity into the concept of moral sensitivity and how to apply this in practice. It shows that all three dimensions together contribute to strengthening moral sensitivity in their own specific way. Students must be aware of the self and reflect critical on their feelings, assumptions and actions. But also noticing moral issues, framing and naming them and reflecting on these situations is part of their moral sensitivity development.

Overviewing the educational programmes, the three dimensions are not yet integrated in most educational programmes. This implies that focussing on only one or two dimensions does not fully provide the ethical training that nursing students need. Although hard evidence is still lacking, this review tentatively points towards the importance of moral awareness training for nursing students by offering real-life or simulated situations in which student nurses interact with caregivers – an interaction that touches student nurses on an affective level. More knowledge is needed about how student nurses learn on this embodied level and the role of reflection on their experiences.

Studies about the moral learning of teachers have shown the crucial role of a critical reflexive dialogue for transformative learning.⁴³ The experienced real-life situation is first told and thereby interpreted by the teller. Then it is questioned by peers and a teacher-coach in a critical reflexive dialogue, which leads to a deeper questioning of one’s own assumptions, values and goals. Experiential learning combined with a critical reflexive dialogue with peers and superiors seems to be a promising way forward.

Limitations

This review study is based on 10 studies from the last decade that were selected because they describe a nursing ethics programme or intervention aimed at some aspect of moral sensitivity and include an evaluation of it. This is a small number of studies. The studies under review also involved quite different interventions for ethics education within the curricula, including simulation exercises, case descriptions, narrative interventions such as diaries and films, mentoring sessions, debates, group discussions and lectures. These interventions were linked to different foci: the three dimensions of moral sensitivity. Moreover, the studies used different evaluation methods, including both quantitative and qualitative methods. Because of this diversity, it is impossible to draw any hard conclusions about the success of particular teaching methods.

The quantitative methods often found no significant changes between pre- and post-measurement. Four of the 10 studies in this review – and all the studies investigating the dimension ‘moral reasoning’ – used the MSQ. However, its subscales do not seem to fit well with the content and goals of these educational programmes. Furthermore, many studies that used the MSQ suffered from methodological challenges, such as non-reporting or relatively low levels of reliability.¹⁴ Therefore, the accuracy and reproducibility of findings from the MSQ can be questioned. The difference between this instrument and practice can be traced back to its development route: the MSQ was theoretically developed and, although validated in practice, it did not emerge from existing curricular programmes. In addition, the MSQ – or any other quantitative measurement – does not help to open the ‘black box’ of nursing ethics programmes: that is, it does not provide evidence for which processes and interventions work for whom and why. This can be captured by qualitative methods (e.g. realistic evaluation design).⁴⁴

The qualitative measurement of outcomes also displayed limitations in this review. Most qualitative methods only offer retrospective self-report information. Some ‘qualitative’ studies only use anecdotal information from participants: students and educators. However, there are some promising research strategies, such as narrative writing approaches. In the study conducted by Tsuruwaka and Asahara,³⁶ students’ narratives about feeling uncomfortable in clinical settings were compared with students’ comment sheets after narrative group work in nursing ethics classes. Using a qualitative content analysis, the researchers identified students’ moral awareness before and after the intervention.

Concluding remarks

This review study resulted in a framework for moral sensitivity that emerged from the analyses of foci of educational programmes and interventions in nursing ethics education. It points towards the importance of integrating the three different dimensions of moral sensitivity within these programmes.

We recommend that the framework of moral sensitivity be used for developing ethics education programmes that intentionally aim at one, two or all three dimensions. In addition, there is a need for a measurement instrument, based on mixed methods, to evaluate the learning and development of student nurses on these dimensions. The framework could be used to develop a ‘dashboard’ with evaluation methods, supporting practitioners in using research strategies and methods that suit the characteristics of each dimension.

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) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Gaby Jacobs

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