Leadership in Ethical Practice: Students Learning Outcomes

Health science students frequently experience ethical dilemmas on clinical placements, yet ethics education rarely prepares students with the ethical leadership skills required. The Leadership in Ethical Practice (LEP) program is an ethics education resource designed to enhance health science students’ knowledge and skills in ethical leadership to prepare them for clinical placements and future professional practice. This qualitative study aimed: to explore the nature of students’ ethical leadership goals; determine whether a specific, measurable, achievable, relevant, and time-bound (SMART) format was an effective tool for students to create ethical leadership goals; and identify any changes in students’ pre- and post-self-ratings of ethical leadership knowledge following the LEP program. Eighty-two diagnostic radiography students from the University of Sydney participated in the study. Inductive and deductive qualitative content analysis (Elo & Kyngas, 2008) were used to explore students’ goals. Descriptive statistics were used to investigate students’ pre- and post-self-ratings. Four themes emerged from students’ goals: initiative, competence, and courage in ethical reasoning; communicating ethical stories through listening, questioning, and connecting; reflecting and growing as an ethical leader; and safe practice and person-centred outcomes. SMART goal format elements were evident in 61% of students’ goals. Students' ethical leadership self-ratings showed positive changes after participating in the LEP program. Findings indicated students planned to further develop ethical leadership skills during clinical placements and future professional practice. This study demonstrated the ethics education approaches used within the LEP could assist health science students to apply ethical leadership in future clinical practice.


Introduction
Ethical leadership is core to safe and effective health professional practice (Edmonson, 2015).Many health professionals are faced with ethical dilemmas (Smith et al., 2017;Zydziūnaite et al., 2010) that involve ethically complex situations where they must choose between two mutually exclusive courses of action with no clear and correct solution (Husted et al., 2015;Jameton, 1984).For example, Hammel (2007) found ethical tensions arose when client-centred practice conflicted with resource restrictions of the health professionals' workplace setting.Ethical conflict may lead to moral distress when the individual knows what the ethically correct decision is but feels powerless to act (Husted et al., 2015;Jameton, 1984).However, ethical leadership skills can help individuals work through ethical dilemmas and reduce ethical conflict.
Ethical leadership can be defined as a leader upholding appropriate conduct through their actions and behaviours, and ensuring the same conduct is adhered to by those around them through communication and shared decision making (Brown et al., 2005;Esmaelzadeh et al., 2017).Therefore, leadership is an extra dimension of ethical practice required for health science students to integrate ethics on clinical placement and future professional practice.
Leadership in ethics can be fundamental for health practitioners to help overcome ethical dilemmas and to minimise moral distress.Ethical leadership encompasses ethical sensitivity, ethical reasoning skills, and ethical courage to advocate for moral change (Zydziūnaite et al., 2010).Ethical sensitivity is needed for health practitioners to be aware of ethical dilemmas and provide patient-centred practice (Weaver et al., 2008).Ethical reasoning skills are required to respond effectively to complex ethical issues (Smith et al., 2017).Ethical courage is essential for health care workers to act and advocate for clients with justice and integrity (Murray, 2010).
Health science students must develop ethical sensitivity, reasoning skills and courage to acquire the values, knowledge, and skills to resolve ethical issues experienced on clinical placements (Yeh et al., 2010).Many health science students have identified experiencing ethical tensions and distress whilst on clinical placement (Bourne et al., 2013;Bushby et al., 2015).Diagnostic Radiography students are taught, in accordance with the professional capabilities for medical radiation practice to take responsibility for their professional decisions, advocate on behalf of their patients, identify radiation risks and implement appropriate risk management strategies (Medical Radiation Practice Board AHPRA, 2020).Yet, Bickoff et al. (2017) found students do not feel empowered to demonstrate the moral courage required to speak up or intervene when faced with unethical practice, despite feeling a moral obligation to do so.Bickoff et al. suggested students perceive pressure to conform due to power imbalance and fear potential consequences of speaking out against unethical behaviours.Clearly, ethical leaders should advocate for patient-centred and evidence-based practice to raise concerns if they observe potentially harmful workplace practices.Moreover, proactive leadership involves acting with self-initiative in anticipation of future problems (Guenter et al., 2017;Kenny et al., 2019;Wu & Wang, 2011).Health science students need to be educated in proactive ethical leadership to help ensure patients' safety (Bessette & Camden, 2017).
Typically, ethics research in the health sciences focuses on ethical dilemmas students experience during clinical placements and professional practice.However, there is limited evidence available on how to prepare health science students for leadership in ethics or the learning outcomes of ethics education (Kirkman et al., 2015).Health science students may be better equipped to manage ethical conflict during clinical placements and future professional practice if they are educated in ethical leadership (Casetto et al., 2016;Power et al., 2018).Therefore, health science students' ethics educators are challenged with teaching ethical leadership education to develop students' sensitivity, reasoning and moral courage.
Ethics may be considered common sense by health practitioners (Kreps & Monin, 2014).However, an ethics as common-sense perspective may overlook complex reasoning skills required for ethical practice.Health practitioners do not always demonstrate ethical behaviours (Cannaerts et al., 2014).Students have identified challenges in applying ethics education skills in professional practice and new graduate health professionals report similar challenges and may struggle with problem-solving or reaching an ethical decision (Kenny et al., 2007;Yeh et al., 2010).Such findings raise questions regarding how to prepare future graduates to practice ethically and demonstrate ethical leadership in their everyday practice.Beauchamp and Childress's (2013) four moral principles of respect for autonomy, nonmaleficence, beneficence, and justice is the most widely taught theory method in ethics education (Lindridge, 2017).In addition to the four moral principles, the skills required to apply theory into clinical practice should be integrated in ethics education (Cannaerts et al., 2014;Shea, 2020).Current practices in health sciences ethics education adopt outcome-based or process-oriented approaches (Godbold & Lees, 2013).An outcome-based approach is where students' responses must align with educators' 'right' decisions whereas a process-oriented approach focuses on learning reasoning skills to engage in critical reflection and analysis (Kenny et al., 2019).While the outcomes of ethical reasoning are important, a processoriented approach is required to develop ethical leaders ready for proactive ethical practice (Kenny et al., 2019).
Previous studies indicate students benefit from case-based, interactive learning experiences to develop their ethical reasoning processes before placement (Dunn & Musolino, 2011;Numminen et al., 2009).A case-based method of ethics education can increase students' awareness of ethical issues in health thereby bridging perceived gaps between ethical theory and clinical practice (Schonfeld et al., 2015).Similarly, providing authentic learning experiences may equip students with knowledge and skills required for professional practice (Hsiao Lu et al., 2017).Further, authentic case-based learning experiences eschews an 'ethics as common-sense' perspective and increases students' engagement with ethics education (Pollard et al., 2018).
There is substantial descriptive literature on the nature of ethics education in nursing and medicine (see Carrese et al., 2015;Caldicott & Braun, 2009;and Donaldson et al., 2010;Langlois & Lymer, 2016 for examples).Yet, limited studies explore participants' learning outcomes following ethics education.Donaldson et al. (2010) discovered students drew upon their knowledge of ethical theories to describe ethical problems after ethics education.Rozmus et al. (2014) used self-evaluation to determine if students' ethics knowledge changed after an ethics education program and found the 755 students who participated in the project reported relatively high ethical knowledge scores post-project.However, the absence of pre-test data makes it difficult to determine the impacts of the ethics education program.
There is a dearth of studies that focus on outcomes of ethical leadership education in health sciences.A recent study by Jeon et al. (2018) found participants' self-evaluation regarding ethical leadership improved post-program.Eide et al. (2015) investigated participants' experiences of a six-week ethical leadership program.Eight manager nurses from a master's leadership program participated in the study.Findings from a post-program focus group showed the eight participants perceived they learned ethical leadership skills that were helpful for the workplace.For example, participants found the program enhanced self-awareness, motivation, and reflection on ethical behaviours (Eide et al., 2015).Thus, there is a need to address the current gap in evidence-based approaches to teaching ethical leadership.Notably, studies by Eide et al., Jeon et al., Rozmus et al. used self-evaluation measures and did not provide objective evaluation of changes in skills and knowledge.Further, research on students' ethics education learning outcomes ethics education is required to determine effective approaches to develop ethical leadership skills.Lawlor and Hornyak (2012) propose the specific, measurable, achievable, realistic, and time-bound (SMART) framework as appropriate for developing and evaluating educational goals and enhancing students' learning outcomes.The SMART goal format is utilised in many industries to effectively guide individuals to achieve goals (Doran, 1981;Latham & Locke, 1983;Lee, 2010;MacLeod, 2012); Sibley et al., 2020).Locke (2018) states that learners who create specific goals build self-efficacy in their learning and practice.Hence, a SMART goal framework may benefit health science students to identify ethical leadership goals and evaluate ethics learning outcomes.
In response to the need for professional preparation in ethical leadership and an existing shortfall in empirical studies of ethics education learning outcomes, the Leadership in Ethics Education program was designed, implemented and evaluated at the University of Sydney.The Leadership in Ethical Practice (LEP) program aimed to facilitate students' knowledge of ethical leadership in ethics and how to apply ethical leadership skills in professional practice.
The LEP program was developed by an interprofessional work integrated learning team of academics and incorporated one case study relevant to health sciences disciplines.Interactive LEP modules are presented in an interactive online e-learning platform called CANVAS.Before commencing the LEP program, a pre-self-rating scale questionnaire is included, to collect information about their attitudes, confidence and skills in professional ethical reasoning.The LEP program then provides video scenarios that follow a student on clinical placement who encounters complex ethical dilemmas.For example, the video case scenario follows a health science student on placement who witnesses a volunteer clean a client's home prior to a health professional home visit for the purpose of over-representing the client's capacity to live in the community safely and independently.Although students may not experience specific LEP ethical scenarios during their placement, each scenario raises interdisciplinary ethical issues.For example, responding to concerns regarding a colleague's professional conduct is shared across professions.Throughout the program, students are provided with information on the active engagement model (Delany et al., 2010) and narrative reasoning (Charon & Montello, 2002) to structure their ethical reasoning.Students explore consequences that may result from the case study student taking no action or specific actions to address the ethical dilemma.Further, videos of reflective commentary from industry leaders guide and challenge students to focus on ethical leadership responsibilities and skills in order to appropriately manage the scenario.Students then create ethical leadership SMART goals, directly relevant to placements, and complete the post-self-rating scale questionnaire.Students completed the LEP program during the first half of a six-week clinical placement in semester one in their third year of study.The program was scheduled as a mandatory, self-directed online learning activity and was facilitated by an academic staff member who monitored the online learning site Discussion Board and supported students' learning.Satisfactory completion of the LEP learning modules required students to demonstrate appropriate ethical reasoning skills in response to the ethical case scenario.
Importantly, the LEP program was specifically developed for students who have progressed to the final stages of their professional preparation programs.Accordingly, the program has adopted an alternative approach to the four principles ethical reasoning process.The LEP program introduced students to a narrative approach to understand the client's story, and multi-perspectives that must be considered in professional practice ethics and proactive ethical leadership (Caeiro et al., 2014;Kenny et al., 2010).Furthermore, the LEP program design was underpinned by the premise that to become ethical leaders, students need to develop self-efficacy (Kenny et al., 2019); belief in their ability to manage ethical situations (Bandura, 1982).Accordingly, Bandura's social cognitive learning theory informed our understanding that ethical leadership involves social learning, expectations of clients, colleagues, and employers, and exists within a workplace culture.Self-efficacy may impact students' and graduates' motivation and capacity to apply ethical leadership skills in professional practice (Cox & Simpson, 2016;Manojlovich, 2005).
The LEP program takes a proactive approach to preparing adult learners for future ethical practice.SMART goals are the tools for identifying and evaluating self-efficacy for ethical leadership and translating individual ethics goals into practice.The study addressed the following research questions: • What are the nature of students' ethical leadership goals after completing the LEP program?-Is SMART goal setting an effective tool to identify and evaluate students' learning in ethical leadership?
• How do health science students' perceptions of their ethical leadership knowledge and skills change following the completion of the LEP program?

Methods
Theoretical Framework Bandura's (1982) learning theory posits that an individual strives to believe they have an influence over events that occur in their life (Schunk & DiBenedetto, 2020).Bandura emphasises a relationship between self-efficacy and the perceptions of self that influence thought patterns and actions (Bandura, 1982).As self-efficacy is important to develop perceptions of empowerment during ethical conflict (Kenny et al., 2019), this study focused on students' development of self-efficacy in ethical leadership skills.

The LEP Project
Design-based research (DBR) methodology was implemented for this study.DBR consists of a cycle of planning, implementation, evaluation of learning experiences and then redesign (Anderson & Shattuck, 2012;Meyers et al., 2018).This approach emphasises theory and the development of design principles to develop practice and research in education through guiding, informing, and improving educational practices (Anderson & Shattuck, 2012;Barab & Squire, 2004).An advantage of using DBR within the LEP project is that it emphasises the partnership between researchers, educators, and students in an educational setting (Amiel & Reeves, 2008;Wang & Hannafin, 2005).Figure 1 presents the major design phases for the LEP program.This study focused on the evaluation stage of DBR (phase three) to develop an understanding of learning outcomes for participating students.

Participants
One hundred and three health science students from the University of Sydney, enrolled in a diagnostic radiography unit, that included a professional placement, were invited to participate in the study.Students had previous lectures in ethical practice within their professional units of study focusing on the Australian Health Practitioner Regulation Agency registration and Code of Ethics.Students were completing semester one in their third year of study and had accrued a minimum two blocks of placement experience (six weeks).The unit coordinators incorporated the LEP program as a mandatory and assessable learning element of their unit.Students completed the LEP program whilst on clinical placement.

Inclusion and Exclusion Criteria
All 103 students enrolled in the clinical diagnostic radiography unit were eligible to participate in the study.An opt-out approach to consent was adopted whereby students responded 'opt out' via email to an academic who was not responsible for teaching or assessments in the unit of study.All students enrolled in the Diagnostic Radiography Placement unit at the time of the study were eligible for inclusion in the study (enrollment number = 103).
Students were excluded if they opted out of the study or did not complete any outcome measures (goal setting, pre and post perceptual ratings).

Data Collection
Students completed the LEP modules on an online e-learning platform, CANVAS in 2019.
A member of the research team extracted the data from the CANVAS site, then entered data onto an excel spreadsheet where all participants were de-identified and assigned a code prior to analysis.

Measures
The LEP program included multiple learning activities that required student engagement.However, the focus of this study was the students' goals and their pre-and post-self-ratings of ethical leadership skills.Students were requested to "write 1-3 personal goals that will facilitate your own ethical practice" and to "write this in the format of a SMART goal".Goals created by students were used as a measure to determine how students perceived their ethical leadership skills would translate to future clinical practice.Students were requested to use the SMART goal format because the authors expected it would be a familiar format and assist in guiding the students to write their ethical leadership goals.SMART goals are widely used in professional practice and one of the aims of the program was to facilitate students to integrate ethics as a core element of professional practice.SMART

Phase Three: Evaluation
Analyse students' learning outcomes of LEP Phase Four: Re-Design

Students participating in the LEP program
Phases One: Planning:

Research and creating LEP
Fig. 1 Design process for leadership in ethical practice using design-based research goal format may also avoid students developing very broad goals (e.g., I want to help people) and focus on specific ethical leadership behaviours they may develop on placement.The SMART goal format was reviewed to determine whether it is an effective tool to evaluate student's ethical leadership outcomes and whether the SMART goal framework is required to create ethical leadership goals.The authors also evaluated the students' use of the SMART goal format to identify potential areas to focus learning support in future LEP teaching.Additionally, aspects of ethical leadership were addressed by five-point Likert scales ranging from 'strongly disagree' to 'strongly agree' (Likert, 1932).For example, "I can clearly define ethical leadership skills''.Students completed the Likert scales immediately before commencing learning activities (pre-self-ratings) and immediately upon completing learning activities (post-self-ratings).Likert scales are considered an effective method to measure self-efficacy (Maurer & Pierve, 1998).

Data Analysis
A combination of inductive and deductive content data analysis was used to analyse students' SMART goals.The basis of qualitative content analysis is to systematically describe and conceptualise textual meaning that requires some level of interpretation (Schreier, 2019).Elo and Kyngas' (2008) process of preparation, organising and reporting of qualitative content analysis informed data analysis.An inductive qualitative content data analysis, where patterns, themes and categories are created to organise the data (Creswell & Creswell, 2018), was used to analyse the nature of the leadership in ethical practice goals created by students.The inductive content analysis process of open coding, creating categories and abstraction described by Elo and Kyngas (2008) was adopted for this study.In the first stage of analysis, the research team familiarised themselves with the data set as a whole and all members independently open coded the first 20 participants' goals.Then all three researchers compared their codes and collaborated to develop seven preliminary categories based upon goal data.One researcher continued the open coding and categorising and met regularly with the team to discuss coding decisions.During this iterative process of coding, discussion and returning to the data, the original seven categories were revised to form eight categories that all researchers collectively agreed upon (Schreier, 2019).Next, categories were grouped into similar and belonging themes where appropriate, through interpretation (Elo & Kyngas, 2008); a process resulting in four main themes.
A deductive qualitative content analysis was used to analyse students' SMART goals.Deductive content analysis is used when researchers retest existing data in a new context (Hsieh & Shannon, 2005) and was used here to determine if the SMART goal format is an effective way to evaluate students' ethical leadership learning outcomes.A structured matrix was used to analyse students' goals against SMART goal categories.The matrix categories were 'specific', 'measurable', 'achievable', 'relevant' and 'timebound'.All authors independently coded data for the first 20 participants' using the categorisation matrix.Then one researcher coded the remaining data and continued to meet regularly with the team to discuss coding decisions.
Students' pre-and post-self-ratings of their ethical leadership skills were analysed using descriptive statistics.The frequency, median, model range and percentages of each response for each scale item was analysed.The data were treated as ordinal because there may not be equal spacing between each value on 5-point Likert scales (Jamieson, 2004;Kampen, 2019).A qualitative approach typically collects multiple sources of data within the participant's natural setting, which provides a holistic account of various aspects interacting in different ways to provide a larger picture (Creswell & Creswell, 2018).The multiple data sources obtained for the study were collected through a single method (surveys) and analysed in a holistic approach that is indicative of a qualitative approach.

Rigour
To enhance trustworthiness, triangulation of the data from inductive, deductive, and descriptive statistics was used to develop a comprehensive understanding of phenomena (Patton, 1999).Dependability was established by having all authors participate in the analysis process where decisions were discussed and agreed upon (Thomas & Magilvy, 2011;Anney, 2014;Elo et al., 2014).Researchers maintained a sense of awareness and openness through collaboration in each stage of the data analysis and by keeping an audit trail throughout the data analysis process to enhance confirmability (Shenton, 2004;Thomas & Magilvy, 2011).

Ethics
Ethical approval was obtained from the University of Sydney Human Research Ethics Committee (project number 2017/413).

Results
This study explored students' learning outcomes upon completion of the program that aimed to develop ethical leadership skills.Students' learning outcomes were analysed in three different ways: inductive qualitative content analysis, deductive qualitative content analysis, and descriptive statistics.Overall, 19 students opted out and 84 students consented to participate in the study and completed learning goals or both pre and post-perceptual rating scales: 82 students wrote ethical leadership goals as two did not complete goal statements as they had not completed the placement at the time of the study, and 74 students provided both pre and post Likert scale data.Overall, a total of 82 diagnostic radiography students created 151 ethical leadership goals.Firstly, the results of the inductive qualitative content analysis that investigated the nature of students' goals will be stated.Secondly, the deductive qualitative content analysis results to determine if students used the SMART framework to create ethical leadership goals are detailed.Finally, the 74 students who completed both the pre-self-ratings and post-self-ratings results are illustrated.The ratings were used to analyse whether students' self-efficacy in ethical leadership changed upon completion of the LEP program.

Nature of Goals
The inductive qualitative content analysis of the nature of students' goals yielded four themes: the first theme was initiative, competence, and courage in ethical reasoning; the second theme was communicating ethical stories through listening, questioning, and connecting; the third theme was reflection and grow as an ethical leader; and the fourth theme was safe practice and person-centred outcomes.All four themes reflected students' perceptions of the attributes of ethical leaders.The themes and categories are displayed diagrammatically in Fig. 2 followed by illustrative exemplars.

Initiative, Competence, and Courage in Ethical Reasoning
The theme initiative, competence and courage reflected students' intention to identify ethical issues, to speak up against unethical behaviours and the significance of developing ethical reasoning skills to work through ethical dilemmas effectively whilst on placements and in their future workplaces.

Sensitivity to Ethical Issues
Identifying ethical and unethical conduct in the workplace was emphasised throughout students' goals.Students' goals reflected that whilst on placements and in future clinical practice they needed to know and identify the difference between ethical and unethical behaviours to become ethical leaders: "Being able to recognise ethical issues that are present in clinical practice."(DR63) Students intended to expand their knowledge of potential ethical issues that could arise during placements:

Develop Ethical Reasoning Skills
Developing strategies to effectively work through ethical dilemmas featured in students' goals.Students revealed the need to seek and understand different perspectives on ethical issues to make an effective ethical decision: "Learning to observe and understand a multitude of views allows a deeper understanding of the ethics in the workplace."(DR17) Students also emphasised the need to develop high-level critical thinking to effectively manage ethical dilemmas as ethical leaders: "I would like to develop the ability to critically evaluate ethical situations and my own behaviour."(DR58)

Courage to Speak Up
Courage to voice concerns when faced with ethical dilemmas whilst on clinical placements was highlighted in students' goals.Confidence to take a stand with ethical concerns was perceived as essential to being an ethical leader: "Develop the courage to approach and speak out about ethical issues when such arise."(DR18) Additionally, students noted that courage and confidence was required to set ethical boundaries for themselves as they transitioned from student to health practitioner: "I want to develop a greater confidence in speaking up for myself and present my opinions to my senior peers, as I enter the workforce in the next year so that I can establish my ethical boundaries for others to see." (DR61)

Communicating Ethical Stories through Listening, Questioning, and Connecting
Students explained the importance of communication skills including listening, questioning, and connecting with others to deliver ethical practice.

Effective Communication with Patients
Students' goals emphasised that teamwork is essential for all health practitioners to ensure quality ethical care for patients.Students described the need for ethical leaders to efficiently communicate and collaborate within a team to provide effective health care:

"Leadership requires good teamwork… Working as a team could also help to know other ideas and help the patient in a more comprehensive way." (DR03)
Additionally, students expressed that being an ethical leader required understanding the patient's narrative: "By being able to understand the needs of my patients, I will be able to advocate for my patients, and fulfil their needs in an ethical manner."(DR63)

Reflect and Grow as an Ethical Leader
Reflection and continuing to grow professionally to be an ethical leader featured strongly in students' goals.Students aspired to build and maintain their integrity and values within their health professions and to grow personally to become ethical leaders.Additionally, students planned to develop leadership skills to be confident ethical leaders whilst on placements and in future professional practice.

Integrity, Personal Growth, and Values
The importance of integrity and values to ethical leadership was evident in students' goals.Some goals identified honesty as an important aspect of ethical leadership whilst on placements and in future professional practice: "To act with integrity at all times….This entails telling the truth at all times even if it is to admit failure or mistakes made."(DR05) Students also wrote goals around learning from experienced staff to ensure ethical practice is maintained and recognising when to ask placement supervisors and other health professionals for help:

"My goal is to raise questions to other health professionals when I have anything which is not fully understood…. And ask for help and advice when I need [it]." (DR30)
While other goals highlighted continued professional development, including training courses, setting goals and reflection as essential for becoming ethical leaders: "Being able to set goals for ethical issues to be achieved and put into practice and rewarding accomplishments and improvements in the workplace for such issues."(DR08)

Modelling Ethical Behaviours
Modelling ethical behaviours was evident throughout students' ethical leadership goals.Students planned to demonstrate ethical values and reflect upon their practice from an ethics perspective:

Safe Practice and Person-centred Outcomes
Ensuring safe practices and providing effective care to contribute to positive patient outcomes underpinned students' ethical leadership goals.

Prioritise Patient Safety
Students' goals intended to ensure safe practices and prioritise patient safety and comfort: "Being active to ask for clients' or patient's requirements and concerns and ensure they feel comfortable for any procedure provided.Since client's safety and comfort are the base of conducting a good ethical practice."(DR04)

Facilitate Positive Experiences and Outcomes
Ensuring that clinical practice contributes to positive patient experiences and consequently the patients' outcomes consistently featured in students' goals: "I want to provide a positive experience to my patient and contribute to their outcomes."(DR11)

SMART Goals Framework
The deductive qualitative content analysis of students' goals provided insight into the number of students' ethical leadership goals that integrated the SMART goal framework.Of the 151 goals created by students, 33% of goals used all elements in the SMART goal framework, 61% used one or more and 6% used none as illustrated in Table 1.Table 2 shows the number of students' goals that used each SMART goal framework element.

Specific
Specific goals were well-defined, detailed, and clear.92% of students' goals met these criteria.For example, one student's goal explicitly stated what their ethical leadership goal would look like in action, describing a consistent, structured approach:

Measurable
Students' goals were measurable if they described how their goal would be measured and/ or criteria for goal achievement.As Table 2 shows, measurability was least represented in students' goals.Some students proposed measuring their goal quantitatively: "Have at least 1-2 strong ethical conversations with your supervisor."(DR38) Other students planned to measure their goals through qualitative evaluation of practice behaviours:

Achievable
Goals were considered achievable if the student explained the steps required to achieve the goal.50% of students provided such details:

"Being proactive everyday will allow me to achieve this goal. Letting clinical supervisors and radiographers be aware of my goal will also allow me to become actively involved when situations arise." (DR62)
Other students' goals explained described achievement criteria based upon abilities and practice: "My skill level should be enough for clearly and precisely interpret stories."(DR31)

Relevant
Students' goals were rated relevant if they justified their importance.56% of goals included explanations of relevance.Some students explained their goal was relevant to their professional development and learning as health professionals: "Ethics is extremely relevant in diagnostic radiography as we are working with radiation which has the potential to cause many negative side effects.We must always consider the consequences of our actions and be conscious of our ethical boundaries so we may avoid situations that overstep our morals."(DR61) Other students stated their goal was relevant as it was essential for ethical leadership: "This goal will encourage me to learn more about ethics and leadership skills in the workplace.This will explore my thinking and awareness by keeping the examples of ethical leadership in the clinical setting."(DR19)

Time-bound
Goals were considered time-bound if students provided a time frame for attainment.Approximately 50% of students' goals stated timeframes.Some students explicitly stated a short-term end date for goal completion:

"I want to achieve this by the end of my next placement block." (DR48)
Other students adopted a long-term perspective and stated that their goal will be incorporated with lifelong learning experiences, as they intended to develop ethical leadership skills throughout their career: "Set mini-goals to reach at the end of each placement, however learning is an ongoing process, therefore knowledge of ethical issues will continue throughout my career."(DR36)

Students' Pre-self-ratings and Post-self-ratings
The descriptive analysis addressed changes in students' self-perceptions of ethical leadership skills and knowledge after completing the LEP program.Overall, 74 students (90%) completed both the pre-self-ratings and the post-self-ratings for the LEP program.Figures 3 and 4 demonstrated an increase in the percentage of students who rated strongly agree in response to all eight ethical leadership questions from pre to post LEP.Findings included positive changes in the 'strongly agree' and 'agree' ratings in response to clearly defining ethical leadership skills, having clear goals for their ethical leadership practice, and knowing how to respond if ethical issues arose during placements.Table 3 displays the median and model range for the pre and postself-ratings.Table 3 shows that all eight ethical leadership questions received median pre-self-ratings and post-self-ratings of either agree or strongly agree.The only question that changed from the pre-self-ratings to the post-self-ratings was "I have clear goals for my ethical practice" which changed from "agree" to "strongly agree".The model range of four reflects the data was spread across the scale from strongly agree to strongly disagree for individual students.

Discussion
The purpose of this study was to explore diagnostic radiography students' learning outcomes from the Leadership in Ethical Practice program.Specifically, this research sought to acquire insights into: the nature of the students' proactive ethical leadership goals; application of SMART goal frameworks for ethics goal setting; and to explore changes in health science students' perceptions of their ethical leadership knowledge and skills from pre to post program.Self-efficacy for ethical leadership was reflected in students' proactive leadership goals.Findings provide students' perspectives on ethical leadership and how they planned to become ethical leaders in professional practice.Most health science students produced proactive ethical goals after participating in the LEP program.The first theme 'initiative, competence, and courage in ethical reasoning', showed students perceived ethical courage and effective reasoning skills were core qualities of ethical leaders.Students planned acquire the leadership skills required to act when faced with ethical dilemmas.The finding that students acknowledge that ethical dilemmas occur in practice aligns with previous studies (Bourne et al., 2013;Cannaerts et al., 2014).The LEP program provided students with opportunities to learn and practice ethical reasoning through guided decision making.Students' goals indicated recognition that ethical reasoning required more than common sense and was perceived as a complex skill they need to improve in professional practice.Ethical leadership goals also showed that students wanted to learn how to act upon ethical concerns.
Students conveyed the importance of effective communication for ethical leadership in the theme 'communicating ethical stories through listening, questioning, and connecting'.Students identified that improving communication skills to interpret and understand ethical dilemmas could enable them to become ethical leaders.These findings align with existing research that indicates effective communication in the health professions is an essential skill for ethical leaders (Brown et al., 2005;Esmaelzadeh et al., 2017).This study highlighted students' perceptions that advanced communication skills are essential to the ethical reasoning process required to become ethical leaders.The narrative reasoning approach adopted in the LEP may have facilitated students' understanding of the importance of competent communication skills required to attend to, interpret and communicate ethical concerns from the perspectives of all involved in an ethical scenario.Competent interpersonal and interprofessional communication is a hallmark of ethical leadership portrayed in the LEP video scenarios.The third theme, 'reflect and grow as an ethical leader', suggested that ethical leaders should be challenged to grow, reflect upon their actions, and model ethical behaviours.Research suggests narrative reasoning can guide students to reflect on behaviours and develop an understanding of patients' experiences (Caeiro et al., 2014).The LEP program's narrative approach challenged students to reflect on ethical behaviours and the consequences of different actions.Importantly, students showed awareness that it was appropriate to seek support when ethical conflict occurred in the workplace.Jeon et al. (2018) expressed role modelling ethical behaviours as a fundamental characteristic of ethical leaders.Findings from this study revealed that students intended to grow as ethical leaders throughout their health professional careers by observing role models and actively modelling professional values in practice.
The fourth theme, 'safe practice and person-centred outcomes' focussed on the importance of providing safe practices and effective person-centred outcomes.Health sciences professional preparation programs stress the importance of safe and ethical practices to safeguard patients' physical health and wellbeing (Donaldson et al., 2010;Eide et al., 2015).However, few studies demonstrate changes in students' behaviours after ethics education (Kirkman et al., 2015).Our findings indicate that students are mindful of the skills and knowledge to provide safe and ethical treatment to patients whilst on clinical placements and in future professional practice.
Students used the SMART goal framework to create ethical leadership goals for clinical placements.Using the SMART goal framework was an innovative approach to evaluating the outcomes of ethics education.Results revealed that over 90% of students applied some elements of the SMART goal framework to develop ethical leadership goals.Lee's (2010) study of goal setting in clinical practice suggests that the more detailed the goal is, the more likely an individual is to achieve it.The high percentage of students writing specific goals could have been due to the students completing the LEP modules whilst on clinical placements facilitating direct application to professional practice.However, not all students used all five elements of the SMART goal framework.For example, only 40% of students defined how to measure their ethical leadership goals.Research indicates that if students do not set a measure, they might not know when their goal is achieved (MacLeod, 2012).Hence, students may be at risk for not achieving their ethical leadership goals.This finding raises a challenge of how to teach students to measure ethical leadership goals, particularly goals that focus on growth and reflection.Additionally, the finding that only 54% of students stated a timeframe for goal achievement suggested some students struggled with knowing an appropriate timeframe for ethics skills even though they may have routinely developed short-and long-term goals for patient care.MacLeod (2012) indicates that including a time-bound element in goals could increase the likelihood of goal achievement.While it is appropriate that some ethical leadership goals may be achieved over their professional careers, it may be helpful to teach students to develop some short-term goals for ethical practice.Overall, findings suggest that a SMART goal framework can guide health science students to create ethical leadership goals.Earlier research indicates that the SMART goal format can also help individuals increase the prospect of achieving their goals (Latham & Locke, 1983;Lawlor & Hornyak, 2012;Sibley et al., 2020).However, further research is required to indicate whether all elements of the SMART goal framework are necessary to help health science students create ethical leadership goals.
In this study post-program goal setting was used to determine how students planned to translate their ethics knowledge within 'real life' placement contexts.Exploring the nature of students' goals, provided insights into how concepts presented in LEP cases and leadership vignettes were incorporated in practice goals.The post-workshop timing for goal setting provided students opportunities to familiarise themselves with their placement setting, duties and responsibilities and to experience workplace culture.Hence, they could develop and implement authentic goals relevant to proactive ethical practice during placements.Future studies could explore changes in goal setting behaviour by requesting students complete pre-training goals as a baseline to compare with post training outcomes.
The frequency of students who strongly agreed with their ability to define ethical leadership and knowing how to respond if ethical issues arise during placements increased after completing the LEP program.These findings indicate that students' perceptions of their ethical leadership knowledge and skills improved following the completion of ethics education programs.The results are consistent with previous research on ethics education, where participants' self-evaluation improved upon completion (Jeon et al., 2018;Rozmus et al., 2014).Improvement in ethical leadership skills following the LEP program must be interpreted with caution given self-perceptions may not align with an objective evaluation of changes in skills and knowledge.However, Bandura (1982) states self-efficacy is essential for an individual's motivation to act.The finding that 93% of students perceived that they knew how to respond if ethical dilemmas occurred in placement suggested high levels of self-efficacy for action after they completed the LEP program.Previous research found an increase in self-efficacy can be linked to improved professional practice behaviours (Cox & Simpson, 2016;Manojlovich, 2005).Through improving self-efficacy, students may be motivated to implement the skills and knowledge learned within ethics education on clinical placements and future professional practice.Once students completed the LEP program, 93% of students perceived they could clearly define ethical leadership providing a strong foundation for aspirational leadership goals.This finding may reflect the nature of LEP learning activities that drew upon the experiences of recognised professional leaders who shared their approaches to ethical reasoning.However, a small number of students perceived they could not define ethical leadership following the program.This finding may indicate that some students had challenges engaging with the program or require further support to implement ethical concepts in professional practice.Overall, these findings indicate ethical leadership education can help improve students' self-efficacy in their ethical leadership skills and knowledge.
The nature of students' goals suggests that students intended to incorporate what was learnt within the LEP modules on clinical placements and become ethical leaders.This study also showed students formed clear perspectives of what ethical leadership should look like as health science students and in future professional practice.Overall, this study's findings provide tools for health science educators to enhance students' ethical leadership skills and knowledge.This study demonstrates that health science student educators' use of the SMART goal framework may facilitate students to create ethical leadership goals for clinical placements.Additionally, the use of narrative reasoning, authentic cases, and a processorientated approach encouraged students to use critical reasoning skills to apply theory to practice in a proactive manner.Students' learning outcomes are promising and indicate the LEP program teaching methods are effective.This study addressed significant challenges in ethics education, focusing on the importance of evaluating students' learning outcomes.This study adopted an innovative approach by using a combination of goal analysis and perceptual ratings to assess students' self-efficacy for ethical leadership.Findings indicate that analysing the nature and format of students' goals provides insights into their perspectives of ethical leadership in professional practice.Measuring changes in perceptual ratings showed changes in students' awareness and confidence with ethical concepts.Therefore, this study contributes new insights to ethics education programs for health science students.

Strengths and Limitations
This study is unique as it focused on exploring learning outcomes of health science students following an ethical leadership program.Participants were diagnostic radiography students and findings may not reflect other health science programs.However, the LEP program is interdisciplinary, as it was created by an interprofessional team that aimed to develop a program that had case studies relevant for multi disciplines across the health sciences.Therefore, the learning outcomes may readily apply to other health science students.Students were invited to participate in the study once their final grades for the unit were released.This recruitment timeframe was implemented to avoid potential perceptions of coercion by students whereby a decision to opt out of the study may have impacted their placement assessment results.Students had already completed LEP outcome measures and their placement prior to study recruitment.Students may not have completed outcome measures because this was not an assessment requirement, they may have experienced learning challenges on placement, or they may have struggled to develop ethical practice goals.The LEP program was compulsory to complete, and there is no guarantee that students intended to implement goals in practice.However, the LEP program challenged students to think about their ethical leadership skills so they could be more sensitive to ethical leadership and consequently implement their goals in professional practice.Self-ratings used in this study were subjective.It is not uncommon for students' perception of their abilities upon completion of a program to have improved.Findings showed that students rated having clear goals for ethical practice more strongly after engaging with LEP.While their perceptions were supported by appropriate goal setting, future studies could explore students' ethical leadership knowledge post LEP program with an objective approach, including an independent pre and post case study response.Finally, some students did not complete all learning outcomes and were excluded from the study.However, the reasons for not completing all learning activities were not explored.The LEP modules were introduced to students in their third year of university study.Therefore, they had previous placement experiences which could impact their learning outcomes within this study.Additionally, students had upcoming placements to provide students with opportunity to implement their ethical leadership goals.
Future research is required to evaluate the effectiveness of strategies that provide ethical leadership skill application opportunities for health science students whilst on placements (Clark et al., 2016;Pollard et al., 2018).Future research may determine whether health science students implemented their ethical leadership goals whilst on clinical placement and in professional practice.The strategies health science student educators use to facilitate ethical reasoning and ethical leadership may also contribute to understanding learning outcomes.Findings from this study will guide the redesign of the LEP program to facilitate health science students' ethical leadership skills to prepare them for clinical placements and future professional practice.
Future recommendations include the benefit of going beyond foundational ethics to facilitate ethical leadership skills in health sciences graduates.Incorporating the LEP program into health science curriculums in later stages of students' professional preparation, provided students with an opportunity to apply knowledge to practice and to enhance their ethical reasoning skills.Students approaching graduation were engaged with ethics when it was framed within leadership skills.Additionally, goal setting offered a proactive approach to analyse learning outcomes.A SMART goal format may need to be adapted and explicitly applied to ethics.

Conclusion
Proactive ethical reasoning goals, an understanding of ethical leadership and self-efficacy for ethical practice may prepare future ethical leaders within the health sciences professions.Findings from this study may assist health science student educators to prepare students to demonstrate ethical leadership on clinical placements and future professional practice.

Fig. 3
Fig.3Percentage of students' responses to pre-self-rating scale items

Fig. 4
Fig. 4 Percentage of students' responses to post-self-rating scale item Conduct research on ethical issues affecting students and relate such issues with personal experience."(DR18) Fig.2Nature of student's ethical leadership goals organised into themes and categories

Table 1
Number of students' goals that followed the SMART goal framework

Table 2
Number of students' goals that used each SMART goal framework element