Introduction

The nursing profession is highly respected and for nearly two decades, the public has ranked nursing as one of the most ethical professions [1]. The ANA Code of Ethics with Interpretive Statements establishes and serves as the ethical standard for all nurses to uphold in their practice [2]. There is an expectation on the part of patients and their families that nurses will perform tasks and provide care that follows the ethical standards of the nursing profession. While this is the case, nurses often provide care unsupervised by others so they must possess a strong ethical foundation on which they can build their professional practice. Research has indicated that health care professionals who achieve higher levels of moral judgment development and acquire strong moral reasoning skills have a greater likelihood of making ethical decisions that are in the patient’s best interest and willing to report errors that occur during interactions [3].

Nursing faculty are charged with ensuring student nurses accrue the necessary foundational knowledge and experiences to become professional nurses [4]. It is vital that nurse educators understand how students perceive ethical situations in order to develop strategies that will adequately prepare them to be worthy of the public’s trust. Students need planned educational activities that highlight the importance and necessity of altruism, autonomy, human dignity, integrity and social justice as these concepts relate to providing quality patient care. Educational activities need to occur in settings that include both classroom and clinical environments [4].

There is ample evidence suggesting nursing students struggle to apply the concepts of honesty, morality, and ethics in academic settings [5-10]. As many as 75% of all college students admit to engaging in academically dishonest activities with 95% reporting they have never been caught [10]. Academic dishonesty is also high among student nurses [8,10]. In a systematic review examining plagiarism in nursing education, Lynch et al. [11] found pervasive evidence that cheating is rampant in programs of nursing and is negatively linked to professional integrity. In a seminal survey by Krueger [7], over 60% of student nurse respondents (n = 216/334) admitted to academic misconduct in the classroom with 54% admitting to similar behaviors in clinical settings when taking care of patients. Nursing student dishonesty impacts clinical environments and the quality of patient care. Dishonest clinical behaviors include falsifying aspects of patient encounters such as documenting care that was never provided or provided by someone else [8]. Park and colleagues [10] found that reasons for student misconduct is varied but can include attempts to improve grades and chance for scholarships or based on lack of punishment for dishonest behavior in the past.

Moral Judgment Development

James Rest’s [12] Defining Issues Test (DIT) resulted in the development of his Four Component Model suggesting that moral functioning is a result of at least four processes, which include: “Moral sensitivity, moral judgments, moral motivation, and moral character,” which interact with each other [13]. The first component of Rest’s [12] model, moral sensitivity, involves the interpretation of the situation. As a part of this component, the person must decide possible actions to take and the consequences of the action for each person involved, including him or herself. This component often results in feeling empathy for others and a “Gut” reaction to the situation [14]. The second component of the model is moral judgment. Within this component, the person must make a decision regarding the course of action, which is influenced by their moral intuition and genetic predisposition [12,13]. In this component, the person judges whether the actions they have decided to take are morally right [14]. The third component of the model is moral motivation. In this component, there is conflict of other values with moral values, and a desired goal can influence the outcome. The person sets priorities to act based on moral values versus personal values [12,13].

The fourth and final component of Rest’s [12] theory is execution and implementation of the plan of action. During the implementation of the plan, the person must determine the order of actions, work around any barriers, resist fatigue and frustration, and focus on the ultimate goal [14]. Characteristics of persons who experience success in the fourth component include perseverance, resourcefulness, and competence [13,14].

The Four Component Model is considered a “Neo- Kohlbergian theory of moral judgment development that can be measured by the DIT” [15]. The DIT represents an understandable and easy way to measure moral judgment development. It is drawn from Kohlberg’s three levels of moral development; pre-conventional, the lowest level, conventional, and postconventional moral reasoning, which is considered the highest level of moral development [15,16]. Included within the three levels are six stages – stages one and two in the pre-conventional level, stages three and four in the conventional level, and stages five and six in the post-conventional level [16,17]. Kohlberg [17] suggested that persons move sequentially through each stage from one through six, with the majority reaching stages three or four, but few moving on to stages five or six. Registered nurses, as well as nursing students, have difficulty reasoning at a postconventional level of moral development, meaning that they are not able to differentiate themselves from expectations, rules from norms, or define moral values and principles [18]. Nursing faculty are called to provide opportunities for students to further develop their level of moral judgment and expand their understanding of ethical decision making in academic and clinical settings [5,8].

There is extensive literature describing dishonest behaviors by nursing students in the classroom and clinical settings [5-10]. With this extensive body of literature, there remains a gap in the investigation of potential differences among nursing students at the beginning of the program to those at the end of the program. different levels in the nursing program. Along with this, the literature concentrating on possible differences that may exist between students’ perceptions of academic and clinical integrity at different points in a baccalaureate program are scarce and some are over twenty years old [19-21].

Purpose

Little is known about how student perceptions of academic and clinical integrity and the students’ associated stage of moral development for nursing students at the beginning and end of their nursing education. The purpose of this study was to investigate potential differences in the moral judgment and associated level of moral development and the perceptions of academic and clinical integrity between these two groups of nursing students. Two research questions guided this study. Research question one asks; in nursing students who are in their first semester or in their last semester prior to graduating, what is the difference in moral judgment scores from the Defining Issues Test Version-2 (DIT-2) between groups? The second research question asks; in nursing students who are in their first semester or in their last semester prior to graduating, what is the difference in perceptions of academic and clinical integrity based on the Hilbert Unethical Behavior Survey (HUBS) between groups?

Methods

Data Collection

A purposive sample of 100 baccalaureate nursing programs were randomly selected from the AACN’s list of Commission on Collegiate Nursing Education (CCNE) accredited institutions. Institutional Review Board (IRB) approval was obtained prior to data collection from each site. Participants were contacted indirectly using a nursing program assistant from each site. The program assistant distributed informational emails created by the investigator to students enrolled in their first and last clinical semester in the nursing programs. A link to the consent form and online surveys were also included in the correspondence. Those participants that consented, were asked demographic questions and completed the DIT-2 [22] and HUBS [20]. Participant surveys were submitted anonymously using online survey software.

Instruments

The demographic questionnaire asked the participants’ age, gender, semester in the nursing program, Grade Point Average (GPA), self-described ethnic background, mother’s education level, father’s education level, and previous schooling or degree attained.

The Defining Issues Test (DIT) is a multiple-choice standardized test that takes about 20-30 minutes to complete. It has been used in studies of cognitive moral development involving over 40,000 participants and provides information on test-taker’s level of moral judgment development [22]. The DIT-2 is the most recent version of the DIT. It contains five ethical dilemma cases that ask the test-taker to rank a sequence of possible solutions to address each ethical case. The options in the DIT-2 are based on different levels of moral judgment. The DIT-2 does not use knowledge-based ethics content, but rather probes how the testtaker would respond to or act in the situations presented allowing for an approximation of a behavior-based assessment [23]. The DIT-2 provides both a P-score and a N2-score. The P-score is calculated on points assigned to the ranking of the ethical cases and dividing by the total number of points. The N2-score is calculated the same way, but also uses additional developmental data drawn from the DIT. The range of scores for the P-score and N2-score is the same; from 0% to 95%. The N2-score has now become the recommended reporting measure because of the additional data utilized [24,25]. There are no interpretations available for specific N2-score ranges, however there are N2-score norms for undergraduate students (M = 36.74, SD = 13.15) [26]. Previous studies that have used the DIT-2 have reported strong internal reliability with a Cronbach alpha of 0.78 [3,22].

The HUBS was developed in 1985 [20] and is a self-reporting questionnaire containing 22 questions pertaining to ethical situations; 11 occurring in the classroom (academic) setting and 11 occurring in the clinical setting. The original survey was adapted with permission from the author to remove the word “Pager” and also replace “Word Processor” with “Computer”. Participants respond to survey questions asking if behaviors presented are unethical, how many times they have participated in those behaviors, or if they have seen others participating in them. All of the classroom and clinical behaviors asked about on the HUBS are considered unethical and measures respondents’ perceptions of classroom and clinical integrity [20]. Internal reliability for the HUBS is reported as a Cronbach alpha of 0.668 [27].

Results

Data analysis was completed with the Statistical Package for the Social Sciences (SPSS) v. 25. Approximately 1,900 students received the informational email inviting them to participate in the study and there was a 9.2% response rate. A total of 141 participants were included at the start of the analysis. Six participants had scores on the HUBS or DIT-2 that were outliers. To normalize distribution of the data these six participants were eliminated. The final sample consisted of 135 participants with 69 participants that identified as first semester nursing students and 66 participants that identified as final semester nursing students. A descriptive analysis of the data revealed the groups to be comparable with regard to gender with 92.7% of first semester respondents and 95.5% of final semester respondents being female. When comparing age, most of the first semester students (72.5%) and final semester students (74.2%) were between the ages of 18 and 24. With regard to ethnicity, the vast majority (91.3%) of first semester and (90.9%) of final semester students identified as being White or Caucasian. Refer to (Table 1) for an overview of demographic data for both first semester and final semester students.

A series of independent-samples t-tests were conducted to evaluate the differences in mean DIT-2 N2-scores and classroom and clinical integrity perception scores from the HUBS for first semester versus last semester nursing students. There was no statistically significant difference in the mean N2-scores of first semester students (M = 36.74, SD = 13.15) and last semester students (M = 38.07, SD = 11.83); t(135) = -0.614, p = 0.539.

There was no statistically significant difference in classroom integrity perception scores of first semester students (M = 93.28, SD = 10.41) and last semester students (M = 93.66, SD = 8.73); t(135) = -0.23, p = 0.818). See (Table 2) for results of the HUBS perceptions of unethical behaviors in the classroom by level in the nursing program.

There was no statistically significant difference in clinical integrity perception scores of first semester students (M = 96.18, SD = 7.70) and last semester students (M = 94.49, SD = 10.19); t(135) = 1.09, p = 0.278). See (Table 3) for results of the HUBS perceptions of unethical behaviors in the clinical setting by level in the nursing program.

Discussion

Findings of this study indicate that levels of moral judgment development between newly admitted first semester students compared to those in their last semester prior to graduating from baccalaureate nursing programs are not significantly different. The results of this study reveal that newly admitted nursing students are already highly morally developed with mean N2-scores of 36.74. According to Dong [26], for undergraduate students to be considered in the post-conventional stage of moral development, they must have a mean N2-score of 34.6 and the participants in this study exceeded this as a whole. While the comparison of N2-score means between the two groups of students did not demonstrate significance, it is interesting to note that the mean N2-scores for all participants (M = 37.39) in this study is similar to Hilbert’s [27] original findings (M = 37.39) which implies that there has been little change between the DIT scores in nursing students from 1988 to today.

Ethical nursing practice is a cornerstone of the nursing profession as a whole [28]. Nurses are expected to identify and contribute to solving ethical problems that arise in the healthcare settings in which they practice [18]. Findings from this study indicate that although students admitted to nursing programs are highly morally developed and therefore should be able to actively participate in solving ethical issues there is room for improvement [5,7,14,27,29]. In order to safeguard patients, it is essential to maintain and improve the ethical principles and standards taught in nursing school and relied upon by the nursing profession and the public at large. Although the results of this study did not yield statistically significant results, there are still implications for nursing practice and education. This study’s results support the continued effort by nursing faculty to evaluate and improve ethics education for nursing students in programs. By designing curricular activities that expose students to specific types of ethical problems commonly faced by nurses, learners are afforded opportunities to work through the steps of ethical decision making. This includes collaborating with their student colleagues while having the support and guidance of faculty. These types of class activities should be developed and be appropriate for large class discussion, small class discussion and/or role playing, online discussion forums, simulation, and/or clinical post-conference.

While the majority of participants in this study perceived the academic and clinical behaviors presented in the HUBS as unethical, most behaviors did not reach 100% identification. These results are similar to other researcher’s investigations into the prevalence and perceptions of academic and clinical integrity [7,10,18,29]. The outcomes are an indication that additional education and opportunities to increase student understanding of what constitutes unethical behavior may be beneficial. Student nurses learn quickly the differences between the idealism and reality of nursing practice. This can lead to a gap between the theory and practice of ethical decision making and action. To decrease this gap, nursing faculty should consistently role model expected behaviors and provide tangible examples to assist nursing students in their socialization into profession [6,7,30]. Faculty can further support student growth by providing ethics education based in theory but also grounded in practical experiences that students can readily associate and identify with. Creating and sustaining learning environments that protect students while they practice ethical decision making will facilitate improved moral judgment, confidence, and willingness to address ethical dilemmas. Along with the classroom, these activities will also allow students to readily apply these skills in clinical practice settings with patients as well [7,14,18].

Limitations

Additional research is needed to further investigate the perceptions of academic and clinical dishonestly along with how and why nursing students engage in misconduct and the role of moral judgment development in these behaviors. One of the major limitations of this study is the potential for respondents to complete the survey tools with answers that are considered socially desirable rather than what they have actually done or believe. A social desirability score to address the bias associated with this type of self-report survey research could be useful to address this bias [31]. A second limitation is the cross-sectional study design itself. In this study there were no significant findings, but if there had been, it would have been difficult to discern if the differences were due to the semester of the program or some other characteristics of the groups. A matched cohort design may be more appropriate and could be matched based on social desirability score, specific demographic characteristics, and GPA. Another limitation was the HUBS itself. The nature of the answers that participants are asked to provide in response to the HUBS (academic and clinical) situations are yes, no, or unsure. These forced choices make it difficult to obtain a composite score of the participant’s perception of academic or clinical integrity. The HUBS tool includes academic and clinical situations that do not accurately reflect the current educational environments. In order for the tool to accurately reflect today’s healthcare environment, the use of smartphones, digital cameras, email, social media, online testing environments, electronic medical records, and Health Insurance Portability and Accountability Act (HIPAA) requirements should be included. Along with updating the academic and clinical situations presented, interval data could be obtained from the survey by changing the options for response from yes, no, or unsure to a Likert-type scale. A Likert scale of scoring would allow for a composite score to be derived regarding the participant’s perceptions of academic and clinical integrity and could better emphasize the potential differences between groups permitting for different types of statistical analysis. In order to accomplish all of the needed updates, a redesign of the HUBS is necessary.

While the sample size for this study included over 60 participants in each group, the sample represented just a fraction of the potential nursing students that could have participated. To prevent underpowered t-tests in future studies, a larger sample would be needed. Additionally, the sample lacked adequate numbers of participants from key groups. According to the National League for Nursing [32], males account for 12% of the population of nursing students. While nursing has traditionally been a female-dominated profession, this study sample still fell short of achieving a closely representative sample of male participants at only 6% of the study participants. This fact limits the ability to generalize the findings to the larger population. Additionally, this sample also lacked ethnic diversity. There were not representative numbers of participants who identified ethnically as Asian Pacific Islander, African American, Native American, or Hispanic. While the NLN [32] reports that the majority of nurses identify as Caucasian (71.3%), in this sample Caucasian participants were overrepresented at 91%. If this study had achieved a representative sample of ethnically diverse respondents, at least 14% would have identified as African American, 7.4% would have identified as Asian Pacific Islander, 6.5% would have identified as Latino or Hispanic, and 2% would have identified as other [32]. Disappointingly, this study recruited zero respondents identifying as African American, 3% identifying as Asian Pacific Islander, 4.4% identifying as Latino or Hispanic, and 1.5% identifying as Native American. As a result, statistical analysis was done comparing Caucasian versus non-Caucasian students, but even then, the small number of ethnically diverse participants limits the ability to generalize these findings to the population and must be viewed cautiously.

Conclusion

The results of this study add to the body of nursing literature and serve as groundwork for future research relating the moral judgment development of nursing students, student perceptions and behaviors in the academic and clinical settings, and reasons underlying these perceptions and behaviors- specifically in media rich learning environments. Nursing educators need to evaluate their current practices to ensure that they are including ethical content in every class that they teach. Similarly, faculty are called to uphold academic honesty policies in the programs in which they teach.

Strategies that nursing educators can utilize to improve academic and clinical integrity should include the development and use of codes of conduct based on the ANA Code of Ethics [18,33]. For class activities where it is imperative to the success of the activity that information sharing does not occur, faculty can have students sign a confidentiality agreement. Highlighting the importance of students not sharing information and explaining how this type of “Helping” is actually a form of academic dishonesty may help students clearly differentiate when sharing and working together is allowed versus not allowed [34]. As an example, if there are multiple sessions for a simulation, exam, skills check-off, case study or other course assignment, faculty can develop different versions of the activity that include slight variations to promote authentic learning or learning that is not as easily influenced by the effects of academic dishonesty. In the clinical setting, preventing dishonesty requires that faculty be highly involved in the care that the students are providing and documenting in order to model appropriate behavior as well as validating the competence of the student’s practice.

This study sought to discover the differences that exist between newly admitted first semester nursing students and those in their final semester preparing for graduation. While there were limitations in this study and the differences between the groups tested using the DIT-2 and the HUBS were not significant, there were still many interesting caveats underscoring the continuing importance for nurse educators to be aware of the importance of providing students opportunities to practice ethical decision making and being prepared to address academic and clinical dishonesty when it occurs. It is imperative that nursing educators have access to strategies that they can utilize to ensure they are providing their students with the ethical foundation that they need in order to successfully practice in the clinical setting caring for patients.

Conflict of Interest: The author declares no conflicts of interest.

Acknowledgement

This article did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors.

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