Ethics positions of nursing students in clinical decision-making

Abstract

Background

Ethics positions, consisting of the two fundamental dimensions of idealism and relativism, influence individuals’ decision-making significantly. Particularly in an applied field such as nursing, the ethics positions of nurses can play a significant role in clinical decisions. Therefore, it is important to know the factors affecting the ethics positions of nurses in clinical decision-making.

Aim

The aim of the study is to examine the factors affecting the ethics positions of nursing students in clinical decision-making.

Research design

This is a two-phase sequential explanatory mixed methods study designed in accordance with the COREQ criteria. A participant Information Form and the Ethics Position Questionnaire were used to collect quantitative data. Qualitative data were obtained through focus group interviews.

Ethical considerations

This study was conducted after receiving written permission from X University Ethics Board. Additionally, permission was obtained from the participating nursing faculty.

Participants

Among the fourth-year nursing students, 180 students participated in the quantitative phase and 30 students in the qualitative phase of the study.

Results

The quantitative data analysis showed that the idealism sub-dimension mean scores of the participants were higher than the relativism sub-dimension mean scores. The analysis of the qualitative data resulted in four main themes that influence participants’ ethics positions in clinical decision-making: (1) attitudes of role models in clinical practice (staff nurses/mentors/lecturers), (2) resources related to clinical practice (labs, hospitals/classrooms), (3) health system (hospital policies/school policies), and (4) personal differences (act with emotion/act with logic).

Conclusion

The results showed that the health system, role models in the clinic, personal differences, and skill-related resources affect the ethics positions of nursing students in clinical decision-making. In this regard, awareness can be raised by providing training to nursing students by academic instructors on ethics positions and the factors that are determined to affect ethics positions in clinical decision-making.

Keywords

ethics position clinical decision-making nursing

Introduction

Clinical decision-making in nursing is a process that includes planning, implementing, and evaluating the results of appropriate interventions to solve the problems encountered in the clinic.¹ The decisions made by nurses in this process affect patient care outcomes, treatment processes, and patient safety.^2-4 Additionally, correct and timely decision-making by nurses in clinics increases the quality of care, patient satisfaction, and the motivation of nurses, as well as helping to reduce care-treatment costs and medical errors and use resources effectively. Therefore, it is very important to help nurses develop their clinical decision-making skills and doing so has been identified as one of the key educational objectives.^5-8

When the theoretical and practical aspects of nursing education are considered, nursing students frequently experience self-confidence and anxiety problems when applying their theoretical knowledge in practice.^9-10 The anxiety experienced by the students in the clinics leads to a decrease in their motivation in clinical practice, causes medical errors, and, as a result, negatively affects their clinical decision-making skills because they perceive¹¹ themselves as incompetent.^9,12 Considering that nursing students will have an important position among other health professionals, much like registered nurses, learning about the factors affecting clinical decision-making in the education process is thought to be important. It has been reported in previous studies that various factors are effective in the clinical decision-making of nursing students, and ethics positions also affect their individual decisions or decisions regarding patient care. In this study, we examined the issue, which was addressed separately as clinical decision-making and ethics position in previous studies, as factors affecting ethics positions in clinical decision-making, and we evaluated it holistically with previous literature information.

Background

Although nurses do not have the final say on decisions about whether any medical intervention should be carried out, they are responsible for providing the prescribed medical care. They play an advocacy role in this direction, fulfilling duties that include safeguarding against the side effects/complications of the medical intervention.¹³ However, it has been pointed out that this process is affected by several variables, including individual differences, acquired skills, knowledge, personality traits, education, values, old habits and experiences, one’s line of work, etc.^2,14 The “moral philosophy” or “ethics position” of individuals, which is considered a way of determining how individuals make decisions, has been stated as an important variable in the decision-making process.^15,16

It is necessary to know moral philosophy to understand the moral judgments and behaviors of an individual in a situation where the individual encounters an ethical dilemma and needs to make a decision.¹⁷ An individual’s moral philosophy has an impact on his/her views and attitudes toward various moral issues, including moral judgments about other people’s behaviors, ways of attributing responsibility for the effects of such behaviors, and how an individual decides what behavior he/she considers unethical. Therefore, the position of making the most ethical decision forces the individual to choose the guiding principles on which the final decision is made indirectly, if not explicitly, and the ethics position of the individual is important in this process.^18,19 In this context, idealism and relativism are seen as also being effective in the ethical decision-making of nursing students^20,21 and it is emphasized that academic nurse educators should focus primarily on activities that increase their knowledge of ethics positions and moral judgments and support them.²²

An ethics position means that actions that cause harm or are inconsistent with commonly accepted standards of morality trigger moral scrutiny.¹⁸ But individuals differ significantly in moral outlook. The ethical ideology model showed two main dimensions (idealism and relativism) that play a significant role in ethical evaluation and behavior. Accordingly, some people are idealistic, and they think that “if an action is going to hurt an innocent person, then it shouldn’t be done.” Some people are also moral relativists, and they believe “what is ethical changes from one situation and society to another.”^16,18

According to ethics position, idealistic individuals insist that the individual should avoid harming others at all times and under all circumstances. On the other hand, individuals with a relativist position believe that individual moral views are above universal ethical rules. These individuals assume that there are no “exceptional” moral codes.¹⁶ Compared to idealists, relativists rely on their own feelings rather than ethical standards.²³ In summary, each person has their own set of personal ethics positions. But ethics position is very important for health professionals, as they must recognize health dilemmas and make the right decisions.²⁴

In the literature, it is seen that idealism and relativism are effective in ethical decision-making in cross-cultural studies. However, it is argued that ethical decision-making does not always depend on one’s moral philosophy.^16,22 Within this scope, this study aimed to investigate the factors affecting the ethics positions of nursing students in clinical decision-making because nursing students will face nursing interventions that require many clinical decisions in their professional lives. Accordingly, answers to the following questions were sought: “What are the ethics positions of nursing students?” and “What are the factors affecting the ethics positions of nursing students in clinical decision-making?”

Method

Design

This is a two-phase sequential descriptive mixed methods study that aligns with the COREQ criteria (Consolidated Criteria for Reporting Qualitative Research).²⁵ The first phase was cross-sectional, and the data were collected using the survey method. This phase of the study sought answers to the question, “What are the ethics positions of nursing students?”. In the second phase of the study, qualitative data were collected through focus group interviewing performed with nursing students. The second phase of the study sought answers to the question, “What are the factors affecting the ethics positions of nursing students in clinical decision-making?”

Sample group

Fourth-year nursing students were included in the sample group as they had gained certain clinical experience and were more likely to have encountered clinical decision-making. Therefore, an announcement was made to 189 students in the last semester of their senior year. Quantitative data were collected from 180 students who agreed to participate in the study, and 30 students who accepted the focus group interview and an audio recording of the interview constituted the sample group for the qualitative phase.

Prior to the formation of the focus groups, the ethics positions of the participants (n = 30) were examined since the participants may have different ethics positions. Accordingly, the ethics positions of the participants who checked the “I want to participate in the focus group interviews” box in the questionnaire we implemented in the quantitative phase of the study and confirmed the questionnaire number were analyzed one by one using the Ethics Position Questionnaire scale included in the questionnaire. It was determined that 22 participants were idealists and 8 were relativists in terms of their ethics positions. Then, inclusion of an equal number of idealist and relativist participants in each group was planned to increase interaction within the group and enrich the data, and three focus groups were formed, each consisting of 10 participants. Participants, who were divided into two groups according to their positions as idealists (n = 22) and relativists (n = 8), were assigned to three different groups by choosing one person from the relativist group first, using the coin toss technique. The same process was used with the idealists, and then the groups were merged. While one group included five idealists and five relativists, the other two groups included six idealists and four relativists. Thus, consistency was ensured with the information that the number of focus group participants can vary and that focus group members can generally consist of 6–8,²⁶ 10–12²⁷ people, but the ideal group should consist of 6–10²⁸ people.

Data collection tools

In the first phase of the study, qualitative data were collected using the Participant Information Form and the Ethics Position Questionnaire. A semi‐structured, piloted interview guide prepared by the researchers was used during the focus group interviews (Figure 1).

Figure 1.

Focus group questions.

Participant information form

The form developed by the researchers in line with the literature consists of seven questions on age, gender, education level of parents, their economic status, the place where they lived the longest, and whether they took the ethics course (elective, 2 credit hours) that is included in the curriculum of the nursing faculty.

Ethics position questionnaire (EPQ)

The five-point Likert-type EPQ, consisting of 20 items and two sub-dimensions measuring moral idealism and moral relativism, was developed by Forsyth.²⁹ The idealism sub-dimension of the scale reflects the extent to which concern for the well-being of others is central to an individual’s moral code (for example, people should make sure that their actions never intentionally harm another). On the other hand, the relativism sub-dimension is about the belief of an individual in the universality of his/her moral principles (for example, an ethical situation may vary between societies).

This study used the Turkish version of the 19-item scale, whose validity and reliability analyses were conducted by Yazıcı and Yazıcı.³⁰ The Cronbach’s alpha value of the scale was reported to be 0.90 for 19 items, 0.92 for the idealism factor, and 0.84 for the relativism factor.³⁰ In this study, Cronbach’s alpha values were determined as 0.75 for the idealism factor and 0.76 for the relativism factor.

Semi-structured interview guide

The semi-structured interview method,³¹ which is the most common data collection tool in qualitative research, was used in this study. First, an interview guide consisting of questions related to a few main themes was developed based on the literature.³² This guide was presented to three academicians who are experts in the field to seek their perspectives on content validity. Based on the experts’ feedback, minor changes were made to the questions. Then, a pilot study was conducted with 10 students who were not included in the sample group to finalize the questionnaire (Figure 1). The pilot study also served the purpose of checking the environment where the focus group interviews will be held and the voice recorder.

Procedure

This study was conducted with 4th year nursing students in the Faculty of Nursing of a state university in Turkey between October 2021 and August 2022. The first author is a female with a PhD in mental health nursing who is experienced in qualitative research. The second author is a female mental health nurse with a PhD. The researchers had no previous relationship with the participants. The questionnaires were then distributed to students in a classroom (during a recess between two classes) by the second researcher and collected once students completed the questionnaires. Then, the first author conducted the focus group discussions face-to-face in a meeting room on a specific day and time at the university where the study was conducted. The interviews were conducted in three groups (for each group, n = 10) which lasted an average of 110 min. In the interviews, the ethics position regarding decision-making processes in clinical practice were evaluated and discussed. The interviews were recorded with a voice recorder.

Analysis of Data

The Statistical Package for the Social Sciences (SPSS) 26.0 program was used to analyze the data obtained within the scope of the study. Frequency and percentage analyses were used to determine the descriptive characteristics of the participants. In the analysis process, first, the Kolmogorov–Smirnov test was performed for the normality distribution of the variables, and it was determined that the data were not normally distributed. The Mann–Whitney U test was used to compare the variables of two independent groups with the scale scores, and the Kruskal–Wallis test was used for the comparison of more than two groups.

Qualitative data were analyzed manually in six steps using thematic analysis.³³ In the first step, the second author (Y) transcribed all focus group discussions. In the second step, both authors (N, Y) read these reports independently, and the data that stood out were coded. In the third step, themes were developed from the codes. The fourth step involved checking for data saturation. As both researchers conducted more than one focus group interview in the same study, they examined whether the identified themes emerged in each group and concluded that data saturation had been reached. In the fifth step, the authors had a discussion to finalize the themes. If no consensus could be reached, an expert opinion (from a faculty member in the psychiatric nursing department who is experienced in qualitative research) was sought, and in the last step, the themes were finalized.

Ethical considerations

This study was conducted in accordance with the Helsinki Declaration after receiving written permission from the X University Social and Human Sciences Scientific Research and Publication Board (Date: 11.10.2021, number: E34743463-605.99–18,462) and the X University Faculty of Nursing, where the study was conducted (Date: 27.09.2021, number: E−87,103,392–105.02.02.01–259,592), and written consent forms from participants. It was explained in detail to the participants who will take part in the focus group discussions that the research will be conducted in accordance with the principle of confidentiality and will be recorded with a voice recorder. A detailed explanation was also provided, stating that all the records will be carefully stored by the second researcher on an external disk and password-protected computer and that no one other than the researchers is authorized to access the records. In addition, the ethical principle of confidentiality-respect for private life-do no harm-was considered, the identity information of the participants was not included, and the coding system was used in the analysis of qualitative data.

Results

Quantitative analysis

It was determined that the majority of the participants, whose mean age was 21.55 ± 0.91 years, were female (79%, n = 143), the mothers (72.8%, n = 131) and fathers (55.6%, n = 100) of the participants had an education level of primary school, the perceived economic status was moderate (76.7%, n = 138), the place where they lived the longest was a city (50%, n = 90), and that they took courses on ethics (63.9%, n = 115) (Table 1).

Table 1.

Descriptive characteristics of the participants (n = 180).

	Frequency (n)	Percentage (%)
Gender
Female	143	79.4
Male	37	20.6
Mother’s education level
Primary school graduate	131	72.8
High school graduate	40	22.2
University graduate	9	5.0
Father’s education level
Primary school graduate	100	55.6
High school graduate	48	26.7
University graduate	32	17.7
Perceived economic position
Good	32	17.7
Moderate	138	76.7
Poor	10	5.6
Place where they lived the longest
Province	90	50.0
District	64	35.6
Village	26	14.4
Taken an ethics course^a
Yes	115	63.9
No	65	36.1

^aElective course (2 credit hours) included in the curriculum of the Faculty of Nursing.

The scores obtained by the participants in the total and sub-dimensions of the EPQ are given in Table 2. Accordingly, it was determined that the idealism sub-dimension score (38.62 ± 4.13) of participants was higher than the relativism sub-dimension score (34.99 ± 5.93) (Table 2).

Table 2.

The EPQ scores of participants.

Scales	Min	Max	Mean ±SD
Ethics Position Questionnaire	Min	Max	Mean ±SD
Idealism	24.00	45.00	38.62±4.13
Relativism	17.00	50.00	34.99±5.93

It was determined that the idealism and relativism mean scores did not show a significant difference according to the descriptive characteristics of the participants (p > 0.05) (Table 3).

Table 3.

Comparison of the EPQ according to the descriptive characteristics of the participants.

Descriptive characteristics	N	Idealism	Relativism
Descriptive characteristics	N	Median (min–max)	Median (min–max)
Gender
Female	143	39 (24–45)	35 (19–50)
Male	37	38 (26–45)	35 (17–50)
Z	—	−0.652	−0,230
P	—	0.51	0.81
Mother’s education level	—	—	—
Primary school graduate	131	38 (24–45)	35 (17–50)
High school graduate	40	41 (26–45)	34.5 (19–45)
University graduate	9	38 (34–44)	36 (25–44)
χ²	—	0.430	0.890
P	—	0.80	0.64
Father’s education level	—	—	—
Primary school graduate	100	39 (24–45)	34.5 (17–50)
High school graduate	48	38 (26–45)	36 (25–50)
University graduate	32	39.5 (32–45)	35 (19–47)
χ²	—	1.095	2.763
P	—	0.57	0.25
Perceived economic position	—	—	—
Good	32	38 (31–45)	36 (24–50)
Moderate	138	39 (24–45)	35 (17–50)
Poor	10	36.5 (33–43)	36.5 (23–47)
χ²	—	1.296	0.631
P	—	0.52	0.73
Place where they lived the longest	—	—	—
Province	90	39.5 (26–45)	35 (21–50)
District	64	38 (24–45)	35 (17–47)
Village	26	37 (32–44)	34.5 (23–50)
χ²	—	2.524	0.227
P	—	0.28	0.89
Taken an ethics course*	—	—	—
Yes	115	39 (26–45)	35 (19–50)
No	65	39 (24–45)	36 (17–50)
Z	—	−1.708	−0.406
P	—	0.08	0.68

Z: Mann–Whitney U test, χ²: Kruskal–Wallis test, *Elective course (2 credit hours) included in the curriculum of the Faculty of Nursing.

Qualitative analysis

In the focus group interviews, it was determined that the mean age of the participants was 21.53 ± 0.93, the majority of the participants were female (n = 22), and most of the females were idealists (n = 13), while 4 of the male participants were idealists and 4 of them were relativists (Table 4) in terms of their ethics positions.

Table 4.

Descriptive characteristics of the focus group participants.

Participant code	Age/gender	Idealist	Relativist	Participant code	Age/gender	Idealist	Relativist
1	F/22	✓	—	16	M/21	—	✓
2	F/22	—	✓	17	F/21	✓	—
3	F/22	✓	—	18	F/22	—	✓
4	F/21	—	✓	19	F/21	✓	—
5	M/20	✓	—	20	F/22	✓	—
6	F/21	✓	—	21	M/21	—	✓
7	F/20	✓	—	22	F/20	—	✓
8	M/22	—	✓	23	F/22	✓	—
9	F/21	✓	—	24	F/22	—	✓
10	F/22	—	✓	25	F/21	✓	—
11	M/22	✓	—	26	F/21	—	✓
12	F/22	✓	—	27	M/22	✓	—
13	F/21	—	✓	28	F/21	✓	—
14	M/22	✓	—	29	F/22	✓	—
15	F/22	—	✓	30	M/24	—	✓

The main findings obtained from the thematic analysis were grouped under four main themes that were “attitudes of role models in clinical practice,” “resources related to clinical practice,” “health system,” and “personal differences.” Each theme is described below, including subthemes and quotes for each theme (Table 5).

Table 5.

The themes obtained from focus groups interviews.

Themes	Subthemes	Quote
Attitudes of Role Models in Clinical Practice	Staff nurses	“They do not involve us in situations where decisions need to be made; they want us to do more file work.” [P5, male, relativist] “Clinical nurses want to make decisions quickly and finish their work. They don’t provide us with any explanation.” [P11, male, idealist] “Nurses approach with prejudice. It damages our self-confidence.” [P19, female, relativist]
	Mentors	“The mentor made very ironic remarks to us when we couldn’t practice, which makes us face dilemmas more in decision making.” [P17, female, idealist] “Mentors do not help us when we face difficulties and dilemmas while practicing. they say we can decision.” [P22, male, relativist]
	Lecturers	“Lecturers who teach the course do not come to clinical applications. That’s why we can’t discuss it when we doubt the decisions made in the clinic.” [P5, male, idealist] “Faculty members say they don’t want to hear complaints about us from clinical staff. And on the other side, warns us about not making a mistake in practice. That’s why implementing the decisions made by the clinical nurses becomes the best approach instead of making a decision.” [P15, female, relativist]
Resources Related to Clinical Practice	Labs, hospitals	“If we can do side-by-side practice or training with our instructors, we can see better how to treat the patient, how to calm the patient, or how to calm ourselves.” [P30, male, relativist]
Resources Related to Clinical Practice	Classrooms	“We find it difficult to apply what we learn in the classroom and what we see in laboratories to the patient. We get stressed.” [P25, female, idealist]
Health System	Hospital policies	“In hospitals, you cannot do anything independent of the nurse. You should not do it even if you know how to do it.” [P16, male, relativist]
Health System	School policies	“We attended the course for a week, and then we were immediately sent to the hospitals.” [P19, female, idealist] “In the lessons, the theoretical subjects should be completed first, and then the practice should start.” [P20, female, idealist]
Personal Differences	Act with emotion	“However, I feel good, and I do the same for the patient.” [P2, female, relativist] “I can cry with the patient.” [P18, female, relativist] “There are social prejudices among patients, such as the fact that the doctor is consulted, and the nurse is not. I get stressed about whether I will make a mistake, especially with these patients.” [P22, male, relativist]
Personal Differences	Act with logic	“I need to know what to do. To be a competent nurse and intervene with the patient, my knowledge must be solid first.” [P1, female, idealist] “I’m not doing something for which I don’t understand logic.” [P5, male, idealist] “You have to be very good at theory to make the right decision.” [P29, female, idealist]

Attitudes of role models in clinical practice

The participants reported that the attitudes of clinical nurses, mentors, and lecturers generally affected their ethics positions in the clinic. They mentioned that they were particularly affected by the negative attitudes and unfair criticism of clinical nurses, mentors, and lecturers.

Resources related to clinical practice

Participants discussed the importance of clinical practice resources in clinical decision-making and its relationship with ethics position. They specifically discussed the differences between the sources related to clinical practice in the form of classrooms, laboratories, and hospitals. They stated that bedside patient evaluations and practices in hospitals had a permanent effect on them and made them feel more idealistic. On the other hand, they stated that although they learned how to practice in classroom and laboratory environments, they had a difficult time transferring the knowledge they acquired to the patient, and they were very stressed.

Health system

Participants in the focus groups reported the effects of the health system on ethics positions. While some participants stated that only hospital policies limit the ethics positions of nursing students, others stated that both hospital and school policies limit the ethics position. They especially drew attention to the negative impacts of this situation on idealism.

Personal differences

Some participants shared that people who act with emotions are more affected by negative experiences, social prejudices toward the profession, and prejudices of patients/clinical staff against nursing students. At the same time, they stated that ethical principles that show appropriate behavior under all circumstances would not be valid. Others stated that an idealist stance should be exhibited by doing research, following the current literature, emphasizing the ethical principle of doing no harm, and putting logic before emotions in the clinical decision-making process.

Discussion

Exploring the factors impacting ethics position in clinical decision-making in nursing students using mixed methods and evaluating the data holistically are important characteristics of this study. Another characteristic is that each focus group includes an equal number of participants with different ethics positions. Thus, while no results could be obtained regarding the factors affecting the ethics positions of nursing students in the quantitative phase, different views and understandings on the subject examined in the qualitative phase were revealed, thereby eliminating the methodological gap. Additionally, consistency was ensured with the content knowledge that “the strengths of another method are used to complement the weaknesses of one method in the same study,” which is described as a strong side of mixed methods.³⁴

In the first phase of the two-phase study, the relationship between the ethics positions and the demographic data of the participants was examined because it is known that nurses may face complex and ethically challenging situations in hospitals. However, no matter what, decisions that nurses make, particularly regarding patient care, should be in accordance with ethical principles.³⁵ In such cases, the importance of ethics position was emphasized, and it was stated that people with idealistic characteristics avoid harming others under all circumstances and comply with ethical standards.³⁶ It has been reported that the ethics positions of individuals is affected by variables such as age, gender,^37-39 knowledge about the role of scientific qualifications, and the development level of the country.⁴⁰

The idealism mean score of the majority of the participants in both phases of the study was found to be higher than the relativism mean score, but no relationship was found between the ethics positions and the sociodemographic characteristics of the participants. The reason for this is the fact that participants with similar sociodemographic characteristics may have the same cultural-religious characteristics because culture and religion are closely related to patient care. Therefore, the culture and religion of the nurse cannot be separated from nursing practices and nursing care practices,^41,42 and thus the ethics position may be affected.^13,15

Although there are criticisms of the focus group method in the literature, such as the researcher’s close involvement in the method, which leads to subjectivity,⁴³ the findings related to the subject examined in this study, in which focus group interviews were conducted, may be considered important in terms of integrating the known literature information. As a matter of fact, as determined in this study, it has been reported in previous studies that role models, clinical resources, health policies, and personal characteristics are effective in the clinical decision-making of nursing students,⁴⁴ and ethics positions also affect their individual decisions or decisions regarding patient care.³⁰ However, the issue, which has been addressed separately as clinical decision-making and ethics position, was examined as the factors affecting ethics position in decision-making in this study and was evaluated holistically with the previous literature information. With this aspect in mind, the study revealed important and helpful findings in terms of educational strategies for nursing students.

Limitations of the study

This study is not without limitations. The first limitation is that the sample of the study consisted of participants with the same cultural characteristics. The second limitation is the use of the focus group method in the qualitative phase. Considering that the individuals have different personal characteristics, participants may not have openly shared their honest opinions in the group setting.

Conclusion

In the study examining the positions of idealism and relativism of nursing students, the EPQ results of the quantitative phase revealed that the idealism mean scores of the nursing students were higher than the mean scores of relativism and that the idealism and relativism mean scores did not have any differences according to the demographic variables. The focus group interviews revealed that the ethics positions of nursing students in clinical decision-making are influenced by the health system, role models in the clinic, personal differences, and resources related to clinical practice. Accordingly, awareness can be raised by providing training to nursing students by academic instructors on ethics positions and the factors that affect ethics positions in clinical decision-making. In order to raise awareness in all nursing students, it is recommended that the ethics course in nursing be included in the education curricula of nursing faculties, not as an elective but as a compulsory course.

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

Nazan Turan

References

Standing

. Clinical judgement and decision making in nursing. 4th ed. London: Sage, 2020.

Johansen

O’Brien

. Decision making in nursing practice: a concept analysis. Nurs Forum 2016; 51(1): 40–48.

Manetti

. Evaluating the clinical judgment of prelicensure nursing students in the clinical setting. Nurse Educ 2018; 43(5): 272–276.

White

Fetter

Ruth-Sahd

. Extern programs promote confidence and reduce anxiety with clinical decision making in nursing students. Nurse Educ 2019; 44(5): 239–244.

Al-Dossary

Kitsantas

Maddox

. Clinical decision-making among new graduate nurses attending residency programs in Saudi Arabia. Appl Nurs Res 2016; 29: 25–30.

Bektaş

Yardımcı

Bektaş

, et al. Psychometric properties of the Turkish version of nursing anxiety and self confidence with clinical decision making scale (NASC-CDM-T). E-journal of Dokuz Eylul University Nursing Faculty 2017; 10(2): 83–92.

Chen

Hsu

Chang

, et al. An exploration of the correlates of nurse practitioners clinical decision-making abilities. J Clin Nurs 2016; 25(7): 1016–1024.

Khatiban

Falahan

Amini

, et al. Lecture-based versus problem-based learning in ethics education among nursing students. Nurs Ethics 2019; 26(6): 1753–1764.

Aktaş

Karabulut

. A survey on Turkish nursing students' perception of clinical learning environment and its association with academic motivation and clinical decision making. Nurse Educ Today 2016; 36(1): 124–128.

10.

Yardimci

Bektaş

Özkütük

, et al. A study of the relationship between the study process, motivation resources, and motivation problems of nursing students in different educational systems. Nurse Educ Today 2017; 48: 13–18.

11.

Bektas

Ayar

, et al. The predict of metacognitive awareness of nursing students on self confidence and anxiety in clinical decision‐making. Perspect Psychiatr Care 2021; 57(2): 747–752.

12.

Paulina Espinosa-Rivera

Morán-Peña

García-Piña

, et al. Self-confidence and anxiety as intervening factors in clinical decision-making in newly nursing bachelor graduates. American Journal of Nursing Science 2019; 8(2): 59–67.

13.

Sevigny

McCarthy

, et al. An international study of nurses' ethical ideology and religiosity. J Comm Pub Health Nurs 2017; 03(2): 165.

14.

Nibbelink

Brewer

. Decision making in nursing practice: an integrative literature review. J Clin Nurs 2018; 27(5–6): 917–928.

15.

White

Peirce

Jacobowitz

. The relationship amongst ethical position, religiosity and self-identified culture in student nurses. Nurs Ethics 2019; 26(7–8): 2398–2412.

16.

Forsyth

. Making moral judgments: psychological perspectives on morality, ethics, and decision-making. New York: Routledge, 2020.

17.

Bass

Barnett

Brown

. Individual difference variables, ethical judgments, and ethical behavioral intentions. Bus Ethics Q 1999; 9(2): 183–205.

18.

Kujala

Lämsä

Penttilä

. Managers’ moral decision-making patterns over time: a multidimensional approach. J Bus Ethics 2011; 100: 191–207.

19.

Forsyth

Nye

Kelley

. Idealism, relativism and the ethic of caring. The Journal of Psychology 1988; 122(3): 243–248.

20.

Şen

Dal

Üstün

, et al. Evaluation of school of health students' ethics position in Turkey. Nurs Ethics 2017; 24(2): 225–237.

21.

Arries

. Professional values and ethical ideology: perceptions of nursing students. Nurs Ethics 2020; 27(3): 726–740.

22.

Abou Hashish

Ali Awad

. Relationship between ethical ideology and moral judgment: academic nurse educators’ perception. Nurs Ethics 2019; 26(3): 845–858.

23.

Rawwas

MYA

Isakson

. Ethics of tomorrow’s business managers: the influence of personel beliefs and vaules, individual characteristics and situational factors. Journal of Education for Business 2000; 75(6): 321–330.

24.

Epstein

Turner

. The nursing code of ethics: its value, its history. Online J Issues Nurs 2015; 20(2): 4.

25.

Tong

Sainsbury

Craig

. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19(6): 349–357.

26.

Krueger

Casey

. Focus groups: a practical guide for applied research. 3rd ed. London: Sage, 2000.

27.

Baumgartner

Strong

Hensley

. Measurement issues in research. Conducting and reading research in health and human performance. New York: McGraw-Hill, 2002.

28.

Powell

Single

. Focus groups. Int J Qual Health Care 1996; 8(5): 499–504.

29.

Forsyth

. A taxonomy of ethical ideologies. J Pers Soc Psychol 1980; 39(1): 175–184.

30.

Yazıcı

. The validity and reliability study of the Ethics Position Questionnaire. Turk J Educ Sci 2010; 8(4): 1001–1017.

31.

Bayyurt

Seggie

. Nitel araştırma yöntem, teknik, analiz ve yaklaşımları. 3rd ed. Ankara:Anı Yayınları, 2021.

32.

Smith

. Qualitative psychology: a practical guide to research methos. 3rd ed. London: Sage Publishing, 2015.

33.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77–101.

34.

Johnson

Onwuegbuzie

. Mixed Methods Research: A Research Paradigm Whose Time Has Come. Educ Res 2004; 33(7): 14–26.

35.

Haahr

Norlyk

Martinsen

, et al. Nurses experiences of ethical dilemmas: a review. Nurs Ethics 2020; 27(1): 258–272.

36.

Henle

Giacalone

Jurkiewicz

. The role of ethical ideology in workplace deviance. J Bus Ethics 2005; 56(3): 219–230.

37.

Dubinsky

Nataraajan

Huang

. The influence of moral philosophy on retail salespeople’s ethical perceptions. J Consum Aff 2004; 38(2): 297–319.

38.

Ulrich

Soeken

. A path analytic model of ethical conflict in practice and autonomy in a sample of nurse practitioners. Nurs Ethics 2005; 12(3): 305–316.

39.

Yamin

MAY

. The relationship between RIGHT ethical behavior perspective, demographic factors, and BEST ethical performance. IRMM 2020; 10(1): 27–39.

40.

Wuensch

Poteat

. Evaluating the morality of animal research: effects of ethical ideology, gender, and purpose. J Soc Behav Pers 1998; 13(1): 139–150.

41.

Fowler

. Religion, bioethics and nursing practice. Nurs Ethics 2009; 16(4): 393–405.

42.

Karatay

Bowers

Karadağ

, et al. Cultural perceptions and clinical experiences of nursing students in Eastern Turkey. Int Nurs Rev 2016; 63(4): 547–554.

43.

Gücan

. Qualitative data collection tool: a study on the application and validity of focus group technique. Mersin Üniversitesi Sosyal Bilimler Enstitüsü E-Dergisi 2021; 4(2): 94–109.

44.

Phillips

Morin

Valiga

TMT

. Clinical decision making in undergraduate nursing students: a mixed methods multisite study. Nurse Educ Today 2021; 97: 104676.