Nurse Education Today 112 (2022) 105336

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Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Research article

Development and application of an online learning platform for nursing

ethics: A teaching practice research
Cheng Zhen a, Wang Zonghua b, Luo Yu c, *, Ma Huijuan a, Tan Jing c, Zhang Suofei c, Zhu Lei d
a
School of Nursing, Third Military Medical University/Army Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing 400038, PR China
b
Department of clinical nursing, School of Nursing, Third Military Medical University/Army Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing
400038, PR China
c
Department of nursing management, School of Nursing, Third Military Medical University/Army Medical University, No. 30 Gaotanyan Street, Shapingba District,
Chongqing 400038, PR China
d
Wuxi Higher Health Vocational Technical School, No. 305 Xingguang Street, Xingwu District, Jiangsu Wuxi 214000, PR China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: It is crucial to diversify the methods for clinical nurses to continue learning nursing ethics in that
Applet ethical decision-making ability in nursing is regarded as one of the core competencies in nursing practice.
Nursing ethics Objective: In response to nurses' learning needs for nursing ethics, this study built an online learning platform for
Online learning
the pertinent topic, and tested its effect on improving nurses' ethical decision-making ability and critical thinking
Critical thinking
ability.
Design: A qualitative method was adopted to develop interventions, which were designed as a teaching practice
research consisting of a study group and a control group.
Participants: A total of 93 nurses, including 20 interviewees and 30 in the study group and 43 in the control
group.
Method: Qualitative methods were employed to understand the learning needs of nurses. The judgment about
nursing decisions and the critical thinking disposition inventory, learning effectiveness questionnaire and
learning software quality evaluation scale were used as research tools in this teaching practice research. The SPSS
25.0 was adopted to analyze data by paired sample t-test and independent sample t-test.
Results: In the measurement of the judgment about nursing decisions scale, the study group scored higher than
the control group. The critical thinking disposition inventory scale identified a similar result in the total score
incorporating the four dimensions, including analyticity, systematicity, critical thinking self-confidence,
inquisitiveness. There is a correlation between learning software quality and learning effect, with a correla­
tion coefficient of 0.640.
Conclusion: The online learning platform of nursing ethics built in this study has positive learning effects, and it
demonstrates effectiveness to improve nurses' abilities in nursing ethics, decision-making and critical thinking. It
is expected to be a viable way to improve the continuity of nurses' study of ethics.

What is known? optimizes a myriad of learning resources, featuring question bank, case
1. Although a multitude of teaching models have been applied in library, course library, and newsletter, and it has optimistic software
nursing ethics education, ways to promote nurses' continuity of ethics functions and learning effects.
learning still lag behind. 2. The social app-based online learning platform can promote nurses'
2. Currently, nursing ethics education is subject to insufficiency in continuity of ethics learning, and it can concurrently improve nurses'
integration and optimization of learning resources and a lack of plat­ decision-making capacity and critical thinking ability.
forms with comprehensive learning resources.
What is new?
1. The online learning platform for nursing ethics integrates and

* Corresponding author.
E-mail addresses: [email protected] (W. Zonghua), [email protected] (L. Yu), [email protected] (M. Huijuan).

https://doi.org/10.1016/j.nedt.2022.105336
Received 29 September 2021; Received in revised form 5 February 2022; Accepted 22 March 2022
Available online 28 March 2022
0260-6917/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
C. Zhen et al. Nurse Education Today 112 (2022) 105336

1. Introduction 2. Methods

Nursing Ethics, as a core curriculum to foster nurses' humanistic 2.1. Research design
spirit, is vital to professional ethics and ideological construction. It plays
a major part to help nurses understand and master the general principles Qualitative research method as development of intervention to
and norms of nursing ethics, cultivate their critical thinking and ethical investigate nurses learning attitude and demand for nursing ethics. In­
decision-making ability in nursing, and guide their clinical practice and terventions were designed in the form of teaching practice research to
nursing actions (Epstein and Turner, 2015). In the face of an urgent need verify the learning effect of the online learning platform.
for humanism and prominent nurse-patient conflicts, nursing ethics is
constantly gaining in importance (Grace and Milliken, 2016). However, 2.2. Ethical considerations
some studies have shown that in the current nursing ethics teaching,
nurses face multi-faceted challenges, such as a lack of theoretical This study was reviewed by the Ethics Committee of the Army
knowledge of ethics (Kangasniemi et al., 2015), inadequate continual Medical University. Despite the fact that the study did not fall into the
education (Sasso et al., 2016), and insufficiency in practicing nursing scope of medical ethics review stipulated in the “Measures for Ethical
ethics (Julia et al., 2017). Therefore, there is an urgent call for inno­ Review of Biomedical Research Involving Humans” (2016), and was
vative learning ways to improve the ethical decision-making ability of exempted from review, it was conducted in accordance with the World
nurses in an attempt to resolve the ethical dilemma in clinical practice. Medical Association Code of Ethics (Declaration of Helsinki) and all
Ethical decision-making ability in nursing refers to the ability to participants provided informed written consent. Meanwhile, in order to
make the most appropriate decisions on ethical issues based on intuition, protect the privacy of the participants, no one except the researchers has
ethical nursing principles, professional values, moral judgment, and access to the participants' data.
moral reasoning principles (Alba, 2018a). Nevertheless, critical thinking
skills and attitudes are also essential for the development of nurses' 2.3. Development of intervention
ethical decision-making abilities. Critical thinking is characterized by
organized, structured, and specific thinking patterns, and shaped by a In the early stage of the research, 20 nurses with experience in
curiosity about the intentions, facts, and reasons behind an idea or ac­ nursing ethics courses were selected for the qualitative research. They
tion, including the formation of questions to gain a deeper under­ were interviewed to survey their cognitive attitudes and learning needs
standing of what and why (Falcó-Pegueroles et al., 2021). It plays a key for nursing ethics and explore strategies to improve the quality and
part in the ethical judgment and decision-making of clinical nursing, and continuity of nursing ethics learning. This part of the study conducted
has been instrumental in higher nursing education (Kotzee and Ignato­ semi-structured and personalized in-depth interviews to collect data. In
wicz, 2016). line with the research purpose and previous literature research, the
In recent years, online learning has found an extensive application in preliminary interview outline was drafted by experts on nursing edu­
medical education research and teaching practice (Rhim and Han, 2020) cation and lecturers who engaged in nursing ethics teaching. The outline
in order to maintain the continuity of education (Al-Balas et al., 2020). of the main questions are as follows:
The emergence of online courses provides an effective and flexible (1) What impact do you think nursing ethics has had on you?
channel for independent learning (Belfi et al., 2021) and the quality (2) What problems do you think exist in the current nursing ethics
courses lay a good foundation for independent learning mode (Emanuel, teaching?
2020). Online learning offers learning content that can be learned and (3) What other learning needs do you have for nursing ethics?
reviewed at students' own pace, affording an opportunity to rethink how The subjects were numbered N1-N20 according to the interview
learning occurs and close the theory-practice gap (Dickieson et al., sequence. The interview recordings were transcribed into texts within
2008). Online courses now are available in basic nursing and adult 24 h, which were further organized, analyzed and summarized accord­
nursing and have already made considerable achievements. However, ingly. The data were analyzed via content analysis methods. Concomi­
there is a paucity of research on the practice and feedback of online tantly, combined with NVivo11.0 software and manual analysis
learning of nursing ethics. methods, two researchers conducted data analysis to ensure the reli­
WeChat applet is a cutting-edge technology to develop application ability of the research results.
systems within the WeChat platform. An unnecessity of downloading, The research analysis brought back the following implications: (1)
installation, and repeated login has greatly simplified the procedures The learning of nursing ethics could help change nurses' ethical cogni­
against the traditional apps. Statistics from the China Internet Network tion and improve their critical thinking ability. (2) The respondents
Information Center show that there have been 1.112 billion registered claimed that some ethics cases were too antiquated and the learning
WeChat users as of June 2020 (Di and Feng, 2021). The applets devel­ resources were fragmented on the whole. Therefore, there is a pressing
oped on the WeChat platform have a wide range of potential users (Shi, need for learning resources that are more comprehensive and that
2021). Researches have suggested that, in current college education, highlight visualization, immediacy, and real-time capability. (3) Hos­
technologies for extracurricular teaching applications embedded within pitals and departments rarely performed ethics-related training in clin­
the WeChat applet are full-fledged, and various assisted teaching applets ical work, except for experience of learning nursing ethics in university.
built on it are beneficial to the improvement of teaching quality (Tu Nurses lacked access to maintain and improve their ethical decision-
et al., 2018). making capacity. According to the results of the qualitative interview,
As a result, concerning the ever-increasing importance of nursing we developed an online learning Nursing Ethics course through the
ethics in clinical and nursing staff training and for the purpose of platform of WeChat applet mainly to improve the ethical cognition and
improving nurses' ethical decision-making capacity, this study focuses critical thinking ability among clinical nurses.
on the development of an online learning platform centered on nursing And we provided the learning channels and resources that used to be
ethics. It adopts the judgment about nursing decisions and the critical unavailable to nurses, maintaining and improving their ethical decision-
thinking disposition inventory to measure the change of nurses' ability in making capacity.
nursing ethics before and after learning, as well as the learning effec­
tiveness questionnaire and learning software quality evaluation scale to 2.4. Content of interventions
explore the effect of online intelligent learning from the learners'
perspective. It is expected to upgrade the function of the online learning The applet is named “NE Smart Learning”, in which N and E stand for
platform and promote the continuity of nursing ethics learning. “Nursing” and “Ethics” respectively. It consists of 5 modules: course

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C. Zhen et al. Nurse Education Today 112 (2022) 105336

library, question bank, case library, ethics newsletter, and personal 2.5. Implementation of intervention
settings(As shown in Fig. 1), and offers integrated and optimized
learning resources, such as animated simulation cases, star mentor lec­ 2.5.1. Participants
tures, textbook and courseware, and test questions (Wang et al., 2017). Convenience sampling was exploited at the beginning of the study,
(1) The course library module encompasses micro-lectures and star and 97 clinical nurses were initially selected from 8 departments in 3
mentor lectures, which are micro-courses on nursing ethics recorded hospitals. Inclusion criteria were: engaged in nursing; having system­
independently by our research team and intensive courses on nursing atically learned nursing ethics; proficient in operating and using cell­
ethics recorded by teachers from colleges. phone applications; and well-informed and voluntary for this research.
(2) The question bank module offers single-choice questions, Participants were excluded if they: had been involved in clinical work
multiple-choice questions, and true or false questions, including chapter less than one year. In accordance with the inclusion and exclusion
assignments, mock test, wrong questions review, and questions gath­ criteria, as well as the willingness of the participants, 90 subjects were
ering function. (The questions are from the second edition of the na­ selected for the study, and were randomly assigned to a study group and
tional planning textbook to ensure the authority of the learning a control group in a 1:1 ratio by using a numerical randomization table,
resources.) with 45 in each group. In the follow-up questionnaire survey and
(3) The case library module includes simulation case videos: sce­ intervention, there was a loss of research subjects in both groups, and 30
narios and interactive animations, animation of theoretical knowledge, in the study group and 43in the control group were finally retained. (See
and common textbook case discussion. The scenario and interactive Fig. 2 for details).
animation would switch to corresponding scenes according to the
choices of learners. 2.5.2. Procedure
(4) The ethics newsletter module contains news, articles, and other Nurses in the study group used the online learning platform to study
reading resources pertaining to real ethical events, real-time hotspots, for 3 weeks, mainly practicing the test questions about nursing ethics,
and cutting-edge technologies. watching case animations, learning case discussion, and completing a
(5) The personal settings module mainly collects learner's name, mock test. The specific learning schedule and content are as shown in
gender, age, work unit, department, etc.. Learners can check the Tables 1 and 2. The control group conducted a self-study offline as
learning record, contact customer service and submit feedback. specified by the provided paper version of the learning resources,
Researches show that the interaction between nursing ethics hands- including systematic slides of nursing ethics courseware and accompa­
on experience and knowledge is invisible and peripheral in an isolated nying exercises.
and parallel discipline (Ramos et al., 2013). Nurses can gain enough Quality control: (1) The nurses in the study group could not adjust
knowledge by being exposed to real-life cases. To make them better the playback progress bar when watching the case animation video. (2)
understand various personal perspectives is conducive to the continuous When the nurses in the study group engage in the case discussion, the
accumulation of their knowledge (Forsgren et al., 2014). Meanwhile, in system will judge whether this part is completed according to the study
clinical practice, nurses should be encouraged to participate in and time and whether the page is slid to the bottom. (3) The system will keep
provided opportunities for ethical reflection, so as to better integrate track of the learning states of the nurses in the study group in the
theory with clinical practice (Lee et al., 2020a). It is consistent with the background every week, and send alert to the nurses who have not
concept of promoting repeatability and sustainability of learning completed the learning. (4) The learning materials of the control group
through the online learning platform constructed in this study. derive all from the second edition of the national planning textbooks to
In summary, the system has the following features. ensure the authority of learning resources. (5) The researchers and head
(1) Integrating and optimizing a variety of learning resources. nurses of the department will supervise the learning progress of the
(2) Enhancing the interest and continuity of learners and effectively control group every week. (6) The learning platform has set learning
meeting their learning needs. permissions exclusive to the nurses in the study group.
(3) Not only convenient for online self-study, but also accommoda­
ting for offline teaching. 2.5.3. Measures
(4) Facilitative to learning management by backstage collection of
personal information and statistics of learning progress. (Note: The 2.5.3.1. General information. The general information of the question­
program has obtained the computer software copyright certificate of the naire includes name, work unit, department, gender, age, working time
People's Republic of China, No. 08820559.) in clinical nursing, level of education, professional title, training expe­
rience in ethical decision making in nursing, etc..
The research tools include four scales, among which the judgment

Fig. 1. Schematic diagram of the applet function module.

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C. Zhen et al. Nurse Education Today 112 (2022) 105336

Fig. 2. Flowchart of the study.

questionnaire, designed by Ketefian (1981), is currently an authoritative

Table 1
one worldwide to measure the ethical decision-making capacity in
Framework of learning intervention schedule.
nursing (Numminen and Leino-Kilpi, 2007). It was revised in 2007 and
Question Case library (Nos.) Mock translated into Chinese by Chinese scholars Zhu et al. (2012) in 2011.
bank test
Scenario and Animation of Case According to the questionnaire, Cronbach's α coefficient is 0.876 and the
(Nos.) (Times)
interactive theoretical study test-retest reliability coefficient is 0.791. The questionnaire is composed
animation learning
of 6 stories and 2 scenarios describing nurses caught in ethical dilemmas
Week1: 236 1 6 6 1 where they are challenged with 5–7 nursing actions in each story or
Chapter scenario. Each respondent needs to answer twice. The first time (column
1–3
Week2: 51 2 7 7 1
A) is for moral reasoning: under ideal conditions, whether nurses should
Chapter adopt these actions; and the second time (column B) is for moral
4–7 behavior: given all restrictions in actual work, the actions might be
Week3: 55 2 7 7 1 taken by nurses in the hospital where you work. A 5-point Likert scale
Chapter
was adopted. The total score represented the sum of the scores of two
8–11
dimensions, ranging between 76 and 380; high level > 304, moderate
level 228–304, and low level < 228. The score of each dimension ranges
between 38–190, with the high level > 152, moderate level 114–152,
Table 2 and low level < 114.
Content of learning chapter topics.
The Critical Thinking Disposition Inventory - Chinese Version (CTDI-
Chapter number Chapter topics CV), revised by Peng Meici et al. (Wang et al., 2004) based on the
1 Introduction Critical Thinking Disposition Scale developed by Facione et al. (1994),
2 The theoretical basis of nursing ethics was employed to measure critical thinking ability in this research. For
3 Principles of nursing ethics in nursing practice the general scale, the content validity index is 0.89 and Cronbach's α
4 Related nursing ethics in reproductive technology
coefficient is 0.90. The scale includes seven categories of CT disposition,
5 Hospice care and nursing ethics of human death
6 Ethics in nursing research including “truth-seeking”, “open-mindedness”, “analyticity”, “system­
7 Ethics in human experimentation aticity”, “critical thinking self-confidence”, “inquisitiveness”, and
8 The ethics of organ transplantation “cognitive maturity”. It is a 6-point Likert scale with a total score of
9 Ethical controversies in nursing practice
70–420. 280 points and above suggest positive critical thinking skills;
10 Nursing ethical dilemma and ethical behavior decision making
11 Legal issues in nursing practices 210 points and below indicate negative critical thinking ability. The
learning effect evaluation tool is created based on scholar Zhu Xuan's
precision teaching evaluation indicator system (Zhu and Cui, 2019) and
about nursing decisions and the critical thinking disposition inventory a 5-point Likert scale was adopted. The scale includes knowledge, pro­
are used to measure the changes in the ability of the participants in cess and emotion as the first-level indicators, with a total of 26 items. On
nursing ethics before and after learning, and objectively reflect the top of this, self-evaluation by students was incorporated. For those with
quality and learning effect of the learning program in terms of ability scores above 90: Excellent; 80–89: Good; 70–79: Average; 60–69: Pass;
changes. The learning effect evaluation tool and the learning software under 60: Fail.
quality evaluation tool are exercised to express the subjective evaluation Scholar Zhong's (2001) learning software evaluation indicator sys­
made by the participants on the quality and learning effect of the tem was put into practice to develop the learning software quality
learning program. evaluation tool, which was measured by a 5-point Likert scale. The first-
The Judgment About Nursing Decisions (JAND) was adopted to level indicators include six dimensions: learnability, scientificity,
measure the ethical decision-making capacity in nursing. The

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technicality, artistry, applicability, and economic efficiency, with a total Table 3

of 22 items. Above 90: Excellent; 80–89: Good; 70–79: Average; 60–69: Chi-square test of homogeneity of basic information for study group and control
Poor; under 60: Very Poor. group.
Item All N Control Experimental χ2 p
2.6. Data collection (%) group N group N(%) Value
(%)

Prior to data collection, participants received a notification about the Gender 0.214 0.685
study and a consent form. This study was carried out on the premise that Male 6(8.2) 3(7.0) 3(10.0)
Female 67 40 27(90.0)
the subjects signed a consent form. In the process of intervention, the
(91.8) (93.0)
learning record of each research subject was logged in the backend of the Age 1.122 0.372
platform to monitor the learning condition. The first questionnaire was 30 years and 59 33 26(86.3)
conducted one week before the intervention and the second question­ below (80.8) (76.7)
naire was completed within one week after the intervention. All ques­ 30 years and 14 10 4(13.3)
above (19.2) (23.3)
tionnaires were distributed and collected by two researchers through the Years of working 12.895 0.005
online questionnaire application. The following 6(8.2) 2(4.7) 4(13.3)
year
2.7. Data analysis 1 to 3 years 28 11 17(56.7)
(38.4) (25.6)
3 years to 10 29 24 5(16.7)
Data were analyzed by SPSS 25.0. Paired sample t-test and inde­ years (39,7) (55.8)
pendent sample t-test were used to compare the differences between the 10 years and 10 6(14.0) 4(13.3)
two learning methods before and after learning through intra-group above (13.7)
control and inter-group control. The learning effect and the quality of Degree of education 0.404 0.817
Junior college 12 8(18.6) 4(13.3)
learning software were evaluated by Pearson correlation analysis. student (16.4)
Continuous variables are described by mean and standard deviation, and Undergraduate 59 34 25(83.3)
p value <0.05 is generally considered to be statistically significant. (80.8) (79.1)
Master degree or 2(2.7) 1(2.3) 1(3.3)
above
3. Results
The title of a 10.457 0.005
technical post
The experiment consisted of 73 nurses, including 30 in the study Nurse 30 11 19(63.3)
group and 43 in the control group. The majority of female nurses were (41.1) (25.6)
under 30 years old (91.8%), and their main working years were between Senior nurse 34 25 9(30.0)
(46.6) (58.1)
3 and 10 years (78.1%). Nearly half of the nurses had undergone nursing Supervisor nurse 9 7(16.3) 2(6.7)
disputes (49.32%), while nearly half of the nurses thought the nurse- (12.33)
patient relationship was in a normal state (52.05%). Most nurses have Whether there have 0.329 0.638
never participated in the training of ethical decision making or partici­ been nurse-
patient disputes
pated in the training of this capability only when they were students
Occasionally 36 20 16(53.3)
(39.73%, 43.84%), and only 16.44% nurses participated in the training (49.32) (46.5)
of it at work. Concurrently, only 54.79% of nurses' hospitals and de­ Never 37 23 14(46.7)
partments had organized the relevant training. (see Table 3). (50.68) (53.5)
In the measurement of the judgment about nursing decisions, there's What do you think 3.007 0.2222
of the current
no difference between the two measured results of intra-group before- nurse-patient
after control of the control group and the first between-group control relationship?
result. As for the two measured results of intra-group before-after con­ Tension 24 14 10(33.3)
trol of the study group, there's no difference in moral behavior, the (32.88) (32.6)
Normal 38 20 18(60.0)
difference on moral reasoning (p < 0.05) and the total scores (p < 0.05)
(52.05) (46.5)
were significant before and after intervention. The study group scored Harmony 11 9(20.9) 2(6.7)
higher the second time than the first time. Among the second between- (15.07)
group control results, disparities show in moral reasoning, moral Nursing ethics 4.991 0.082
behavior, and total scores, and the study group scored higher than the decision making
training
control group, as shown in Table 4. experience
In the measurement of the critical thinking disposition inventory, Never 29 18 11(36.7)
only the analyticity is different between the two measured results of (39.73) (41.9)
intra-group before-after control of the control group (p < 0.05). Among I attended 32 15 17(56.7)
training in (43.84) (34.9)
the two measured results of intra-group before-after control of the study
studenthood
group, disparities emerged in analyticity, systematicity, and self- I attended 12 10 2(3.7)
confidence (p < 0.05). There's no difference in all dimensions in the training in (16.44) (23.3)
first between-group control results. But in the second between-group working period
control results, disparities arise in analyticity, systematicity, self- Whether the 2.898 0.101
hospital or
confidence, inquisitiveness, and total score, as shown in Table 5. department has
The learning effect and software quality of the online learning plat­ carried out
form were desirable as a whole according to the evaluation. The quality nursing ethics
of learning software is associated with the learning effect, with a cor­ decision-making
ability training
relation coefficient of 0.640. A total of 18 respondents evaluated the
Yes 33 23 10(33.3)
learning effect as Excellent, accounting for 60%; and 12 evaluated it as (45.21) (53.5)
Good, representing 40%. The scores of knowledge, process, and emotion No 40 20 20(66.6)
dimensions are shown in Table 6. 24 respondents evaluated the software (54.79) (46.5)

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Table 4 making ability and critical thinking ability in certain dimensions. Be­
Comparisons on JAND between control group and study group before-after sides, it also found that the current ethical decision-making ability in
interventions. nursing and critical thinking ability of nurses still need to be further
Dimensions Before(X ± S) P After(X ± S) P improved.
Control Study Control Study
From the view of the second between-group control, nurses in the
group group group group study group scored higher than those in the control group in the judg­
ment about nursing decisions scale and the critical thinking disposition
Moral 156.43 159.13 0.622 155.29 170.11 0.000
reasoning ± 16.117 ± ± 15.605 ± inventory. The first between-group control results may eliminate the
15.152 13.201 disparity between the two baselines in the initial phase. The intra-group
Moral 154.95 157.30 0.541 154.83 162.19 0.034 before-after control shows that there's no distinction in scores of the
behavior ± 15.14 ± ± 15.232 ± control group, while the study group, under the learning intervention,
13.753 15.477
Total score 311.77 316.00 0.456 310.51 332.54 0.001
displayed upgraded scores in some dimensions in the two scales.
± 30.176 ± ± 29.856 ± Therefore, it may be concluded that nurses learn nursing ethics on the
25.747 26.429 online applet, through which they make headway in capacities of
making ethical choices and decisions. Meanwhile, it improves nurses'
critical thinking ability in terms of analyticity, systematicity, and self-
Table 5 confidence when addressing ethical issues.
Comparisons on CTDI-CV between control group and study group before-after Some studies believe that when nurses have higher ethical decision-
interventions. making ability, they can better establish a sound nurse-patient rela­
Dimensions Before(X ± S) P After(X ± S) P tionship (Chen et al., 2021), provide high quality of care (Amiri et al.,
2019), and avoid moral conflicts (Poorchangizi et al., 2019). In the
Control Study Control Study
group group group group
measurement of the judgment about nursing decisions in this study,
clinical nurses demonstrate a stronger ability to make moral reasoning
Truth-seeking 34.3 ± 34.76 0.779 36.13 ± 35.43 0.380
on the whole, but some of them are still average performers. Meanwhile,
8.139 ± 6.225 7.158 ± 5.819
Open- 39.62 ± 39.76 0.797 40.42 ± 41.35 0.370 the scores of moral reasoning and behavior have shown that, although
mindedness 6.227 ± 6.545 5.131 ± 4.925 clinical nurses have a better command of the knowledge about ethical
Analyticity 44.18 ± 43.46 0.498 42.62 ± 46.33 0.000 decision-making in nursing and know how to make decisions in an
4.387 ± 4.992 3.276 ± 4.453 ethical dilemma, when in clinical practice, they rarely conform
Systematicity 39.42 ± 40.28 0.493 38.59 ± 42.91 0.000
5.820 ± 6.415 3.898 ± 5.190
completely to the theoretical knowledge, which is consistent with the
Self- 43.10 ± 41.50 0.064 41.69 ± 47.98 0.000 previous research conclusions (Lee et al., 2020b). The reasons are that
confidence 6.078 ± 5.881 4.428 ± 3.638 nurse ethical practice is a complex process of reasoning, decision-
Inquisitiveness 44.4 ± 45.02 0.649 42.94 ± 46.28 0.011 making and implementation of decision-making in practice. The pro­
6.819 ± 6.721 4.018 ± 5.661
cess is influenced by personal and environmental factors. It is affected by
Cognitive 37.74 ± 38.59 0.928 37.68 ± 39.74 0.089
maturity 8.870 ± 6.867 6.486 ± 6.252 the difficulties that nurses encounter and their difficult working condi­
Total score 282.76 283.54 0.816 280.65 299.80 0.001 tions (Goethals et al., 2010). Hence, the current clinical nurses' knowl­
± ± ± ± edge and skills of ethical decision-making need to be improved. Besides,
32.232 34.868 21.119 28.361 the factors influencing nursing students' ethical decision-making and
how to put high-level ethical decision-making and choice into clinical
ethical action are also worth exploring by scholars.
Table 6 It has been suggested that the increasing complexity of modern
The score of each dimension of learning software quality evaluation tool and health care requires nurses to have a high level of critical thinking skills
learning effect evaluation tool among the study group. to make optimal nursing decisions (Zuriguel et al., 2015; Li et al., 2019;
Nos. of items Highest score (X ± S) Sommers, 2018). In the measurement of critical thinking in this study,
Learning software quality evaluation tool
the proportion of positive critical thinking increases from 46.7% to
Learnability 8 40 36.433 ± 4.284 73.3%, and that of strong critical thinking disposition goes up to 10%
Scientificity 3 10 9.233 ± 1.093 from 6.7% in the two measurements of the study group. The share of
Technicality 7 20 18.420 ± 2.250 positive critical thinking only accounts for 46.5% and there are only 2
Artistry 2 10 9.233 ± 1.040
nurses (4.7%) exhibiting strong critical thinking disposition, the rest of
Applicability 1 10 9.400 ± 1.070
Economic efficiency 1 10 9.267 ± 1.230 the nurses had negative critical thinking. The surveyed nurses show
Total score 22 100 91.99 ± 10.171 positive results in analyticity, inquisitiveness, and self-confidence, while
their qualities of truth-seeking and cognitive maturity are below posi­
Learning effect evaluation tool tive, and their total scores of critical thinking are below average. This
Knowledge level 7 23 18.716 ± 2.736 indicates that the critical thinking ability of current clinical nurses needs
Process level 9 65 54.396 ± 7.424 to be honed.
Emotion level 10 12 10.326 1.339
±
The online learning platform constructed in this study has satisfying
Total score 26 100 83.438 ± 2.038
learning effect and software quality in the evaluation of the nurses in the
study group. In analysis, there may be the following three reasons: it
quality as Excellent on the whole, accounting for 80%; and 5 evaluated it enjoys the advantages of online learning, the case study mode is adop­
as Good, representing 16.67%; and only one evaluated it as Average, ted, and the case animation contains game elements. First, The online
representing 3.33%. The scores of learnability, scientificity, technicality, learning platform constructed in this study possesses the online learning
artistry, applicability, and economic efficiency are shown in Table 6. function, which can provide equal opportunities for those who cannot
access to face-to-face education, can meet the learning needs of most
4. Discussion nurses, and can make self-learning and lifelong learning possible (Eycan
and Ulupinar, 2021). At the same time, the flexibility this feature pro­
This study found that the online social app-based learning of nursing vides in terms of space and time allows nurses to plan learning at their
ethics is significantly effective. It can improve nurses' ethical decision- own pace (Schuler et al., 2021). In addition, previous research results

6
C. Zhen et al. Nurse Education Today 112 (2022) 105336

have also shown that online learning helps to promote nurses' intrinsic boosted to better suit empirical research.
learning motivation, stimulate their interest in learning, and enable
them to actively participate in the learning process (Ropero-Padilla 6. Conclusion
et al., 2021).
Secondly, this learning platform focuses on the construction of a case Through qualitative research, this study found that there are some
study section, emphasizing the combination of theory and practice. It problems in current nursing ethics, such as outdated case resources and
based its teaching materials on relevant cases, simulating the real insufficient continuing education. Based on the existing problems and
environment to guide nurses back to some real-life scenarios (Bi et al., nurses' learning needs for nursing ethics, this study constructed an on­
2019). In addition, it provided a framework for situational dilemma line learning platform of nursing ethics based on social software. The
analysis through virtual scenarios and repeated exercises, allowing platform covered rich learning resources to effectively meet the learning
students to leverage multiple learning experiences that promote reflec­ needs of nurses, and the flexible online learning mode broadened the
tion and discussion, structured thinking and judgment. Research has channels for nurses to continue learning nursing ethics. Through
shown that, in nursing education, case-based learning promotes active teaching practice, this platform has a good learning effect and has a
and reflective learning, critical thinking and effective problem solving certain effect on improving nurses' ethical decision-making ability and
skills (Chao et al., 2017). Meanwhile, interactive situations, feedback critical thinking ability. Meanwhile, this study found that the nursing
and repeated exercises based on online learning help to integrate decision-making ability and critical thinking ability of clinical nurses
thinking, promote knowledge transfer and learning retention, which are need to be further improved, and how to apply good ethical decision-
consistent with the results of this study (Alba, 2018b). making ability and selection ability to clinical ethics practice also
Thirdly, nurses could submit feedback that they were most interested needs to be further explored by scholars.
in and were most influenced by the scenarios and interactive anima­
tions. The case displayed in the form of animation is more conducive to Funding
vividly restoring the passage of the event. Furthermore, the case ani­
mation is also built with the function of choosing the plot independently. The funding was provided by 2019 Chongqing Higher Education
Some nurses commented that this function is similar to that in role- Teaching Reform Research Project, Grant Number: 193362, and the
playing games, which can help them become more aware of their Educational Reform Research Project of Army Medical University, Grant
decision-making responsibilities and actions. Studies have shown that a Number: 2018A04.
teaching model presented in stories helps reduce the cognitive load of
learners, while enhancing their immersion and understanding of a given CRediT authorship contribution statement
situation, enabling them to have a positive perception of problem
solving and improving learning efficiency (Park et al., 2020). In addi­ Cheng Zhen: Conceptualization, Investigation, Data curation,
tion, learning models that include game elements also have positive Writing-review & editing.
effects on learners' higher-order skills such as decision-making, critical Wang Zonghua: Conceptualization, Writing-review & editing.
thinking, problem-solving, and collaboration skills (Chang et al., 2021). Luo Yu: Conceptualization, Writing-review & editing.
These above implications are consistent with the findings of this study. Ma Huijuan: Data curation, Investigation.
According to research analysis, this learning platform can not only be Tan Jing: Conceptualization, Project administration.
actively applied to online self-study of nurses, but can also provide Zhang Suofei: Project administration, Data curation.
continuous nursing ethics learning for nurses who have participated in Zhu Lei: Providing research tools.
work or practice. Its case database resources and test question resources
can also facilitate teachers' offline teaching application, which can not
Declaration of competing interest
only address the problem of outdated case resources in qualitative
research results, but also actively assist in evaluating nursing students'
The authors declared no potential conflicts of interest with respect to
learning in the course of teaching.
the research, authorship, and/or publication of this article.
We also consider that the learning effectiveness of the online
learning platform constructed in this study may be affected by many
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