Curriculum Design to Promote the Ethical Decision-Making Competence of Accelerated Bachelor’s Degree Nursing Students

Few nursing curricula offer a course dedicated exclusively to ethical decision making. More often, ethical decision making is integrated into nursing courses and clinical experiences along with other course content. This article describes an accelerated bachelor’s degree nursing curriculum systematically organized to promote ethical decision-making competence from the first to the last nursing course. Examples of course objectives, ethical indicators, and teaching strategies emphasizing ethical decision making from trimester to trimester are outlined. A survey that assessed the similarities between critical thinking and ethical decision making perceived by faculty and students justified using critical thinking skills to measure ethical decision-making competence. t-Test calculations indicated significant improvement in the critical thinking scores of 100 students from four consecutive classes at the beginning and end of the nursing program. Examples of ethical questions examined by students are included. By integrating critical thinking skills throughout the nursing curriculum, faculty heightened the capacity of students to make and defend their own ethical decisions.

need for "ethical reflection to discern moral dilemmas and injustices" (p. 28). Their call for "radical transformation" in nursing education challenges nurse educators to integrate "ethical comportment" (p. 167) and ethical decision-making in both classroom and clinical settings (p. 30). Sullivan confirms the imperative that nurse educators prepare students "to enter and uphold the social contract with the public that they serve" (2005, p. 80).

Purpose
The purpose of this article is threefold. First, to describe the design of an accelerated bachelor of science in nursing (ABSN) curriculum at Dominican College, Orangeburg, NY, that was systematically organized to promote ethical decisionmaking competence. Second, to link ethical decision-making and critical thinking to justify using critical thinking skills to measure ethical decision-making competence. And third, to measure the pre-and post-program critical thinking test scores of 100 students from four consecutive ABSN classes. Examples of course-and clinical objectives, teaching methodologies and learning activities, and students' work-all intended to promote ethical decisionmaking-are included.
Overall, the aim is to inform faculty about the top-down steps of curriculum design from institutional mission to course objectives, and perhaps inspire faculty to integrate ethical decision making in their own curricula-regardless of the course of study. Rogers' Science of Unitary Human Beings (1986) and Watson's Theory of Transpersonal Caring (1988) were selected by faculty consensus as the theoretical foundation of the curriculum, several years prior to this study. With regard to ethical decision making, Rogers emphasized that when nursing interventions are derived from a "valid, scientific body of knowledge, they concur with the ethical standards of nursing practice and support human betterment" (Rogers, 1986, p. 4). She wrote that . . . the education of nurses has identity in the transmission of nursing's body of theoretical knowledge. (Rogers, 1986, p. 4) Watson, on the other hand, emphasized that nursing is based on human values with a primary interest in the welfare of others-factors that supported the ethical decision-making competence the faculty in this study sought to promote (Watson, 1988). Armed with Rogers' principles of holism and Watson's tenets of caring, faculty outlined and sequenced all classroom and clinical nursing courses for the entire prelicensure curriculum.

Curriculum Design Process From College Mission to Clinical Evaluations
The curriculum committee, comprised of five full-time faculty members from the Division of Nursing, met with the entire full-time nursing faculty of 11 additional members over an 8-year period. The primary goal of these monthly, 3-hr meetings was to contemporize the curriculum of the accelerated and traditional bachelor's degree nursing programs for synchrony with current issues in nursing, nursing education, and health care.
To summarize the curriculum design process, faculty analyzed the Mission Statement of Dominican College, noting the emphasis on empowering its "community of learners to . . . serve with integrity and to engage responsibly in the pursuit of a more just, ethical and sustainable world" (Dominican College, 2015b, p. 1). In turn, faculty designed the Mission Statement of the Division of Nursing to emphasize a "curriculum that assists students to learn ethical, civic, and social responsibility" and a commitment to "the development of culturally sensitive, caring leaders who promote moral courage . . . " (Dominican College, 2015a, p. 1). Then faculty selected seven core curricular concepts to support the objectives of each nursing course, for example, holism and caring (the theoretical foundation for each course); critical thinking (the basis for clinical reasoning); clinical-, technological-, and ethical competence (the tools of nursing practice); professional development (the key to professional and personal success); and leadership and research (the standard-bearers of evidence-based practice). Next, they developed the course descriptions and the course objectives for all 14 nursing courses in the curriculum. And last, they generated a clinical evaluation form based on the course objectives for each of the nine clinical nursing courses and designated at least one ethical indicator from the American Nurses Association (ANA) Code of Ethics (2015) on each form (see Figure 1).
To legitimize and facilitate the curriculum design process, faculty reviewed nursing-and education issues in current journal articles, investigated trends in other nursing curricula, and assessed prior students' course evaluations and satisfaction surveys-all to determine by consensus, each core concept, each course description, and each course objective. The discussions and debates to reach consensus were lively and sometimes heated, and personified Rogers' concepts of innovative change, increasing diversity, and energy transfer (Fawcett, 1989). Once completed, the entire curriculum was presented to the collegewide Committee on Instruction for final approval.

Program and Student Characteristics
The ABSN option is a 12-month program, begun in 1994, for college graduates holding the minimum of a non-nursing baccalaureate degree. The 58-nursing credit program continues today in its originally conceived trimester format, from May to May (see Table 1).
Before starting the first nursing course in the ABSN option, 11 prerequisites must be completed: six sciences (general chemistry, biochemistry, anatomy and physiology I and II, microbiology, and pathohysiology), four social sciences (sociology, general psychology, developmental psychology I and II), and statistics.
Of the 100 ABSN students in this study, 76% were female, and the average age was 26 years. Their undergraduate GPAs ranged from 3.0 to 3.8. The majority were White, with no prior experience in health care and whose first language was English. Undergraduate majors included biology, finance, and teacher education. Three percent held master's degrees in social work, biochemistry, and communication. Generally, they fit the description of accelerated nursing students in that they were highly motivated to learn new clinical skills and master complex material quickly (Korvick & Williamson, 2008).

Ethical Decision-Making Course Objectives and Ethical Indicators
During the early stages of the curriculum design process, the faculty agreed that ethical decision-making competence meant identifying an ethical dilemma, formulating a relevant ethical question, then designing and defending a reasoned, principled opinion-orally and in writing (Davis, Fowler, & Aroskar, 2010;Porter-O'Grady & Malloch, 2013   provisions from the ANA Code of Ethics (2001,2015), and addressed compassion, respect, professional values, integrity, and patient safety (see Table 2).

Teaching Strategies
Faculty endorsed Stephen Brookfield's time-honored "handson-survival manual," The Skillful Teacher (1990Teacher ( , 2006. They were energized by his suggestions to engage students in dialogue that explored their values, tested-out their ideas, and strengthened their "ethical" voice-each to confirm what they valued and defend what they believed. And, they supported Swallow's premise that a reasoned defense of one's decision to invested listeners was an essential component of ethical decision-making competence (2011). In addition, faculty were mindful of the American Association of Colleges of Nursing's (AACN, 2008) recommendation that ethical decision-making competence should be firmly embedded in each nursing course. They selected teaching strategies that promoted ethical decision-making competence, assuring that the corresponding learning activities increased in complexity from course-to-course (see Table 3).

Critical Thinking and Ethical Decision Making
During the early stages of curriculum design, faculty confirmed the definition of critical thinking by Assessment Technologies Institute (ATI) as a dynamic, purposeful, analytic process that results in reasoned decisions and judgments (ATI, 2000). They also agreed with Rubenfeld and Scheffer that consistently demonstrated habits of the mind such as "discriminating, information seeking, applying standards, logical reasoning, predicting, and transforming knowledge" were vital to solving problems (2000, p. 358; 2015). And, they concurred with the behaviors of critical thinkers proposed by Paul and Elder (2006)

Measuring Ethical Decision Making
During the search for a specific tool to measure ethical decision-making competence, faculty noted that the critical thinking competencies cited by ATI (2000) shared vocabulary-and in some instances behaviors-with the steps of Matthews' decision-making algorithm (2008). It was then that they asked themselves if the same tool that measured critical thinking could also measure ethical decision-making competence. And if so, this could be good news since each nursing student already completed a standardized critical thinking assessment at the beginning and the end of the nursing program. They concluded that justification for using critical thinking scores to measure ethical decision-making competence was needed.

Critical Thinking Assessment Test
Designed by ATI, the standardized Critical Thinking Assessment, which was already in use, tested six cognitive skills routinely associated with critical thinking: interpreting, analyzing, inferring, explaining, evaluating, and self-regulating (2000). Indeed, the 40-question, 1 min-per-question test was administered in paper-and-pencil form to each entering and exiting student in the ABSN program. The first test was completed 3 weeks after the program started, and the second, 1 week before the program ended. The test had a global alpha reliability of .694 for all 40 items, with demonstrated construct and content validity. Readers can refer to the Interpretation of the Critical Thinking Assessment: Nurse Educators Guide by ATI (2000) for a more detailed description of each cognitive skill.

Linking Critical Thinking and Ethical Decision-Making
As the search for a tool to measure ethical decision making progressed, the curriculum committee decided to survey the full-time nursing faculty, plus a sample of graduating nursing students, for any perceived similarities between critical thinking and ethical decision making. They designed a survey of six sets of behaviors; each set paired a critical thinking  (2000) with a step of ethical decision making from Matthews' algorithm (2008). Content validity for the survey was established by a panel of health care professionals comprised of full-time and part-time classroom and clinical nursing faculty, each holding a master's or doctoral degree in nursing or higher education (see Table 4). Thirteen full-time, two part-time nursing faculty, and 29 graduating accelerated nursing students indicated on a 5-point scale whether or not they perceived any similarities between each set of behaviors. "Strongly agree" was assigned a value of 5 points and "strongly disagree" was assigned a value of 1 point. With this schema, the higher the score the more positive the rater's perception of similarity between critical thinking and ethical decision-making.
The 15 nursing faculty who completed the survey "strongly agreed" or "agreed" that 80.0% of the critical thinking skills and their corresponding ethical decisionmaking steps were similar in meaning. The 29 students who completed the survey "strongly agreed" or "agreed" that 88.8% of the same skills and steps were similar in meaning. Both faculty and students perceived the highest similarity between the critical thinking skill and ethical decision-making step for interpretation and self-regulation at 87% and 92% respectively. In addition, students also rated the paired sets of critical thinking and ethical decision-making for analysis and evaluation at 92%.
Once the perceived similarities between the critical thinking skills and ethical decision-making steps were confirmed • • To utilize the critical thinking skill of inference means: To draw conclusions based on evidence, to differentiate between conclusions/hypotheses that are logically or evidentially necessary and those that are merely possible or probable, and to identify knowledge gaps or needs (ATI, 2000, p. 1). • • To define the choices available to you as a registered nurse. What are the values . . . [and] ethical principles related to this choice? (Matthews, 2008).
• • To utilize the critical thinking skill of explanation means: To explain, in writing or orally, the assumptions and reasoning processes followed in reaching conclusions, and to justify one's reasoning/conclusions in terms of evidence, concepts, methodologies, or contextual considerations (ATI, 2000, p. 1). • • To consider an ethical theory as validation (Matthews, 2008). 5 4 3 2 1 • • To utilize the critical thinking skill of evaluation means: To assess the credibility of sources of information, the strength of evidence, the relevance, significance, value, or applicability of information in relation to a specific situation, and to assess information for biases, stereotypes, and clichés (ATI, 2000, p. 1). • • To consider similar or comparable decisions (Matthews, 2008).

5
4 3 2 1 • • To utilize the critical thinking skill of self-regulation means: To continuously monitor, reflect on, and question one's own thinking; to reconsider interpretations or judgments as appropriate based on further analysis of facts or added information; and to examine one's own views with sensitivity to the possible influence of personal biases or self-interest (ATI, 2000, p. 1). • • To make and validate the decision as to whether the intended outcome produces the most good and the least harm. (Matthews, 2008).
by the faculty and students surveyed, the decision to use preand post-program critical thinking test scores to measure ethical decision-making competence was made.

t-Test Calculations
Each class completed the same 12-month 58-credit ABSN curriculum that included completing the ATI Critical Thinking Assessment test during the first and last accelerated nursing course. The t-test calculations for the pre-and postprogram critical thinking test scores of four consecutive accelerated classes-100 students-indicated significance at the .05 level for a two-tailed test. In addition, the mean Critical Thinking Assessment test exit score for each of the four classes exceeded the national mean by 4.6% to 5.8% (see Table 5).

Discussion
The teaching strategies and clinical indicators faculty instituted across the curriculum promoted the ethical decisionmaking competence of four consecutive classes of accelerated nursing students. The perceived similarities between critical thinking and ethical decision making justified using pre-and postprogram critical thinking scores to measure students' ethical decision-making competence. From the beginning, the faculty in this study took guidance from Butts and Rich (2013) who wrote that practical wisdom and moral ways of being do not just happenthey must deliberately be formed with education and intelligent habits of practice . . . . Knowing textbook ethics is critical, but taking care to deliberately form one's character is of significant importance for nurses. (p. xv)

Limitations
While the findings of this study are heartening, they are limited by the one-school sampling, the one-program sampling, and the small size of the sample. And yes, the perceptions of faculty and students were used to justify using critical thinking scores to measure ethical decision-making competence. However, a tool specifically designed to measure ethical decision-making competence is preferable, and one exclusively for nursing students would be even better.

Implications for Nursing Faculty and Nursing Education
The systematic effort to incorporate ethical decision-making competence across the nursing curriculum in this study began when students followed the steps of the nursing process to identify patient problems, then examined the ethical decisions made by others, and finally designed and defended their own ethical opinions.
During their final capstone course, students examined the ethical questions listed in Table 6. While it is not the intention of this article to discuss these questions in depth, their diversity and that the students independently selected ethical questions pertaining to the most common ethical principles of autonomy, beneficence, justice, veracity, and distributive justice are indeed noteworthy.
Also during the capstone course, students submitted a schematic drawing of their own ethical decision-making process. Intended as an exercise in reflective thinking, few, if any, words were required. Instead, the drawing was meant to convey-in symbols-the decision-making process as it unfolded. An example of a schematic drawing is seen in Figure 2.
On their capstone course evaluations, students wrote enthusiastically about the opportunities to "explore diverse ethical points of view" and that they "loved the ethical issue presentations-they made me think." Here were reasons to believe that the nursing curriculum paved the way for these students to begin their nursing careers with an appreciable level of ethical decision-making competence.
In terms of global relevance, the ethics of health care in developing countries and the need to broaden nursing curricula beyond delivering patient care to one or two patients at a time has intensified. International nursing research by investigators from different countries and cultures, who know how to generate ideas for providing "existing products and services to those in need is often equally or more important" (Nuffield Council on Bioethics, 2002, p. 5). As a result, ethically responsible curricula must teach nursing students to not only identify but also anticipate globally diverse ethical problems and design morally reasoned solutions.
And, as nursing curricula are already filled with so many required courses and clinical hours, online computer programs are proving to be an efficient approach to teaching students to make ethically accountable decisions. As students learn to make ethical decisions in clinical situations, this instructional method simulates real-life situations in the context of nursing practice and duly warrants further faculty investigation (Park, 2013).

Future Directions
Next on the horizon is measuring the peaks and troughs of students' ethical decision-making competence throughout the nursing curriculum, and time-teaching learning strategies to be consistent with those highs and lows. Matching ethical decision-making teaching strategies with students' learning styles, and measuring critical thinking at different levels during the curriculum-perhaps prior to starting the nursing program-could build on the curricular developments made so far. Assessing ethical decision-making competence at scheduled intervals after graduation could determine the longevity of the teaching and learning effectiveness. A prerequisite bioethics course is another possibility. And then there are the big policy issues such as how a country spends money to disperse health care, or what nurses world-wide tolerate in their work environment, or how nurses intentionally distribute health care by culture, gender, or religion (Cipriano, 2015). The feasibility of interdisciplinary ethical decision-making courses is real. And most importantly, faculty must conduct ongoing assessments of ethical issues in health care to assure that their course content stays up-to-date and consistent with the newly released ANA Code of Ethics with Interpretive Statements (2015).

Conclusion
Faculty answer a critical need in nursing education when they teach students how to identify ethical issues, how to ask related questions, and how to design and defend their own reasoned opinions. When faculty educate nurses to think critically in ethically difficult situations, their professional voices are strengthened (Pavlish, Brown-Saltzman, Hersh, Shirk, & Nudelman, 2011). Ethical decision-making competence is the

Ethical principle Question
"meat and potatoes" of effective nursing education and nursing practice. In the end, the words of Bevis still ring true: There is a compelling splendor about both teaching and nursing that demand the highest forms of endeavor, for their ends are linked to the magnificent miracle of human thought and the quality of human life. They have a common core of caring about the human condition and an obligation to its improvement that confers a radiant beauty on the meanest of tasks in their service.
They are a societal trust. And, for those who combine these two tasks into the teaching of nursing, there is a moral commitment to society's needs that requires industrious constancy in improving care so that this trust will be steadfastly and excellently honored. It is to this trust that our revolution is dedicated. (1990, p. 1)

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.