A comparative analysis of ethical development of student nurses registered for a basic degree and basic diploma programme in KwaZulu Natal

A comparative descriptive study was conducted to estab­ lish whether the Comprehensive Basic Nursing Course (CBNC) is able to develop students ethically, and how edu­ cational preparation from two different programmes (basic degree and basic diploma) influence their ethical develop­ ment. This study was conducted because of the concerns on the escalating number of litigations instituted against nurses. Several studies have indicated that some of these litigations are as a result of the growing complexity of the health care system and the society’s increasing awareness of their human rights. Some studies have shown that nurses are failing to make principled and ethically sound decisions because they are inadequately prepared to handle ethical issues in an ethically responsible manner. A purposively selected sample of third and fourth year students from both programmes was used. Data was col­ lected from both groups through the use of questionnaires. The findings revealed that the students are developing ethi­ cally in a CBNC but the level of ethical development is influenced by their educational preparation, teaching ap­ proaches and strategies used, clinical environment, hospi­ tal bureaucracy, rules and policies. Opsomming ‘n Vergelykende beskrywende studie om te bepaal of die Komprehensiewe Basiese Verpleegkunde Kursus (KBVK) studente eties voorberei, en of die onderrig voorbereiding van twee verskillende programme (die basiese graaden die basiese diplom a kursus) die student se etiese ontwikkeling be'invloed. Hierdie studie is gedoen as gevolg van die stygende aantal gevalle van geregtelike vervolging teen verpleegkundiges. Verskeie studies het aangetoon dat sommige van hierdie geregtelike vervolgings die gevolg van die groeiende kompleksiteit van gesondheidsdienste en die gemeenskap se toenemende bewustheid betreffende menseregte is. Sommige studies het aangetoon dat verpleegkundiges in gebreke bly om beginselvaste en eties suiwer besluite te neem as gevolg van onvoldoende voorbereiding betreffende die verantwoordelike hantering van etiese kwessies. ‘n Doelgerigte en uitgesoekte steekproeftrekking van derdeen vierdejaar studente van beide programme is gebruik. ‘n Vraelys was benut om die data van beide groepe in te samel. Die bevindinge het aangetoon dat die studente wel etiese vaardighede ontwikkel in ‘n KBVK maardat die vlak van etiese ontwikkeling deur die onderrigvoorbereiding, onderrig benaderings en strategieë wat benut word, kliniese omgewing, hospitaal burokrasie, reels en regulasies beïnvloed word.


Introduction
Nursing programmes worldwide are challenged to produce graduates who will be able to meet the changing needs of the population existing in the post modem era, which is character ized by heterogeneity, difference, fragmentation and indeter minacy.The post modernism era poses the greatest challenge more especially in the democratic South Africa with diverse multi-cultured population, which is literary reflected by eleven languages.Nursing graduates in this country are expected to live up to these diversities by being well prepared in all forms of knowing (personal, aesthetic, ethical and empirical).Their educational preparation should enable them to make sound decisions in their daily practice, of which most of these deci sions are ethical in nature.Ethics therefore is vital to nursing as it is perceived as the foundation of committed service to mankind (Pera and van Tonder, 1996).Kollermoten, Strandberg, and Thomsen (1981) argue that health professionals are generally prepared to function in the scien tific realm, whereas clinical decision making demands that they are taught the logical analysis of ethical problems.Dewey (1963) indicated that there is a need to overcome the widening gap between scientific knowledge and morality.He felt that ethics is failing to keep pace with advances in technology and physical science.As a solution to this concern, Reilly and Oermann (1985) contend that moral and ethical development (which is part of the affective domain) needs to be seen as important as the cognitive and psychomotor domains.Rutty (1998) further asserts that "although scientific realm is a neces sary, important and critical element of nursing it is important to acknowledge the aesthesic, personal and ethical (own empha sis) knowledge too because all are crucial to nursing practice" p246.Ethical and legal responsibilities attached to nursing practice cannot be ignored.They pose a challenge to academic nursing programmes.In summary the recommendations from the stud ies related to the ethical development of nurses included that: • Academic nursing programs should have ways of assisting nurses to increase their knowledge base regarding ethics and ethical decision making to develop their ability to articulate and defend their decisions.

•
Introduction of innovative curricular approaches and teaching strategies.

•
Exposure of students to clinical environments with rich and varied learning experiences.

Problem Statem ent
The reviewed literature indicated that there is a limited number of studies done on ethical development of nurses, especially in South Africa.Studies previously done have focused on the qualified nurses' abilities in handling ethical issues, and less attention has been given to the ethical development of the students.
Ntombela, Mzimela, Mhlongo and Mashaba (1996) conducted a study on the clinical performance of graduates from the CBNC.The professional nurses who were participants in this study evaluated the clinical performance of CBNC graduates.The findings indicated that CBNC graduates' clinical performance in all aspects (including application of nursing ethics to prac tice) was far below that which was expected.The researcher in the present study decided to evaluate the students themselves to ascertain whether they are developing ethically in the CBNC.

Objectives of the study
The study was aimed at: • Establishing whether the four year CBNC does foster ethical development of students.

•
Comparing the level of ethical development of diploma and degree students both involved in a four year CBNC.

•
Establishing whether there is a relationship between educational preparation and ethical development.

The International Council of Nurses Code for Nurses
The value statements in the ICN Code for Nurses (1973) were used to measure the degree to which the students' practice reflects an ethical behavior.According to Fry (1994) the codes provide an ethical foundation and appropriate content for de cision making in nursing practice.Certain nursing values were observed under each value statement, see Table 1.

Methodology
A comparative descriptive design was used in this study.This design was relevant because comparative descriptive designs are structured to describe and compare differences in variables in two or more groups (Polit and Hungler, 1991) The principle of optimacy Maintenance of competence in practice ing students ethically, compare their level of development in two different programmes, diploma and degree and how edu cational preparation influence their ethical development.
A purposively selected sample of third and fourth year di ploma and degree students involved in a CBNC was used.The researcher assumed that nursing students at these levels of training had adequate knowledge foundation and clinical ex periences in handling ethical issues.All students enrolled in these two programmes volunteered to participate but only eighty-one participants responded.

D ata collection instrum ent
A three sectioned questionnaire was used for collecting data.Data was collected on demography, application of nursing eth ics to practice; and solving and ethical dilemma.An ethical dilemma was extracted from Crishaw ( 1981) see Appendix 1.The application of nursing ethics theory to practice was based on the ICN Code for Nurses (1973) and an ethical dilemma had three subsections which were based on Kohlberg's theory of cognitive moral development.After the careful construction of the instrument, content validity and test retest reliability was done before the administration of the instrument to the participants.

Data collection and analysis
The questionnaire was distributed to the participants and col lected by the researcher.Forty diploma students (n= 49.5%) and forty-one degree students (n= 50.5%) responded.The data was analyzed statistically.Frequency counts were done to analyze the demographic data and cross tabulations using the Chi-square test were performed to test the difference between the responses of the diploma and the degree students and the level of significance was at .05.

Application of nursing ethics theory to nursing practice
Both groups scored relatively high on twenty one (21) out of twenty five (25) items in the application of ethics theory to practice, but differences were noted in their scores.The di ploma students scored higher than degree students in eight een (18) items which evaluated professional practice, patient advocacy, accountability and cooperation.The degree students scored higher than the diploma students in three items which were associated with the clients' right to self-determination, autonomy and maintenance of competence in practice.
The statistical significance was noted only on four (4) items reported in Table 2.The table shows the percentages of the number of students that strongly agreed and agreed to the given statement; the Chi square, the significance level and the degrees of freedom (DF).

Accepting gifts and rewards from patients
This statement aimed at evaluating the maintenance of stand ards of professional conduct.By comparison, fifty nine per cent (59%) of degree students and thirty percent (30%) of di ploma students agreed strongly to this statement.The differ ence was statistically significant at .02 level and the chi square 11.0.The higher percentage of degree students agreed to this statement.

Practicing afte r removal from the register
The values of interest which were attached to this statements were commitment to the nursing profession, maintenance of professional standards and the duty to maintain registration.By comparison seventy one percent (71 %) of degree students

Advertising medical products
The fundamental concept behind this statement was the nurse as the patient and public's advocate.About seventy one percent (71 %) of degree students and thirty three percent (33%) of diploma students indicated that nurses can advertise medical products.The level of significance was .03 and the Chi-square was 15.8.

C onfiden tiality and clients or patients living w ith HIV/AIDS
Concerning the rights of clients/ patients living with HIV/AIDS to confidentiality, about thirty three percent (33%) of diploma students and 24% of degree students agreed and strongly agreed to ignoring this right.The level of significance was .02 and the Chi-square 11.4

Level of ethical developm ent in handling an ethical dilemma
The level of ethical developments was established through evaluating the student' autonomy in decision making, princi pled thinking and familiarity with ethical dilemmas, and the following results were obtained: Autonom y in decision m aking in an ethical dilemma In the ethical dilemma that was used, the participants had to make a decision on whether to answer the questions of a dying cancer patient or to respect the wishes of the family as ordered by the physician, by keeping the information from the patient.This was aimed at evaluating the student's autonomy in han dling ethical dilemmas in their practice.Table 3 has the sum mary of these results.
Seventy five percent (75%) of diploma students and eighty percent (80%) of degree students chose to respond to patient's question and ten percent (10%) of diploma students and eight een percent (18%) of degree students could not decide what to do in such a situation.Ten percent (10%) of diploma students and two (2%) of degree students felt that the nurse should not answer the patient.

Principled thinking
The participants were given items to rank according to their importance when handling an ethical dilemma, see Table 4.The level of ethical development was interpreted according to the ranking of items in terms of their importance when handling an ethical dilemma.The reported results are only on the two items, the most important and the least important considera tions when handling an ethical dilemma and the results on how the responses were spread throughout the six considerations when handling an ethical dilemma are not reported.According to Kohlberg (1981), the item ranked as the most important consideration is considered the highest level of thinking of that individual and the item ranked the least important consid eration as the lowest level of thinking.

The most im portant consideration when handling an ethical dilemma
The highest concentration (32%) of diploma students selected item 2 as their most important consideration when handling an ethical dilemma.The decision on how to handle the dilemma depended on the presence of a physician in the unit.Accord ing to Kohlberg (1981) item 2 indicates a low level of thinking in making moral judgements, where one cannot act or make deci sions without consulting others.The most important consideration for the highest number (42%) of the degree students was item 1, "how I can best follow the specifications on sharing information on the patients Bill of Rights".According to Kohlberg (1981) considering the pa tients Bill of Rights before making decisions represents level four of thinking.Individuals at this level see everyone in the society as having a right to be protected by law.

The least im portant consideration when handling an ethical dilemma
The highest percentage (53%) of diploma students considered item 1 " how I can best follow the specifications on sharing information on the patients Bill of Rights", as the least impor tant consideration when handling an ethical dilemma.The de gree students (46%) considered item 2, "practical considera tions in handling ethical dilemmas" as the least important.

Fam iliarity with an ethical dilemma
The participants had to indicate how familiar they were with an ethical dilemma.Sixty-nine percent (69%) of degree students and twenty-five percent (25%) of diploma students were famil iar with an ethical dilemma, and whether they previously had an opportunity to make a decision in an ethical dilemma.Thirty seven percent 37% of degree students and sixty-eight (68%) of diploma students were not familiar with the ethical dilemma but the dilemma that was presented was conceivable to them.To five percent (5%) of diploma students the ethical dilemma seemed remote and unreal.

Discussion
Although the results were inconclusive because of the sample size, the results on the application of nursing ethics to practice indicated that nursing students in the CBNC are developing ethically although their level of development, and the areas of development are not the same.The findings also indicated that education preparation plays an important part in the students ethical development.

The influence of educational preparation in ethical developm ent
The higher scores of diploma students in the application of ethics theory to practice supported the reported findings by Yung (1997) and Crishaw (1981).These findings suggested that exposure in the wards environment facilitates the ability to apply ethics theory to practice, and that clinical experiences challenges the students' ethical development.The students in a diploma programme were based in hospital throughout their course and therefore had more time in the ward environment.The degree students were involved in a Community Based programme which required them to spend time in the commu nity and a certain portion of time in ward environment.Be cause of the limited time spend by the degree students in ward environment, they had less exposure to practice applying eth ics theory to their practice in ward environment, where profes sional nurses role model and assist them in their ethical devel opment as professional nurses.In the community the degree students were working in multidisciplinary and multi-sectoral teams.Professionals from these teams served as their role mod els and influenced their development in working collaboratively with others.
In addition to these findings, degree students were prepared using a Problem Based approach and diploma students were prepared through a conventional method.Studies have shown that conventional methods covers more content, whereas prob lem based learning enhances more depth coverage than breath (Coulson and Osborne in Albanese and Mitchell, 1993).The diploma students covered more ethics theory (the breadth) in their programme whereas degree students covered more depth.
The ethics content covered in degree programme was based on the existing ethical problems identified in the clinical set tings.They focused more on what was relevant at that time.This accounts for diploma students scoring higher than de gree students in the application of ethics theory to practice.
The degree students scored higher than diploma students on issues of patients' rights to self-determination and autonomy because of their socialization.The degree students in their programme are socialized to place greater value on professional autonomy.The degree students are developed to view them selves as autonomous beings with freedom to approach the lines of communication in the ward environment, ask ques tions and free to make suggestions.In their programme, part nerships with patients in patient care is emphasized and clients are regarded as autonomous beings with rights to make their own decisions under the guidance of the health professional.These findings were confirmed by de Jong in Yung (1998).
The degree students scored higher in the maintenance of com petence in their practice.In the Community Based/ Problem Based programme the students are developed in a way that enables them to continue to learn throughout their work expe rience.Developing the students to be lifelong learners assists in maintaining and improving their personal competence, and this may account for their high score in maintenance of com petence.

Autonom y in the clinical environm ent
A high level of autonomy is a necessary prerequisite for ap propriate confrontation of ethical issues and dilemmas and for upholding ethical standards of practice, since nurses function in complex and difficult nursing environments.Due to the na ture of the work done by nurses, (caring for vulnerable indi viduals, working with colleagues and other professionals who may have conflicting opinions, and working in institutions with their own vested interests) to work as patients advocates they need to be able to stand for what is morally or ethically ac cepted, as indicated by Cassidy and Oddi (1988).
The findings suggested that the students in both groups have developed to a certain level, the ability to make decisions on their own, but the degree student scored higher than the di ploma students.This is because of their community based ex periences.Community based experiences facilitates self direc tion, autonomy and independence.The community exposure fosters critical thinking, problem solving and autonomy in de cision making as they spend most of the time on their own in the community with the facilitator available only when neces sary.Bellack (1998) stated that community based experiences provide the students with greater opportunities for autonomy, independence and risk taking and that it develops in them broader competencies which include problem solving.The stu dents in communities get front line experiences which they may not get in hospitals and this may have contributed to degree students scoring higher in autonomy.

Bureaucracy, organizational policies and ethical developm ent
The socialization of diploma students may have contributed to the majority of the diploma students selecting the item that indicated the lowest level of thinking.According to Yung (1997) college nurses are socialized in an environment where they cannot freely make decisions without consulting the seniors or existing bureaucratic structures.This handicaps them in making decisions when faced with an ethical dilemma because their thinking is moulded into a fixed pattern by the existing structures which must be followed or consulted.Socialization in such an environment may hinder the students' ethical de velopment.Yung (1997); Gaul (1987) and Ketefian (1981) sup port this finding in their argument that institutional policies hinder the growth of students since they practice in an envi ronment with tight bureaucratic structures, and the students do not get adequate opportunities to take responsibility in decision making.
Medical staff also contributes to the problem of inadequate development in decision making because they are regarded as team leaders with more power and they therefore make most of the decisions sometimes without even consulting other team members (Cassidy and Oddi, 1988).The current health care approach emphasizes a multidisciplinary approach with part nerships in patient care and that includes partnerships in deci sion making.The doctors should not be regarded as having more power than other team members, but all members should be recognized by the roles they play in providing total patient care.
According to Bellack (1998) community based students are exposed to ethical realities which they may be insulated from in hospital settings.The degree students's exposure to self di rected learning and work in the community settings contrib utes to their growth in decision making.These students in the communities are less encumbered by the complexity and regu lations of the hospital policy and they have an opportunity to explore their potential in managing situations (Bellack, 1998).
Practicing independently and the lack of close supervision in the community environment gives the students enough time to manipulate ethical dilemmas and make ethically sound deci sions freely.The results of the study by Boss (1994) also sug gested that community work or exposure helps improve the students' confidence in decision making because of the real life experiences they encounter independently in the absence of their teachers.
These results in this study also indicated that very few stu dents from both groups (diploma and degree) were at the high est level of solving ethical dilemmas of which according to Kyriocus (1995) is common in most programmes.Most of the graduates reach level five and six of development after gradu ation.Exposure to the clinical environment and less constraints in making decisions after graduation develops the nurses abil ity in handling ethical dilemmas up to maturity.
Ethical dilem mas and developm ent of thinking skills A higher percentage of degree students were familiar with an ethical dilemma because in their programme they are required to identify ethical dilemmas in the clinical environment and analyze how they were handled using ethics theories and prin ciples.Identifying and solving ethical dilemmas familiarized the degree students with the ethical dilemmas of which ac cording to Crishaw (1981) familiarity with solving ethical di lemma improves critical thinking skills and contributes to higher level of thinking.Familiarity with ethical dilemmas therefore accounted for the higher level of thinking in most degree stu dents.

Recom mendations
The theory of nursing ethics should be introduced early in nursing programmes to promote the correlation of ethics theory/ content to daily nursing practice in the clinical environment.In partnership with the college, the staff in the clinical learning environment should draw the students' attention to ethical issues to make them conscious of these issues and how they can apply theory in dealing with them.
Clinical supervision may facilitate ethical development of stu dents by encouraging the students to reflect on their experi ences related to handling ethical issues in the clinical settings, because reflecting facilitates academic and emotional growth and development as stated in Boud, Keogh and Walker (1985).
The students should also reflect on their experiences during class interaction, and in writing.They may reflect in writing through reflective learning diaries and assignments based on real life ethical dilemmas encountered in the clinical situation.
In their reflection they should clearly indicate what they have learned as a sign of growth in handling ethical issues.
The members of the multidisciplinary team, especially the ward sisters, should be approachable for the students to be able to feel free to make inquiries and reflect on the ethical issues identified in the learning environment.The college staff, facilitators and the ward staff should give the students oppor tunities to make decisions in ethical dilemmas, under their di rection.This will help students to develop their analytical think ing and problem solving skills.
The bureaucratic structures in the hospital settings may frus trate the degree students who are used to be independent and autonomous in the community settings.Their autonomy may create some friction between them and staff in the clinical envi ronment.These students need to be prepared for that para digm shift by their facilitators.In the ward environment the students from Community Based programmes should be given good orientation to existing hierarchical structures or chan nels of communications, hospital and ward policies, and stand ing orders, to be accessible to all if there is a need for them to be consulted before making a decision.
Partnerships should also be encouraged between nursing schools and the health service.This will make it possible to update service personnel on the new developments on the teaching strategies and this could be done through in-service training of ward personnel.This may prove to be helpful to the students' development because they are with the ward per sonnel most of the time.For the ward sisters to be of assist ance in guiding and directing the students in the clinical envi ronment, they need to have a better understanding of the learn ing approaches used in the teaching of students.
When using teaching approaches such as a problem based approach, that do not cover adequate content, other ap proaches may be used.A case study approach is one approach that may be used to ensure adequate content coverage while at the same time developing the problems solving and critical thinking skills.Cases used may be developed in such that im portant aspects necessary for ethical development of students are covered.
In the programmes where ethics is integrated in other courses, it is more likely that it is not taught at all, or the teaching may be inconsistent or it may not be explored deep enough, if the teachers have inadequate preparation in nursing ethics as stated in Aroskar and Veatch (1977).To counteract this problem, the educators need to be in-serviced or updated on new develop ments in the teaching of nursing ethics.

Conclusion
Nurses play a vital role as advocates and protectors of the client's autonomy, therefore nursing programmes should ad equately prepare them to fulfil this ethical responsibility.They should be prepared in such a way that will make them con scious of ethical issues in their daily practice, and the accept able ways of handling them, despite the pressures surround ing them.Nursing programmes should facilitate the develop ment of analytical, problem solving and decision making skills which are necessary for handling ethical issues.They should learn to reflect on their experiences to facilitate their process of growth.The adequate preparation of students ethically will equip them for meeting the needs and challenges of the multi cultured and multi-lingual society in South Africa.
Due to the complexity of the research study, two frameworks were used to guide the entire process namely; Kohlberg's cognitive theory of moral development(1981)and the Interna tional Council of Nurses (ICN) Code for Nurses(1973).

evel III P o st-co n v en tio n a l
The in d iv id u a l autonom ously exam ines and d efin es m oral values and principles apart from group norms and culture.

Table 1 :
ICN Code for Nurses value statements and nursing values

Table 2 :
Differences in the application of ethics theory to practice

Table 3 :
Frequency scores in response to " What should the nurse do?"

Table 4 :
Frequency scores of ranked items indicating stage of thinking in moral judgement development Item 6= Nursing principled thinking representing Stage 5 and 6 Item 5 =Represents Stage 1 thinking Item 4= Represents Stage 3 thinking Item 3 =Represents Stage 2: thinking Item 2 = Practical considerations "low level of thinking" Item 1= Represents Stage 4 thinking Source: Rest 1979 cited in Crishaw 1981:107