The effect of flipped-jigsaw learning models on ethical decision-making

Abstract

Background

Ethical decision-making education in nursing can be taught effectively by combining different teaching models that support the visualisation of taught concepts and integrating theory into practice.

Objectives

The study aims to examine the effect of flipped and jigsaw learning models on ethical decision-making and ethical sensitivity in nursing.

Research design

We used a nested mixed design. A pretest-posttest single-group quasi-experimental design was used in the quantitative part, and a case study method was used in the qualitative part.

Participants and research context

This study was conducted in fall semester with second-year nursing students who studied an ethics course for the first time, using two different collaborative learning models. In the quantitative part, ethical dilemma and ethical sensitivity scales were made as pre-test with 117 and post-test with 128 students. In the qualitative part, a semi-structured three focus group interviews was conducted with 16 students.

Ethical considerations

After obtaining the approval of the University’s ethics committee, the study was carried out after obtaining participants’ informed written and verbal consent.

Findings

Students’ perspectives changed positively after training. This was related to six cases in section A of the Ethical Dilemma Scale. In part B, Practical Consideration (PC) and Principled Thinking (PT) mean scores were similar, showing no significant difference. For Familiarity in section C, it was determined that 68.4% of students in the pre-test and 77.3% in the post-test were familiar with similar dilemmas. The ethical sensitivity scale’s total scores were in a similar range. In the qualitative stage, ethical decision-making, ethical sensitivity, ethical dilemma and the improvement process were obtained as a theme.

Conclusions

There was an increase in the level of ethical sensitivity and familiarity with ethical dilemmas of nursing students after education. Flipped and jigsaw learning models can be used for nursing ethics courses.

Graphical Abstract

Keywords

Ethics education ethics and leadership/management moral sensitivity mixed methods codes of ethics

Introduction

Ethics education allows nursing students to develop critical thinking and ethical decision-making skills.¹ Ethical decision-making in nursing refers to the ability to make the most appropriate decisions about ethical issues based on intuitive, ethical nursing principles, professional values, codes of moral judgement and moral reasoning.^2,3 Ethical sensitivity is the ability of nurses to recognise ethical problems and to distinguish the existing ethical problem in order to make the right decisions to solve the problems.⁴ Solving ethical problems carefully and correctly requires students to receive guidance on discussion and decision-making.⁵ Although the traditional educational methods provide students with information in a short period, they remain limited in making sense of basic concepts, providing critical thinking skills and adapting knowledge to new situations.^6,7,8,9

As a result of the developments in education in recent years, collaborative learning models such as flipped and jigsaw have gained importance in teaching.^7,10 Collaborative learning is an education model that includes cooperative, team-based, project-based and problem-based learning; this model is used based on peer education by dividing students into small study groups.¹¹ Choe et al. (2014)¹² stated that constructivist teaching models positively affect nursing students’ understanding of bioethical cases and their ethical competencies. Additionally, some nurse educators believe ethical knowledge and ethics education should be conveyed through structured educational content based on real cases and practical problems.^13,14 Flipped and jigsaw models are based on constructivist theory. Flipped and jigsaw learning models have been used together in many fields, but studies in the field of nursing are limited.^15,16,17

Background

Ethics education is essential for nursing students to gain ethical sensitivity, ethical attitudes and make ethical decisions.¹⁸ For this reason, ethics, an abstract concept in education, can be taught more effectively through a combination of different teaching models in which the student takes an active role with concrete cases.¹⁹ The flipped model shares basic information with students through short videos before the lesson. The students try to develop their knowledge of the subject so that the course can be conducted in the classroom with case-based, problem-based and team-based strategies that encourage learning.^7,20 Students interact closely with their peers in this educational model and participate in problem-solving activities.²¹

Similarly, the jigsaw model is based on collaborative learning but goes beyond teamwork. With this method, the student’s effort is vital for the whole group in a learning environment where individual responsibility is dominant.^21,22 The jigsaw method has two fundamental concepts: main groups and expert groups.^22,23 In the jigsaw method, students are divided into non-homogeneous main groups in which they are experts in a subject. In the jigsaw learning model, there are main groups and expert groups. Jigsaw expert groups consist of different main group members who come together to study the same subject. In the Jigsaw model, after the students learn the subject in the expert groups, they return to their main groups and transfer the information they have learnt to each other²⁴ (Clarke, 1999). Students learn from each other by discussing their assigned topic in expert groups. Finally, they return to the main groups and teach what they have learnt to the other students in their group.^21,22,23,25 What makes the jigsaw method unique is the active participation of the student.

There is still no consensus on the content of ethics education and teaching modules in undergraduate nursing education, and studies evaluating the impact of ethics education are limited.²⁶ Likewise, studies evaluating the effectiveness of ethics education in nursing emphasise that in addition to quantitative measurements, it is essential to determine students’ views about the education method and to examine it in detail.²⁷ The combined use of these two methods can develop students’ skills in research, inquiry, communication, critical thinking and ethical issues based on practical problems. There are quantitative studies on ethics education in the literature, but qualitative data are needed to provide detailed data.^{1,7,12,14,23,26,28,29} Therefore, we aim to investigate the effect of combined education methods in nursing ethics education to fill the literature gap.

Method

Design

This research planned to investigate the effect of flipped and jigsaw learning models on nursing students’ ethical decision-making and ethical sensitivity. In this research, in which the nested mixed design method was used, a qualitative step was added to the quantitative procedure as detailed data could not be obtained from a single quantitative data set. The nested mixed pattern is a pattern that emerged by embedding qualitative data into experimental designs.³⁰ Nested mixed design is shaped by the inclusion of qualitative data before, during or after an experiment. Accordingly, in this study, which is a single-group quasi-experimental design, the qualitative method was applied during and after the experiment because two different educational methods were carried out at the same time.³¹ In the quantitative part of this study, the pretest-posttest single-group quasi-experimental design was used, and in the qualitative part, the case study method was used. The experimental intervention was carried out over five sessions, and a qualitative interview was conducted after the third session.

(QUAN (Quantitative) → QUAL(Qualitative) → QUAN → QUAL). Thus, qualitative interviews were embedded in the experimental process, and more detailed data were collected.

Setting and participants

The research population consisted of 170 students who took a nursing ethics course at a university in Northwest Turkey. In the qualitative part of the study, students who were not required to attend class (12) and absent (13) were not included. In total, 145 students were invited to participate in the study, the average response rate for the pre-test (n = 117) was 80%, and the response rate for the post-test (n = 128) was 88%.

In the qualitative part of the study, the effects of students’ flipped and jigsaw learning models on ethical decision-making and ethical sensitivity were investigated. The theoretical sampling method was used to achieve data saturation, and three focus group interviews were conducted. The criteria for inclusion in the study were that the participants were volunteers and could participate in both qualitative groups and all activities. In line with this information, 20 participants were invited to the qualitative part. In total, 16 participants, 13 females and 3 males, participated in the qualitative part of the study. The average age was 19.43 ± 0.51.

Instruments

Modified moral sensitivity questionnaire for student nurses (MMSQSN)

The scale created by Comrie (2012)³² adapted from Lützen (2010)’s³³ the Moral Sensitivity Questionnaire (MSQ). The validity and reliability of the scale in Türkiye were tested by Yılmaz Şahin et al. (2015).³⁴ Thirty statements were rated using a seven-point Likert-type scale, ranging between 1 point (I do not agree at all) and 7 points (I completely agree). Total scores can vary between 30 and 210. A high score indicates high ethical sensitivity, and a low score indicates low ethical sensitivity.

Nursing dilemma test (NDT)

The Turkish validity and reliability of the scale developed by Crisham (1981)³⁵ were performed by Cerit (2010).³⁶ The scale has three sections: (1) Section A concerns ethical dilemmas created with six cases and what the nurse should do about them. (2) Section B involves asking six questions about the current cases, and the points of principled and practical thinking are calculated according to the answers given. (3) In section C, the percentage of familiarity is calculated by specifying the situation of encountering similar cases with the score obtained from section A. In line with these cases, the ethical decision-making process of nursing students is evaluated.

Semi-structured focus group interview form

This form consisted of 4 open-ended questions to evaluate the students’ views on ethical decision-making and ethical sensitivity after the course was taught using different methods. The semi-structured focus group interview form was evaluated by five different experts in the field of nursing. The final version of the focus group interview questions is provided below.

1. How do flipped and jigsaw learning models affect your ethical decision-making?

2. How do flipped and jigsaw learning models affect your ethical sensitivity?

3. How did your teaching with flipped and jigsaw learning models contribute to the clinic?

4. What are your suggestions regarding these learning models?

Data collection procedure

The procedure of the study is summarised in Figure 1.

Figure 1.

Procedure.

The quantitative dimension of the research application procedure

Ethical education in nursing is a theoretical course that is carried out for 14 weeks and 2 h per week in fall semester in this university. After the fundamental ethical issues were explained to the students who took the course for the first 7 weeks, case studies were applied using the flipped classroom and jigsaw learning models among the active education models. In the first session, pre-tests were applied and information about flipped and jigsaw learning models was given. In the second session, students were divided into jigsaw main groups. They chose the subjects they would be experts on. In the preparation phase of the research, articles, theses, books, e-resources and journals related to ethics were examined, and four informative videos were prepared, each video lasting 15 min. In four videos, researchers gave information about certain topics and their case studies (ethical dilemma, ethical decision-making, paediatric, geriatric, obstetric, intensive care, emergency and palliative care) as two topics in each videos. The videos were delivered to the students 1 week before the lesson. Students watched these videos before discussing in expert groups. In Session 3, students discussed the topics that they would be experts on in jigsaw expert groups. They created videos on their own topics. In the 4th session, students who were experts on their own topics returned to their jigsaw main groups. In the jigsaw main groups, each of them discussed the topics they were experts in. In the 5th session, students continued to discuss, and at the end of the training, the researcher summarised the topics. Afterwards, post-tests were conducted.

The qualitative dimension of the research application procedure

Examining students’ views on education models is one of the research aims. According to Bowling (2002), focus group interviewing is using the effect of group dynamics in a semi-structured interview and discussion with a small group, obtaining in-depth information and generating ideas.³⁷ Studies have indicated that 3–5 focus groups are sufficient to reach saturation.^38,39 In this study, a discussion environment was created using focus group interviews and detailed information was obtained for this reason; focus group interviews were conducted by NYZ and HK twice. Data saturation is reached when data starts to repeat. Focus group interviews were conducted and ended when data saturation was reached. Qualitative interviews were conducted in a nested mixed pattern design. Focus group interviews were held with the same students at the end of the third and fifth sessions of the flipped and jigsaw technique. Interviews were audio recorded, transcribed verbatim and reviewed for accuracy by the study team. Interviews were conducted in a calm, quiet meeting room for 20–60 min.

Data analysis

The SPSS 29.0 (Statistical Package for The Social Sciences) statistical package program was used to analyse the quantitative research data. The significance value in all statistics was evaluated as p < 0.05. The Kolmogorov–Smirnov distribution test examined descriptive statistics (frequency, percentage, mean and standard deviation) and normal distribution. Pearson correlation analysis assessed the relationship between the two measurement scores. The Cronbach alpha assessed the reliability of the scales.

Focus group interviews were conducted using the MAXQDA 2022 package program. The deciphered interviews were read several times to facilitate familiarisation with the data, and notes were created from initial notes outlining potential code and ideas. A thematic analysis examined nursing students’ thoughts on ethical decision-making and ethical sensitivity. Themes were revealed, combined, divided, reviewed and then checked to confirm the relationship of the coding scheme with the data and findings.⁴⁰ Abbreviations (such as P1 and P2) are emphasised and explain which student said it at the beginning of each quote. The determination of the codes was carried out by (NYZ, ÖD and RB).

Rigour

Guba and Lincoln’s criteria were taken into account for the validity and reliability of the study.^41,42 The criteria they set for trustworthiness in qualitative research were reliability, credibility, transferability and confirmability.⁴² In this study, the triangulation technique was used to ensure reliability.⁴³ Focus group interviews were conducted with different groups with similar experiences on the same subject. Researcher diversity was provided by three different researchers who deciphered, analysed and interpreted these interviews. For credibility, we can highlight the fact that research held for 5 weeks and participants and all researchers were in contact during this process of the study. Qualitative questions were presented to four experts in their fields. For transferability we can mention that we use the sample selection method (purposeful sampling), participants and environment are explained in detail in the methods section. For confirmability, all stages of the study were documented and recorded for others to access. The participant quotes are presented along with the research findings to ensure confirmability.

Ethical considerations

After obtaining the University’s ethics committee approval (E-61923333–050.99-179303), the participants were informed, and their written consent was obtained. All the students were assured that participation was voluntary and would not affect their academic achievement scores.

Findings

Quantitative findings

For the dilemmas of six cases from section A of the Ethical Dilemma Test, answers given before and after the training to the question ‘What should a nurse do?’ are presented in Table 1.

Table 1.

Distribution of nursing students’ responses to the question ‘what should a nurse do’ in Section A of the ethical dilemma scale before and after education.

Ethical dilemmas		Pre-test		Post-test
Ethical dilemmas		n	%	n	%
Performing a resuscitation attempt in a newborn baby with anomaly	Must be applied	44	18.0%	53	21.6%
	I’m undecided	51	20.8%	58	23.7%
	Should not be applied	22	9.0%	17	6.9%
Forced drug administration	Must be applied	31	12.7%	18	7.3%
	I’m undecided	41	16.7%	62	25.3%
	Should not be applied	45	18.4%	48	19.6%
The adult’s desire to die	Must be applied	77	31.4%	64	26.1%
	I’m undecided	32	13.1%	50	20.4%
	Should not be applied	8	3.3%	14	5.7%
Adaptation of a newly appointed nurse to the clinic	Must be applied	42	17.1%	47	19.2%
	I’m undecided	54	22.0%	69	28.2%
	Should not be applied	21	8.6%	12	4.9%
Reporting a medication error	Must be applied	91	37.1%	75	30.6%
	I’m undecided	23	9.4%	46	18.8%
	Should not be applied	3	1.2%	7	2.9%
Failure to inform adult individuals with a deadly disease	Must be applied	36	14.7%	41	16.7%
	I’m undecided	66	26.9%	67	27.3%
	Should not be applied	15	6.1%	20	8.2%

The ethical sensitivity level of the students before and after the education was at a reasonable level and had a similar average. It was observed that the scale showed a significant difference only with the sub-dimension of creating ethical meaning (p = 0.031, r = −0.131) (Table 2).

Table 2.

The pre- and post-training scale mean scores of the students and comparison.

	Pre		Post		r; p
	α*	Mean (SD)	α*	Mean (SD)	r; p
MMSQSN	0.666	149.40 (11.87) 4.98 (3.26–6.00	0.812	149.47 (14.99) 4.98 (3.87–6.53)	0.966; 0.03
Interpersonal orientation	0.644	23.43 (2.58)	0.714	23.75 (2.66)	0.060; 0351
Experiencing ethical dilemmas	0.792	11.05 (2.72)	0.826	11.58 (3.23)	0.087; 0172
Beneficence	0.673	37.20 (5.03)	0.709	37.77 (5.70)	0.053; 0411
Creating ethical meaning	0.585	30.83 (3.32)	0.631	29.81 (3.98)	−0,131;0031
Modified autonomy	0.639	23.42 (3.29)	0.728	23.94 (3.87)	0.072; 0263
Getting expert opinion	0.693	16.05 (2.51)	0.683	15.45 (2.53)	−0.118; 0065
NDT
Familiarity	0.778	16.18 (2.41)	0.793	15.58 (2.49)	−0.122; 0057
Practical considerations		12.87 (6.94)		12.35 6.38)	−0.039; 0548
Principled thinking		30.90 (7.27)		29.78 (7.68)	−0.075; 0245

α: internal consistency values; * calculated in the study; min-max: minimum-maximum values; a from scale; calculated in the study; SD: standard deviation; MMSQSN: Modified Moral Sensitivity Questionnaire for Student Nurses; NDT: Nursing Dilemma Test.

In the ethical dilemma level results of the nursing students, the mean PC score was moderate, with 12.87 + 6.94 on the pre-test and 12.35 + 6.38 on the post-test. While the mean PT score was 30.90 + 7.27 in the pre-test and 29.78 + 7.68 in the post-test (Table 2).

In the study, the MMSQSN Cronbach alpha reliability coefficient was between 0.631 and 0.826, revealing an acceptable level.

In section A, the ‘Familiarity’ sub-dimension was obtained with the sum of the scores obtained from section C of the ethical dilemma test. While the students’ familiarity was 16.18 + 2.41 on the pre-test, it was 15.58 + 2.49 on the post-test. A noticeable change was observed because familiarity was negatively affected as the mean score increased (Table 2). This showed that the case studies given in the course also affected familiarity. When the students’ responses to familiarity were evaluated, the percentage of students between 6 and 17 points was 68.4% in the pre-test and 77.3% in the post-test. It was determined that the percentage of those familiar with similar dilemmas increased (Figure 2).

Figure 2.

Familiarity of nursing students before and after education.

In the study, the NDT Cronbach alpha reliability coefficient was between 0.78 and 0.80, revealing an acceptable level.

Qualitative findings

In the qualitative part of this study, 4 four main themes were determined. These themes are ‘ethical decision-making’, ‘ethical sensitivity’, ‘ethical dilemma’ and ‘improvement process’ (Figure 3).

Figure 3.

Sub-theme cloud.

Ethical decision-making theme

The student’s statements about ethical decision-making were combined with this theme. Situations that increase students’ decision-making were determined as sub-themes. Sub-themes and student opinions are provided below.

Gaining a different perspective

Most students stated that they gained a different perspective by discussing situations with their peers, which positively affected their ethical decision-making. Some opinions of the students include:

P2: It increased my decision-making. The discussions were excellent. I liked that what did not occur to me came to someone else’s mind; it was nice to discuss (Focus Group (FG) 1; 2. Interview; Female; 19).

P7: I evaluated it from different perspectives. In other words, everyone’s ethical decision-making skills have increased (FG 2; 1. Interview; Female; 19).

Clinical integration

Most students stated that the cases during clinical practice were similar to those they studied in the lessons; therefore, they could make connections. They stated that this situation also affected their clinical decision-making. Sample opinions include:

P13: For example, I realised the importance of ethical practices in the cases I looked at in intensive care, so I realised that I need to practice ethical practices in intensive care (FG3; 2. Interview; Female; 19).

P16: The cases of explaining to patients about their illness are really very similar to the clinic (FG 3; 1. Interview; Female; 20).

P12: …as a student, we have just become aware of the ethical situations in the clinic. But it’s good to be aware of that already. Because while we are thinking a lot now, we will start to think less about it as a nurse, and we will be able to decide more quickly. (FG3; 2. Interview; Male; 20).

Critical thinking

Critical thinking skills and attitudes are essential for the development of nurses' ethical decision-making abilities.⁴⁴ Some students stated that their critical thinking and ethical decision-making skills also increased. One of the participants’ opinions is presented below.

P1: Taking this course with these methods greatly impacted my ethical decision-making. These methods positively affected my critical thinking and were beneficial (FG 1; 1. Interview; Female; 19).

Ethical sensitivity theme

The students’ statements about ethical sensitivity were transferred to this theme. The students’ statements about the situations that increase their ethical sensitivity were determined as the sub-theme. Ethical sensitivity is the ability of nurses to recognise ethical problems and to distinguish the existing ethical problem in order to make the right decisions to solve the problems.⁴ In this regard, sub-themes of awareness of ethical issues and discovering ethical principles were formed. Sub-themes and student opinions are presented below:

Awareness of ethical issues

Most students stated that their ethical awareness increased in this sub-theme, increasing their ethical sensitivity. The statements of some of the participants regarding this sub-theme are included below:

P15: Now, I evaluate the events that I encounter in the clinic from an ethical point of view. I am thinking in more detail that like ‘it should have happened like this, but actually, it should not have happened’ (FG 3; 1. Interview; Female; 19).

P7: Our thoughts changed when we learned other ideas. That is why we are sensitive. We were able to look at the events in great detail. We became aware of ethical issues (FG 3; 2. Interview; Female; 19).

Discovering ethical principles

Some students stated that they discovered the ethical principles more quickly in the clinic and the cases, which increased their ethical sensitivity.

P14: I actually encountered such an event in the clinic. For example, I used to think these cancer patients should be told about their disease, but I don’t think so anymore. This point of view has changed because I could look from the perspective of the patients, people made me think differently here. I just didn’t think my thoughts were correct. I became more conscious of privacy and secrecy and learned to look at it from the patient’s point of view (FG 3; 2. Interview; Female; 20).

P1: I realised that by not taking care, harm can be done, and I became more aware of the events, and I saw which principle matched which event in the clinic (FG 1; 2. Interview; Female; 19).

P5: I realised that we can say "it looks like this in the clinic". I realised the autonomy of the patients the most. So, I think I realised the value of explaining to the patient. (FG1; 2. Interview; Female; 20).

Ethical dilemma theme

This theme includes students’ views on ethical dilemmas. Situations that increase students’ ethical dilemmas were determined as sub-themes. Sub-themes and student opinions are included below.

Ethic impasse

The students stated that some ethical problems could not be solved, and the decision-making processes took a long time. Examples of the views of some of these participants are given.

P6: …we can question the situation more easily with our friends. It was better from that point of view; it just took a long time to decide (FG 2; 2. Interview; Male; 19).

P12: We exchanged our ideas, we actually learned better through discussion. I started to question my decisions too often. This made us make a very difficult decision. Maybe it’s not too negative, but I can’t make the decision clearly (FG 2; 2. Interview; Male; 20).

Need for expert approval

Some students stated that they experienced more ethical dilemmas and needed an expert opinion. Some comments are quoted below.

P10: We saw different opinions of our friends and expert group, and we saw different points of view in our discussion with our own group. It was very nice in this respect; frankly, we want to see your ideas. It positively impacted our ethical sensitivity, but we still fell short in some areas, so we want to hear your teachers’ thoughts on the cases (FG 2; 1. Interview; Female; 20).

Improvement process theme

In this theme, the interview sentences that students’ thoughts that need to be corrected about application of flipped and jigsaw learning models were transferred to this theme. Sub-themes and student opinions are below.

Group dynamics

The majority of the students stated that they were negatively affected by their friends who did not discuss the cases in their groups. Some sample comments are included below:

P10: Some of our friends do not participate in the discussions. Then we are really affected negatively. (FG 2; 2. Interview; Female; 20)

P8: Someone who did not participate in group discussions negatively affected us (FG 2; 2. Interview; Female; 19)

Physical environment

Most of the participants stated that the amphitheatre environment is not suitable and noisy. The opinions of the participants are included below.

P6: It was very loud (FG 2; 2. Interview; Male; 19).

P9: I agree with my friends, and it was hard to be on the amphitheatre and could not hear our voices (FG 2; 2. Interview; Male; 19).

Time management

Some students stated that their discussions of cases took a long time and that more time could be given. Some of the students’ quotes are as follows.

P1: Could it be more time? There may be smaller groups and silent groups. (FG 1; 2. Interview; Female; 19)

P3: In a case, we couldn’t decide; we were really stuck in that case. We had little time and it’s time-consuming. Alternatively, cases could be practised within a predetermined period. (FG 1; 1. Interview; Female; 20).

Discussion

The selection and adoption of appropriate teaching methods to meet the learning needs of nursing students are extremely important and necessary. In a study on ethics education, the authors propose a combination of inquiry-based teaching and a narrative-based approach in nursing ethics education.³⁵ In the current study, two different active learning methods were used: flipped and jigsaw learning models. We planned to determine the effect of an ethical course delivered with these models on the ethical decision-making process of nursing students. When the results of the current study were examined, there was no significant difference in ethical decision-making in dilemmas and ethical sensitivity before and after education.

The scores from the ethical sensitivity scale were obtained at a similar and good level before and after education. Although the sub-dimension averages showed similarities, there was a visible difference in minimum and maximum values (Table 2). Considering interview responses, when we examined the effect of flipped and jigsaw teaching methods on the students’ ethical sensitivity, they stated that these education methods developed the level of knowledge in terms of ethical sensitivity. We observed that students’ awareness and understanding of ethical problems developed, they gain critical thinking skills and the ability to grasp ethical problems more easily. While there was a significant difference in ethical decision-making from the scale sub-dimensions, there was a significant difference between the groups in seeking expert knowledge. Indeed, when examining the qualitative results, participants stated that the reason for the increase in their ethical sensitivity was due to the need to create ethical meaning, experience ethical dilemmas and gain expert knowledge.

In addition, Baykara et al. (2015)⁴⁵ concluded that ethics education improves the ethical sensitivity of nursing students. Another study showed that the ethical sensitivity of nursing students increased significantly after ethical education.⁴⁶ Previous literature also reports that ethical sensitivity increases positively and significantly through education level and experience.^47,48 Similar to our finding, there are also studies in which ethical education does not affect the level of ethical sensitivity.^28,32,34 Findings by Kim (2015)⁴⁹ state that moral sensitivity decreases with exposure to ethical dilemmas and clinical practice experience. In our study, second-year nursing students went to clinical practices 1 day per week and encountered few clinical problems. For this reason, because they evaluated even the smallest problems ethically, their ethical sensitivity may have increased at a low level.

In the current study, when Table 1 was examined, it was observed that the students’ ambivalence about cases increased in the final test results on the ethical dilemma scale. Our qualitative findings also support this finding. It was determined that students’ awareness of ethical dilemmas increased. Students stated that the decision-making was time-consuming in the main theme of ‘ethical dilemma’ and that some cases could not be fully resolved. Our quantitative and qualitative findings are combined in the ethical dilemma dimension. This may indicate that with the ethical training, the students’ ethical awareness has developed; however, they seek expert approval when making decisions. In contrast to our quantitative findings, other research shows PT and PC scores to be moderate among students.^36,50,51

There are also findings similar to our own. Gül et al. (2013)⁵² obtained moderate PT and PC points in their work. Perhaps there are different results in the literature due to a large number of samples, regional differences and differences in the learning methods used. In the current study, where two different learning methods were applied, it was observed that negative interaction occurred due to a large number of students in the classroom and the lack of available classrooms for training to do in small groups. This situation has also been documented in qualitative data and conveyed with the ‘improvement process’ theme. It was stated that learning in small groups, in a non-noisy environment, outside the amphitheatre, and with time management might be more efficient. Other studies also state that active learning should be done under appropriate physical conditions.^23,53

In our study, the familiarity levels of nursing students increased after the training. This shows that students faced with ethical dilemmas during their education could apply this positively in practice. Previous research shows similar findings;^36,47,50,54 however, further research shows contrasting findings.^51,52,55 Being familiar with ethical dilemmas contributes to the ethical decision-making processes; in addition, the increasing ability to discuss ethical problems and solve problems can shorten the length of time needed to make decisions.^47,54,55

At the same time, within the framework of our qualitative findings, students stated that their ethical decision-making skills have increased. Using two active learning models in this study and presenting a discussion-based environment in multiple cases with small groups positively contributes to ethical decision-making. In addition, since students have the opportunity to practice in rotation in more than one clinic and can observe the functioning mechanisms of different clinics, their familiarity with ethical dilemmas is high. It has been stated that active learning with case examples combines theory and practice for students, develops a holistic approach, provides permanent learning with different perspectives and is a useful method for preparing students for their professional careers.⁵⁶

In summary, this study showed positive and negative reflections of using flipped and jigsaw learning models on ethical decision-making and ethical sensitivity. Students united in ethical decision-making by sharing their learning experiences in expert groups. Students gained ethical sensitivity, ethical awareness and time management. Based on the data in this study, the effectiveness of active learning models is not at the desired level. The fact that there was not much significant difference in the quantitative data made us think that the physical environment and the number of students were not suitable for the applied education methods.

Previous research using the jigsaw learning model has included factors such as excessive student workload, physical conditions that make group discussions difficult and the practice of frequent collaborative learning sessions.²² In our study, factors such as the fact that the teachers of the ethics course conducted with the flipped and jigsaw educational models show long efforts in the background and the student think that these methods are unusual teaching models, students make more effort, feel that they have to attend the course, are positive results in terms of student achievement, although the applicability of the models makes it difficult. In the current study, the absence of differences before and after the training showed that it is important to consider the physical conditions, although necessary preparations were made regarding the content. Student nurses should integrate theoretical knowledge into their clinical experiences to ensure ethical education is applied.³⁴ Each participant had clinical experience, which enabled them to gain practical education experience. Moreover, practical experience contributes to contact with patients, ethical thinking and identifying problems and improving their ethical sensitivity.

Limitations and future studies

This study was conducted with second-year nursing students of a university in northwest Turkey. The qualitative and quantitative data of the study are limited to this group. The findings obtained with quantitative data in the study were detailed with qualitative data. Qualitative data are based on students' individual experience and experience. The findings obtained from the research are limited to the information provided by the students, and some emphasised that others did not work actively in the group. In future studies, we recommended creating an innovative classroom environment where all group members can participate. In this study, most students stated that the amphitheatre was noisy; subsequently, the noise negatively affected learning. A limitation of this study is the absence of a control group. In this direction, randomised controlled studies in which the flipped and jigsaw education methods are used together are recommended. Therefore, future researches which will use these methods should be created quiet classroom environments where small groups and round tables.

Conclusion

As a result of the education course for nursing students, the ethical sensitivity level and familiarity with ethical dilemmas increased. Students stated that ethical sensitivity and ethical decision-making skills increased in the qualitative part of the study. This result shows that our quantitative and qualitative findings are aligned. At the same time, students remain undecided in cases of ethical dilemmas related to the post-test. In our qualitative results, students emphasised that their ethical awareness to ethical dilemmas have increased. Although this situation may seem negative, it has contributed to the students’ clinical skills. The students believed that using these models helped them to identify with the cases they encountered in the clinic. Therefore, this study will likely guide researchers who provide ethics education. Ethical problems experienced in the clinic are not always the same. For this reason, it is vital to offer educational programs that broaden nursing students’ experiences of different cases. However, physical conditions and group dynamics should also be considered when applying these constructivist models. According to the results of this study, we recommend using flipped and jigsaw learning models within the scope of a nursing ethics course.

Footnotes

Acknowledgements

We want to thank the nursing students for sharing their opinions.

Author contributions

NYZ and OD designed the study; NYZ, RB and HK collected the data; OD, RB and NYZ analysed the data; NYZ, OD, RB and HK wrote the manuscript and all authors revised and confirmed the final version of the manuscript.

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 iDs

Nasibe Yağmur Ziyai

Ramazan Bozkurt

Hatice Kilickiran

Ozlem Dogu

References

Khatiban

Falahan

Amini

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

Alba

. Factors that impact on emergency nurses’ ethical decision-making ability. Nursing Ethics 2018; 25(7): 855–866.

Cerit

Dinc

. Ethical decision-making and professional behaviour among nurses: a correlational study. Nursing Ethics 2013; 20: 200–212.

Metin

Fırat

Karataş

, et al. Investigation of ethical sensitivities of emergency service nurses. E-Journal of Dokuz Eylul University Nursing Faculty 2017; 10(4): 229–235.

Chen

Liu

, et al. The relationship between moral sensitivity, professional values, and ethical decision-making in nursing students. Nurse Education Today 2021; 105: 105056.

Barranquero-Herbosa

Abajas-Bustillo

Ortego-Maté

. Effectiveness of flipped classroom in nursing education. A systematic review of systematic and integrative reviews. International Journal of Nursing Studies 2022; 135: 104327.

Dong

Yin

, et al. The effects of flipped classroom characterized by situational and collaborative learning in a community nursing course: a quasi-experimental design. Nurse Education Today 2021; 105: 105037.

Mohamed Abobaker

Sulaiman Alamri

Alshaery

, et al. Impact of jigsaw cooperative learning strategy on academic achievement and opinion among nursing students. Journal of Holistic Nursing and Midwifery 2023; 33(1): 43–51.

Sezer

Esenay

. Impact of flipped classroom approach on undergraduate nursing student’s critical thinking skills. Journal of Professional Nursing 2022; 42: 201–208.

10.

Karasu

. Hemşirelik eğitiminde işbirlikli öğrenme modeli. [Cooperative learning model in nursing education]. İnönü Üniversitesi Sağlık Hizmetleri Meslek Yüksek Okulu Dergisi 2020; 8(3): 973–988.

11.

Yang

. A historical review of collaborative learning and cooperative learning. TechTrends 2023; 67(1): 1–11.

12.

Choe

Park

Yoo

. Effects of constructivist teaching methods on bioethics education for nursing students: a quasi-experimental study. Nurse Education Today 2014; 34(5): 848–853.

13.

Krautscheid

Brown

. Microethical decision making among baccalaureate nursing students: a qualitative investigation. Journal of Nursing Education 2014; 53(3): 19–25.

14.

Lin

Chung

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

15.

Haftador

Shirazi

Mohebbi

. Online class or flipped-jigsaw learning? Which one promotes academic motivation during the COVID-19 pandemic? BMC Medical Education 2021; 21(1): 1–8.

16.

Uppal

. Flipped jigsaw activity as a small group peer-assisted teaching learning tool in biochemistry department among Indian medical graduate: An experimental study. Biochemistry and Molecular Biology Education 2020; 48(4): 337–343.

17.

Sanchez-Muñoz

Carrió

Rodríguez

, et al. A hybrid strategy to develop real-life competences combining flipped classroom, jigsaw method and project-based learning. Journal of Biological Education 2022; 56(5): 540–551.

18.

Zolkefli

. The use of debate in teaching nursing ethics. Teaching and Learning in Nursing 2021; 16(4): 365–367.

19.

Bah

Sey-Sawo

. Teaching and practicing nursing code of ethics and values in the Gambia. International Journal of Africa Nursing Sciences 2018; 9: 68–72.

20.

Prober

Khan

. Medical education reimagined: a call to action. Academic Medicine 2013; 88(10): 1407–1410.

21.

Kiegaldie

Pepe

Shaw

, et al. Implementation of a collaborative online international learning program in nursing education: protocol for a mixed methods study. BMC Nursing 2022; 21(1): 252.

22.

Ziyai

Dikmen

. The effect of the jigsaw technique on the knowledge and skills of nursing students. Bangladesh Journal of Medical Science 2022; 21(4): 820–824.

23.

Leyva-Moral

JM.

Camps

. Teaching research methods in nursing using Aronson's jigsaw technique. A cross-sectional survey of student satisfaction. Nurse Education Today 2016; 40: 78–83.

24.

Clarke

. Pieces of the puzzle: the jigsaw method. In: Sharan

(ed). Handbook of Cooperative Learning Methods. Westport, CT: Preager, 1999.

25.

Luo

O’Steen

Brown

. Flipped learning wheel (FLW): a framework and process design for flipped L2 writing classes. Smart Learning Environments 2020; 7: 1–21.

26.

Sanaie

Vasli

Sedighi

, et al. Comparing the effect of lecture and Jigsaw teaching strategies on the nursing students’ self-regulated learning and academic motivation: a quasi-experimental study. Nurse Education Today 2019; 79: 35–40.

27.

Desimone

. Curriculum redesign to build the moral courage values of accelerated bachelor’s degree nursing students, 5. Sage Open Nursing, 2019. 2377960819827086.

28.

Kim

Park

. The effects of debate-based ethics education on the moral sensitivity and judgment of nursing students: A quasi-experimental study. Nurse Education Today 2019; 83: 104200.

29.

Zhang

Zhao

Zeng

, et al. A comparison of inquiry-oriented teaching and lecture-based approach in nursing ethics education. Nurse Education Today 2019; 79: 86–91.

30.

Creswell

Clark

PVL

Gutmann

, et al. Advanced mixed methods research designs. Handbook of Mixed Methods in Social and Behavioral Research 2003; 209(240): 209–240.

31.

Cresswell

Clark

PVL

. Designing and conducting mixed methods research. 2nd Ed. Los Angeles: Sage Publications, 2011.

32.

Comrie

. An analysis of undergraduate and graduate student nurses’ moral sensitivity. Nursing Ethics 2012; 19(1): 116–127.

33.

Lützén

Evertzon

Nordin

. Moral sensitivity in psychiatric practice. Nursing Ethics 1997; 4(6): 472–482.

34.

Yilmaz Sahin

Iyigun

Acikel

. Validity and reliability of a Turkish version of the modified moral sensitivity questionnaire for student nurses. Ethics and Behavior 2015; 25(4): 351–359.

35.

Crisham

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

36.

Cerit

. Hemşirelik etik ikilem testi'nin geçerlik-güvenirlik çalişmasi ve hemşirelerin etik karar verebilme düzeyi. [A study of validity and reliability of nursing dilemma test and nurses’ level of ethical decision-making]. Journal of Hacettepe University Faculty of Nursing 2010; 17(2): 47–67.

37.

Bowling

. Research methods in health: investigating health and health services. Philadelphia, PA: McGraw-Hill House, 2002.

38.

Holloway

Wheeler

. Qualitative research for nurses. Oxford: Blackwell Science Ltd, 1996.

39.

Onwuegbuzie

Leech

. A Call for qualitative power analyses. Quality and Quantity 2007; 41: 105–121.

40.

Braun

Clarke

. Using thematic analysis in psychology. Qualitative Research in Psychology 2006; 3: 77–101.

41.

Guba

. Criteria for assessing the trustworthiness of naturalistic inquiries. Ectj 1981; 29(2): 75–91.

42.

Guba

Lincoln

. Epistemological and methodological bases of naturalistic inquiry. Ectj 1982; 30(4): 233–252.

43.

Başkale

. Nitel araştırmalarda geçerlik, güvenirlik ve örneklem büyüklüğünün belirlenmesi. [Determination of Validity, Reliability and Sample Size in Qualitative Studies]. E-Journal of Dokuz Eylul University Nursing Faculty 2016; 9(1): 23–28.

44.

Falcó-Pegueroles

Rodríguez-Martín

Ramos-Pozón

, et al. Critical thinking in nursing clinical practice, education and research: From attitudes to virtue. Nursing Philosophy 2021; 22(1): e12332.

45.

Baykara

Demir

Yaman

. The effect of ethics training on students recognizing ethical violations and developing moral sensitivity. Nursing Ethics 2015; 22(6): 661–675.

46.

Yeom

Ahn

Kim

. Effects of ethics education on moral sensitivity of nursing students. Nursing Ethics 2017; 24(6): 644–652.

47.

Arslan

Türer Öztik

Kuzu Kurban

. Do moral development levels of the nurses affect their ethical decision making? A descriptive correlational study. Clinical Ethics 2021; 16(1): 9–16.

48.

Kucukkelepce

Dinc

Elcin

. Views of nursing students on using standardized patient and in-class case analysis in ethics education. Nurse Education Today 2021; 107: 105155.

49.

Kim

. Influence of moral sensitivity and ethical values on biomedical ethics awareness of nursing students. J.Korean Acad. Soc. Nurs. Educ 2015; 21(3): 382–392.

50.

Ham

. A comparison of ethical reasoning abilities of senior baccalaureate nursing students and experienced nurses. PhD Thesis. USA: The University of Memphis, 2002.

51.

Küçük

Uysal

Çalbayram

NÇ

, et al. Hemşirelik öğrencilerinin etik karar verme düzeyleri ve etkileyen faktörlerin belirlenmesi. [Determination the ethical decision making process levels of nursing students and the factors that effect them], 3. Acıbadem University Health Sciences Journal, 2017, pp. 157–162.

52.

Gül

Güler

Bayrak Kahraman

, et al. Etik dersi alan ve almayan hemşirelik öğrencilerinin etik karar verebilme düzeylerinin incelenmesi. [Investigating ethical decision-making levels of nursing students who did and did not take ethics courses]. Journal of Research and Development in Nursing 2013; 15(1): 23–31.

53.

Youhasan

Chen

Lyndon

, et al. Exploring the pedagogical design features of the flipped classroom in undergraduate nursing education: a systematic review. BMC Nursing 2021; 20(1): 1–13.

54.

Sabancıoğulları

Usku Kol

Arslantaş

, et al. Hemşirelerin etik karar verme düzeyi ile profesyonel benlik kavramları arasındaki ilişkinin incelenmesi [Examination of the relationship between ethical decision making levels and professional self-concepts of nurses]. E-Journal of Dokuz Eylul University Nursing Faculty 2018; 11(2): 105–112.

55.

Kurt

Atay

Arıkan

. Hemşirelik öğrencilerinin etik karar verebilme düzeyi. [The level of ethical decision-making of nursing students]. Turkiye Klinikleri J Med Ethics 2013; 21(2): 79–87.

56.

Forsgren

Christensen

Hedemalm

. Evaluation of the case method in nursing education. Nurse Educatipn in Practice 2014; 14: 164–169.