Introduction

Nursing ethics education is crucial for addressing ethical issues that arise in the patient-nurse relationship (increasing patients' expectations from health care services, communication between patient and nurse, power distribution, trust, nurses' attitude, professional values, etc.) as well as adapting to the shifting dynamics in the healthcare industry (technological developments, increasing the burden of scientific information and increasing the quality of nursing care, etc.). Ethics education provides the opportunity for students to advance/improve their ethical decision-making and attentiveness skills (Jasemi et al., 2022; Kucukkelepce et al., 2021). According to studies, nursing students' awareness, moral reasoning, and ethical decision-making abilities increase as a result of ethics education (Jasemi et al., 2022; Kucukkelepce et al., 2020). Nursing ethics education is acknowledged as a professional and legal requirement with national and international regulations (ICN, 2012). In this context, ethics education should be included in nursing. Although ethics education is a part of the nursing curriculum, there are a number of distinct aspects (such as teacher qualifications, course content, teaching styles, and assessment procedures). These differences lead to the use of different teaching methods in ethics education. Teaching techniques frequently used in ethical education include didactic lectures, case discussions, role-plays, and standardized patients (Jasemi et al., 2022; Kucukkelepce et al., 2020; Lee et al., 2020). The teaching technique used directly affects student learning. Therefore, the appropriate teaching technique must be preferred. It is stated that today's Generation Z students, who constitute the sample of this research, prefer innovative, student-centered, and simulation-based methods to traditional learning methods. Dramatization simulation is a teaching method that potentially corresponds to these preferences.

Dramatization simulation is a kind of theater or role-playing method that allows students to learn through experience while portraying content on the subject, similar to real nursing care (Hess et al., 2022; Wyss et al., 2022). Dramatization simulation has been used in only a few studies in nursing education (Hess et al., 2022; Wyss et al., 2022).

Studies have found that dramatization simulation is an effective learning and teaching strategy for nursing students (Wyss et al., 2022) and increases students' knowledge of female genital mutilation (Hess et al., 2022). No study has been found in which a dramatization simulation has been used in the education of ethics in the nursing profession. Consequently, our research is the first in its field. Nursing students must master simulation methods that dramatize real-life situations. In this situation, dramatic simulation in nursing education needs to be backed by scientific evidence. Our study will add to the body of knowledge already found in the literature.

Objective

This study aims to determine the effect of dramatization simulation on the ethical attitudes of nursing students. The following hypothesis was tested:

  • H1: Compared to the control group, students who received ethics instruction using the dramatization simulation method have heightened ethical attitudes.

Methods

Design

A mixed-method approach was used in this study to collect both quantitative and qualitative data.

Participants

This study was conducted between November and December 2022. The study's context was formed by 100 senior students enrolled in the nursing department of a public university. Students took a Nursing and Ethics course for two hours per week during the fall semester in their third year. The methods of memorandum and case discussion were used within the parameters of the course. Of the sample population, 30 students chose not to participate, and ten were not included due to a poor understanding of Turkish/or an insufficient grasp of Turkish. This was due to the study had to take place outside of class, and students had to make time for the study. The remaining 60 students were randomly divided into control (n = 30) and experimental (n = 30) groups based on gender and academic achievement scores. The research was finalized with 60 students (Fig. 1). The registration number "ID: NCT05618977" was obtained from ClinicalTrials.gov prior to the launch of the study. Written approval for the research was granted by the university ethics board (September 28, 2022, no. 27) and by the institution involved (October 25, 2022, no. E-52950036-212.01-96307). After explaining the study's purpose and methodology to the students, written informed consent was obtained from them.

Fig. 1
figure 1

Flowchart of the study

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Data Collection and Instruments

Data were collected with the "Introductory Characteristics Form", "Scale for Attitudes of Ethical Principles", and "Semi-Structured Focus Group Interview Form". The Introductory Characteristics Form consisted of 5 closed-ended questions prepared by the researchers to determine the students' sociodemographic characteristics, such as age, gender, and GPA. The Scale for Attitudes of Ethical Principles (SAEP) used in the study was created by Uysal Kasap and Bahçeci to determine nurses' attitudes toward ethical principles in health care practices. The 5-point Likert-type scale comprises six subdimensions: "Justice, No Harm, Honesty, Respect for Autonomy, Benefit, and Confidentiality," and items 9, 11, 28, and 35 are coded in reverse. The highest score is 175, and the lowest score is 35 points. A high score on the scale reveals a positive attitude toward ethical principles. The scale's Cronbach's alpha value was 0.85 in the original validity and reliability study (Uysal Kasap & Bahçecik, 2020) and was 0.83 in this study. Researchers developed the semi-structured focus group interview form, which consists of two open-ended questions, by reviewing the literature to ascertain students' opinions of the teaching strategy used (Hess et al., 2022; Wyss et al., 2022).

The questions used in the interview are as follows:

  1. 1.

    What are your thoughts on the teaching strategy (dramatization simulation)?

  2. 2.

    In your opinion, how does dramatization simulation affect the formation of ethical attitudes?

Research Process

This study was carried out in two stages: preparation and intervention.

Preparation

The preparation of the four case sample scenarios used in the study involved a two-stage process. Researchers identified four cases as the most common ethical problems by reviewing the literature and scripting them per the scenario formats (Alinier, 2011; Bringedal Houge, 2022; Nestel & Bearman, 2014; Yoder et al., 2022; Zeydi et al., 2022). These were domestic violence, fair planning of nursing care, threatening patient safety, and informing an adult with a terminal illness. We reviewed and evaluated according to the following scale.

Three faculty members with expertise in nursing ethics reviewed the prepared cases and scenarios (1: Appropriate, 2: Appropriate but insufficient, 3: Not appropriate). Statistical agreement between the expert opinions was found (Kendall's W = 0.200; p = 0.045), so the changes were made following their recommendations.

Intervention

All participants were handed the Introductory Characteristics Form and Scale for Attitudes of Ethical Principles (pretest) and asked to complete them.

Applying the Procedure to the Experiment Group

Four groups of seven or eight students were created for the experiment group. The four prepared case samples were randomly distributed to the four student groups. Researchers took part in the roles of patient and nurse. The students in the experiment group received a five-minute pre-brief (preliminary information) before the scenario was played. The scenarios were played for approximately 15 to 20 min in the faculty where the study was conducted. The students in the experimental group watched the dramatization simulation while the scene was being played out. A 15–20-min debriefing session was held with the students in the experiment group following the dramatization simulation. The "PEARLS" model was applied during the discussions. This method is known as Promoting Excellence and Reflective Learning in Simulation (PEARLS). The PEARLS method consists of four stages. These are the reaction, identification, analysis, and summarization stages. The lead researcher took part in the "Clinical Simulation in Nursing" course, graduated with a certificate, and had prior experience in this area. The following questions were posed to the students during the decoding session:

  • How did the simulation make you feel?

  • Did the standard patient provide the responses you anticipated?

  • What are your thoughts on the doctor-patient relationship?

  • What did you consider to be well done?

  • If you had the chance to change something, what would you do?

  • What possible ethical implications could this experience have?

  • What lessons did you take away from this scenario, in conclusion?

The Scale for Attitudes of Ethical Principles was handed to the participants to complete after the dramatization simulation applications and decoding sessions (post-test). Three focus groups were held on the same day to determine what the experimental group students thought about the dramatization simulation. The interviews, which involved 30 students, used the semi-structured focus group interview form and took place over the course of 20 to 30 min. The interview was continued until the data reached sufficient saturation. Throughout the interviews, the researcher took field notes to triangulate. With the students' permission, voice recordings of the interviews were made. The students verified the transcription of the interviews after they had been written.

Applying the Procedure to Control Group

The procedure was not applied to the control group. Students in the control group were given the Scale for Attitudes of Ethical Principles and asked to complete it four weeks after completing the Introductory Characteristics Form. (post-test).

Data Analysis

The quantitative data were analyzed using the SPSS statistical package (version 22.0; SPSS, Inc., USA). The descriptive statistical analysis of the data used values such as number, percentage, mean, and standard deviation. With the help of the skewness, kurtosis, and Kolmogorov‒Smirnov tests, the normality of the distribution of the data was tested. Using chi-square (χ2) analysis, the relationship between the grouped variables was examined. The Wilcoxon test was used to find the difference between the first and last scores in paired groups, and the Mann‒Whitney U test was used to compare quantitative continuous data between two independent groups. The qualitative data gathered from the interviews was transcribed and double-checked by the students. A random code was assigned to each student (such as P1 and P2). The transcripts were coded by two researchers (YO, SY) by methodically identifying key expressions (such as frequently repeated expressions and similar expressions). The researchers then discussed how to create the themes using codes and subthemes. The phenomenological analysis steps described by Colaizzi (1978) and MAXQDA 2020 software were used for the analysis of qualitative data.

Reliability

To ensure the study's reliability, the researchers adhered to the four criteria put forth by Lincoln and Guba (1985): credibility, reliability, transferability, and confirmability. Participant confirmation and expert review were provided to ensure credibility. Students verified transcripts. Data analysis was reviewed by an expert external to the research. Two separate researchers independently coded the data to ensure its reliability. Consistency between coders was ensured by determining that two researchers coded the same data in the same data set in a similar way. The interview form was used to ensure consistency in the data collection process. This interview schedule consisted of a series of set questions followed in the same order every time. Additionally, MAXQDA 2020 software was used for reliability. Clear explanations of the research methodology were provided and used to ensure transferability. Quotes from student statements were made to ensure confirmability.

Results

Quantitative Findings

The distribution of students according to their descriptive characteristics did not statistically differ between the control and experimental groups (p > 0.05) (Table 1).

Table 1 Distribution of students based on their descriptive characteristics (n = 60)
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The pretest mean scores did not significantly differ between the groups. The SAEP total mean score of the experiment group and the mean score of the Justice, Benefit, and Confidentiality subdimensions were statistically significantly higher than the control group in the post-test mean scores (p < 0.05). There was no difference between the pretest and post-test mean scores of the control group when considering the change in the mean scores of the groups among themselves. It was found that the mean scores for the subdimensions of Justice, No Harm, Benefit, and Confidentiality in the experiment group increased statistically significantly (p < 0.05) (Table 2).

Table 2 Scale for attitudes toward ethical principles pretest and posttest score distributions of the groups (n = 60)
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Qualitative Findings

Data analysis yielded two themes and four subthemes regarding nursing students' views on dramatization simulation and ethical attitude.

Themes 1: Views on Dramatization Simulation

Two subthemes were identified from the students' opinions on the dramatization simulation method. These are positive (n = 20) and negative (n = 10) opinions (Fig. 2). Student quotes related to this theme are as follows:

  • Subthemes 1.1. Positive opinions

  • "It was a unique study. We never participated in something like this before. It created awareness" (OG1, P5).

  • "We are not in the plot. We are only commenting now. However, this provided us with useful information prior to our graduation." (OG3, P27).

  • "It was very true to life. We had a unique experience because nothing like this had ever happened to us before" (OG2, P12).

  • Subthemes 1.2. Negative opinions

  • "I was anxious. I had the impression that I was actually experiencing this situation, and I pondered my course of action" (OG1, P8).

  • "What if I find myself in a similar situation in the future? I considered the repercussions of making the incorrect choice or being unable to decide" (OG3, P24).

  • "I had a small amount of profession-related anxiety." (OG2, P15).

Fig. 2
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Themes and subthemes of dramatization simulation

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Themes 2: Views on Ethical Attitude

Two subthemes emerged from the students' opinions on how the dramatization simulation method affected the formation of ethical attitudes. These are ethical decision-making (n = 12) and ethical awareness (n = 18) (Fig. 3). Student quotes related to this theme are as follows:

  • Subthemes 2.1. Ethical decision making

  • "When I encounter situations like these in the clinic, I can handle myself more professionally" (OG2, P14).

  • "I understood that I had to keep my emotions under control in an ethical manner" (OG1, P1).

  • Subthemes 2.2. Ethical awareness

  • "It enabled us to view things from a variety of perspectives" (OG3, P30).

  • "When I found myself in an ethical predicament, I understood how crucial my choice was. I therefore realized that I must always base my decisions on ethical principles" (OG1, P9).

Fig. 3
figure 3

Themes and subthemes of ethical attitude

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Discussion

This study examined how dramatization simulation affected nursing students' ethical attitudes. The use of dramatization simulation in nursing education has been studied in both quantitative (Hess et al., 2022) and qualitative (Wyss et al., 2022) aspects in the literature. To our knowledge, this is the first study that directly integrated dramatization simulation into nursing students' ethics education. As a result, the findings of this research were discussed with the study's results in different teaching methods used in ethics education in nursing. These methods are standardized patient (Basak & Cerit, 2019; Kucukkelepce et al., 2020), role-play (Jasemi et al., 2022), and simulation (Donnelly et al., 2017; Krautscheid, 2017; Sedgwick et al., 2020).

The SAEP total mean score of the experimental group was found to be significantly higher than that of the control group. This result shows that dramatization simulation is an effective method for nursing students to develop ethical attitudes. According to studies, using standardized patients in ethics instruction greatly enhances nursing students' moral sensitivity (Kucukkelepce et al., 2020) and ethical decision-making skills (Basak & Cerit, 2019). In their study, Jasemi et al. (2022) discovered that teaching nursing students ethical rules through the role-play method has a more beneficial impact than the course on developing ethical sensitivity and ethical performance. There are additional benefits to using simulations in ethics education, including improved ethical sensitivity to ethical dilemmas (Sedgwick et al., 2020), improved knowledge of ethical principles (Donnelly et al., 2017), and increased ethical decision-making skills in nursing students (Krautscheid, 2017). In another study, it was discovered that teaching nursing students about female genital mutilation using a common patient dramatization simulation method increased their knowledge of the practice (Hess et al., 2022). The outcome of this study is in line with the findings of the studies mentioned above.

Students' participation in the dramatization simulation in this study, the scenario-based approach to supporting learning, and gaining knowledge by observing and discussing the life experiences of others may have had an impact on the students in the Experiment group's high ethical attitudes. It is well known that the most effective way to teach ethics is through practice. Students may not always be able to develop ethical attitudes through practical experience in today's world. However, observing and talking about other people's life experiences can help you gain experience (Boz & İnce, 2019). Additionally, scenario-based instruction is reported to support students in learning about clinical ethics (Bagnasco et al., 2014).

The qualitative section of this study examined students' opinions of the dramatization simulation method. The majority of students (n = 20) had favorable things to say about this teaching strategy. They claimed that it aids in forming ethical attitudes by promoting ethical decision-making and awareness. According to nursing students who participated in the Wyss et al. (2022) study, the dramatization simulation used to teach about female genital mutilation is a useful and interesting teaching tool. In a different study, standardized patient-oriented nursing students who participated in ethics instruction claimed to have a better understanding of the material, developed their capacity for multidimensional thought, and became more conscious of ethical issues (Kucukkelepce et al., 2021). According to Akgül (2022), Generation Z (those born in the year 2000 and later) students value innovation and favor student-centered, active participation learning over more conventional narrative-oriented teaching methods. Generation Z characteristics of the interviewed students, their participation in the dramatization simulation, and their exposure to a different type of learning environment may have had an impact on their positive opinions in this study. In addition, in this learning method, dramatizing a situation that students could experience in real life may have contributed to positive student opinions by giving them the feeling of being involved in and experiencing the event. Experience is known to be effective in developing ethical awareness or ethical attitudes. The fact that the dramatization simulation was realistic and provided a different experience may also have affected the positive student opinions.

Limitations

The sample of this study consisted of only senior students in the nursing department of a university. Therefore, the results cannot be generalized beyond the study context.

Conclusion

Study results revealed that the dramatization simulation raised the overall average score of nursing students' ethical attitudes on the ethical principles attitude scale. Additionally, the majority of the students gave the dramatization simulation favorable reviews. Consequently, we recommend using dramatization simulation as a teaching strategy to help nursing students develop their ethical attitudes. This study should be conducted with a larger sample size and on a variety of topics.