Ethical Sensitivity in Nursing Students: Developing a Context–based Education

Introduction & Background: With growing ethical challenges in health care systems, focusing on ethics education is essential to develop ethical sensitivity in nursing students. This should be based on clarifying experiences of ethical sensitivity in nursing students in care contexts.
Methods: To determine a framework for ethical sensitivity education based on explaining experiences of ethical sensitivity in nursing students. A qualitative approach was used as the study design. Data were analyzed using the conventional content analysis method. Ten nursing students and two nursing instructors in different educational hospitals in an urban area of Iran were selected using a purposeful sampling method. In-depth and semi-structured interviews were used for data collection. The study protocol was approved by the Research Ethics Committee of medical university located in South of Iran. The ethical principles were carefully followed throughout the study.
Results: Nursing student’s ethical sensitivity consists of ethical perception, affectivity, critically cognitive processing, and intimate cooperation. Based on categories and subcategories of ethical sensitivity, an educational framework for teaching ethical sensitivity including teaching-learning purpose, content and methods was developed.
Conclusion: Based on the results, ethical sensitivity education should be based on a virtue–based approach with the aim of developing practical wisdom. The content and teaching–learning approaches that lead to the development of practical wisdom and evolution of all dimension of ethical sensitivity are suggested.


INTRODUCTION
Today, providing nursing care is a physically demanding and intellectually challenging process delivered in contexts that are increasingly complex and fraught with ethical questions and dilemmas (1). Under such circumstances, nursing students on clinical placements are routinely faced with situations involving ethical conflicts (2). Without logical and effective solutions for their ethical concerns, they are likely to experience despair and ethical distress (3)(4)(5)(6), which will, in turn, adversely affect both nurses and patients (7). New ethical challenges require practicing nurses and nursing students, as a future generation of nurses, to be competent ethical decisionmakers who focus on the ethical dimensions of nursing care (8,9), and be skilled in detecting and responding to various ethical issues (10). This goal can be achieved by teaching ethics that focuses on preparing students to be ethically competent decision-makers, possessing knowledge and skills necessary for ethical decision-making (11)(12)(13). Ethical sensitivity is recognized as a necessary skill for ethical decision-making, and as an outcome of ethics education in professional programs (14)(15)(16). However, the effectiveness of ethics education in nursing continues to be disputed among educators in terms of how to prepare nursing students to be able to practice essential knowledge and skills in order to make ethical decisions that arise during the delivery of patient care (4,13,(16)(17)(18)(19). Woods (2005) believes that the challenge for development of appropriate nursing ethics education lies in curricula (20), strategies and methodologies which focus on the real context within which nursing is practiced (21). It is necessary to develop guidelines and educational methods for ethics education in a variety of contexts (22). Moreover, the development and expression of ethical sensitivity in professional practice may be limited if students do not learn a more comprehensive pattern of strategies reflective of the complex, multidimensional nature of ethical sensitivity (23). Therefore, a comprehensive understanding of what the concept entails is needed in various contexts to develop ethics education curricula for improvement of ethical sensitivity.

Issues in Teaching Ethical Sensitivity in Iran
Iran is an ancient country, and religious attitudes and beliefs have spread into every dimension of Iranians' lives, including the health system and nursing profession (24,25), so that respect for human and ethical values has a special place in Iranian culture and among nurses (26,27).
Iranian nurses confront many challenges in their daily practices. The challenges are mainly due to the shortage of nurses, job dissatisfaction, poor social position, and curriculum shortfalls with regard to ethics (25,28,29) which can lead to increased ethical distress and subsequent burnout and higher turnover (29,30). Also, the problems such as an insufficient salary and benefits, a heavy workload, and a lack of support from the authorities occasionally affect the performance of healthcare personnel (31). Moreover, in spite of compilation of nursing ethical codes, challenges ahead of nursing are mostly are how to implement the national guides and ethical code that have already existed (32). Growing ethical challenges requires a solid educational preparation of a neophyte nurse on ethical issues in nursing (21,(33)(34)(35)(36). Universities should develop their curricula in such a way that the students end up with ethical sensitivity development, as critical component of ethical decision-making.
Ethics education in the Iranian nursing education system faces many challenges. Currently, the Nursing Ethics course is once offered to undergraduate students, consisting 17 hours for theoretical topics and 17 hours for practical work. The challenges in ethics education in Iran include the lack of coherent ethical content, the use of traditional methods, the lack of qualified and trained ethics educators, the deficiency of educational headlines and rich curriculum resources, the teaching of ethical issues irrespective of the context and situation in which students work, emphasized Western culture in ethics education, lack of motivation and interest in the nursing profession, lack of self-awareness, evaluation problems, and lack of objective tools to evaluate professional ethics abilities in nursing students, interpersonal communication weaknesses and clinical environment constraints (31). Given the development of ethical sensitivity and the promotion of decision-making skills as an important goal and consequence of ethics education (37), one of the concerns of the health system in Iran, is the quality and quantity of the ethical sensitivity development, and consequently, ethical development in students (32). At present, the concept of ethical sensitivity in Iranian nursing schools is being taught in a two-hour session. Results of recent studies on educational outcomes and ethical sensitivity show the average level of ethical sensitivity in Iranian students and nurses (38)(39)(40)(41)(42). The findings show that students and nurses are relatively familiar with the ethical implications of patient care, but this level of ethical sensitivity is not sufficient to provide a satisfactory and high-quality care. Ethical sensitivity is the core of patient care and is the first step in the ethical decisionmaking process. To this end, the improvement and development of ethical sensitivity should be the priority of ethical education in the Iranian nursing system, and effective educational needs to be provided in order to develop ethical sensitivity in educational and clinical settings. According to Weaver, however, the most important challenge in this area is the lack of conceptual clarity about the concept of ethical sensitivity of nursing students for effective teaching in ethical sensitivity. Therefore, the first step is to analyze the concept of ethical sensitivity in nursing students based on their experiences in order to make suggestions on teaching it to the students.

Objectives
The purpose of this study was to determine a framework for ethical sensitivity training based on explaining experiences in nursing students.

Research Questions
1) What are experiences of ethical sensitivity in nursing students?
2) How do nursing students and educators describe ethical sensitivity?
3) What is the educational framework that can be used to promote ethical sensitivity education based on students' experiences?

Design
In this study, qualitative content analysis was used to explore experiences of ethical sensitivity in nursing students. The conventional approach to content analysis was then used because ethical sensitivity is a new concept and there is not enough knowledge about it in Iranian nursing student's contexts.

Participants and the Research Context
For accessibility reasons, the participants were selected from the nursing students of Shiraz University Medical Sciences in southern Iran. The participants were chosen using purposive sampling method. Ten BS Nursing students who passed more than one clinical course and did not work as staff position in hospitals, were selected to share their experiences of ethical sensitivity. They were introduced to researchers by clinical instructors as whom compliance with ethics in their practices. To achieve maximum variation sampling, the nursing students were chosen from various clinical experiences in terms of their semesters and type of clinical courses they passed. Moreover, two clinical nursing educators were interviewed to gain more information in detail.

Data Collection
The data were collected through in-depth, semi-structured interviews with open-ended questions. One researcher who was responsible for conducting the interviews first introduced herself to the participants and continued with a brief explanation about the subject and objectives of the study. If the candidate consented to participate, she collected demographic information of the participant. At the beginning of each interview, the participants were asked to "describe their experiences about ethical sensitivity", and then to explain their own perceptions and experiences regarding following questions: "Give me an example of being ethically sensitive as a nursing student".
"Can you mention several qualities of ethical sensitivity that you possessed"?

Data Analysis
The present study used a conventional content analysis described by Granheim and Lundman (43). The interviews were transcribed verbatim, and the transcripts were read and reread in order to understand the meaning within the context of significant words or phrases. The texts were read several times to obtain a sense of the whole. Meaning units that corresponded to the aim were underlined, condensed, and coded (44). The final four categories were examined by the authors, in order to ensure there is no obvious difference between them. Meaning units within all subcategories were checked for accuracy. Minor revisions were made thereafter. After categorization of the data at the group level, the researchers returned to the individual level to ensure that the categories were differentiated at an equal level of abstraction. This constant comparative analysis was an inductive process, and the goal was to create a detailed description and a list of categories related to the subject under investigation.

Rigor
As per Lincoln and Guba's criteria, the credibility of the data was ensured through individual interviews, choosing participants from various clinical course experiences, peer and member checking. To facilitate transferability, a clear description of culture and context, characteristics of participants, data collection, and the process of the analysis were used to ensure that the findings fit the data. To ensure the conformability of the data, the comments made by qualitative research experts with an experience in nursing ethics were implemented. The dependability of the data was ensured through a constant comparative analysis of the data, clarifying the data analysis process, reflective comments, and peer review (45).

Ethical Considerations
The present study was approved by the Ethics Committee of Shiraz University of Medical Sciences under the code EC-93-7039. To comply with the code of ethics, the participants were first briefed on the objectives of the study, and then ensured of the confidentiality of their data and their right to withdraw from the study at any point in time, and were also informed about the process of accessing the final results. Thereafter, they submitted their informed written consents to participate in the study.

RESULTS
The findings of the present study illustrate the characteristics of ethical sensitivity in nursing students in the four main categories of ethical perception, affectivity of moral status, critical cognitive processing, and intimate participation. In this study, the ethical sensitivity of nursing students is the dynamic capacity of the wise decision-making in an ambiguous care situation with the participation of the teacher and peer group. In this case, the nursing student is aroused by observing the client's vulnerability, and can identify an ethical situation. They recognize the situation more deeply along with establishing caring relationship, using approaches including; contextual interpretation, critical recognition of strategies and reflexivity, to be aware of possible solutions.
The first characteristic of ethical sensitivity in nursing students is "ethical perception", which provides relative awareness of the ethical dimensions of the situation and enables them to determine the client's need. In this regard, a student described ethical perception as:

"Ethical sensitivity means that I have the ability to recognize a moral case, a patient need and a care need that can be in different areas like physical or emotional need. For example, I go to my patient's room, I see that my patient is suffering from pain. I should not neglect that."
The ethical perception of a situation includes the characteristic of moral wakening and the cognitive processing of moral concern. The "moral awakening" is the starting point of awareness of the ethical nature of a problem that can have a negative impact on the client's well-being. A student commented:

"Sometimes when I go into my patient's room, I first feel that there is a problem. It is as a sixth sense, there is a flick that makes me realize that my patient has a problem now, and I have to look at it and find out what it is."
According to the students, awakening is experienced as an alarm. It may be originated as soon as the students encounter the client or their relatives; they intuitively senses encountered a moral problem, and recognition of the hidden or obvious problem that is important to them. A student stated,

"At first, it is experienced as a feeling. For example, when I face my patient, I feel something is going on. Through talking with him/her, or from nonverbally cues, I understand he/she is upset, His/her greetings, or bad manner in answering to questions makes me motivated to realize what the problem really is."
Another characteristic of ethical sensitivity is "cognitive processing of ethical concern", which means the perceptual processing of signs and symptoms of vulnerability that enables the student to identify client needs and gain a general understanding of the situation. A student said, "In the intensive care unit, I had a patient planned to undergo CABG surgery, but the surgery was canceled. When I went to the patient, I found he was very frustrating and worried. I saw the patient tossing and turning on the bed, and rubbing his hands. Considering that the surgery was canceled, I realized that he was worried and I needed to do something about it." The next characteristics of the sensitive student is "affectivity", which is the spontaneous response to the others. It is described as the feeling of "shaken" created by the student when confronting ethical issues. In this case, the affected student makes a caring relationship with the client by expressing emotions and caring values such as commitment, compassion and empathy. The student strives to gain a deeper understanding of ethical issues by gathering more information. In this regard, a student stated, This means that usually the person is initially affected emotionally and tries to understand the patient the way he or she is. However, from the students' perspective, this is not enough alone. It is the students' responsibility to deeply understand the patient's concern and respond to the patient's need by establishing a caring relationship. A student expressed, "Usually someone who is ethically sensitive is someone who is kind, compassionate, being advocate, and the patients' concern is important to him/her. As an important feature, he/she has the ability to communicate well. That is, he/she can make the patients trust him/her, influence on the patients, feel the patients with their disease, and take an action, for example, communicate and assessed more to find out what the problems are. Why are they developed? What are other factors that can be important and have an impact?" In this regard, another feature of ethical sensitivity, "critical cognitive processing", is raised in order to purposeful deliberation on the ethical situation and what is going on. This is a cognitive response that the nursing students learns other people's perspectives and deeper deliberation of the ethical situation using different approaches. in this way, they gain a deeper understanding of the moral situation and become aware of possible solutions. In this regard, one of the approaches is the "contextual interpretation" in which the student tries to look at the ethical situation with one's and other people's perspective. Accordingly, students gather more information from the patient through a purposeful assessment, and consider others' views on moral. In this regard, a student commented, "Critical Recognition of Solutions" is another approach to cognitive processing of the situation. in this regard, the student being aware of possible solution for meeting ethical demands and evaluated using moral imagination and sources such as knowledge, experience, law and sometimes, ethical principles and theories. Also, the consequences for client and the profession are considered. in this regard, a student described his/her experience as; "In a ward, I had a patient that his iv line was locked, the nurse told me to do intravenous catheterization. I found that the patient was severely dehydrated, he was injected with broad spectrum antibiotics and had not any healthy vessel at all. His platelet count was extremely low, and He had a common cold. I told my teacher that this patient has no healthy vessels, and his platelet count is low. Perhaps I can't find his vein. If I try several times, it may bleed. We had better inform ward attendant to perform cat down, or an expert nurse done iv catheterization." Another approach of students to critically recognize the situation is "critical reflection or reflexivity". This feature allows the student to take a step back and reassess one's ethical position to avoid any probable bias. In this regard, a student said; "However, all of us have a set of values, beliefs, interests, and preferences. There is a verse in the Qur'an that says," Take account before you are held accountable", that is, when I want to do something for my patient, I have to evaluate myself first and remember that I don't want to impose something on the patient according to my personal desire." In this case, the student is aware of his/her judgments, prejudices, and desires, so this leads him/her to do the right thing and do what is useful for the patient, and avoid the prejudices and preferences that may have negative effects on his/her jobs.
The last characteristic of ethical sensitivity in nursing students is "intimate participation" in which a nursing student requires intimate peer interaction and teacher support in dealing with an ethical situation. According to the students, in this situation, they share their emotions, information, and experiences with their peers for a variety of reasons, such as lack of information and skills needed, lack of independence, and authority to care for the patient during clinical practices. Also, the students can perceive ethical nature of the situation and respond to it through the inevitable informational, and emotional supports of their teacher. In this regard, one student stated;

DISCUSSION
The results of the present study showed that ethical sensitivity in nursing students has characteristics such as ethical perception, affectivity, critical cognitive processing, and intimate participation. These qualities led to the development of a conceptual framework for teaching ethical sensitivity in nursing students. Given that the virtue-based approach is value-laden, and is close to the strong Islamic, indigenous, and cultural support of Iran (46), so it was used as an appropriate framework for teaching ethical sensitivity to nursing students. Various studies also support the idea that the virtue-based approach provides a comprehensive framework for nursing ethics education that can lead to the cultivation of ethical sensitivity (4,21,(47)(48)(49)(50).
The purpose of ethics education in the virtue-based approach is to develop practical wisdom. Various scholars have emphasized the role of practical wisdom in ethics education, and believe that educators should facilitate this qualification in students to enhance the quality of nursing care (51)(52)(53)(54)(55)(56)(57). Ethical sensitivity has also been recognized as the practical wisdom that the caring person has it (50,58,59), so ethics education should foster ethical virtues along with ethical sensitivity (47,50,60,61). Therefore, the purpose of ethics education in the present study is to foster practical wisdom and to develop the ethical sensitivity of nursing students.
Content of ethical sensitivity education should be formulated theoretically and practically to facilitates practical wisdom and nurture all dimensions of ethical sensitivity, including; cognition, emotion, knowledge, skill, and responsibility. Accordingly, one of the basic topics in educational content is related to caring relationship. in order to foster a caring relationship, the student should be able to receive others as they are (62), learn how to get focused attention on what is happening to a particular person in a specific context (63), and understand how one would feel in the others' place (64). Then, these feelings are transformed into obligations to respond and help clients meet their needs (65). To this end, it is necessary to emphasize the cultivation of values, virtues, and emotional traits. In this context, there is no need to discuss a list of values and virtues in the content. There is a need to present ethical situations to feed the mind, nurture the moral imagination, emotions, and provide opportunities for students to gain experience during practical exercises. It is not always, possible to gain experiences through practice, we can rely on Vicarious experiences. These experiences can be acquired through reading about or observing others' experiences and life histories. while the situation to which the students respond are imaginary, the felt emotion by the students are real (47).
Interpersonal communication skills are other topics that should be included in educational contents. In this regard, the student must learn how to give and receive positive feedback, understand body language, be self-confident in presenting views, and be able to express hidden fears and prejudices (66). The student should be an active listener; in other words, being alert to "ethically important moments" and making connections between patient's circumstances, beliefs, values, and his/her goals, values, resources, and his/her action or the others' ones (67). Furthermore, he/she should be assertive, and advocate for the patient, because protecting the patient and his/her interests is at the center of the nursing profession (21). Principles and models of ethical decision-making (68,69), culture and cultural care should also be included as a prerequisite for ethically competent nursing care (21). Another important topic is the focus on the knowledge needed to develop practical wisdom. The sources of knowledge used in ethical decision-making are ethical knowledge, academic knowledge, clinical knowledge, personal knowledge or selfknowledge, personal values, and the values and beliefs of other decision-makers (70). Ethical knowledge refers to ethical principles, guides, and rights (71). student's responsiveness can be influenced by these structures (70). Therefore, content should include ethical principles and theories (10,21,50,61), human rights laws, nurses' rights and duties, institutional regulations, professional practice legislation, standards of care, and codes of conduct (10,50,70,72). Indeed, it should be pointed out to students they should not blindly use these norms in all nursing situations, but it is important to pay attention to the necessity of applying the rules in the specific situations. This means that the rules are not the blue print for nursing practice, but are guidelines that align with the specific characteristics of a situation. In practical wisdom, the rules are used as guides, responsiveness is demonstrated in real world, and solutions are provided through experience.
The principles and skills needed for reflective thinking should also be emphasized in the educational content. Reflexivity means being aware and paying attention to one's own perspectives and voice in a situation. To make connection with others and to recognize ethical dimension in their work, nursing students need to be self-aware, reflexive, and mindful to their own unique contribution and their identity as a nursing student in patient's care. Reflexivity enhances student's awareness of their personal values, emotional reactions, practices, and how they might influence their reactions and choices toward the patient (67). This involves turning self into an object of attention to distinguish motives, biases and assumptions. Antecedents such as, perseverance, intelligence, foresight and self-knowledge affect reflexivity. individual and collective processing of clinical based issues and personal value journaling help to develop reflection skills (70).
Critical thinking is an essential skill for nursing students, and nursing ethics education should facilitate critical thinking skills. In this way, the student should be able to reflect on how his/her choices affect others. To do so, the first step is acquiring knowledge and developing skills that will enable them to critically reflect on the essence of good care. The second step is enabling students to participate in ethical decision-making scenarios (73). In addition, education on how to order thoughts, construct arguments, reach logical conclusions, help critical thinking development. Also, providing opportunities to become familiar with perspectives of others, exposure to cultural diversity, reviewing ranges of cases, comparative analysis using two or more groups with vastly different experiences, and role-playing are needed to cultivate this ability (70).
In the nursing profession, values and the perception of the care of patients are largely influenced by religious and Islamic values (74). Therefore, it is important to teach the values based on the Islamic-Iranian perspective and the Islamic content should be included in education ( Table 1).
In order to provide the necessary conditions for educating practical wisdom, teaching-learning approaches should focus on the three main factors of teaching methods, educators and the environment.
Teaching methods are the core of ethics education programs, so, creative teaching -learning methods must be employed to facilitate practical wisdom, to acquire the virtues necessary for a caring nurse, and to develop the student's moral character (21). For this purpose, educational methods can be used in the constructivist approach. This approach focuses on student-centered learning and student ability to solve real-life problems in an academic context. According to this approach, learning is considered an active social process in which students actively construct knowledge within a social environment based on individual experiences.
Action-based learning and problem-based learning are the examples of constructive approach to learning. Researchers and educators have stressed that knowledge about ethics and attitude learning should be based on real situations and be started from identifying problems (75). In these methods, learning is student-initiated, and there is an emphasis on group discussion. Both the approaches, help students find the most optimal solutions for a problem through activity in small groups of five to six persons (9). This approach is particularly useful in ethics education because it aims to encourage recognition and analysis of moral problems, and where to do better than in peer discussion (66). Many ethicists believe that realistic scenarios based on true life cases can facilitate reflection about practice, and provide an opportunity for students to become familiar with clinical ethical issues (76). Clinical cases analysis in group sessions helps to develop critical thinking skills, to satisfy students (77)(78)(79), to strengthen ethical discrimination, to develop problem-solving abilities, and to cultivate a lifelong learning capability (80)(81)(82). Also, they will help to develop perception and empathy by providing affective engagement (49,83). Students learn not only about the realities of the subject through interaction with each other, but also learn the skills of membership in a group, how to communicate, how to lead and how to differentiate essentials from noise (66). Discussions are usually most effective when they are provoked with methods such as clinical debriefing (67,76), panel discussions, meetings, or events such as reading, video, and role playing. The use of narratives is also a good starting point for many group discussions as they can provide a safe access to very personal fears and emotions (66).
Two types of tutors are employed in problem-based learning: expert and non-expert. Some insist the use of skilled tutors and suggest that the tutor must be equipped with both the ability to facilitate group discussion and professional knowledge of the related subject matter, while others insist on using peers as tutors. In one study, there was no significant difference between the two types of tutors in terms of stimulating, leading, and controlling the group discussion process (75). Non expert tutors can concentrate more easily on facilitating the group discussion process rather than controlling the academic content of learning (84). learners often prefer tutors to be nondirective (84,85). In this regard, using methods such as peer-based learning and team learning can be helpful.
Critical companionship is one of the teaching methods used to facilitate cultivation of virtue-based attitude in nursing students during the clinical internship course. Since some credits in clinical nursing are currently offered in the last year in Iran as an internship course, using this method can be useful in promoting the ethical sensitivity of Iranian nursing students. this internship represents an important learning experience from a virtue ethics perspective (86). Mentors Create learning moments, to help the students analyze, interpret, and evaluate internship experience and the knowledge gained through that experience. They help the students to question their behavior by giving them detailed feedback. The mentors can assist students to perform self -evaluation by taking a critical look at the feelings, experiences and interactions, while providing emotional support to them. They also serve as an exemplars of skilled companion for students (87).
Interdisciplinary education is one of the other educational approaches that are appropriate to the ethical sensitivity training of Iranian nursing students. In this case, there is a team of clinicians and non-clinicians colleagues (88) or two or more educators with complementary technical and personal abilities, teaching cooperatively. They collaborate in planning, delivering and evaluating the educational process (89). Given to a small number of nursing ethicists in Iran, educational courses can be organized in collaboration with medical ethicist to help fill the gap caused by a shortage of nursing ethics specialist and, achieving educational goals.
Shared teaching is an interdisciplinary teaching-learning approach in which students of different professions learn ethics in small groups or student seminars (21). By teaching ethics to students from different professional groups and interacting students on ethically challenging issues, one can help to develop a climate of cooperation, trust, willingness to listen, and learn from each other (90,(104)(105)(106)(107).
Another student-centered approach, which provides opportunities for students to learn more about ethics, is elearning and web-based learning. A problematic clinical scenario is discussed in class, and then followed using the web (108,109). The website can be interactive, and can include learning support features such as scenario discussions and simulated ethical film. Therefore, students can access whenever and whatever. This method is a significant way of active engagement of students in the construction of knowledge and meaning (21,91). Given the availability of webbased learning platforms in many academics and hospitals in Iran, this method can be used along with other educational methods to promote student's ethical sensitivity (110,111).
In the virtue-based approach, there is a great emphasis on the role of educators because it is about the influencing the heart sand minds of students. Nursing ethics educators and clinical educators should be able to facilitate effective teaching-learning of the students, and use the approaches in theory and clinical class that integrate cognitive, emotional, and psychomotor skills, so that nursing values are constantly practiced, virtuous character developed in nursing students, Affections Skill • To educate on social support and group participation skills and rational moral judgment is facilitated (47). Therefore, some believe that the existence of trained nursing educators is one of the essential principles of ethics education. In this regard, Gorgulo believes that teaching ethics requires first, the knowledge and skills of teachers of ethics (112). in order to prepare nursing students for facing the ethical challenges of clinical practice, ethics educators are required to have pure experiences in the field of clinical practice and a sound theoretical knowledge base in the field of ethics (76). Also, they should gain the expertise to facilitate discussions and reflection of the "difficult" topics covered in nursing ethics education (92,113). Therefore, postgraduate programs and continuing education sessions should provide opportunities for nursing educators to specialize in nursing ethics education (21), in particular, value education (93).
Another issue to consider in ethical sensitivity education is that role modeling and habituation are two important tools in the virtue-based approach. Seeking the truth in ambiguous situations is an iterative process, and the educators should create the opportunities for students to repeat and reflect on choices and decisions (94). In order to facilitate practical wisdom, nursing ethics educators should themselves display virtuous character trait inspiring students to follow them as role models (114)(115)(116). The existence of role models is one of the most effective ways to teach values to students (93) . This approach is supported by various studies confirm that students are more profoundly affected by role models than formal coursework (1). It is noteworthy, it is not enough to simply model behavior, there is also a need for discussion and reflection in the form of journaling (47).
Learning environment is another important factor in ethics education. To achieve practical wisdom, there must be an environment in the classrooms and clinical settings where the values of nursing are practiced (21). Nursing students need to work in a context of value support to be challenged to learn and encouraged to continually improve their performance (68,69). The organizational context is influential due to clear ethical policies, ethical advisors such as the ethics committee and the position of power between the nurse and the physician. A special teaching -learning environment should be such a way that both nursing educator and students are able to create intra and interpersonal relationships necessary to seek understanding of the human conditions, accepting and sharing perceptions, feelings, and taking responsibility for the teaching-learning process (52,95). Nursing managers at all levels have a responsibility to influence staff and act as a mediator between organizational and professional values (96). Effective collaboration and communication between higher education institutions and health care facilities is essential for quality of nursing ethics education. In addition, the Nursing Ethics Education Program should include continuous educational courses based on clinical setting facts to improve the skills of professional nurses (117). Another issue affecting the ethical sensitivity education of Iranian nursing students is the perception of managers of higher education institutions that nursing educators should be generalist. However, managers need to understand that specialization in any area of nursing education requires continuous development of expertise in such an area. They should not expect nursing educators to be involved in other areas of nursing education, as this will reduce their expertise in ethical knowledge and skills (21,118). manageable student numbers are another issue which need to be considered. According to Searle (1988), the "Achilles heel" of nursing education is to focus on quantity (97). The high student numbers in the class and clinical wards challenges the quality of nursing education generally, and has a long term negative impact on the value system of nursing, as educators becomes disheartened and tired (119).
In addition to the three factors of teaching methods, environments and educators, other factors are also important in designing a successful ethics education program. One of these is the timing of ethics course. In the virtue-based approach, ethical virtues are nurtured through repeated exercises and appropriate direct or indirect experiences (120). Accordingly, some scholars believe that ethics education early in the professional development allow students to have enough opportunities for the habituation of moral virtues and ethical sensitivities throughout their professional education (13,61,98,99). Therefore; ethics content needs to be placed in preclinical years. Also, for the development of moral reasoning, students need to reflect on their enriched experience with clinical practice in the class. Hence, the ethics education is also recommended in clinical years. Various scholars believe that to educate values and develop practical wisdom skills, a systematic long-term education is needed from the first to final year of study (100)(101)(102).
The placement of ethics course is another issue to be discussed. The nursing ethics education in nursing curriculum is usually designed in two areas. First, plans that integrate ethics content into the whole nursing program, and second, plans that provide a separate ethics course (4). It seems that when the purpose of ethics education is to develop practical wisdom, along with rationalistic ethical concepts such as moral principles, moral judgment and so forth, there must also be room for concepts such as personality, virtues, attitudes, emotions, so forth, Obviously, a broader perspective on ethics education is needed (50). Therefore, integrated ethics education is suggested (103). In this regard, Armstrong proposes a "sandwich approach" that consists of a general course in ethics that is followed by a variety of nursing courses. the ethical considerations of each specialized course are presented as case studies and homework problem. Also, in clinical courses, the development of ethical skills and focusing on real ethical situation are determined as the learning objectives. Case studies and homework help students spot ethical issues and reinforce good ethical reasoning. This approach can increase student's awareness of ethical issues and increase their moral reasoning ability. Hence, it is appropriate to cultivate ethical sensitivity and ethical reasoning (121).

CONCLUSION
Based on the results, nursing students with ethical sensitivity have characteristics such as ethical perception, affectivity, critical cognitive analysis, and intimate participation. The results of adjusting the intervention to the characteristics and dimensions identified in concept analysis of nursing students 'ethical sensitivity created a framework on which the ethical sensitivity educational program in nursing students can be designed. This framework has created an integrated format of content and teaching methods that can foster practical wisdom and all aspects of ethical sensitivity (cognition, emotions, skill, responsibility, and knowledge). Using this framework, educators can be aware of the full range of actions that describe the multifaceted nature of ethical sensitivity, and be more influential in the process of learning ethical sensitivity. It seems that due to the educational conditions prevailing in nursing ethics education in Iran, it is currently possible to implement ethical sensitivity promotion programs in the form of hidden curriculum. To this end, after the general course of ethics, along with specialized course, nursing educators using a combination of teaching methods to present real ethical case in theory and clinical practice. This approach provides continuous education in ethics, and consequently, facilitates the development of ethical sensitivity in nursing students. Also, simulated ethical care centers or "ethical care lab" in universities are a convenient and protected environment that can facilitate ethical sensitivity learning process in nursing students by providing a variety of teaching methods. In addition, efforts should be made by the Nursing Board to design and approve a comprehensive Islamic-Iranian practice of nursing ethics curriculum, with emphasis on enhancing decision-making skills, particularly ethical sensitivity.

ACKNOWLEDGEMENT
This article was extracted from a part of the PhD dissertation of "Designing and evaluating psychometric properties of nursing student's ethical sensitivity questionnaire" supported by Shiraz University of Medical Sciences, Shiraz, Iran. The authors thank the participants for taking part in this study.

Declaration of Conflicts of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. This study was financially supported by the Research Deputy of Shiraz University of Medical Sciences (grant no, .