Abstract
Moral sensitivity is one criterion for competent professional ethics. This sensitivity can be reinforced by specific educational practices. The purpose of this study was to investigate the impact of professional ethics-based education on the ethical sensitivity of health information technology students.
Method
This quasi-experimental pre-post study was conducted in 2022 with 49 students. A researcher-created questionnaire based on Lutzen was used for data collection. Data were analyzed using descriptive statistics and paired t-tests.
Findings
Students' moral sensitivity score was 7.4 ± 0.7 before and 7.6 ± 0.8 after, a significant increase in post scores (P=0.031). The moral sensitivity score of students who had not previously received professional ethics training was statistically significantly increased by case-based learning.
Results
The professional ethics-based teaching method was effective in increasing the moral sensitivity of health information technology students, so it is recommended to use this method of teaching medical ethics courses.
Keywords: Moral sensitivity, moral strength, moral responsibility, case-based learning, health information technology.
Introduction
Ethics is one of the most important, common, and challenging issues across all academic disciplines, especially in the medical sciences. Rapid advances in technology in the field of health, increases in public information, changing patterns of disease, and differences in the type and volume of health service requests have created new ethical issues1, 2.
Often, professional staff do not know the solutions to some ethical conflicts or are unaware of ethical decisions. Today, ethical decision-making is essential to professional work3. Ethical decision-making is the decision-making process of identifying issues through analysis according to ethical criteria and deciding whether or not to do it4-6. In other words, ethical decision-making is a debate about good or bad, and the conflict between acting and not acting on one's values7. Identifying ethical conflicts is very important in the decision-making process and staff need to be able to recognize ethical situations and evaluate the situation quickly and accurately to make decisions that are ethically beneficial to patients8-11. For example, hospitals are responsible for responding to legal requests for patient information disclosure by the principle of confidentiality of patient data12. Because of this, deciding whether to disclose sensitive patient information, such as information about sexually transmitted diseases, is an ethical situation that challenges staff to make decisions. Making ethical decisions not only requires moral knowledge but also moral sensitivity. Ethical sensitivity means the ability to identify an ethical issue, understand the ethical consequences of the decision, and how one's actions affect others13.
Lutzen defines moral sensitivity as one's "awareness of a sense of responsibility, moral burden, and moral ability." In other words, moral sensitivity includes cognition and awareness that a person's decision or action may affect others' interests, welfare, or expectations, and may conflict with one or more ethical standards14. Thus, people with moral sensitivity are better equipped to resolve ethical conflicts in complex situations15.
One way to increase ethical sensitivity is through professional ethics training16-17. Teaching professional ethics and institutionalizing these ethical principles among employees is a principal concern among health authorities. Increasing students' ability to practice professional ethics as future employees of the health system is also a concern for education authorities18-20. If these professional principles and beliefs are not institutionalized during a student's educational career, it may reduce the student's moral sensitivity and, consequently, make it more difficult for them to practice ethical decision-making in the future19-21.
Some texts provide specific training methods for increasing ethical sensitivity, such as group discussion22, problem-solving, case-based or scenario-based methods7,23,24, or workshops25 More objective training (e.g., examples, case studies, and the use of teaching aids) affect moral sensitivity positively26. Student-centered teaching methods are also more useful than traditional teaching methods to help develop critical thinking skills, problem-solving, and decision-making27. One strategy that enhances active learning and prepares students for future careers and service in a real-world environment is case-based teaching7, 23, 28. Case-based teaching is a combination of traditional (lecture) and problem-solving teaching29. In this method, scenarios are used, real or realistic, which require problem-solving and decision-making. In this way, the teacher acts as a facilitator, guiding the students toward the goals, and students learn to think critically to solve the problem and make decisions in the new situation. This teaching method helps students organize knowledge, identify gaps in the field, communicate with students, develop problem-solving, and decision-making skills, and has the added benefit of increasing motivation for learning30. Today, the use of case-based methods in medical sciences pedagogy, especially in basic sciences, is expanding in most universities around the world. Therefore, given the benefits of this teaching method, this study investigated the impact of case-based ethics training on the ethical sensitivity of health information technology students.
Method
The present study was a quasi-experimental pre-post study with health information technology students at the Tabriz University of Medical Sciences. The sample consisted of 49 students in the fifth through eighth semesters who were enrolled in the study. The instrument used in this study was a researcher-created questionnaire on moral sensitivity designed based on the Lutzen questionnaire in two parts: demographic information and moral sensitivity dimensions. The first part of the questionnaire included information on age, sex, semester, work experience, duration of work experience, and prior study of professional ethics and the second part of the questionnaire included dimensions of ethical orientation (three items), moral strength (two items) and moral responsibility (five items).
The first dimension of moral inclination or moral burden means the "negative" aspect of morality and resembles the experience of moral stress14, which is something that must be done ethically. The second dimension is about moral power, which means having the courage to act, being able to reason, and having flexibility and endurance14. The third dimension is a moral responsibility, reflecting the ethical commitment to work according to laws, regulations, and insights14.
In this questionnaire, each question was scored on a five-point Likert scale, with a score of always =1, often = 0.75, in some cases = 0.5, rarely = 0.25, and never = 0. The total score range of the questionnaire was 0 to10, with the range of moral tendency score of 3, moral strength of 2, and moral responsibility of 5. Students' moral sensitivity to decision-making based on the total scores of the questionnaire was divided into four categories: very low (scores 0 to 2.5), low (scores 2.75 to 5.75), moderate (scores 5.25 to 7.5), and high (scores 10 to 7.75). The questionnaire was reviewed by a team of nine members (including health information management specialists, medical informatics from the Tabriz School of Management and Information Science, and members of the Medical Ethics Working Group of the Tabriz University of Medical Sciences). To test reliability, the retesting method was used at a distance of 10 days. (Cronbach's alpha= 0.73, CVI= 0.87, CVR= 0.96).
This study was carried out after approval by the Ethics Committee of the Tabriz University of Medical Sciences and control of ethical criteria in the study including confidentiality of information and informed consent of the subjects in the study. All questionnaire information was distributed in a professional ethics training session and completed by students both pre-and post. The data were entered into SPSS 23 software and a paired t-test was used to analyze the data at a significance level of 0.05.
Findings
Of the 49 students in the study, 40 (81.6 percent) were female and 9 (18.4 percent) were male. The mean age of the study samples was 21.5 and the mean work experience was 11 months. In total, 32 (65.3 percent) students had work experience and 17 (34.7 percent) did not. Additionally, 33 (67.3 percent) students had no prior professional ethics training, and 16 (32.7 percent) students had prior professional ethics training.
Table 1 shows average scores of students' moral sensitivity before and after ethics training. According to the results of the paired t-test, the ethical sensitivity score was 7.4 ± 0.7 before education and 7.6 ± 0.8 after education this increase was statistically significant (P = 0.031).
In all, 27 (55.1 percent) of students showed moderate moral sensitivity and 22 (44.9 percent) showed high moral sensitivity before ethics training took place, after training, 24 (49 percent) students showed moderate moral sensitivity and 25 (51 percent) students showed high moral sensitivity. In terms of ethical susceptibility, responsibility and moral power subscales scores before and after ethics training were statistically significant (PV< 0.05).
Table 1: Comparison of mean and standard deviation of moral sensitivity score and subscale scores in students before and after ethics training
|
Moral Sensitivity
|
Moral Burden Score
|
Moral Strength Score
|
Moral Responsibility Score
|
Moral Sensitivity Score
|
|
Before
After
Pv
|
2.1 ± 0.5
2.1 ± 0.5
0.51
|
1.1± 0.3
1.3 ± 0.3
0.001
|
4.4 ± 0.4
4.7 ± 0.3
0.000
|
7.4 ± 0.7
7.6 ± 0.8
0.031
|
There was a statistically significant difference between the mean scores of responsibility subscale ethical sensitivity of students without work experience at the time of education (P =0.000); however, the mean scores of students with work experience were not statistically significant (P=0.35).
As can be seen in Table 2, the moral sensitivity scores of sixth semester students before and after ethics training were statistically significant. There was also a statistically significant difference between the scores of students who did not have work experience while studying. Having work experience and passing a course in ethics seemed to have no significant effect on students' post-training sensitivity scores.
Table2: Comparison of mean and standard deviation of students' moral sensitivity scores before and after ethics training
|
|
|
Moral Burden Score
|
Moral Strength Score
|
Moral Responsibility Score
|
Moral Sensitivity Score
|
|
Work experience
|
Before
After
Pv
|
2.07 ± 0.5
1.96 ± 0.5
0.30
|
0.78 ± 0.3
0.79 ± 0.4
0.74
|
4.4 ± 0.5
4.6 ± 0.4
0.010
|
7.2 ± 0.7
7.3 ± 0.8
0.35
|
|
No work experience
|
Before
After
Pv
|
2.3 ± 0.4
2.4 ± 0.4
0.48
|
0.86 ± 0.3
0.89 ± 0.4
0.75
|
4.4 ± 0.3
4.8 ± 0.2
0.000
|
7.7 ± 0.5
8.1 ± 0.6
0.008
|
|
Passing the ethics unit
|
Before
After
Pv
|
2.2 ± 0.6
2 ± 0.6
0.18
|
0.64 ± 0.3
0.54 ± 0.4
0.13
|
4.4 ± 0.5
4.7 ± 0.4
0.032
|
7.3 ± 0.9
7.3 ± 0.9
0.75
|
|
No passing the ethics unit
|
Before
After
Pv
|
2.1 ± 0.4
2.1 ± 0.5
1
|
0.89 ± 0.3
0.96 ± 0.4
0.19
|
4.4 ± 0.3
4.6 ± 0.3
0.000
|
7.4 ± 0.6
7.8 ± 0.6
0.017
|
|
5th semester students
|
Before
After
Pv
|
2.47 ± 0.6
2.31 ± 0.5
0.31
|
1.38 ± 0.3
1.47 ± 0.3
0.22
|
4.63 ± 0.5
4.9 ± 0.2
0.16
|
7.72 ± 0.8
7.77 ± 0.7
0.88
|
|
6th semester students
|
Before
After
Pv
|
2.1 ± 0.3
2.3 ± 0.4
0.16
|
0.94 ± 0.3
1.05 ± 0.4
0.32
|
4.4 ± 0.3
4.7 ± 0.3
0.001
|
7.5 ± 0.4
8.1± 0.6
0.001
|
|
7th semester students
|
Before
After
Pv
|
2 ± 0.6
1.8 ± 0.6
0.13
|
1.22 ± 0.3
1.59 ± 0.3
0.038
|
4.5 ± 0.3
4.7 ± 0.2
0.082
|
7.2 ± 0.7
7 ± 0.7
0.055
|
|
8th semester students
|
Before
After
Pv
|
2.03± 0.4
2 ± 0.6
0.84
|
1.01± 0.23
1.21± 0.28
0.002
|
4.1± 0.4
4.4 ± 0.5
0.028
|
7. 2 ± 0.8
7.6 ± 0.9
0.11
|
Discussion
The results of this study showed that case-based ethics training increased the score of ethical sensitivity of health information technology students. In this regard, the results of various studies have emphasized the positive impact of education on students' moral sensitivity and identifying ethical dilemmas17, 31-33. Some studies have addressed the impact of different educational practices on moral sensitivity7. For example, some point out that the more objective a training is by exemplifying and using teaching aids, the more moral sensitivity is affected30. Another study examines nursing students' experience with exposure to the first case of ethical decision-making in the clinical setting. Film screenings, creating situations similar to those that practitioners and nurses face, and role-playing, far beyond mere theory training, can be effective in teaching students about ethical decision-making27. Gaul quotes Bostani as the reason for inappropriate teaching of ethics and states that teaching ethics is not comprehensive enough that students get a good picture of the subject of ethical decision-making and reasoning34.
Since students will be future employees, it is imperative that they are sensitive to the ethical issues of their profession and that they acquire the necessary skills and competencies before entering the workplace. Education is one of the most important and powerful ways of helping students acquire these skills and enhance their moral sensitivity31. Likewise, one of the most important principles in education is the use of appropriate teaching methods.
Accordingly, various studies have referred to a variety of ethics training methods such as simulated environments, formal lectures, group discussions, and so on7, 20, 23, 24, 32. One teaching method for ethics that has been emphasized in most of the literature is case-based teaching3, 28, 32-34. Case-based teaching is a student-centered approach to teaching that engages students as learners through active learning in small, collaborative groups to solve problems that uses ethically conflicting learning35. Case-based learning (CBL) is a teaching approach that engages students as learners through active learning in small, collaborative groups to solve problems that resemble real-world examples. The professor selects problematic situations and asks students to discuss the situation and examine the ethical conflicts of the case and the outcome of the various responses. Discussion of ethical conflicts introduces students to important ethical questions both professionally and socially. Working with cases of ethical conflict is a useful way to understand moral theory. These cases help students identify ethical situations and apply ethics and reasoning enhancing the ethical judgment of students36, 37.
One reason for using this method is that students have the opportunity to discuss, debate, and present different opinions. As these cases and scenarios reflect real-world situations, students realistically exchange ideas, process and enjoy course content in a real situation37, 38. Numerous studies have shown that case-based teaching improves independent learning skills32, critical thinking, decision-making skills, communication skills, problem-solving skills, the ability to identify relevant issues, and the ability to objectively judge and motivate learning.
The results of the current study showed that ethics education was more effective in those who had not previously studied ethics than in students who had prior exposure. In this respect, Myyry16 states that technical and professional knowledge has nothing to do with moral sensitivity. To improve sensitivity to ethical issues and to increase awareness and judgment, ethics education must be included in curricula. A study conducted in Korea by Lutzen also found that moral sensitivity was influenced by several factors, including culture, religion, education, age, sex, experience, and education, and varied from person to person14.
The greatest effect of ethics training in this study was seen in the subscales of moral responsibility and moral power. The results of the present study showed that students with no work experience while studying at school were more likely to have a higher level of moral sensitivity than students with work experience. However, other studies have shown a significant relationship between work experience and students' moral sensitivity scores38. In comparing ethical sensitivity scores between sixth and eighth-semester students, there was a statistically significant positive difference in the sensitivity score of the sixth-semester students and their power and moral responsibility subgroups compared to eighth-semester students.
This finding also underscores the impact of students' work experience on students' ethical sensitivity, which may be one reason for students' use of departments that incorporate more routine and repetitive health information management processes, where they perceive no need for complicated and case-based decisions. Therefore, students are in most cases not confronted with ethical conflicts and challenging situations in these settings.
One of the study limitations was the fact that the single-group pre-test and post-test design with no control group. Consequently, there was no conclusion on the causal relationship. Another limitation was the small sample size of the study, although all eligible students were included in it.
Conclusion
The findings of this study indicate that ethics education through case-based learning is an effective strategy for improving students' ethical sensitivity. This teaching method is also useful for actively engaging students in learning and facilitating the learning process. Thus, this method is recommended for ethics education to health information technology students.
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Author Biographies
Shahla Damanabi, PhD, is an associate professor of health information management in the School of Management and Medical Informatics, at Tabriz University of Medical Sciences, Tabriz, Iran.
Mozhgan Behshid, PhD, is an assistant professor in the Medical Education Research Center, Health Management and Safety Promotion Research Institute, Nursing & Midwifery Faculty, Tabriz University of Medical Sciences.
Zahra Moradi, is a Master’s student in the Department of Health Information Technology, School of Management and Medical Informatics, at Tabriz University of Medical Sciences.
Leila Ghaderi- Nansa, PhD (leila.gadery@gmail.com) (corresponding author) is an assistant professor of health information management in the School of Management and Medical Informatics, at Tabriz University of Medical Sciences.