Ethical values in nursing education : a literature review

Introduction: Nursing begins with education and educational ethics guarantees the health the process of teaching and learning in the universities. Exact definition of the ethical values related to learning and education helps the students to receive the best education they deserve. Moreover, it also helps to recognize the status of science and dignity of the educators. This study was adopted in order to determine ethical values for nursing education in various countries. Materials and Methods: This literature review was conducted based on the Center for Reviews and Dissemination guidelines in 2016-17. The search of article in English was carried out in Medline, CINAHL, PubMed, Scopus, Ovid and Proquest databases. The search of article in Persian was conducted in databases of Magiran, SID, and Irandoc publication. After assessing and analyzing the obtain data, 14 articles were chosen and subjected to a thorough study. Results: The search led to the identification of 3 main competencies related to ethical values in nursing education, including personality competency, technical-professional competency, and socio-cultural competency. Discussion: Analysis of the literature related to ethical values in nursing education suggests that categorizing ethical values based the three aforementioned major competencies may provide a proper framework for the assessment of these values in different areas of education, research, and management in nursing education institutes and to evaluate their performance. However, considering the cultural diversity and prevailing philosophy in different societies, it is important to define these values clearly in the context of the target educational population.


INTRODUCTION
Nursing begin with education, a process that institutionalizes nursing norms and ethical values (1).Considering the complexities and rapid changes of the modern world and globalization of the workforce, and internationalization of the nursing education, it is important that education authorities think, train and behave globally (2).
Nursing education has been an 'export industry' since the inception of the professional era in nursing following the Nightingale reforms in the Western world in the 1880s.In other words, the culture and values prevailing in western countries, especially England and the US, became involved in nursing education, research, and performance.Since English was the professional language of the world, these values entered the libraries of consumer countries through journals and books, but with different cultural perspectives and practices (23).For example, the concept of "self" has an "individualist" and "collectivist" definition in western and eastern value systems respectively that are different in both the title and the content.Individualism is a predominant concept in Europe, North America, and English speaking countries like Australia and New Zealand, while collectivism is a value in eastern philosophy and in countries like China and Japan (3).Therefore, it can be concluded that students will have a different understanding and interpretation of educational autonomy in these two societies.
Choe and et al believe in the important role of nursing educators in the education of values (4).To achieve and internalize professional values and professional socialization, nursing students should acquire the necessary skills and knowledge in different cognitive, psychomotor, and emotional domains (5).Observation of educational ethics guarantees the health the process of teaching and learning in the university.In fact, ethical values and regulations related to teaching and training help the students to receive the best education they deserve.Moreover, they also help to recognize the status of science and dignity of the educators.The students are entitled to decent education and correct ethical values are very helpful in achieving this goal ) 6 ( .In the meantime, faculty members play the major role in managing and directing educational affairs, and their commitment to the principles and values of professional ethics is very important for the development of organizational culture based on ethics and also for the transfer of outstanding human values to students and their dissemination (24).
After reviewing many articles on ethics in nursing education, Anne J Davis and Marsha D Fowler concluded that most of these articles addressed curricular matters of ethics education and paid little attention to ethical issues within the context of nursing education (1).Considering the ever-increasing importance of universities and higher education centers as one of the most important institutes for institutionalizing ethical principles and values, and with regards to the fact that training nurses that are committed to ethical values is the cornerstone of decent nursing care in today's society, and due to lack of any review studies on ethical values in nursing education from the viewpoint of nursing educators/students, this literature review was conducted to identify ethical values in nursing education in the world.

METHODS
This literature review was carried out in 2016-17 to determine ethical values in nursing education of various countries.A review of the literature enables us to use the overall results and experiences reflected in the literature.These findings provide adequate and appropriate evidence to reach an integrated definition of ethical values in nursing education considering social, cultural, economic, and other underlying conditions.
To conduct this literature review, the York University four-step approach was applied.These steps are as follow: Forming questions and determining search strategies, extracting synthesis, providing quality assessment and applying study evaluation tools, and suggesting methods to analyze and data synthesis.

SEARCH STRATEGY
In this literature review, English articles from January 1, 2000 to September 1, 2016 and Persian articles available in Iranian data banks from March 2001 to July 2016 were reviewed.An extensive search was applied for articles published in credible international databases, including the Medline, CINAHL, PubMed, Scopus, OVID, and Proquest, and Iranian databases including Irandoc, SID, and Magiran using the selected keywords of nursing, ethics, ethical values, education and nursing values, singly and in combination.The words AND / OR were used to combine keywords.Moreover, snowball sampling was also applied via manual searching of the reference lists of selected papers, and relevant articles were included in the study.
Considering the keywords and their combination, 111 articles were retrieved and their titles and abstracts were evaluated with regards to the study objective and inclusion criteria.The inclusion criteria were publication in English or Persian and discussing ethical values in nursing education.In this stage, 44 articles were selected.In the next stage, the full texts of the articles were studies.Finally, 14 articles that were relevant to the study objective and met the inclusion criteria were evaluated.
For data extraction, the values in each article were identified.Then, the researchers together with other members of the research team compared these findings among all studies and placed similar values in a table.After comparing the names of the values in the table, considering the best definitions presented for the values, the most comprehensive title defining all values in the table was selected.The research team scrutinized the quality of all selected papers according the criteria of "study quality evaluation tool" using 2 questions: 1-Does the paper discuss ethical values in nursing education?2-Are the ethical codes in nursing education presented based on ethical values?
The research team developed tool for evaluation and assessment of the quality of the studies.To increase the credibility of the study, the abstracts were evaluated by members of the research team independently and ambiguities were discussed.If there was an ambiguity regarding including a paper in the study, a third member of the team further evaluated the paper.Ambiguous cases were discussed in the group and a final decision was made.
In the stage of data combination, which is in fact the Discussion section of our study, the textual data of all papers were categorized.After extracting the textual data and critical appraisal, based on the trait presented for each ethical value or concept, these traits were separated, grouped, placed in a table, and represented by the most comprehensive title selected by the research team.

ARTICLE METHODOLOGICAL TRAITS
There were 3 articles from the USA, 1 article from Norway, 1 article from Taiwan, 1 article from Finland, and 8 articles from Iran.
These studies used different sampling methods and explicitly stated the reason for their choice.The total sample size of all the included studies was 2492 persons.A total of 1763 students and 342 nursing educator were included in the 6 qualitative studies using random and census sampling.In the qualitative studies, 85 nursing instructors, 32 nursing students, and 270 clinical nurses were included, all through purposive sampling.The number of participants ranged from 20 (14) to 504 (16)individuals in each study.Individual interview was the most frequent data collection tool in qualitative studies (9,14,15).A study (13) also used group discussion.One study (17) extracted the data through content analysis, draft preparation, focus group discussion, and experts' comments.One qualitative study (16) used manifest content analysis to collect data through an online survey with two open-ended questions on ethical principles in education.In the stud (3), the data were collected through discussion and content analysis.Study ( 12) reviewed a previous study by herself in 1983, and study (1) was a review of the literature.
As for quantitative studies, two used researcher-made questionnaires (8,9) and three used standard questionnaires with confirmed reliability and validity (7,11,18).

QUALITY APPRAISAL
A scientific approach was applied to evaluate the selected studies using the research questions, research project, data collection method, method of data analysis, data credibility, ethical considerations and the result.
In the evaluated quantitative studies, standard and researcher-made questionnaires with confirmed validity and reliability were used for data collection, the data analysis method was reported in detail, and ethics approval was obtained from the university or other required institutes.The results of these studies were in line with the research question.
In the evaluated qualitative studies, the methodology and data analysis method were reported in detail, and informed consent was obtained to address ethical considerations.They used different methods to enhance the credibility of the study, like different data collection methods, precision in data extraction, data recheck, and conformability with participants and colleagues.

RESULTS
The evaluated studies assessed different aspects of ethical values in nursing education.Table 1 presents the overall characteristics of the evaluated studies.
In a qualitative study entitled "Nursing Students' Perception of Ethical and Professional Characteristics of an Ideal Faculty Member", salarv and et al identified 450 codes and 5 structural concepts, including academic abilities, professional teaching, personal characteristics, role modeling, and nursing ethics as values in nursing education (14).Salminen and et al conducted a study entitled "Ethical principles in the work of nurse educator" identified, Students most often named professionalism, justice, and equality as the main ethical principles for a nurse educator.Nurse educators considered justice, equality, and honesty as the main ethical principles.The content analysis showed that professionalism and the relationship between educator and student were the key categories for ethical issues as perceived by nursing students.Nursing students most often identified inequality between the nurse educator and nursing student as the ethical issue faced by the nurse educator (16).

Salarvand, 2014
According to the results, proficiency on the course, fluency in speech and having interest in teaching are the items that in selecting the teachers should be considered.Therefore, it seems some workshops are necessary for university lecturers about how to organize the contents, teaching methodology, and how to communicate with others in order to improve the quality of teaching and learning.Different studies have identified and presented these values in different ways.Some studies have introduced more than one value while others have focused on one value.Harding only introduced the value of cultural safety, and quoted from Wood that cultural safety includes key components of ethics that reflect "communal values, traditional practices, and co-operative virtues within a multicultural society" (3).
In 1983, Rosenkoetter stated that nursing instructors were responsible for helping students and colleagues to comprehend and use ethical guides which should be relevance and related to today's nursing performance.He also developed and revised some codes for nursing educators.In his study, he used the word "patient" for any person receiving nursing care, including the individual, family, group, and society.The ethical codes for nursing educators are derived from the American Nurses Association Code of Ethics for Nurses and the ICN Code of Ethics for Nurses (12).
Ghorbani reported that the most important features of a good university professor from the students' perspective were proficiency on the course, fluency in speech, organizing the contents and having interest to teaching.On the other hand, decisiveness of teacher, having interest to research and the teaching experience were those items that had the least important for students (18).Izadikhah in her thesis on "Developing codes of ethics for clinical medicine extracted 55 ethical codes under 18 topics, conscientiousness, accountability, respectfulness, scientific excellence, respect for others' freedom, equity, patience, religious commitment, modesty, trustworthiness, humility, contentment, relationship with coworkers, attentiveness toward patients, attentiveness toward learners, kindness, confidentiality, and discipline from Iranian-Islamic literature (17).Moreover, Melnick in a thesis entitled "Values Education in Baccalaureate Nursing in the Tri-State Area New York, New Jersey, Connecticut" focused on two essential values, namely, altruism and human dignity.In this study, the four qualitative themes that emerged from the qualitative interviews, notably in terms of teaching the value of altruism, were promoting awareness, reflection, social justice, and role modeling.Three qualitative themes emerged in terms of teaching the essential value of human dignity.These three qualitative themes were human dignity and the core concept of respect; human dignity and professionalism; and lastly, the theme of forms of protecting the human dignity of clients.This study found that the teaching of the essential value competencies to nursing students occurs within an informal context (9).

DISCUSSION: INTEGRATING THE DATA OF LITERATURE REVIEW
A review of the literature related to ethical values in nursing education in Iran and the world led to the identification of three main competencies, including personality competency, technical-professional competency, and socio-cultural competency.In this section, we discuss each competency according to its values (Figure 1).

Personality Competency
Values like respect, accountability, enhancement of personal competencies, self-esteem, good temper, respecting the boundaries, lack of sex discrimination, good humor, patience, appearance, flexibility, openness to criticism, consultation, fairness, scientific humility, reverence, good management skills, liberalism, strength, conscientiousness, contentment, order, self-dignity, aesthetics, and humanity indicated ethical values in the domain of personal competency from the viewpoints of educators and students (1,8,10,12,14,18).
In 2016, Salminen et al. evaluated ethical principles in nursing education from the perspective of educators and students.In this study, 76% of the educators and 18% of the students mentioned justice, 40% of the educators and 6% of the students mentioned honesty, and 9% of the educators and 1% of the students mentioned openness as the most important ethical values (16).

Technical-Professional Competency
After grouping the values based on the similarity of definitions, the majority of the values were categorized as technical-professional competency.Enhancement of critical thinking, advocator, Facilitates and guides the learning of students, knowledge-seeking, use of proper technologies in learning, self-assessment, multi-dimensional growth, utilization of best educational methods, authorship, awareness, standard evaluation and quality improvement, fairness in evaluation, professional and comprehensive care, disease prevention, health promotion, scientific mastery, eloquence, addressing students' problems and questions, power of speech, introducing new and up-to-date education material, appropriate educational behavior and performance, attention to research, attention to student, attention to patient, professional capabilities, interest in teaching, level of education, teaching skill, scientific excellence, expertise, availability, being a good role model, decisiveness in teaching, and professionalism were some of the values categorized as technicalprofessional competency based critical appraisal of the evaluated studies (8,10,12,14,15).Sobhani Nejad et al reported that emphasis on research and creating motivation could contribute to the promotion of professional ethics in the process of teaching and increase the effectiveness of the teaching process (10).
In 2015, Farokhzadian et al conducted a study to evaluate the use of different medical information resources by nurses and their information search and retrieval skills in the context of EBP in Iran.They concluded that their information literacy skills to find the best evidence from different databases and the Internet were not sufficient.They also suggested that nurses needed to learn how to use necessary resources to embrace new and innovative techniques for providing effective and quality care to improve the clinical outcomes for their patients.Providing access to online resources in clinical wards can also encourage nurses to learn and use these resources (19).

Socio-Cultural Competency
Values like attention to religious issues, being a believer, attention and respect to religious beliefs of other people, allowing making mistakes to learn, attention to individual differences of the students, not using students for personal affairs, organizational commitment, communication and collaboration with colleagues, consultation, cultural safety, observing the privacy and limitations of faculty members, promotion of cultural capabilities, receiving fair bonus, and individuality were some examples of socio-cultural competency (1,3,8,11,12,(14)(15)(16)(17)(18).
Our literature review showed that cultural competency was one of the aspects of ethical values in nursing education, which was emphasized by many participants.Burke has quoted from Yoder et al that cultural competency is the development of self-awareness and increased knowledge about the target population, and understanding of cultural and health beliefs of different groups (20).Bacote introduced 5 items of Cultural awareness, Cultural knowledge, Cultural skill, Cultural encounters, and Cultural desire as prerequisites of cultural competency (21).According to the literature, the role of educators in transferring cultural competencies to students, acting as a good role model, personality characteristics, and interaction with students as well as cultural diversity of the students in the university is very important (22).
Marsh Fowler defined faculty freedom and its limits as Academic freedom, outside employment, financial fraud/misappropriation in budgets or in grant administration, Conflicts of interest, and Competing loyalties: profession, school, student, patient, and self, Creedal/religious institutions and Curricular bias (1).

CONCLUSION
Analysis of the literatures related to ethical values in nursing education suggests that categorizing ethical values based the three aforementioned major competencies may provide a proper framework for the assessment of these values in different areas of education, research, and management in nursing education institutes and to evaluate their performance.However, considering the cultural diversity and prevailing philosophy in different societies, it is important to define these values clearly in the context of the target educational population.

Figure 1 :
Figure 1: Ethical values in nursing education in Iran

Table 1 :
Outline of studies included in the review

Table 2 (continued):
Outline of studies included in the review Students most often named professionalism, justice, and equality as the main ethical principles for a nurse educator.Nurse educators considered justice, equality, and honesty as the main ethical principles.The content analysis showed that professionalism and the relationship between educator and student were the key categories for ethical issues as perceived by nursing students.Nursing students most often identified inequality between the nurse educator and nursing student as the ethical issue faced by the nurse educator.