Impact of Education on Student Nurses' Advocacy and Ethical Sensitivity

Abstract

The nursing literature emphasizes that there are still inadequacies, differences, and inconsistencies in the definition of nurses' advocacy role, and that nursing education plays an important role in educating nurses for patient advocacy. The aim of the present study is to determine the effects of advocacy education onsocial justice advocacy and ethical sensitivity. Pre-test, post-test, parallel group, randomized controlled study. The study was carried out on 80 undergraduate nursing students in Turkey. Students was divided into experimental (40) and control (40) groups. Experimental group received advocacy education cirruculum. Both groups were applied as Socio-Demographic Characteristics, as pre- test and post-tests Social Justice Advocacy Scale, and Moral Sensitivity Questionnaire. The data were statistically evaluated with, the chi-square test, Two-Way Anova. The study was approved by Selcuk University Faculty of Health Sciences Non-Interventional Clinical Research Ethics Committee (09.25.2019/1218). Written informed consent was obtained from all participants. The pre-test score of the intervention group and that of the control group were similar(p > 0.05). The study group's post-test score was significantly higher than its pre-test score and the post-test score of the control group “social justice advocacy skills” and “moral sensitivity Questionnaire.” In two-way analysis of variance in repeated measures, there was a significant main effect of the type of groups. The two-way ANOVA results in repeated measures showed that group-time interaction was significant. The advocacy education cirruculum the experimental group increased in the social justice advocacy knowledge, attitude and skills and moral sensitivity. The advocacy education cirruculum the experimental group increased the social justice advocacy skills and moral sensitivity. The Advocacy education cirruculum can be suggested to be integrated into the undergraduate nursing curriculum.

Keywords

Education nursing patient advocacy social justice advocacy ethical sensitivity

Introduction

Social and economic inequalities cause poor health outcomes. The health system has to offer to ensure a healthy future and provide better healthcare for society. In the globalizing world, unfortunately, healthcare cannot be provided equally to everyone. The World Health Organization (WHO 2018) wants to change this inequality by aiming for greater justice in health for all people around the World.¹ In the nursing profession, there are certain roles against these inequalities which try to reduce inequalities and provide additional benefits to improve patients’ health and healthcare by developing and implementing advocacy plan. Thus, advocacy in nursing practice has used strategies such as being a spokesperson, coordinating care, and collaborating with other stakeholders when their social rights are violated, and providing access to health resources and social services.²

Patient advocacy is a fundamental nursing role and an ethical responsibility of İnternational Council of nursing (ICN 2012).³ The American Nurses Association (ANA) defined advocacy as the imperative role of the nurse in 2001 (ANA 2001, 2015).⁴ The term of advocacy highlights the safety of patient in every aspect. Nurses advocate to protect patient rights and help patients to make decisions. ^2,5 Nursing healthcare system provides services to vulnerable individuals, families, and communities who are more likely to experience the negative effects of social, economic conditions that prevent access to health services.⁴ Additionally, nursing schools should create advocacy curriculum that for students in the complex health system to develop their advocacy knowledge and practice.^6-8 Learning advocacy and doing advocacy activities within the system help students to get achievement of the best health outcomes for population. Basically, advocacy education is necessary and beneficial to strengthen the bond between nurse and patient and support nurses to do their duty properly.

Although advocacy was discussed as a modern view in the 1970s, its origin is based on Florence Nightingale. Florence Nightingale ensured the environmental aspects that are required for the patients for injured soldiers in World War 2.⁹ In modern view, three important theorists in nursing presented advocacy models.² First, Curtin (1979) argued that the nurse–patient relationship is reciprocal and that advocacy supports nurses' patient choices.¹⁰ Second, Gadow (1980) argued that patient and nurse share a human relationship.¹¹ Lastly, Kohnke (1980) saw advocacy as a natural role of the nurse.¹² He argued that the nurse can sometimes actively advocate by respecting the patient’s views when necessary ² In the nursing literature, advocacy took place as concept dimension sources rather than research in the 2000s.¹³ When the researcher scanned the literature, drew a conclusion that evidence-based research is needed for the term of advocacy.

Social justice advocacy in nursing education is one of the first steps to help the struggle of people who experience social and economic inequality.¹⁴ Social justice is a mechanism to respond to the minimum expectations of social classes that suffer from inequalities in the face of increasing inequalities.^15-17 By using an effective method like social justice advocacy, nursing profession may achieve the goals of social justice. Social justice advocacy has developed as a dimension of advocacy in order to protect the rights of individuals and groups who feel the increasing pressure arising from the social system as a result of the increase in social inequalities.¹⁸ Social justice includes doing what is necessary to live without social and economic differences and fulfilling all kinds of conditions at the individual, institutional, and managerial level for every human being in the society.¹⁹ Social justice advocacy has a great importance for individuals or groups who feel the ever-increasing pressure stemming from the social system.¹⁸ There are lots of examples of inequalities in our daily life which need social justice advocacy. For example, the WHO (World Health Organization) report states that 150 million children live on the street in the world.¹ International Labor Organization (ILO) data display that there are 200 million uneducated child laborers in the world.²⁰ Furthermore, in Turkey while 28.7% of the population is in poverty, 20% of the population shares 47.4% of the total income. The Gini coefficient has been estimated 0.405 with an increase of 0.001 points compared to the previous year.²⁰ Briefly, these examples of socio-economic inequalities adversely affect the healthy lifestyle and quality of life.^21-24 A study in India has indicated that the average height of children living in rural areas with low access to resources was below average.²⁵ Another study conducted in India has revealed negative health outcomes in a low-socioeconomic society.²⁶ Additionally, a study on children has shown that the lower socio-economic conditions negatively affected health due to the lack of basic needs such as access to healthcare, a safe home, and food.²⁷ The professional roles of nursing are to strengthen care by working to increase access to health and change the situation of the population experiencing inequality.²⁸ Nurses can advocate by helping individuals, groups, and the community to determine their priorities by reducing the effects of social determinants of health on health.²⁹ Patients who are weak as a social class; they should be empowered socially, economically, environmentally and culturally and should be encouraged to seek solutions and take necessary steps by understanding the reasons for the negative conditions they suffered due to these effects.^17,22 Therefore, social justice should be protected and social justice advocacy should be prioritized by nursing profession in order to improve the field of health.

Another important concept in this research is that ethical sensitivity of nursing students. Professional ethics are the behavioral patterns expected from members of the profession who demonstrate professionalism.³⁰ For this reason, professional ethics are important in terms of protecting patient rights, ensuring patient safety, and developing a moral perspective on the problems encountered in nursing practice.³¹ Ethics are a key to the success and integrity of the nursing profession because ethics are guide to how nurses approach individuals, groups, and society in advocacy practices.^10-32 Nurses can see the most sensitive, miserable and private aspects of their patients or witness their feelings of pain, grief, loneliness, and despair. This requires the nurse to make decision and act on patients’ behalf; thus, even a very simple decision should be based on ethical principles and moral judgment.³³ Moreover, application of ethical principles is related to ethical sensitivity. Nurses who have a developed ethical sensitivity exhibit attitudes according to seven fundamental principles of ethics such as beneficence, autonomy, benevolence, holistic approach, conflict, practice, and orientation.³⁴ The ethical sensitivity shows the nurses' knowledge, attitudes and behaviors in the processes of respecting the patient’s preferences, observing the benefit of the patient, being able to take a holistic view, considering the ethical dimension in decision-making. Ethical values strengthen the autonomy of nurses through the formation of the philosophy that drives the nursing profession and increasing loyalty.³⁵ However, the studies have shown that the ethical sensitivity level in nurses was generally at a moderate level.^36-40 There are studies conducted to determine the level of ethical sensitivity has been observed that the nursing students had higher sensitivity.^41–43

Since the studies in the field of advocacy and ethical sensitivity are generally theoretical, evidence-based research is needed. According to the literature review authored by Oliveira and Tariman (2017) on the advocacy role in nursing practice, the nurses have expressed a lack of resources, funds, and institutional support to increase their knowledge and competence in advocacy and professional development.⁴⁴ Studies of has shown that the educational practice planned to develop advocacy was successful in the undergraduate nursing students.^{45,7,46,47,48,49} Briefly, evidence-based studies are powerful sources for improvement of the field so that the researcher wanted to be inspirational and aimed that this study’s findings can be used for further studies.

The present study was designed to evaluate the effectiveness of the nursing education curriculum to provide advocacy knowledge, attitude, behaviors, and ethical sensitivity for the development, protection, and maintenance of health. The researcher used knowledge, models, theories, and evidence from different fields of science to achieve the aim. Bloom’s Taxonomy is one of the effective theories that the researcher used while conducting the research. Bloom’s Taxonomy is a framework to categorize the level of knowledge, attitude, and psychomotor learning of advocacy and ethical sensitivity of students.^50,51 In addition, advocacy education will increase nursing students’ the awareness of social justice, advocacy, and ethical sensitivity and create evidence for advocacy practices. The researcher has a purpose to increase the competence and autonomy of nursing students about the fundamental topics such as collaborative movement, client empowerment, social/political advocacy, and client/community advocacy with this research. Therefore, it is thought that it will contribute to the protection and development of values of nursing profession besides scientific progress.

Research hypothesis

H1₀ hypothesis: There is no difference between the experimental group and the control group in terms of Social Justice Advocacy total and sub-dimensions score.

H2₀ hypothesis: There is no difference between the experimental and the control group in terms of Moral Sensitivity Questionnaire total and sub-dimensions score.

Methods

Research design and participants

The study is a pre-test, post-test, parallel group, randomized controlled study (RCT). The research protocol has been registered in Clinical Trials (ID: NCT04578821). The study report (The Quality of Reports of Parallel Group Randomized Trials) has been written according to the CONSORT-2017 criteria (Figure 1).⁵²

Figure 1.

CONSORT diagram of study design.

The research was carried out in the Faculty of Nursing in Necmettin Erbakan University in Konya, Turkey, in the 2019–2020 academic year. The study group consisted of 80 students selected by simple random sampling from 112 students who complied with the inclusion criteria among 120 students enrolled in the fall semester. The students were randomly assigned to the experimental (40) and control group (40) (www.randomizer.org). The basic characteristics of the students assigned to the experimental and control groups were found to be similar (p>0.05) (Table 1).

Table 1.

Socio-demographic characteristics of the experimental and control group students.

	Experimental group (n:40) number	%	Control group (n:40) number	%	X²	p
GenderFemaleMale	328	8020	328	8020	0.000	1000
Family structureCoreLarge	364	9010	337	82,517,5	0.949	0.330
Social securityYesNo	364	9010	391	97,52,5	1920	0.166
Graduated High SchoolAnatolian high SchoolHigh schoolHealth college	3523	87,557,5	3244	801,010	3001	0.391
Mother Education StatusNo educationPrimary schoolHigh schoolUniversity	33,052	7,57512,55	23,053	57512,57,5	0.400	0.940
Father EducationPrimary schoolHigh schoolUniversity	2299	5522,522,5	191,110	47,527,525	0.472	0.790
Income StatusBadModerateGood	3298	7,572,520	22,810	57,025	0.440	0.803
Longest Living PlaceCityTownPut	19,138	47,532,520	20,155	5037,512,5	0.861	0.650
ReceiveAdvocacy EducationYesNo	634	1585	238	595	2222	0.136
	%	SS	%	SS	t	p
Age	21.18	0.63	21.47	0.71	−1098	0.052

Abbreviations: χ2, Chi-square test.

Research group inclusion criteria

• A senior (4th grade) student, no failed course

• Being fluent in Turkish language skills

Forming research study groups

There was no previous experimental study conducted with both scales. Considering that it will better represent the population, sample size was determined as 70 students for both groups. Assuming a 5% dropout rate the required sample size was 40 students in each group and 80 students in total.

Randomization

After taking the consent for participation and making the pre-test, the students were randomly assigned to the experimental (40) and control (40) groups by an independent statistician who used a simple randomization method from the random numbers table created on the computer. The students assigned to the experimental group were enrolled in the patient advocacy course by the registrar’s office, while control group students made a routine course selection. The researcher who carried out the trials saw the names of the students after they were assigned to the system and just before the trials started.

Blinding

Blinding was performed in the collection, statistics, and reporting of the data. Collecting research data and entering them into computer system were carried out by a nursing faculty member who was unaware of the experimental and control groups. The data entries were made with the codes "A" and "B" without specifying the experimental or control group. The groups were coded in the analysis of the data and the writing of the research report. After performing the statistical analysis and writing the research report, the coding for the experimental and control groups was explained to the researcher by the coder.

Data collection

Socio-Demographic Characteristics (SDC) of Participants was prepared based on the literature by the researcher^22,48 consisted of questions determining the students' age, gender, high school education, family structure, place of residence, mother’s education, father’s education, mother’s job, father’s job, income perception, and whether they have received advocacy education before.

Social Justice Advocacy Scale (SJAS) was developed to quantitively measure the skills required for social justice advocacy.⁵³ The scale consisted of 43 items and four sub-dimensions. The sub-dimensions include: collaborative action, client empowerment, social/political advocacy, and client/community advocacy.⁵³ The adaptation of the scale to Turkish and its validity and reliability were carried out by Serpen and Duyan.⁵⁴ The Cronbach’s alpha coefficient for the whole scale was found to be 0.92. The points that can be obtained from the scale: in total: 41–287 and in sub-dimensions: Collaborative action: 17–119, client empowerment: 9–63, social/political advocacy: 8–56, and client/community advocacy: 7–49 points. Higher scores on the scale indicate that social justice advocacy behaviors are more approved.

The Moral Sensitivity Questionnaire (MSQ) was developed to determine the moral sensitivity shown in the ethical decision-making process (Lutzen K 1994).⁵⁵ The scale consisted of 30 items and six sub-dimensions. The sub-dimensions include: autonomy, benevolence, holistic approach, conflict, practice, and orientation. The adaptation of the scale to Turkish and its validity and reliability was conducted by Tosun.⁵⁶ The scale was a 7-point Likert type scale and is scored between 1 (strongly agree) and 7 (strongly disagree), where “1 point” indicates high moral sensitivity and “7 point” indicates low moral sensitivity. The Cronbach’s alpha coefficient for the whole scale was found to be 0.84. The lowest and highest scores that can be obtained from the scale are: 30–210 in total, and in sub-dimensions autonomy: 7–49, benevolence: 4–28, holistic approach: 5–35, conflict: 3–21, practice: 4–28, and orientation: 4–28 points. A high score indicates low sensitivity in terms of ethics, and a low score indicates high sensitivity.⁵⁶

Pre-application

Prior to the research, were applied SDC, SJAS, MSQ to third-year nursing students. It has been observed that there was no problem with the clarity of the scales in the preliminary application and that the implementation of the scales took a total of 30 min.

Data analysis

The data obtained in the study were analyzed with SPSS 23 statistical software. The statistical tests were conducted at the significance level of p < 0.05. The data were given as number, percentage distribution, mean, and standard deviation. The statistical methods applied were the chi-square test for the similarity of experimental and control group’s basic characteristics, t-test for the comparison of the post-test scores of the experimental and control group, t-test for the comparison of the pre- and post-test scores of the experimental group. Time and group interactions of the experimental and control group’s score changes were examined using two-way analysis of variance in repeated measures. The effect of the advocacy education based on SJAS and MSO was evaluated using the partial eta-squared (η2) value. This value is accepted as small if it is 0.01, while the value was considered as moderate if it is 0.06 and large if it is 0.14.95% confidence interval values of the effect size were calculated.

Ethical considerations

Prior to the research, Selcuk University Faculty of Health Sciences Non-Interventional Clinical Research Ethics Committee approval (09.25.2019/1218), institutional permissions, and written consent from the participants were obtained.

Research implementation

The study was carried out in the spring semester of the 2018–2019 academic year. Advocacy education curriculum began after pre-tests. The advocacy education curriculum prepared according to GREET-2017 (Guideline for Reporting Evidence-Based Practice Educational Interventions and Teaching).⁵⁷ The duration of the theoretical part of the advocacy education was a total of 22 h given in 11 weeks (four weeks, 90 min). After the completion of the advocacy education curriculum, the post-tests were administered. While the students in the experimental group received both advocacy education and regular curriculum, those in the control group just took regular curriculum. The educational tools were computer, barcovision, posters, as well as the lecture notes and resources prepared by the researcher. The resources (target checklist, data collection form, guidance of communication, and case samples) were shared electronically with the students after pre-test done. The SDC, SJAS, and MSQ were applied as pre- and post-tests to the experimental and control groups. The advocacy roles of nurses (caring, giving empowerment, making a difference, using evidence-based practices, and developing health policies) were carried out with slide presentation and narrative method. The scope of the education curriculum was created according to Bloom’s taxonomy, considering that it would be effective in developing knowledge, attitudes, and skills in nursing. Learning occurs in the three fields such as cognitive, affective, and psychomotor in Bloom’s Taxonomy.^50,51 Bloom’s Taxonomy helps teachers to specify the outcomes of students which show different levels of cognitive, affective, and psychomotor learning and assist in improving instructional strategies and appropriate activities. The evaluation of knowledge, attitude, and skill about cognitive, affective, and psychomotor target were provided with different methods such as quiz, question-answer or written exam, observation, composition, poster design, and individual study. Theoretical topics such as lecture notes and resources were presented to achieve cognitive target, movies, and videos were shown to achieve affective target and SSI practice and posters were done to achieve psychomotor target. In addition, two case studies about individual and system advocacy were discussed in the class.^58,59 Students received counseling outside of the classroom through the Whatsapp group formed with the researcher. The content and stages of the advocacy education curriculum based on the Bloom’s Taxonomy are shown in detailed (Figure 2).

Figure 2.

Content of the education curriculum based on the Bloom Taxonomy.

Results

The majority of nursing students in the experimental and control groups were female (80%), and 85% of the experimental group and 95% of the control group had no prior advocacy education. The mean age was 21.18 ± 0.63 in the experimental group and 21.47 ± 0.71 in the control group (Table 1) There was no statistical difference between the experimental group and the control group in terms of pre-test scores of SJAS and MSQ scales (p > 0.05) (Table 2).

Table 2.

Social justice advocacy and ethical sensitivity by group over time.

	Intervention group		Control group			Grups	Time	Grups x time
	Pre-test	Post-test	Pre-test	Post-test		Grups	Time	Grups x time
SJAS Sub-Dimension
Collaborative movement	77.17±13.04	105.82±7.24	76.30±11.91	84.92±10.82	F-value	27,808	197,288	56,939
					p	0.000	0.000	0,000
					η2	0.263	0.717	0,422
Client empowerment	42.92±6.97	55.52±4.33	42.25±6.53	46.67±6.29	F-value	15,866	164,223	37,865
					p	0.000	0.000	0,000
					η2	0.169	0.678	0,327
Social/political advocacy	27.37±6.34	41.35±3.99	26.45±6.09	30.37±5452	F-value		146,420	46,156
					p		0.000	0000
					η2		0.652	0372
Client/community advocacy	32.37±5.30	38.25±3.20	33.52±4.84	31,825±4.71	F-value	9,688	13,093	43,102
					p	0.003	0.001	0,000
					η2	0.110	0.144	0,356
Total score	179,8±25,2	240,9±15,8	178,5±24,9	193,8±22,7	F-value	30,624	233,796	84,166
					p	0.000	0.000	0,000
					η2	0.282	0.750	0,519
MSQ Sub-Dimension
Autonomy	20.50±6.34	15.62±5.25	21.55±5.07	21.72±5.06	F-value		13,609	15,712
					p	11,773	0.000	0000
					η2	0.001	0.149	0,168
Benevolence	12.17±4.44	8.20±3.18	11.45±3.59	11.10±2.56	F-value	2,519	31,510	22,136
					p	0.117	0.000	0,000
					η2	0.031	0.288	0,221
Holistic approach	11.40±3.24	7.85±2.29	11.72±3.24	12.30±4.17	F-value	14,575	14,180	27,262
					p	0.000	0.00	0,000
					η2	0.157	0.154	0,259
Conflict	11.52±3.01	9.02±2.57	12.22±2.36	12.22±2.65	F-value	14,944	15,575	15,575
					p	0.000	0.000	0,000
					η2	0.161	0.166	0,166
Practice	15.47±4.03	10.97±3.18	15.60±4.37	15.02±3.90	F-value	7,391	36,010	21,539
					p	0.008	0.000	0,000
					η2	0.087	0.316	0,216
Orientation	7.70±2.49	5.95±1.75	7.22±2.41	8.52±3.58	F-value	3952	0.715	32,840
					p	0.050	0.400	0,000
					η2	0.048	0.009	0,296
Total score	90.4±17.0	64.70±14.26	90.4±17.0	89.92±13.83	F-value	23,060	84,146	56,996
					p	0.000	0.000	0,000
					η2	0.228	0.519	0,422

Abbreviations: CI*: 95% confidence interval of partial η2.

The social justice advocacy scale

The pre-test score of the experimental group and that of the control group were similar (p > 0.05). The experimental group’s post-test score was significantly higher than its pre-test score and the post-test score of the control group (p < 0.001). In two-way analysis of variance in repeated measures, there was a significant main effect of the type of groups. The time per groups interaction was statistically significant (p = 0.000), indicating the score change between the two groups in the post-test. The estimated effect size (η2 = 0.519) was found to be large (Table 2). The two-way ANOVA results in repeated measures showed that group-time interaction was significant in scale sub-dimensions. The estimated effect size was found to be large in the sub-dimensions (Collaborative movement (η2 = 0.168), Client empowerment (η2 = 0.327), Social/political advocacy (η2 = 0.372), and Client/Community advocacy (η2 = 0.356). The time per groups interaction was statistically significant (p = 0.000). H1₀ hypothesis (there is no difference between the experimental group and the control group in SJAS total and sub-dimension scores) was rejected.

The ethical sensitivity scale

The pre-test score of the experimental group and that of the control group were similar (p> 0.05). The experimental group’s post-test score was significantly higher than its pre-test score and the post-test score of the control group (p <0.001). In two-way analysis of variance in repeated measures, there was a significant main effect of the type of groups. The time per groups interaction was statistically significant (p = 0.000), indicating the score change between the two groups in the post-test. The estimated effect size (η2 = 0.422) was found to be large (Table 2). The two-way ANOVA results in repeated measures showed that group-time interaction was significant in scale sub-dimension. The estimated effect size was found to be large in the sub-dimensions was large (Autonomy: (η2 = 0.168), Benevolence: (η2 = 0.221), Holistic Approach: (η2 = 0.259), Conflict: (η2 = 0.166), Practice: (η2 = 0.216), and Orientation: (η2 = 0.296)). The time per groups interaction was statistically significant (p = 0.000) (Table 2). H1₀ hypothesis (no difference between the experimental group and the control group in MSQ and sub-dimension scores) was rejected.

Discussion

The findings of this study were examined under main three aspects such as advocacy education curriculum, social justice advocacy, and moral sensitivity. With the completion of this study and the data analysis, the researcher highlighted the effect of advocacy education on knowledge, attitude, and skill development in students. In the obtained data, both the experimental and control group’s pre-test scores of SJAS and MSQ were similar. The experimental group’s post-test score was significantly higher than the post-test score of the control group and the pre-test score of the experimental group. Furthermore, SJAS and MSQ where the time per groups interaction was statistically significant, indicating the score change between the two groups in the post-test. It can be concluded by considering data as that students' awareness of professional values, their attitudes towards patient needs, and their knowledge and skills about advocacy and ethical sensitivity developed.

Advocacy education curriculum

One of the purposes of this study was that to show the effectiveness of the advocacy education in nursing profession by using randomized control trial. The nursing profession should struggle against inequalities in the health system. Education is a key to be aware of these inequalities and to be a part of the rise of social justice.⁶⁰ When we examine the studies, it is possible for nurses to gain advocacy knowledge, attitude, and skill with a comprehensive preparation in the education process. Cognitive learning about health inequality, social justice, laws, and regulations of students was observed according to Bloom’s taxonomy. In addition, affective learning helped to increase the students’ awareness of class inequality by doing poster preparation and Web-supported work. Counseling and communication skills of students developed with psychomotor learning. The analysis of this concept may help to develop educational or managerial theories and design instruments for evaluating the performance of nurses in patient advocacy. Moreover, the analysis may be the source to develop strategies for enhancing patient advocacy and improve the safety and quality of nursing care in the community and healthcare system. In the studies, it is seen that the advocacy education is important for the nursing students and is needed in the nursing faculty programs.^61,62 Another contribution of the education program is that advocacy education is effective but lack of advocacy education curriculum in Turkey nursing school and lack of evidence-based research. Education was effective in our study and this was supported as evidence. The students saw that improving health could only be possible by ensuring that all segments of society access services equally. It was also emphasized that advocacy was a professional duty and an ethical responsibility at every stage.

Social justice advocacy sub-dimensions are related to following current laws and regulations, recognizing vulnerable groups and their needs, preparing written materials for public awareness, and cooperation with non-governmental organizations. Advocacy counseling is used to improve social rights and increase the personal power of clients. It includes helping with the resolution of institutional and social problems.⁶³ Counseling and communication skills, multi-disciplinary perspectives, individual, group, and organizational skills, internet access, evaluation, and research skills have an important role in advocacy. At the end of this study, the students gained achievements that were needed for these sub-dimensions of skills. In our study, collaborative action skills, awareness about laws and regulations, and SSI practice provided the opportunity for students to communicate with individuals in need, to notice problems and to apply their counseling skills.

Moral sensitivity scale

When the literature is examined, it is seen that there is no study conducted to determine the effect of advocacy training on moral sensitivity. With this study, the researcher wanted to demonstrate the nursing students how ethical sensitivity can contribute to advocacy practice. Since advocacy is a moral responsibility, we wanted to determine the level of moral sensitivity in our study. Moral sensitivity indicates the capacity to make scientific and sensitive decisions in uncertain situations.⁶⁴ Identifying professional values for moral sensitivity, teaching, and learning in nursing literature included limited empirical evidence of the values of quality improvement, social justice, personal authority, and self-care. Ethical sensitivity shows the knowledge, attitudes, and behaviors of nurses in the processes of respecting the patient’s preferences, taking care of the patient’s benefit, being able to look holistically, and making decisions that will affect patient relations. However, ethical sensitivity studies of nurses show that ethical sensitivity is moderate level.^37-40 There are studies conducted to determine the level of ethical sensitivity in nursing students. In the study of Aykan et al., it has been observed that the nursing students had higher sensitivity level.^42,43 In our study, the level of ethical sensitivity was found to be higher in the total score and in all sub-dimensions except the conflict sub-dimension. The students’ awareness of patient needs and healthcare simultaneously increased. It is thought that giving the advocacy and ethics education program in the final year of the nursing undergraduate curriculum would contribute to the professional preparation of the student.

High professional attitudes of nurses regarding autonomy and patient rights are closely related to nurses' education.⁶⁵ The high sensitivity of the autonomy sub-dimension in our study shows that the students can be effective in making independent decisions. Autonomy comprises different situations that nurses act independently in their practices on behalf of the patient and when patients are violated they can defend patient rights. The autonomy should also include helping the patient in their independent decisions. When vulnerable individuals who need healthcare want to make decisions based on their beliefs and opinions, the nurse should support their decisions. The students gained a greater awareness of the balance between autonomy and the patient with the advocacy education. Moreover, the holistic approach in nursing care requires not harming the patient and protecting the patient’s integrity. In our study, the significantly higher mean score of the practice sub-dimension and its high level of effect size supported the literature. Nursing students encounter with many situations during practices such as guarding privacy of the patient, getting permission for treatment, socio-economic, cultural and racial discrimination, and maltreatment. These situations cause a conflict of values for the students.⁵⁵ Ethical education facilitates the decision-making in ethical dilemmas and contributes to the resolution of conflicts. Thus, in our study, it was determined that the difference between the pre-test and post-test scores in conflict sub-dimension was significant, and the effect size was medium. Conflict is a process that is felt internally and affects decision-making. It is thought that our study will be effective for students to act with ethical sensitivity in their decision-making processes in their professional lives after graduation. As a result, this study was well-received by students and was able to produce development in knowledge of the main topics and, more importantly, further studies might be conducted in light of this study.

Conclusion

The random selection of the sample among students has increased the external validity. The strengths of the study are that there were no students who refused to participate in the study and the allocation of the study group was randomized. In addition, blinding was performed in the collection, statistics, and reporting of the data. Data collection tools consisted of the scales whose validity and reliability have been proven. An expert opinion was obtained for the education curriculum applied to the experimental group. In the analysis of the data, appropriate statistical methods and effect size values were calculated. The fact that the present study included a certain number of nursing students in a public university may have created a limitation. The study revealed that the education given to the experimental group increased the social justice advocacy skills and moral sensitivity. The advocacy education has been effective in increasing the social justice advocacy score. It was determined that the social justice advocacy skills increased positively in the experimental group after the education, and the education was effective and the effect size was high. For future studies, it is suggested that advocacy education curriculum can be conducted using different tools and can be included in nursing curriculum as a separate course. Furthermore, it is recommended to integrate advocacy initiatives into care practices and to carry out evidence-based research for better advocacy skills.

Limitations of the study

It is thought that the fact that the Public Health Nursing course is in this period within the scope of the fall semester routine courses in which the research was applied may create a limitation in terms of reducing the effect of the intervention. The fact that the research included a certain number of nursing students at a public university may have created a limitation.

Footnotes

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

Demirören Nesime

References

World Health Organization . Advocacy Report. Published by the World Health Organization, 2018.

Kibble

. A sistematic literature review. Patient advocacy in nursing practice. Tuas Bathesıs 2012; 5–53.

ICN .https://www.icn.ch/sites/default/files/inlinefiles/2012_ICN_Codeofethicsfornurses_%20eng.pdf. accessed: 25 July 2021.

American Nurses Asosiation . Code of Ethics for Nurses with Interpretive Statements, http/www.nursinword.org/ethics/code/protected_nvcoe303.htm/2002 (2002, accessed 16 May 2019).

Hanks

. The live experience of nursing advocacy. Nurs Etics 2008; 15: 469–476.

Hines

Jernigan

. Devoloping a komprehensive curriculum for public health nursing. Public Healt Nurs; 2014; 13: 733–737.

Radius

Galer-Unti

Tappe

. Education for advocacy. Recommandatin for Professional preparation and development based on needs and capacity assesment of health education faculty. Soc Public Health Edu 2009;10(1): 83–91.

O’Connar

Kelly

. Bridging the gap: a study of general perception of patient advocacy in İrland. Nurs Etics 2005; 12: 454–467.

Meleis

. 2016. Teheoretical Nursing. In: Wolter Kluwer, Lippincott Williams and Wilkins: Philadelphia.Ed.5,178–82.

10.

Curtin

. The nurse patient advocate a phlosophical foundation for nursing. Advences Nurs Sci 1979; 1: 1–10.

11.

Gadow

. Existential advocacy: philosophical foundation of nursing. NLN Pulb. 1990; 20-2294: 40–51.

12.

Kohnke

. Advocacy: what is it? Nurs Health Care 1982; 3:145–154.

13.

Vaartio

Lenio-Kilpi

. Nursing Advocacy-areview of the empirical research 1990-2003. Int J Nurs Stud 2004; 42: 705–714.

14.

Klugman

Allen

Benjamin

, et al. Mortality rates as a measure of quality and safety. caveat emptor, Am J Med Qual 2010; 25(3), 197–201.

15.

Belek İ Sınıf . Sağlık Ve Eşitsizlik. Sorun yayınları. 1998. Kurtiş matbaa. p. 25–27.

16.

Sheafor

Horejsi

. Sosyal Hizmet Uygulaması Temel Teknikler ve İlkeler. In: Çiftci, Durdu Baran (Çev. Ed.), 1. Baskı, Ankara: Nika; 2014

17.

Reisch

ve Garvin

. Social Work and Social Justice: Concepts, Challenges and Strategies. 1. Baskı. New York: Oxford University 2016, s8–25

18.

Lewis

Ratts

Paladino

. et al. Social justice counseling and advocacy: developing new leadership roles and competencies. J Soc Action Couns Psychol 2011; 3: 5–16.

19.

Tuncay

. ve Erbay E. Sosyal hizmetin temel hedefi: sosyal adalet, güçlendirmeyle retorikten pratiğe. Toplum Ve Sosyal Hizmet 2006; 17,1, 53–59.

20.

International Labor Organization . 2. International Labour Organization Bulletin. https://www.ilo.org/(2017, accessed 16 May 2019).

21.

Türkiye İstatistik Kurumu . Gelir Ve Yaşam Koşulları Araştırması. TÜİK Haber Bülteni. www.tuik.gov.tr (26–29) (2019, 22 December 2020).

22.

Bell

Buelow

. Teaching students to work with vulnerable populations through a patients advocacy course. Nurse Educatör 2014; 39: 236–240.

23.

Bright

Haynes

Patterson

, et al. The value of social network analysis for evaluating academic-community partnerships and collaborations for social determinants of health research. Ethn Dis 2017; 271: 337–347.

24.

Koçoğlu

Akın

. Sosyoekonomik eşitsizliklerin sağlıklı yaşam biçimi davranışları ve yaşam kalitesi ile ilişkisi. DEUHYO ED 2009; 2: 145–154.

25.

Lopalo

Coffey

Spears

. The consequences of social inequality for the health and development of India’s children: The case of caste, sanitation, and child height. Soc Justice Res 2017; 32: 239–254.

26.

Coffey

Deshpande

Hammer

, et al. Local Social ınequality, economic ınequality, and disparities in child height in India published online. Popul Assoc America Demogr 2019; 56:1427–1452.

27.

Linton

Nagda

Olanrewaju

, et al. Advocating for immigration policies that promote children’s health. Pediatry Clinic 2019, 66: 619–640.

28.

Howze

Redimen

. The use of teoryİn Healt advocacy: Politica and Program. Health Edu Qarterly 1992; 19: 369–383.

29.

Mcleroy

Bibeau

Stecler

. An ecological perspective on healt promotion program. Health Edu Qarterly 1988; 15: 351–377.

30.

Çobanoğlu

, Tıp Etiği. Ss.9–17. İlke Yayınevi.1. baskı, 2007.

31.

Marsh

Supples

McLaurin-Jiang

, et al. Introducing the concepts of advocacy and social determinants of health within the pediatric clerkship. MedEd Portal 2019; 15: 10798.

32.

Mallik

. Advocacyin nursing review of literatüre. J Advence Nurs 1997; 25: 130–138.

33.

Gastmans

. Care as a moral attıtude in nursıng. Nurs Ethics 1999; 6(3): 215–222.

34.

Elliott

. Identifying Professional Values in Nursing: An Integrative Review, Teach Learn Nurs 2017;12: 201–206.

35.

Vural

İnanç

. Hemşirelikte hatalı uygulamaların ve etik tartışmaya yol açabilecek olayların öyküsel vakalarla incelenmesi, Gülhane Tıp Dergi 1999; 2(5): 1–10.

36.

Arslan

Taylan

Gözüyeşil

. Hemşirelerin çalışma ortamı yaşam kaliteleri ve etik duyarlılıkları. İzmir Kâtip Çelebi Üniversitesi Sağlık Bilimleri Fakültesi Dergisi 2017; 2: 21–26.

37.

Dalcalı

. Hemşirelerin kişisel değerleri ile etik duyarlılık arasındaki ilişkinin belirlenmesi. F.N Hem Derg 2016; 24: 1–9.

38.

Temiz

Öztürk

Ünver

, et al. Cerrahi birimlerde çalışan hemşirelerin etik duyarlılıklarının belirlenmesi. Anadolu Hemşirelik Ve Sağlık Bilimleri Dergisi 2017; 20: 2–11.

39.

Yılmaz

Düzgün

Yılmaz

, et al. Dahili kliniklerde görev yapan hemşirelerin etik duyarlılıklarının ve etkileyen faktörlerin incelenmesi: üniversite hastanesi örneği. DEUHFED 2018; 11: 157–163.

40.

Özdemir

Gültekin

Kavak

. Determination of moral sensitivities of healthcare. Personnel Int J Caring Sci 2019; 12: 11–39.

41.

Karaca

. Hemşirelik öğrencilerinin ahlaki duyarlılık düzeyinin belirlenmesi. HSP Sağlık Bilimleri Ve Meslekleri Dergisi 2018; 5: 24–30.

42.

Gürdoğan

Aksoy

Kınıcı

. Hemşirelik öğrencilerinin etik duyarlılık düzeyleri ve mesleki değerler ile ilişkisi. J Health Nurs Manag 2018; 5: 3, 147–154.

43.

Aykan

Fidancı

Yıldız

. Hemşirelik Öğrencilerinde Ahlaki Olgunluk ve Etik Duyarlılığın Değerlendirilmesi. Sağlık Bilimleri Üniversitesi Hemşirelik 2019; 1: 2,84–91.

44.

Oliveira

Tariman

. Barier to the patient advocacy: an integrative review of the literatür. J Nurs Pract Aplication 2017; 7:2,7–11.

45.

Peltzer

Cynthia

Teel

, et al. Strategies for building advocacy skills among undergraduate and graduate nursing students. J Nurs Edu 2016; 55: 177–181.

46.

Belcowitz

. Teaching health advocacy to medical student: a comparison study. Public Health Manag Pract 2014; 20: 10–19.

47.

Dennis

Xia

Secord

, et al. Health advocay projeckt: evaluating the benefits of service learning to nursing students and low income individuals involved in a community based mental health promotion project. Nurs Edu 2015; 13: 97–108.

48.

Foley

Minick

Kee

. How nurses learn advocacy. J Nurs Sholarship 2002; 34: 181–186.

49.

Marsh

Supples

Skyler McLaurin-Jiang

, et al. Introducing theconcepts of advocacy and social determinants of health within the pediatric clerkship. MedEd Portal 2019; 15: 1–9.

50.

Bloom

. Taxonomy of educational objectives, the classification of educational goals handbook I: cognitive dom ain. New York, 1956, pp. 36–48.

51.

Bloom

Beckwıth

. Talking with feeling: Integrating affective and linguistic expression in early language development. Cogn Emot 1989; 3: 313–342.

52.

Boutron

Altman

Moher

et al. CONSORT statement for randomized trials of nonpharmacologic treatments: A 2017 Update and a CONSORT extension for nonpharmacologic trial abstracts. Ann Intern Med 2017; 16: 40–47.

53.

Dean

. Quantifying Social Justice Advocacy Competency: Development of the Social Justice Advocacy Scale. Georgia State University Department of Counseling and Psychological Services 2009; Georgia.

54.

Serpen

Duyan

Aldoğan

. Sosyal adalet savunuculuğu ölçeği güvenirlik ve geçerlik çalışması. Toplum Ve Sosyal Hizmet 2014; 25: 20–31.

55.

Lutzen

Evertzon

Nordin

. Moral sensitivity in psychiatric practice. Nurs Ethics 1997; 4: 6,472–482.

56.

Tosun

, 2018. Moral sensitivity questionnaire (MSQ): Turkish adaptation of the validity and reliability. J Contemp MedıcıneJ Contemp, 8, 4, 316–321.

57.

Phillips

Lewis

Maureen

, et al Development and validation of the guideline for reporting evidence-based practice educational interventions and teaching (GREET). BMC Med Edu 2016; 16(237): 1–10.

58.

Lopez-Baez

Paylo

. Social justice advocacy: community collabration and systems advocacy. J Couns Dev 2009; 87: 276–282.

59.

Toporek

Lewis

Crethar

. Promoting systemic chance through the aca advocacy competencies. J Couns Dev 2009; 87: 260–266.

60.

Spreen

Vally

. The curriculum and citizenship education in the context of inequality: seeking a praxis of hope. Perspect Educ 2012; 30: 88–111.

61.

Rozendo

Salas

Brenda Cameron

. A critical review of social and health inequalities in the nursing curriculum. Nurse Edu Today 2017; 50: 62–71

62.

Abbasinia

. Ahmadi Fand, Kazemnejad A. Patient advocacy in nursing: a concept analysis. Nurs Ethics 2020; 27: 141–151.

63.

Kisilica

Robinson

. Bring advocacy counseling to life: the history, issues, and human dramas of social justice work in counseling. J Couns Dev 2001; 79: 387–397

64.

Weaver

Fordhem

. overstepping ethical boundaries: limitations on state efforts to provide. Justice Fam Courts, Heınonline 2013; 2: 724–756

65.

Pankratz

Pankartz

. Nursing autonomy and patient rights development of nursing attitute scale. J Health Soc Behaivor 2018; 12: 211–213.