This study was conducted to determine the ethics taught in the curriculum of undergraduate nursing programs in Turkey.
Nurses today face many ethical dilemmas. In nursing education programs, it is necessary to develop students' ethical decision-making skills.
The descriptive design research includes 124 undergraduate nursing education programs in Turkey.
The courses related to ethics are titled 'Nursing History and Deontology' and 'Ethics in Nursing', and they both have high ratings. The students have begun clinical practice before the ethics course. Lecture and case analysis were frequently used teaching methods. Course content demonstrated shortcomings compared to the National Nursing Core Curriculum.
It is proposed that the curriculum be updated to ensure that theoretical knowledge is transferred to clinical practice in order for the students to develop their ethical decision-making skills.
Ethics, Undergraduate students, Nursing, Education, Care
All healthcare professionals experience ethical problems , and nursing students experience these problems just as commonly as other health professionals. Some of these issues involve medication and treatments, quality care, harmful behaviour, force-feeding, and patient confidentiality . In a study by Erdil and Korkmaz , ethical problems observed by nursing students in the clinic were examined. The most frequently observed problems of the students were related to psychological maltreatment, patient confidentiality, and unsuitable information . Good care for individuals should be one of the primary goals of nurses . Today, good nursing care includes creative solutions that focus on the personal needs and well-being of patients, including solutions to ethical dilemmas. When nurses encounter ethical dilemmas, they usually employ traditional methods to solve them. This situation evokes a discussion of nurses' ethical decision-making competences .
Ethical training-indispensable for establishing an excellent system of values and improving students' abilities-should enable students to apply ethical behavior by improving their judgment and sensitivity. At the same time, ethics education should contribute to the awareness of nursing students of their social roles as healthcare professionals  and to ensure that practices in professional health programs are safe, effective, and ethical . For these reasons, ethical decision-making skills should be developed during nurses' undergraduate education . To discover ways of improving these skills, studies were conducted on ethics courses in a nursing curriculum, and the teaching of ethics was evaluated in different countries [2,9-13].
Turkey joined Bologna's process in 2001 . The National Nursing Core Curriculum (NNCC) aims to improve education in Turkey, determine criteria for the European Union in accordance with the national framework, and set minimum standards in nursing education, all to achieve standardization in nursing education in the country. NNCC is a framework program for undergraduate nursing education institutions to use as a basis for developing their own training programs . Nursing educators and researchers need to pay attention to the issue of ethics education in order to improve the ethical decision-making competencies of nurses .
This appears to be the first study consisting of all undergraduate nursing programs. This study will explore the features of the ethics courses in the curriculum of undergraduate nursing programs in Turkey.
This descriptive study covers 124 undergraduate nursing education programs in Turkey.
In order to collect data, the curricula of 124 universities with undergraduate nursing programs were examined via the schools' web pages. The universities with undergraduate nursing education were determined by examining the program atlas of the Higher Education Council .
The data obtained between March and May 2018 are included in the data collection form created by the researcher. On this form, the type of undergraduate program, the title of the ethics course, the semester of the ethics course, ECTS (The European Credit Transfer and Accumulation System), type and weekly course hours, clinical practice before the ethics course, and the teaching and evaluation methods are illuminated.
The statistical evaluation was made with precise information from the programs. The content and learning outcomes of the ethics courses in the nursing program curricula have been evaluated according to the content and learning outcomes of the NNCC, which contains curriculum-related topics, content, and learning outcomes. Ethics is included in curriculum-related topics in NNCC. The content of the ethics courses consists of nursing values, codes of ethics, professional codes of ethics, ethical dilemmas, ethical decision making process, ethical sensitivity, ethics in nursing practice, ethics of care, and human and patient rights. Learning outcomes were intended to analyze ethical issues in the health care industry, to take into account ethical principles, to recognize ethical dilemmas, to be able to start the process of decision-making in ethical dilemmas, to be able to consider human/patient rights in nursing practice, to be able to behave according to professional values, and to be able to provide nursing care while taking into account ethical principles to show sensitivity to ethical issues .
PASW (Predictive Analytics Software) 18 was used for data analysis. Data were analyzed using descriptive statistics (frequencies and percentages).
Research data were obtained by searching the web pages of the universities. The information on the web pages is public. Therefore, the ethics committee approval was not indicated. In the article, there is no information to reveal the names of universities.
Of the undergraduate nursing programs in Turkey, 54.8% are in the Health Sciences departments. A courses titled 'Nursing History and Deontology' was taken as a 5th semester course in most undergraduate nursing programs. The majority of ethics courses were obligatory (Table 1). In 85.1% of the programs, the ethics course was taught in two hour per week classes, and almost half the programs consisted of two ECTS credits (Table 1). In one nursing program, there were only about two hours of weekly practice. Ethics courses are taught in one semester, and the majority are taught in 14 weeks (57.3%). In most of the programs, students began clinical practice before ethics education, and the evaluation method was midterm and final exam. The primary teaching method was formal lectures (89.1%), and the secondary was case analysis (67.2%) (Table 1).
Table 1: Characteristics of ethics courses in the curriculum. View Table 1
Ethics course content addressing human and patient rights according to the NNCC represented the highest percentage of overall course content; however, ethical sensitivity represented the lowest percentage. The low percentage of ethical codes is also remarkable (Table 2).
Table 2: Ethics course content according to national nursing core curriculum (n = 103). View Table 2
Being able to analyze ethical issues in the health care industry according to the NNCC was the learning outcome representing the highest percentage of course content; however, being able to show sensitivity to ethical issues represented the lowest percentage (Table 3).
Table 3: Ethics course learning outcomes according to national nursing core curriculum (n = 100). View Table 3
This study was conducted to determine the ethics content in the curriculum of undergraduate nursing programs in Turkey. The ethics course was titled "Nursing History and Deontology", and it was a 5th semester course in most of the undergraduate nursing programs. In most of the programs (90.0%, n = 110), students begin clinical practice before ethics education. In nursing education, it is necessary to transfer students' theoretical knowledge about ethics to clinical practice . Nursing students experience conflict during their training, but ethics training helps them solve these conflicts . The importance of ethics training given before clinical practice is emphasized in the studies related to ethics training that includes nursing and medical students [6,18]. Studies show that it is important to complete basic ethical training before clinical training begins.
An ethics course was obligatory in 84.3% of Turkish nursing programs. The belief is that ethical education should be compulsory for all students in medicine, including nursing students [6,18]. Ethics training should be provided for nursing students in clinical practice and even after graduation. This will raise awareness of ethical issues and increase the ability of nurses to reflect ethical knowledge in their practice .
The majority of nursing program ethics courses were taught for two hours per week for 14 weeks. In Korea, nursing students are given ethical education for 13 weeks at 90 minutes per week. It is believed that this education increases students' awareness of ethical codes . As a result of another study in which the ethics course was taught in 4-32 hours, the moral reasoning skills of the nursing students increased as the duration of the ethics course increased .
In 45.5% of the programs, the ethics course consisted of two ECTS credits. ECTS is accepted as the national credit system in many countries of the European Higher Education Area (EHEA). ECTS places the student at the center of the educational process, using learning outcomes and the workload in curriculum design and delivery. Workload is the estimated time that an individual must complete all learning activities, such as lessons, seminars, projects, practicing, work placement and individual work required to achieve defined learning outcomes in formal education settings. The use of credits makes it easier to create and document flexible learning paths, thereby enabling students to have more autonomy and responsibility. In national legislation the use of ECTS is necessary for accrediting higher education programs or qualifications .
In the majority of nursing programs, the evaluation method was midterm and final exam, but no information is available on the type of examination. A variety of tests or case-based exams can be used to assess moral reasoning skills in evaluating students in ethics education. In addition, students' behaviors can be evaluated in ethically difficult situations .
Teaching methods and techniques frequently used in ethics education are lectures, small group discussions, and case analysis. In addition, role playing, videos, movies, empirical articles, moral philosophy, and literature/humanities are other teaching methods and techniques . Formal lectures were the most common teaching methods in this study. Park, et al.  found that as the duration of the non-lecture methods increase, the students' moral reasoning skills increase, and that the development of methods to provide effective use of teaching methods in large classes is important for the development of principled thinking in students . In another study, it was found that students' ethical knowledge increased with the use of various teaching methods such as lectures, videos, films, group presentations, and discussions . In a study by Dinç and Görgülü , it was found that a case analysis study conducted by using ethical principles is useful in developing the ethical decision-making skills of nursing students . Also, public lectures, discussion groups, and journal clubs offer the option of informal learning in ethics education .
According to the national nursing core curriculum, the highest percentage of ethics course content was directed towards human and patient rights; however, ethical sensitivity represented the lowest percentage. Studies show that the subject of human and patient rights has an important place in the curriculum [10,18]. The results of the current study are similar to the results of these studies. Ethical sensitivity refers to knowledge of ethical principles and theories . In other words, ethical sensitivity is defined as a process in which one is aware of the existence of ethical problems, interprets the situation, and decides which options are applicable . Nurses face ethical dilemmas in their professional work life . In a study by Kim, et al. , it was found that a high level of ethical sensitivity positively influenced ethical decision making . In addition, studies indicate that ethical sensitivity increases with education [23,24]. The literature reveals the importance of placing the issue of ethical sensitivity into the curriculum.
On the other hand, it was found that the issue of ethical codes represented a low percentage in the curriculum. Ethical codes are useful for nurses in cases of ethical dilemmas and provide a guide for reflecting on ethical practices in nursing . In a study by Dinç and Görgülü , it was found that the use of ICN codes in ethical education is useful in developing ethical decision-making skills of nursing students . Ethical codes are at the core of nursing care and thus of nursing education , and they should be taught to nursing students.
When the learning outcomes of the ethics course were analyzed according to NNCC, it was found that there were deficiencies in defining the outcomes. Learning outcomes need to be determined to assess learning .
One of the limitations of the research is that statistical evaluation is done through the programs that complete the data entry, since the curriculum information is not fully entered in all of the nursing programs. Under ethics course title in Table 1, other category is in the highest frequency. No other category could be created due to the large number of different ethics course titles. This is the other limitation of the research.
It is determined that there are deficiencies according to NNCC standards in ethics course content and learning outcomes in undergraduate nursing programs in Turkey. In order to improve the quality of ethical education that is required for good nursing care, the content of ethical training should be restructured according to NNCC standards. In addition to this, it is recommended that ethics courses be included in the curriculum before the beginning of clinical practice, and the courses should include laboratory practice, an increase in non-lecture methods to enable the active participation of students, and the evaluation of the effectiveness of the ethics training.
This study was supported by Scientific Research Coordination Unit of Pamukkale University under the project number 2018KRM002-287.