Development, implementation, and effects of an integrated web-based teaching model in a nursing ethics course

Development, implementation, and effects of an integrated web-based teaching model in a nursing ethics course

    Development, implementation, and effects of an integrated web-based teaching model in a nursing ethics course S.-Y. Chao, Y.-C. Chang...

701KB Sizes 1 Downloads 25 Views

    Development, implementation, and effects of an integrated web-based teaching model in a nursing ethics course S.-Y. Chao, Y.-C. Chang, S.C. Yang, M.J. Clark PII: DOI: Reference:

S0260-6917(17)30080-1 doi:10.1016/j.nedt.2017.04.011 YNEDT 3524

To appear in:

Nurse Education Today

Received date: Revised date: Accepted date:

28 September 2016 22 February 2017 7 April 2017

Please cite this article as: Chao, S.-Y., Chang, Y.-C., Yang, S.C., Clark, M.J., Development, implementation, and effects of an integrated web-based teaching model in a nursing ethics course, Nurse Education Today (2017), doi:10.1016/j.nedt.2017.04.011

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

T

TITLE: DEVELOPMENT, IMPLEMENTATION, AND EFFECTS OF AN INTEGRATED WEB-BASED TEACHING MODEL IN A NURSING ETHICS COURSE

SC R

CONTRIBUTORS: Chao, S.-Y. DNSc. RN.

IP

Word Count: 5030

Professor, Department of Nursing, Hungkuang University

1. Study design

NU

2. Data collection, data analysis, and interpretation of data 3. Prepare manuscript

MA

Chang, Y.- C, Ph. D. Associate Professor, Department of Computer Science and

TE

D

Information Engineering, Hungkuang University 1. Establish the teaching web 2. Assist in preparing teaching materials 3. Assist in teaching course 4. Assist in data collection

AC

CE P

Yang, S. C. Ph.D. Assistant Professor, Department of Cultural and Creative in Industries, Hungkuang University. 1. Assist in preparing teaching materials 2. Assist in teaching course 3. Assist in data collection Clark, M. J., Ph.D. RN. Retired Professor, Hahn School of Nursing and Health science, University of San Diego Final version approval Corresponding Author: Chao, Shu- Yuan #1018, Taiwan Avenue, Sec. 6thHungkuang University. Tel:886-4-26318/652ext 3013. Email address: [email protected] FUNDED:

Minister of Science and Technology (#

MOST104-2511-S-241-001-MY2) ACKNOWLEDGEMENTS: in our study.

We appreciate the funding support, and the participants

ACCEPTED MANUSCRIPT

Abstract

IP

T

Background: Ethical competence, which is reflected in the ability to detect ethical

SC R

challenges in clinical situations and engage in deliberate thinking on ethical actions, is one of the core competencies of nursing practice.

NU

Purpose: The purpose of this study was to develop and implement an interactive situational e-learning system, integrating nursing ethical decisions into a nursing

MA

ethics course, and to evaluate the effects of this course on student nurses’ ethical

D

decision-making competence.

TE

Project Design: The project was designed to be carried out in two phases. In the first

CE P

phase, an interactive situated e-learning system was developed and integrated into the nursing ethics course. The second phase involved implementing the course and

AC

evaluating its effects in a quasi-experimental study. The course intervention was designed for two hours per week over one semester (18 weeks). Participants: A total of 100 two-year technical college nursing students in their second year of the program participated in the study, with 51 in the experimental group and 49 in the control group. Results: After completing the course, the students in the experimental group showed significant improvement in nursing ethical decision-making competence, including skills in “raising questions,” “recognizing differences,” “comparing differences,”

ACCEPTED MANUSCRIPT “self- dialogue,” “taking action,” and “identifying the implications of decisions made,” After controlling for factors

T

compared to their performance prior to the class.

IP

influencing learning effects, students in the experimental group showed superiority to

SC R

those in the control group in the competency of “recognizing differences.”

The

students in the experimental group reported that the course pushed them to search for

NU

and collect information needed to resolve the ethical dilemma.

MA

Conclusions: The interactive situational e-learning system developed by our project was helpful in developing the students’ competence in ethical reasoning. The

TE

D

e-learning system and the situational teaching materials used in this study may be

CE P

applicable in nursing and related professional ethics courses. Key words: Nursing ethic, interactive situation web-based, ethical decision-making,

AC

nursing students

ACCEPTED MANUSCRIPT INTRODUCTION With

T

Nursing ethics literacy is essential for nursing professionals (Yu, 2010).

IP

the advancement of medical technology and an increasingly complex care Nurses are on the front

SC R

environment, nursing ethics literacy is especially important.

line of caring for patients; they need to collect relevant information, apply knowledge,

NU

and make decisions in response to specific ethical situations to provide the most

MA

appropriate interventions for patients and their families. Ethics courses are required for nursing professionals domestically and

D

After graduation, however, when nursing students face ethical

TE

internationally.

In 2013,

CE P

dilemmas in clinical situations, they often still lack confidence (Park, 2009).

the researchers conducted a survey of 100 nurses who had graduated more than a year Respondents reported several challenges in responding to ethical

AC

previously.

dilemmas, including recognizing key issues and clarifying relevant stakeholders’ positions and stances (Chao, Yang, & Chang, 2014).

In that study, nursing graduates

reported the need to strengthen their critical thinking skills in solving ethical problems. The findings also showed that theoretical knowledge gained in the classroom is not enough to effectively assist caregivers to solve ethical problems in clinical situations. Garity (2009) noted that traditional ethics teaching strategies focus on theoretical principles but often lack situational application.

Nursing students are likely to

ACCEPTED MANUSCRIPT experience a gap between theory and applied skills, caused by a lack of clinical Hsieh (2004)

T

experiences, when faced with the complexity of real-life situations.

IP

also pointed out that the competencies of reasoning and reflecting, required for

SC R

identifying ethical issues, should be fostered in real situations.

Contextual learning theorists emphasize that the learning of knowledge cannot be Learning must be closely combined

NU

isolated from its application in real situations.

Tu and Chen

MA

with real situations so that learning retains its meaning and relevance.

(2009) emphasized that students learn to use actual knowledge and skills through real This will stimulate students’ experiences and feelings,

TE

D

or realistic learning situations.

CE P

promote active participation, and develop positive attitudes toward seeking knowledge and resolving problems using meta-cognitive skills, which are all

AC

necessary abilities for ethical decision-making. With the advancement and widespread use of technology and the internet, the use of digital learning environments to support learning has been identified as an essential academic consideration (Usluel & Mazman, 2009). Because of its flexibility of place and location, e-learning technology has become more and more popular in nursing education (Natarajan & Kirsham Marg, 2015). The use of technology in education can increase students’ access to learning resources and materials, facilitate communication, assist in collaborative work among and between students and academic staff, and

ACCEPTED MANUSCRIPT enhance learning (Smyth et al., 2012; Lancaster, Wong & Roberts, 2012).

T

Supplemental content provided online can be repeated and reviewed at the students’

IP

own pace, providing an opportunity to rethink how learning happens and closing the

SC R

theory–practice gap (Petit Dit Dariel, Wharrad & Windle, 2013; Duijin , Swanick, & Donald, 2014).

NU

Ethical considerations require time to ponder, and e-learning allows students the E-learning systems

MA

freedom to conduct autonomous learning in their own time.

provide “free-play” simulations in which students act in realistic roles in complex

TE

D

work-related situations and allow students to reflect on the appropriateness and Interactive situations,

CE P

effectiveness of their actions and decisions (Selwyn, 2011).

feedback, and repeated mental exercises help to integrate thinking and promote the

AC

transfer of knowledge and retention of learning, enhancing the ability to put theories into practice (Dabbagh, 2005; Dickieson, Carter, & Walsh, 2008). Recent studies have indicated realistic practice simulations enable students to gain knowledge, apply skills, and increase confidence (Rostad et al., 2014; Hainey, Green, & Kelly, 2017), especially for novice learners (Feng et al., 2013). As noted earlier, nursing students lack experience in confronting ethical dilemmas.

Providing a framework for situational dilemma analysis through virtual

scenarios and repeated exercises gives students learning experiences using multiple

ACCEPTED MANUSCRIPT strategies that promote reflection and discussion, structured thinking, and the ability

T

to judge.

IP

The present project occurred in two phases. The first phase involved creating an

SC R

interactive situational e-learning system and integrating it into a nursing ethics course. In the second phase, we implemented the modified course and studied its effects on

NU

students’ ethical decision-making abilities.

MA

METHOD

Phase One: Developing a blended e-learning nursing ethics course

TE

D

The blended e-learning course in our project is defined as a combination of

CE P

traditional face to face teaching with an interactive multimedia online system to achieve predetermined learning objectives.

The project used situated learning theory

AC

to design an interactive multimedia online teaching module which included ethical dilemma scenarios, an ethical decision making process, and information sources related to the scenarios. The components of system included the following: 1. Presentations of situational ethics dilemmas using multimedia teaching materials – animated videos were presented so that students were immersed in the situation. The multimedia teaching materials included four scenarios: “informing a patient of bad news,” “consequences of one-night stands,” “a

ACCEPTED MANUSCRIPT baby born with HIV infection,” and “removal of life support” (see Figure 1).

T

2. Explication of an ethical decision-making model: The online system ethical

IP

decision-making model (depicted in Figure 2) follows the decision making

SC R

process developed in the researchers’ prior study and incorporates the following:

NU

a.) Event description: Identifying the ethical events involved.

MA

b.) Intuitional action: Decision making based on typical intuitional responses to the ethical event without deliberate thought.

TE

D

c.) Ethical awareness: Considering the ethical event’s background, as

CE P

well as the positions and viewpoints of the people who may be involved in the event and identifying values conflicts among those

AC

involved.

d.) Recognizing and comparing differences in perspectives among the people involved in the event, including patients, families, health professionals, the public, and students’ own personal moral views. Students are then asked to collect and organize related information on ethical norms, laws and regulations, and sociocultural and religious viewpoints. The nursing students’ personal beliefs and feelings are explored to determine whether or not they have a bias

ACCEPTED MANUSCRIPT that could affect how they handle the event.

T

e.) Self-dialogue and examination of the implications of the decision

IP

made: With the knowledge gleaned above, nursing students

SC R

evaluate possible actions and strategies, analyze advantages and disadvantages of the strategies, and make any needed changes or

NU

adjustments to provide the greatest benefit for the client.

MA

3. Creation of a resource data archive including: a. Student information storage: In addition to students’ personal information,

TE

D

the e-learning system also saves the results of each learning process for

CE P

students to engage in self-reflection and for teachers to assess students’ status and performance.

AC

b. A teaching materials database for faculty: Teachers can upload teaching materials and record the results and feedback on related materials for continuous improvement of the teaching materials and method.

c. An online resource database: Resources provide relevant information on laws and regulations needed for problem-solving and learning regarding ethical principles. 4. Provision of instruction using the interactive system as follows: a. Students watch the ethical dilemma scenario

ACCEPTED MANUSCRIPT b. After watching the scenario, students respond to questions designed

T

by the instructors to elicit feelings, reactions, and thoughts on how to

IP

resolve the dilemma in light of the ethical decision-making model Questions must be responded to in sequence, and

SC R

described above.

have been addressed.

NU

students cannot progress to subsequent questions until prior questions

MA

c. Once students respond to a question, the system will provide a "golden coin" as a reward to encourage students to think deliberately

TE

D

and reflect on their own feelings and decisions.

CE P

d. In the last step, students are asked to evaluate and reflect on the potential results of decision options and make their final decision.

AC

e. During the process, students can apply related information provided in the online resource data base, if relevant (e.g., theory perspectives or relevant regulations).

f. The system records students’ reactions allowing faculty to evaluate their performance in the ethical situation. The researchers in this study were the instructors, who guided the students through the system in lab.

Additionally, there were two teaching assistants providing

students with technical support.

Thus, instructors were able to respond to students'

ACCEPTED MANUSCRIPT problems immediately, and students could continue practice after lab sessions.

T

Instructors were also able use the e-learning system to monitor student thinking and

SC R

In summary, the system has the following features,

IP

activity, and check the network as well.

1. Use of specific cases, in line with clinical practice situations.

NU

2. Employment of a game and entertainment format to promote interest in learning.

MA

3. Encouragement of self-study during free time, interaction through context, feedback, and repetition of mental exercises to help integrate thought processes.

TE

D

4. Creation of a database link to promote retention of knowledge and learning transfer.

# M494988 )

CE P

(Note: the system has been approved by the Intellectual Property Office R.O.C. patent

AC

Course Design: The nursing ethics course, “Medical Ethics and Regulations,” was required for students in the second year of a two-year technical college nursing program.

In the experimental section of the course, students used the online

interactive learning system to reflect on and clarify their own personal values in scenarios depicting specific ethical dilemmas. Then through face to face probing, debates, and discussions, students engaged in decision-making to plan for ethical care for the patient or family. The teaching model is shown in Figure 3. Items 1, 2, 3, and 4 occurred within the e-learning system; item 5 occurred subsequently in the classroom.

ACCEPTED MANUSCRIPT Course Foci: The course, which is offered 2 hours a week over 18 weeks, The first aspect focuses on students’

T

incorporates three consecutive aspects.

For the next 12 weeks, e-learning and classroom

SC R

principles (a total of 6 weeks).

IP

sensitivity to ethical issues and awareness of relevant nursing ethics theories and

First, students access the ethical decision-making model using

the internet system.

The online guidance leads students through progressive thinking

NU

instruction alternate.

Then students engage in

MA

and reasoning using interactive scenario-based exercises.

face-to-face classroom discussion to clarify the situation and their thinking and come

TE

D

to a decision regarding resolution of the ethical dilemma.

CE P

Phase Two: Testing Effects

The second phase of the project involved implementation and evaluation of the

AC

effects of the experimental blended e-learning course. This phase occurred during the first semester of the 2015-2016 academic year (September 2015 to January, 2016). The study was approved on 7/16/2015 by KuanTien Hospital IRB Committee review (#10445). Using a quasi-experimental design, research was conducted using an experimental group and a control group before and after the intervention.

The

intervention consisted of exposure to the experimental blended e-learning course. The control group received the traditional nursing ethics course without the

ACCEPTED MANUSCRIPT web-based enhancements. The dependent variable was nursing students’ ethical

T

decision-making ability, measured before and immediately after curricular activities to

IP

assess changes in ethical decision-making competencies.

of a two-year technical nursing program.

SC R

Two class cohorts were randomly selected from seven classes in the second year One class was randomly selected as the

NU

experimental group, and the other class was the control group.

MA

The experimental group consisted of 51 senior nursing students in a two-year college who experienced the interactive situational e-learning system described above,

The control group comprised 49 nursing students in the same program who

CE P

week).

TE

D

integrating nursing ethical decisions over one semester (eighteen weeks; 2 hours per

took the same course in the same semester over the same period of time. The control

AC

group received the same content related to ethical principles and theories for making decisions in ethical dilemmas using traditional in-class teaching strategies, including lectures, discussions, debates, and film discussions, without the enhanced web-learning system. Two hypotheses guided the study: 1. After attending a semester of an interactive situational e-learning system integrating nursing ethics decisions, the experimental group will demonstrate significantly better performance on ethical decision

ACCEPTED MANUSCRIPT making than before intervention.

T

2. After attending a semester of an interactive situational e-learning

IP

system integrating nursing ethics decisions, the experimental group

SC R

will demonstrate significantly better performance on ethical decision-making than the control group.

NU

Ethical decision-making competencies were assessed for each group before and

MA

after the intervention as indicated in Figure 4. Competencies were assessed using the “nursing ethical decision-making ability scale” developed by the researchers in a The original scale contained a total of 30

TE

D

previous study (Chao et al., 2014).

CE P

questions reflecting four dimensions: “recognizing differences” (15 items - e.g. “I can consider diverse viewpoints of people involved in the event”); “comparing

AC

differences” (7 items - e.g. “I can compare differing viewpoints between the family and medical personnel”); “self-dialogue” (4 items - e.g. “During the process of conducting ethical decision-making, I can examine my own feelings”), and “identifying implications”(4 items - e.g. “Usually, I know my decision will benefit the client”) . The content validity of the scale was assessed in 2013 with 100 nurses. Cronbach’s α values for the recognizing differences, comparing differences, self-dialogue, and identifying implications subscales were: 0.82, 0.80, 0.83, and 0.80,

ACCEPTED MANUSCRIPT respectively, with that of the total scale at 0.89 (Chao et al., 2014).

In the current

T

study, the scale was reviewed by experts based on the research subjects and purpose

IP

and revised to include six dimensions: “raising ethical questions” (6 questions),

SC R

“recognizing differences” (15 questions), “comparing differences” (7 questions), “self-dialogue” (4 questions), “taking action” (2 questions), and “identifying

NU

implications” (2 questions), for a total of 36 questions.

The Cronbach’s α value for

MA

the total scale was 0.918, while those of the subscales were 0.91, 0.86, 0.82, 0.85, 0.88, and 0.84, respectively.

TE

D

Data on students’ demographic characteristics, including age, gender, past

CE P

nursing employment, personal experience of a loved one facing serious illness, and awareness of and familiarity with nursing ethics and regulations were also collected

AC

by a written self-administered questionnaire created by the researchers. Demographic and competency data were collected in the first week of the semester for both experimental and control groups. Competency data were collected from both groups again in the last week of the semester.

All subjects completed the

written tests together. Data were collected, classified, and coded.

Descriptive and inferential

statistical analyses were conducted using SPSS22.0, and the Generalized Estimating Equations (GEE) method was utilized for the analysis of repeated measures.

ACCEPTED MANUSCRIPT RESULTS

T

The teaching experiment consisted of 100 students, with 51 in the experimental

IP

group and 49 in the control group. Most (94%) were female students aged 21 and 22

SC R

years old, and 90% had never had clinical nursing work experience. For those with work experience, the typical length was less than one year. Only 13% reported an

NU

awareness of and familiarity with nursing ethics, and only 6% considered themselves

MA

familiar with ethical regulations. Most (73%) had experiences with loved ones suffering from serious illness (see Table 1).

TE

D

To demonstrate the similarity between the groups, comparisons were made

CE P

among the influencing factors measured before the pretest and intervention. The basic information is shown in Table 1.

Only gender and clinical work experience

AC

showed significant differences between the two groups. Table 2 shows the comparison between the experimental and control groups before and immediately after measurements of each aspect of ethical decision making. The experimental group showed significant growth in all six dimensions. The control group showed significant growth in four aspects of competence, including “comparing differences,” “self-dialogue,” “taking action,” and “identifying implications.” The GEE method takes into account the pretest effect and the growth effect of

ACCEPTED MANUSCRIPT the comparison group (control group). Table 3 shows the impact of the experimental

Only two dimensions, “raising ethical

IP

effectiveness of the web-based course.

T

intervention on the students’ ethical decision-making ability and the evaluation of the

SC R

questions” and “recognizing differences,” exhibited significant differences between groups with the experimental group demonstrating greater growth in these areas than

MA

NU

the control group.

DISCUSSION

D

Many authors have noted that the ethical decision-making process originates

TE

from “moral consciousness” or “values” (Fry & Johnstone, 2008). Recognition of

CE P

ethical dilemmas requires awareness of one’s own values, patients’ values, and other professionals’ values and insight into the “root causes of conflict” in order to make a

AC

decision based on the patient’s well-being or welfare.

In the first stage of our course,

we provided the context surrounding client suffering or uncertainty to lead students to attend more fully to ethical issues and increase their willingness to address them. The result is reflected in significant growth in the post-test ability to raise ethical questions. The previous literature has indicated that assessing competence in ethical decision-making should be based on one’s response in a particular circumstance (Fischer, 2011; Vogelstein, 2014). The ethical dilemmas in our e-learning system not

ACCEPTED MANUSCRIPT only provided students a learning environment for making ethical decisions, but also

T

allowed faculty to assess students’ responses and ethical reasoning. The e-learning

IP

system focused on the scenarios and posed questions to guide students to assess the

SC R

different viewpoints of those affected by the situation and to engage in self-dialogue to clarify the issues. They were guided to collect and organize information on

NU

ethical norms, laws, and regulations; academic theories and studies of health care; and

MA

sociocultural and religious viewpoints related to the scenario. These activities allowed students to identify the object of concern, assess possible nursing actions, conduct a

TE

D

preliminary analysis of the advantages and disadvantages of strategies, make

CE P

adjustments based on their analysis, and identify the implications of decisions for the clients’ welfare.

AC

The course, in general, promoted students’ positive growth in their ethical deduction abilities in terms of “recognizing differences,” “self-dialogue,” “comparing differences,” and “identifying implications.”

In other words, this project helped

nursing students to achieve the following objectives: (a) grasp the nursing ethics in contexts associated with “who, when, what, where, and how,” (b) objectively analyze key positions in relation to the problem, (c) be familiar with the relevant ethics rules, laws, regulations, and theories and apply them appropriately, (d) assess and judge the pros and cons of strategies, and (e) self-reflect on the measures taken during the

ACCEPTED MANUSCRIPT process.

The decision-making model used educates nursing students to have some

T

degree of reaction, observe keenly, use information to analyze an ethical issue, and

IP

establish and recognize their own viewpoint and position when faced with ethical

SC R

dilemmas.

The e-learning system was grounded in the situated theory and constructivist

NU

perspective, and used animated situations and questions to help students to carefully

MA

view their own feelings and emotions, as well as the emotional and cultural factors that influence one’s decision-making. The system facilitated students using multiple

TE

D

perspectives to articulate problems and reflect on their own thoughts, providing an

CE P

environment for students to explore, interpret and finally make meaning of their decisions. Information about related laws and regulations was set in the system

AC

database for the students. The system provided one-on-one mentoring and guidance, increasing convenience and applicability, assisting students in performing the task. The interactive system in the project incorporated a forum discussion area where students could share and exchange ideas with each other online. In Taiwanese culture, most students fear to express their thoughts in public or debate each other. This platform helped students to share their thoughts and was beneficial for instructors in classroom discussions using students’ views.

As Smith and Smith (2014) noted,

e-learning should address the issue of students’ active and passive participation in

ACCEPTED MANUSCRIPT discussion as a source of learning.

In our design, we rewarded the students with a

T

virtual golden coin in the simulations to promote engagement, and participation in the In addition,

IP

discussion forum counted towards participation credit for the course.

SC R

students who did not participate in the discussion forum were encouraged by faculty to express their thoughts in class.

NU

The effectiveness of e-learning, however, may be affected by several factors,

MA

including computer literacy, whether students understand the curriculum, network environment, degree of participation, learning attitude, motivation, familiarity with

TE

D

the system used for the teaching method, students’ characteristics, and network

CE P

self-efficacy (Carruth, Broussard, Waldmeier, Gauthier, & Mixon, 2010; Henderson, Finger, & Selwyn, 2016).

Computer access and technical issues also influence

AC

student adoption of e- learning modalities (Petit Dit Dariel et al., 2013). Prior to implementation of the web-based system, the researchers considered and prepared for several influencing factors, including instruction on how to use the e-learning system applied in the course. However, many factors remained beyond their control. For example, this was a required course, and students’ learning motivation and attitude maybe difficult to control, and may have influenced part of the results. There was little significant difference between the experimental and control

ACCEPTED MANUSCRIPT groups except with respect to competencies related to identification of ethical

T

questions and recognition of differences in values and viewpoints among those

“This process urged me to make

SC R

experimental group are reflected in this statement:

IP

involved in the situation. Responses to open-ended survey questions of students in the

my own inquiry and gather relevant data to guide me to find the answer.

It can be

NU

very challenging, but can lead to self-discovery and self-understanding.” This

MA

comment may indicate that the e-learning process helped with recognition of ethical issues.

TE

D

The experimental group also showed significantly greater improvement than the

CE P

control group with respect to recognition of differing values and points of view among those involved in the ethical situation.

The data suggested that the e-learning

AC

system assisted students to understand different positions among the opinions of people, societal judgments and opinions, and their own moral views. The e-learning system may also have assisted students to collect and organize information on ethical guidelines, laws and regulations, relevant theories, social, cultural, religious, and other views, and other helpful materials related to the issue. When asked to evaluate the database resources in our web-system, students responded "the provided database expands our knowledge".

The database could assist students to collect relevant

information to resolve ethical dilemma, but may also inhibit students from seeking

ACCEPTED MANUSCRIPT knowledge from other resources.

In this study, we did not ask whether students used

T

other digital technology to resolve the dilemma, which might influence the learning

IP

effects of the system.

SC R

Both the experimental and control groups showed significant growth in “comparing differences,” “self-dialogue,” “taking actions,” and “identifying

NU

implications.” These positive results in the control group suggest that further research

MA

is needed to evaluate the effects and utility of e-learning in promoting ethical decision making.

During the process of discussion and debate, teachers

CE P

the ethical situations.

TE

D

Both groups experienced teaching strategies of discussion and debate regarding

encouraged, stimulated, and led students to think, clarify their questions, and identify

AC

their values, which should facilitate ethical reasoning and help to clarify the implications of decisions made. The findings of our study echo previous scholar's conclusion, that face-to-face discussion may be a crucial element in creating knowledge (Carruth et al., 2010; Feng,et al., 2013; Petit Dit Dariel et al., 2013; Henderson et al., 2016). Many authors have pointed out that e-learning requires more resources and supportive measures to advance student and teacher interaction, such as providing students with tutors (Carruth et al. 2010 ; Lewis & Price, 2007).

Also, e-learning

ACCEPTED MANUSCRIPT needs sufficient web space to prevent the network system from running slowly or not

T

working. E-learning needs to consider providing students opportunities to ask

In our project, two teaching assistants were available in

SC R

Petit Dit Dariel et al., 2013).

IP

questions and to address possible anxiety over using computers (Muirhead, 2007,

the lab to assist students with technical issues. In addition, the second author in this

NU

study is an expert in information technology and was responsible for checking the

MA

network each day.

E-learning requires the opportunity for interaction between faculty and students.

TE

D

Therefore, some scholars have used an immersive and blended teaching style (Carruth

CE P

et al., 2010; McCutcheon, Lohan, Traynor, & Martin, 2015). For these reasons, this project was planned and conducted to foster both online and face-to-face interaction

AC

among students and faculty.

CONCLUSION

The interactive e-learning system integrated into a nursing ethics course in our project effectively prompted students to identify ethical dilemmas, approach problems using multiple viewpoints, and make decisions based on deliberate consideration. The system also fostered greater growth in recognition of different viewpoints than the traditional teaching methods. However, it remains unclear whether difference in improvement in only two dimensions of ethical decision making competency warrant

ACCEPTED MANUSCRIPT the extensive effort required to develop and implement e-learning modalities in It may be worthwhile, however, to incorporate some of the

T

nursing ethics education.

IP

elements of the web-based course into traditional courses. For example, the video

SC R

animations developed for the system and the ethical decision making model could be easily incorporated into a traditional face-to-face teaching format. Similarly, the

NU

discussion and debate of scenarios seemed to be of help to both groups of students

AC

CE P

TE

D

MA

and could be included in traditional courses, as well.

ACCEPTED MANUSCRIPT References Carruth, A. K., Broussard, P. C., Waldmeier, V. P, Gauthier, D. M., & Mixon, G.

T

(2010). Graduate nursing online orientation course: Transitioning for success.

IP

Journal of Nursing Education, 49, 687-690.

SC R

Chao, S. Y., Yang, S. C., &Chang, Y. C. (2014). Exploration of the effectiveness of the “Interactive Situational Learning Web System- Integrating Nursing Ethical Decisions into the Course” on the improvement of nursing students’ ethical

NU

decision-making competence. NSC Thematic Research Report. (MOST 102-

MA

2511-S-241-003-), unpublished.

Dabbagh,N. (2005). Pedagogical models for e-learning: A theory-based design

D

framework. International Journal of Technology in Teaching & Learning 26,

TE

25-44.

Dickieson, P., Carter, L., & Walsh. M. (2008). Integrative thinking and learning in

CE P

undergraduate nursing education: Three strategies. International Journal of Nursing Education Scholarship, 5, 1-15.

AC

Duijin A., Swanick K., & Donald E. (2014). Student learning of cervical psychomotor skills via online video instruction versus traditional face-to-face instruction. Journal of Physical Therapy Education 28, 94-102. Feng,J-Y., Chang,Y-T., Chang, H-Y., Erdley, W. S., Lin, C-H., & Chang, Y-J. (2013). Systematic review of effectiveness of situated e-learnign on medical and nursing education. Worldviews on Evidence-Based Nursing,10, 174-183. Fischer, S. (2011). Developing moral decision-making competence: A quasi-experimental intervention study in the Swiss. Ethics & Behavior, 21, 452–470 Fry, S. T., & Johnstone, M. J. (2008). Ethics in nursing practice (3rded.). Oxford, UK: Blackwell Science Ltd.

ACCEPTED MANUSCRIPT Garity, J. (2009). Fostering nursing students’ use of ethical theory and decision-making models: Teaching strategies. Learning in Health and Social

T

Care, 8, 114-122.

IP

Hainey, K., Green, A., & Kelly, L. (2017). A blended learning approach to teaching

SC R

CVAD care and maintenance. British Journal of Nursing, 2, 4-12. Henderson, M., Finger, G., & Selwyn, N. (2016). What's used and what's useful ? Exploring digital technology use(s) among taught postgraduate students. Active

NU

Learning in Higher Education, 17, 235-247.

MA

Hsieh, B. S. (2004). Modern medicine in Taiwan (2nd Ed.).Taipei, Taiwan: College of Medicine, National Taiwan University.

D

Lancaster, J. W.. Wong, A., & Roberts, S. J. (2012).‘Tech’ versus ‘talk’: A comparison

TE

study of two different lecture styles within a Master of Science nurse practitioner course. Nurse Education Today 32(5) (2012), 14-8.

CE P

Lewis, A.P., & Price, S. (2007). Distance education and the integration of E-learning in a graduate program. The Journal of Continuing Education in Nursing, 38,

AC

139-143.

McCutcheon,K., Lohan,M., Traynor,M.& Martin, D. (2015). A systematic review evaluating the impact of online or blended learning vs. face-to-face learning of clinical skills in undergraduate nurse education. Journal of Advanced Nursing 71, 255–270. doi: 10.1111/jan.12509 Muirhead, R. J. (2007). E-learning: Is this teaching at students or teaching with students. Nursing Forum, 42, 178-184. Natarajan, M, & Kirsham Marg, K. S. (2015) Evaluation methods for E-learning: an analytical study. International Journal of Library and Information Science 1(1): 1–14 Park, M. (2009). Ethical issues in nursing practice, Journal of Nursing Law, 13(3),

ACCEPTED MANUSCRIPT 68-77. Petit Dit Dariel, O., Wharrad, H., & Windle, R. (2013). Exploring the underlying

T

factors influencing e-learning adoption in nurse education. Journal of Advanced

IP

Nursing 69, 1289–1300. doi: 10.1111/j.1365-2648.2012.06120.x

SC R

Rostad ,H., Karine, E., & Moen, A. (2014). Considerations for design of an e-Learning program augmenting advanced geriatric nurse practitioner’s clinical skills training. Nursing Informatics, 285-289.

NU

doi:10.3233/978-1-61499-415-2-285

MA

Selwyn, N. (2011). Education and technology: Key issues and debates. New York, NY: Continuum International Publishing Group.

D

Smith, D., & Smith, K. (2014). The case for "passive" learning --The "silent

TE

"community of outline learners. European Journal of Open, Distance and e-Learning, 17,85-98.

CE P

Smyth, S., Houghton, C., Cooney, A., &Casey, D. ( 2012 ). Students' experiences of blended learning across a range of postgraduate programmes. Nurse Education

AC

Today,32,464-468. http://dx.doi.org/10.1016/j.nedt.2011.05.014 Tu, C. H., & Chen, Y. M. (2009). Concept and practice of situated learning. Taipei County Education, 69, 46-50. Usluel, Y. K., & Mazman, S. G. I. (2009). Adoption of Web 2.0 tools in distance education. Procedia - Social and Behavioral Sciences, 1, 818-823. Vogelstein, E. (2014). Competence and ability. Bioethics, 28, 235-244. Yu, Y. M. (2010, August, 9). The meaning and development of nursing education accreditation in Taiwan. Taiwan Association of Nursing Education, Newsletter, issue 4. Retrieved from: http://www.tane.org.tw/show.php?news_no=38)

SC R

IP

T

ACCEPTED MANUSCRIPT

AC

CE P

TE

D

MA

NU

Figure 1. Screen of an animated video

NU

SC R

IP

T

ACCEPTED MANUSCRIPT

AC

CE P

TE

D

MA

Figure 2. Nursing ethical decision-making model

ACCEPTED MANUSCRIPT

the ethical decision

decision model to develop

model

a solution

T

3.Use of the ethical

5. Discussion and debate in class.

SC R

an ethical dilemma

2.Presentation of

IP

1.Presentation of

NU

4.Data Base

Policies / Law /Regulations Theories/

MA

Related Information

AC

CE P

TE

D

Figure 3. Teaching Model for Integrating E-learning Technology into a Nursing Ethics Course.

ACCEPTED MANUSCRIPT Pretest

Control Group:

Pretest

New Treatment Traditional Treatment

T

Experimental Group:

AC

CE P

TE

D

MA

NU

SC R

IP

Figure 4. Quasi-experimental Study Design

Posttest Posttest

ACCEPTED MANUSCRIPT Table 1: Chi-Square Test of homogeneity of basic information for experimental and control groups

N(%)

N(%)

N(%)

6(6.0) 94(94.0)

6(12.2) 43(87.8)

Age 82(82.0) 18(18.0)

TE

D

Yes 10(10.0) Years of work experience in nursing (n=10) Less than one year 5(50.0) One year and above 5(50.0)

AC

CE P

Awareness of and familiarity with nursing ethics Unfamiliar Somewhat familiar Familiar Awareness and familiarity with ethical regulations Very Unfamiliar

Unfamiliar Somewhat familiar Familiar Life experience with loved ones facing serious illness Never Experienced

16(16.0) 71(71.0) 13(13.0)

8(16.3)

2(3.9)

11(22.4) 3(67.3) 5(10.2)

0.012

1.288

0.340

4.273

0.049

2.500

0.444

3.256

0.196

4.268

0.234

1.558

0.262

5(9.8) 38(74.5) 8(15.7)

3(6.1)

2(3.9)

26(26.0) 63(63.0) 6(6.0)

14(28.6) 27(55.1) 5(10.2)

12(23.5) 36(70.6) 1(2.0)

16(32.7) 33(67.3)

6.644

0(0.0) 2(100.0)

5(5.0)

27(27.0) 73(73.0)

P Value

44(86.3) 7(13.7) 49(96.1)

5(62.5) 3(37.5)

X2

0(0.0) 51(100.0)

41(83.7)

MA

90(90.0)

38(77.6) 11(22.4)

NU

21yrs and below 22yrs and above Clinical work experience No

T

Experimental Group

IP

Gender Male Female

Control Group

SC R

Item

All

11(21.6) 40(78.4)

ACCEPTED MANUSCRIPT Table 2: Measurement of Change in Dimensions of Ethical Decision Making in

T

Experimental and Control Groups before and after Learning Experimental Group

IP

Time

M(SD)

M(SD)

20.72(1.873)

20.48(1.571)

21.48(2.032)

20.96(1.978)

2.260*

1.463

57.08(5.358)

57.02(5.436)

61.38(6.213)

58.15(5.918)

4.714***

1.197

Before

27.94(2.787)

27.54(2.449)

After

29.70(2.971)

29.04(3.101)

3.468**

2.866**

Before

15.76(1.465)

16.00(1.738)

After

17.22(1.694)

17.04(1.701)

4.803***

2.947**

Before

7.88(1.136)

7.79(1.071)

After

8.46(0.930)

8.29(0.849)

3.092**

2.62*

Before

7.84(0.766)

7.70(0.922)

After

8.60(0.930)

8.46(0.988)

4.977***

4.488***

SC R

Before After

Raising ethical questions

Before After

MA

T(Value)

D

Comparing differences

CE P

TE

T(Value)

Self-dialogue

T(Value)

Taking action

AC

NU

T(Value)

Recognizing differences

T(Value)

Identifying implications

T(Value) *p<0.05; **p<0.01; ***p<0.001

Control Group

ACCEPTED MANUSCRIPT Table 3: Growth and Effects of the Alternate Teaching Method on Ethical

T

Decision-making Ability

IP

SC R

Estimated Standard Parameter Error s(B) (SE)

95% Wald Confidence Interval

Raising ethical questions 17.687

0.5837

MA

Intercept

NU

Upper

p

Lower

16.543 18.831

0

-0.163

0.2138

-0.582

0.256

0.446

Time

-0.173

0.2005

-0.566

0.22

0.389

0.091

1.069

0.02*

54.285 63.188

0

D

Group

0.2494

58.736

2.2713

-0.448

1.1438

-2.69

1.793

0.695

0.254

1.1168

-1.935

2.443

0.82

3.666

1.3571

1.006

6.326

0.007**

27.87

1.414

25.098 30.641

0

Group

0.18

0.544

-0.886

1.246

0.741

Time

1.245

0.628

0.014

2.476

0.047

Group x Time

0.512

0.717

-0.893

1.916

0.475

14.176

0.7492

12.707 15.644

0

-0.467

0.3359

-1.125

0.191

0.164

0.76

0.3996

-0.024

1.543

0.057

0.58

Intercept Group

AC

Time

CE P

Recognizing differences

TE

Group x Time

Group x Time

Comparing differences Intercept

Self-dialogue Intercept Group Time

ACCEPTED MANUSCRIPT Group x Time

0.607

0.4494

-0.274

1.488

0.177

7.513

0.3924

6.744

8.282

0

0.00006641

0.2354

-0.461

Time

0.277

0.1886

-0.092

Group x Time

0.242

0.2569

7.115

T

1

0.647

0.142

-0.262

0.745

0.347

0.2967

6.533

7.696

0

0.1691

-0.284

0.378

0.781

0.1949

0.037

0.801

0.032

0.211

-0.258

0.569

0.461

Identifying implications Intercept

0.047

Time

0.419

Group x Time

0.156

MA

Group

AC

CE P

TE

D

*p<0.05; **p<0.01

0.462

IP

Group

SC R

Intercept

NU

Taking action

ACCEPTED MANUSCRIPT Highlights:

T

IP

SC R NU MA D TE CE P

 

The interactive situational e-learning system provides a learning environment for enhancing nursing student’s competence in ethical reasoning. The e-learning program promotes students’ abilities to reflect on ethical issues. The course design provides a model for integrating e-learning technology into a nursing ethics course.

AC